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Teaching session for GP registrars. Dr Mohinder Kapoor Consultant Psychiatrist. TOPICS. RISK ASSESSMENT & MANAGEMENT DEMENTIA MOOD DISORDERS. Primary care: Older people are high users of primary care time and resources High prevalence of Dementia & Depression Public Health

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Teaching session for gp registrars

Teaching session for GP registrars

  • Dr Mohinder Kapoor

  • Consultant Psychiatrist


Topics

TOPICS

  • RISK ASSESSMENT & MANAGEMENT

  • DEMENTIA

  • MOOD DISORDERS


Why is old age psychiatry important

Primary care:

Older people are high users of primary care time and resources

High prevalence of Dementia & Depression

Public Health

Older people over-represented in many care settings

More treatments available

e.g. anti-dementia drugs etc, with cost implications

Treatment outcomes affected by psychiatric illness…

Why is old age psychiatry important?


Dementia

Dementia


Dementia across uk

Dementia across UK

Current estimate is there are 700,000

dementia sufferers in UK

Expected to double to 1.4 m in 30 years

Total cost of dementia in the UK - £17 billion per annum

Tripling £51billion pa in 30 years


Figures for calderdale

Figures for Calderdale

population prevalence over 65(dementia (total) sufferers)

2010 32,100 1605

2015 36,600 1830

2020 39,800 1990


Facts about dementia

Facts about dementia

Common but not inevitable part of aging

Most of us will (or do) experience dementia directly or through someone we care about

2 thirds of people with dementia live in their own homes in the community

Quality of life is as much related to the richness of interactions and relationships as to the extent of the brain disease


Prevalence of dementia

Prevalence of dementia


Epidemiology

Epidemiology

  • Incidence rates approximately doubles with each decade over 60

  • Prevalence of AD was 3% in 65-74 (Evans et al. 1989).

  • In the 75-84 year cohort the figure was 18.7%

  • 1 in 50 aged 65-70 have dementia

  • In the 85-94 the figure rose to 47.2%.

  • Currently 700,000+ people in the UK

  • 18,500 (2.5%) aged under 65

  • Fewer cases in ethnic minorities

  • Risk in learning disability


Early diagnosis

Early diagnosis

20-40% of people with dementia receive a formal diagnosis

Often too late

At a time of crisis

Too late for effective intervention


Overview of dementia

Overview of dementia

Dementia (meaning "deprived of mind") is a serious cognitive disorder.

Dementia is a word for a group of symptoms caused by disorders that affect the brain.

Memory loss is a common symptom of dementia. However, memory loss by itself does not mean you have dementia. It is characterized by three main symptomatic domains, as shown below.

Activities – inability to perform activities of daily life

Behaviours – psychiatric symptoms/behavioural disturbances

Cognition – neuropsychological impairments


Socioeconomic impact

Socioeconomic Impact

  • 150,000 people thought to be in residential/nursing home care in UK

    • require 24 hour care

    • approximate cost £20,000 per year

  • Assuming 50% suffer from AD - total cost of AD residential care is >£1 billion

  • The annual cost of treating and caring for people for AD in the UK is £5 billion.


Ad and other dementias

AD and other dementias

  • Direct and indirect costs

  • Treatment costs

  • Financial and emotional costs to family

  • Great need for effective well organised systems of service delivery

  • Elderly overlooked in planning mental health and other services

  • Older people in community suffer from untreated depression/dementia

  • May lead to premature institutionalisation


Teaching session for gp registrars

Dementia defined

  • “a syndrome due to disease of the brain usually of a chronic or progressive nature, in which there is disturbance of multiple higher cortical functions, including memory, thinking, orientation, comprehension, calculation, learning capacity, language and judgement.”

  • not a disease in its own right

  • deterioration in intellectual functioning and social behaviour

  • presents in a variety of ways:

  • causal condition

  • individual concerned

  • does not affect the brain uniformly


Teaching session for gp registrars

Dementia syndromes

  • Categorised by:

  • their nature

  • degenerative – Alzheimer’s disease, Frontotemproal dementia, Lewy Body Disease, Progressive supranuclear palsy, Huntington’s disease

  • vascular – multi-infarct

  • traumatic – head injury

  • infective – AIDS, prion diseases


Teaching session for gp registrars

Dementia syndromes

  • Or, categorised by:

  • their site

  • cortical – Alzheimer’s disease – cognitive changes most notable

  • sub-cortical – Parkinson’s – neurological and physical symptoms

  • multi-focal – prion diseases – severe cognitive and physical problems


Risk factors ad

Risk factors (AD)

  • Age

  • Inherited risk

  • Female

  • Head injury

  • Educational attainment

  • Smoking (protective)

  • Metal ions


Teaching session for gp registrars

Relative frequency

  • Alzheimer’s disease55%

  • Vascular dementia20%

  • Lewy body dementia 15%

  • Others10%

  • questions re diagnosis of Alzheimer’s

  • pure AD rarely seen in clinical practice


Teaching session for gp registrars

Dementia

Early-amnesia

Yes

No

Behaviour changes, non-fluent aphasia

Apraxia, agnosia, Fluent aphasia

Parkinsonian features , Hallucinations

Focal neuro signs

FTD

AD

DLBD

VAD


Dementia1

Dementia

80 year old presents with his wife to the GP. His wife is concerned because she has noticed a gradual impairment of his memory. His family has noted him to have ‘changed’ in himself. He denies any problems with his memory. He seems to be more disorientated at home.

What is his most likely diagnosis?

What would be your management plan?


Alzheimer s disease

Alzheimer's Disease

Progressive, Irreversible condition

S-T memory affected first

Amnesia, Aphasia, Apraxia, Agnosia

Behavioural, personality and psychiatric symptoms

5% of people over age of 65

Depletion of Acetylcholine implicated

Other NT’s involved- 5HT, NA, glutamate


Teaching session for gp registrars

Clinical features

  • Amnesia- recent memories initially affected

  • Aphasia- Language problems

  • Agnosia- difficulty recognising and naming objects e.g. autoprosopagnosia

  • Apraxia- difficulties in complex tasks

  • Visuospatial difficulties


Teaching session for gp registrars

Clinical features

  • Functional impairment- often most impact on individual- e.g. finances, dressing/personal hygiene

  • Mood disorders

  • Psychosis- delusions and hallucinations

  • Personality change- “living bereavement”

  • Other behavioural manifestations


Teaching session for gp registrars

Symptoms

  • Problems remembering:

  • ‘’When I try to remember things, it goes further away from me’

  • Find it hard to find the right words:

  • ‘I don't put the right word in the right place’

  • Can't understand what people are saying:

  • ‘A direct question brings me up short’

  • Have problems recognising people:

  • ‘I knew him from somewhere, but I couldn't remember where’

  • Find it more difficult to complete tasks and solve problems:

  • ‘Cooking has become more difficult. I have problems working out what comes next’

  • Find it harder to concentrate:

  • ‘My mind wanders sometimes’


Teaching session for gp registrars

Changes in dementia

  • often subtle onset

  • only recognised after diagnosis

  • memory, language, behaviour, personality

  • symptom under-reporting, lack of self-awareness

  • gradual loss of self or ‘personhood’


Teaching session for gp registrars

Neuropsychiatric: Personality and Behavioural Changes

Personality Changes

Behavioural Changes

  • indifference

  • lack of concern

  • decreased interest

  • reduced affection

  • poor motivation

  • agitation

  • depression

  • delusions

  • hallucinations

  • stubbornness

  • resistance to care

  • suspicion

  • abusive language

  • hiding articles

  • outbursts

  • restlessness

  • wandering

  • sundowning

  • catastrophic reactions


Alzheimer s disease diagnosis

Alzheimer's disease-diagnosis

MMSE-screening test, not diagnostic, 24/30 further investigations may be required

Bloods- FBC, ESR, LFTs, Renal Function tests, TFTS, blood sugar, B12 and folate, Urine C&S, ECG, CXR

CT/MRI if any significant history or positive findings or suspect infarct or SOC


Teaching session for gp registrars

Drug therapies

  • Cholinesterase inhibitors: donepezil, rivastigmine, galantamine

  • Memantine

  • Vitamin E, ginko biloba

  • NSAIDs

  • Simvastatin

  • Antidepressants

  • Antipsychotics


Dementia 2

Dementia (2)

75 year old man with sudden impairment of memory is taken to Emergency department by his. He was noted to have ‘slumped in his chair’ at home a week ago but recovered shortly after. He seems to be more confused at night time

What is his most likely diagnosis?

What would be your management plan?


Vascular dementia

Vascular Dementia

Unequal distribution of deficits in higher cognitive functions and other relatively spared

Focal brain damage

CBV disease evident

Abrupt onset/stepwise progression

Vascular risk factors


Clinical issue differentiation of diseases

Clinical issue: differentiation of diseases

Evidence suggests that vascular dementia can co-exist with Alzheimer’s Disease leading to diagnostic confusion and mixed forms of dementia.

Vascular lesions may also contribute to the severity of AD [Snowdon, 1997].

Neuroimaging studies showing cerebrovascular disease – infarcts or deep white matter ischaemia – support the diagnosis of vascular dementia.


Dementia 3

Dementia (3)

60 year old woman presents to the emergency department with her daughter. Her daughter is worried because she is having increased number of falls with fluctuations in her alertness. Over the past few days, she has become increasingly agitated as she is experiencing visual hallucinations of elves playing the piano in her house. She has a resting tremor

What is your differential diagnosis?

What would be your management plan?


Lewy body dementia

Lewy body dementia

Fluctuations in cognition with alterations in attention and alertness

Recurrent vivid visual hallucinations

Motor features of Parkinsonism

Possible repeated falls, syncope neuroleptic sensitivity


Prescribing antipsychotics in dementia

Prescribing Antipsychotics in dementia

Summary of evidence

When can prescribing of antipsychotics be justified

Assessment prior to prescribing

Choice of drugs

How long to treat


Teaching session for gp registrars

Risks associated with Antipsychotic Treatment

CSM 2004 - apparent 2-3 fold increase risk of cerebrovascular event in people with dementia prescribed olanzapine & risperidone. Not recommended.

2005- increased mortality rate (1.6-1.7fold) also with ‘typicals’ or conventional antipsychotics due to heart failure, sudden death, pneumonia)

No evidence to say any antipsychotic is safer than another


Dh report on antipsychotics in the management of dementia nov 2009 prof sube banerjee

DH report on antipsychotics in the management of dementiaNov 2009 Prof Sube Banerjee

150 000 people given antipsychotics unnecessarily

Only 1 in 5 gain benefit

Cause of extra 1 800 deaths per annum amongst elderly

Benefit does not extend beyond 3 months


When are antipsychotic justified

When are antipsychotic justified

NICE/SCIE guideline 42

NOV 2006

Offer a pharmacological intervention in the first instance ONLY if the patient is severely distressed or there is an immediate risk of harm to the person or to others.

Psychosis

Severe agitation


Assessment before prescribing

Assessment before prescribing

physical health

depression

possible undetected pain or discomfort

side effects of medication

individual biography

environmental factors

behavioural and functional analysis


Check list

Check list

Discussion about risks and benefits

with patient and or carer

Assessment of cerebrovascular risk factors

Consider the effect of co-morbid conditions such as depression


Teaching session for gp registrars

  • Principles of prescribing

  • Identify target symptom

  • Aim to reduce agitation or aggression without sedation

  • Start low go slow

  • Avoid high doses and combinations.

  • Time limited with regular review (3 mthly or as needed).


Antipsychotics in dementia

Antipsychotics in dementia


Prescribing follow up

Prescribing follow up

Based on the current evidence in relation to prescribing antipsychotic drugs in dementia we recommend an ongoing prescription of no more than 3 months as the evidence suggests there can be serious adverse effects from antipsychotic drugs for patients with dementia. In addition these drugs may become ineffective after this time . We suggest you review medication after three months with a view to gradually withdrawing the antipsychotic over 1-2 weeks. You should then review the patient’s progress and only consider a further short term prescription if the target symptom for which medication was prescribed recurs on discontinuation. If you need further advice about prescribing please contact Dr …...Team leader ….... Pharmacist………


Teaching session for gp registrars

Management: carers

  • Support for the family

  • Practical advice to enhance/compensate for memory deficits- “memory training”

  • Education

  • Advice on communication

  • Self help groups

  • Financial and legal help

  • Practical support from social services etc.


National audit office

NATIONAL AUDIT OFFICE

  • Half of people not diagnosed

  • Lack of training and awareness

  • “not uncommon” for GPs to dismiss dementia as “normal effects of aging”

  • Specialist services were patchy

  • Support from CMHTs “varied considerably”

  • Many CMHTs have no social worker

  • 2/3 of people with dementia are cared for in the community with carers losing employment/pensions/lower earning and depression

  • Access to home care restricted


Teaching session for gp registrars

NICE key priorities

  • Non discrimination

  • Valid consent

  • Carers

  • Coordination and integration of care

  • Memory services


Teaching session for gp registrars

Key priorities continued

  • Structural imaging

  • Behaviour that challenges

  • Training

  • Mental health needs in acute hospitals


Dementia diagnosis

Dementia-Diagnosis

  • History and informant history

    • Mode of onset/course/pattern of impairment

    • Behavioural disturbance-wandering/aggression

    • Co-morbid depression

  • MSE

  • Geriatric depression scale to rule out depression


Dementia2

Dementia

Biopsychosocial approach

Aim to keep elderly person in own surroundings as long as possible

Continuing care and support to relatives/carers

Memory clinics

Treat any underlying physical disorders that can lead to acute confusional states


Dementia3

Dementia

  • Alzheimer’s- Acetyl-cholinesterase inhibitors-

  • MMSE between 10-20

    • Dose reviewed regularly

  • Treat other co-morbid conditions

  • Anxiety and depression- antidepressants

  • Paranoia and hallucinations-Antipsychotics

  • Behavioural symptoms-antipsychotics,

  • SSRI’s and mood stabilisers

  • Insomnia with hypnotics


Dementia management

Dementia-management

  • Psychoeducation

  • Psychological input

    • Behavioural methods, memory aids

  • Day hospitals

  • MDT/CPN/OT/Physiotherapists/Dietician

  • Social services- care assessment of needs and carers assessment

  • Voluntary organizations- Alzheimer's soc.

  • Long-term placement


What is mild cognitive impairment or early dementia

What is mild cognitive impairment or early dementia?

Early dementia, also known as mild cognitive impairment, involves problems with memory, language, or other cognitive functions. But unlike those with full-blown dementia, people with mild cognitive impairment are still able to function in their daily lives without relying on others.

Becomes more common with age


Symptoms of mild cognitive impairment

Symptoms of mild cognitive impairment

Frequently losing or misplacing things

Frequently forgetting conversations, appointments, or events

Difficulty remembering the names of new acquaintances

Difficulty following the flow of a conversation

Intact activities of daily living


Normal memory loss v mci

Normal memory loss v MCI

Risk of developing AD: 0.2% in general population as compared to 6% in MCI (65-69); 4% in general population as compared to 25% in MCI (85-89)


Most cases of mild cognitive impairment do not become dementia

Most Cases of Mild Cognitive Impairment Do Not Become Dementia

The number of patients with mild cognitive impairment (MCI) who progress to dementia is at least half of what it was previously believed to be, new research suggests. A large meta-analysis showed that the cumulative risk over 10 years ranged between 30% and 50%, depending on whether the studies that were analyzed used a definition of MCI that included subjective memory complaints.


Most cases of mild cognitive impairment do not become dementia1

Most Cases of Mild Cognitive Impairment Do Not Become Dementia

Until now, the prevailing opinion was that the progression rate from MCI to dementia was about 10% per year, or a 100% conversion to dementia over 10 years.

This research suggests that instead of always being an invariable transitional state between normal aging and dementia, MCI is a condition in which some patients stay static and some even improve


Conclusions

Conclusions

  • Common

  • Important

  • Challenging

  • Community mental health resources

  • Treatments directed at memory syndrome and behavioural complications

  • Supporting families

  • Pursuing the least restrictive options

  • Complex problems to health and social care

  • Permeates all aspects of hospital care

  • Go beyond stereotypes of ageing


What is generalised anxiety disorder

DSM-IV-TR definition

Excessive anxiety and worry about a number of events or activities, which occur more days than not for at least 6 months

Person finds it difficult to control the worry

At least 3 additional symptoms from a list of 6:

restlessness or feeling keyed up or on edge

being easily fatigued

difficulty concentrating or mind going blank

irritability

muscle tension

sleep disturbance

ICD-10 definition

Anxiety generalised and persistent but not restricted to, or even strongly predominating in, any particular environmental circumstances (i.e. "free-floating")

Dominant symptoms variable but include complaints of:

persistent nervousness

trembling

muscular tension

sweating

lightheadedness

palpitations

dizziness

epigastric discomfort

What is generalised anxiety disorder?


How common is generalised anxiety disorder

How common is generalised anxiety disorder?

12-month prevalence in general population is 3.1%1

Lifetime prevalence in general population is 5.1%1

Prevalence of anxiety disorders in the UK is estimated at 17-95 per 1,000 people depending on age2

Prevalence

Most frequent anxiety disorder in primary care3

Mean 1-month prevalence 7.9%4

Primary care

Affects women more than men, especially in midlife3

Lifetime prevalence in those over 45 years old: 3.6% (men) vs. 10.3% (women)3

12-month prevalence ratio 1:2.2 males:females5

Gender

Frequently chronic3

Social disability as severe as with chronic physical diseases4

Low remission rates6

Symptoms wax and wane at different times3

Often co-occurs with other psychological disorders and physical conditions7

Course

1. Wittchen H-U, et al. Arch Gen Psychiatry 1994;51:355–64; 2. Kings Fund 2011. Paying the Price: The cost of mental health care in England to 2026; 3. Wittchen H-U. Depress Anxiety 2002;16:162–71; 4. Maier W, et al. Acta Psychiatr Scand 2000;101:29–36; 5. Vesga-López O, et al. J Clin Psychiatry 2008;69:1606–16; 6. Yonkers KA, et al. Br J Psychiatry 2000;176:544–9;

7. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text revision. Washington DC: American Psychiatric Association; 2000.


Lifetime prevalence of generalised anxiety disorder increases with age

Lifetime prevalence of generalised anxiety disorder increases with age

12

Male

10.3%

10

Female

8

7.2%

7.1%

6.6%

Lifetime prevalence (%)

6

4.7%

4.6%

3.6%

3.6%

4

2.5%

1.5%

2

0

15–24

25–34

35–44

≥45

Total

Age (years)

Wittchen H-U, et al. Arch Gen Psychiatry 1994;51:355-364.


Generalised anxiety disorder is often not recognised in primary care

Generalised anxiety disorder is often not recognised in primary care

Mental disorder recognisedbut generalised anxiety disorder not diagnosed

Mental disorder not recognised

28%

38%

34%

Specific generalised anxiety disorder diagnosis

Based on a sample of 17,739 patients

5.3% with generalised anxiety disorder (DSM-IV)

DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, 4thed, criteria

Wittchen H-U. J Clin Psychiatry 2002;63(Suppl 8):24–34.


Generalised anxiety disorder symptoms overview

Generalised anxiety disorder symptoms overview

  • Most people with generalised anxiety disorder experience a combination of symptoms:

    • psychological1–3

    • physical1,2,4

    • behavioural5

  • Often the worry is out of proportion to the likelihood of the event1

  • Symptoms can:

    • vary widely between different individuals

    • wax and wane6

    • become more persistent with age7


  • Psychological symptoms associated with generalised anxiety disorder

    Psychological symptoms associated with generalised anxiety disorder

    Nervousness, irritability and worrying1

    Anxiety1,2

    Psychological

    symptoms

    Difficulty concentrating or mind going blank1,2

    Restlessness, tension and inability to relax1

    Intolerance of uncertainty3

    Poor assessment and response to problems3


    Physical symptoms associated with generalised anxiety disorder

    Physical symptoms associated with generalised anxiety disorder

    Gastrointestinal symptoms

    e.g. nausea, diarrhoea, irritable bowel syndrome3–5

    Insomnia and difficulty falling asleep1,4

    Physical

    symptoms

    Dizziness, light headedness1,2

    Pain and muscle tension, aching and soreness1,2,4

    Tachycardia, palpitations, sweating2,4


    Screening for generalised anxiety disorder

    Screening for generalised anxiety disorder

    DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, 4th edition

    ICD-10, International Classification of Diseases, 10th revision.

    • Several self-report questionnaires are available to assist doctors in the detection of generalised anxiety disorder and depression:

      • GAD-2 – quick screening tool for generalised anxiety disorder1

      • GAD-7– screens for generalised anxiety disorder2

      • Hospital Anxiety and Depression Scale (HADS) – screens for anxiety and depression3

        However, full diagnosis should be confirmed using DSM-IV or ICD-10 diagnostic criteria

    1. Kroenke K, et al. Ann Intern Med 2007;146:317–25; 2. Spitzer RL, et al. Arch Intern Med 2006;166:1092–7; 3. Zigmond A, Snaith RP. Acta Psychiatr Scand 1983;67:361–70.


    Before prescribing pharmacological therapy for generalised anxiety disorder

    Before prescribing pharmacological therapy for generalised anxiety disorder

    Age1

    Severity of illness2

    Tolerability1

    Previous treatmentresponse1,2

    Consider…

    Cost1,2

    Co-occurringdisorders2,3

    Possible interactions withconcomitant medications1

    Risks of deliberate self-harmor accidental overdose2,3

    Patient preference1,2


    Nice 2011 guidelines for the management of generalised anxiety disorder

    NICE 2011: Guidelines for the management of generalised anxiety disorder

    STEP 2

    STEP 1

    STEP 3

    STEP 4

    SSRI, selective serotonin reuptake inhibitor ; SNRI, serotonin norepinephrine reuptake inhibitors; *Review effectiveness and side effects of pharmacological therapy every 2–4 weeks; during the first 3 months of treatment and every 3 months thereafter; **Not licensed for the treatment of GAD in the UK; †Not licensed for the treatment of GAD in the UK except for escitalopram and paroxetine

    NICE. Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults. Clinical Guideline 113, January 2011.

    Please refer to local Summary of Product Characteristics before prescribing


    What is depression

    What is depression

    Diagnostic criteria for depression ICD-10 uses an agreed list of ten depressive symptoms

    Key symptoms:

    persistent sadness or low mood;and/or

    loss of interests or pleasure

    fatigue or low energy

    at least one of these, most days, most of the time for at least 2 weeks

    if any of above present, ask about associated symptoms:

    disturbed sleep

    poor concentration or indecisiveness

    low self-confidence

    poor or increased appetite

    suicidal thoughts or acts

    agitation or slowing of movements

    guilt or self-blame


    Continued

    Continued

    the 10 symptoms then define the degree of depression and management is based on the particular degree

    not depressed (fewer than four symptoms)

    mild depression (four symptoms)

    moderate depression (five to six symptoms)

    severe depression (seven or more symptoms, with or without psychotic symptoms)

    symptoms should be present for a month or more and every symptom should be present for most of every day


    Overlap in symptoms between generalised anxiety disorder and depression

    Overlap in symptoms between generalised anxiety disorder and depression

    Generalised anxietydisorder

    Depressed mood

    Apathy

    Withdrawal

    Loss of interest

    Worthlessness/guilt

    Weight loss

    Suicidality

    Anticipatory anxiety

    Uncontrollable worry

    Irritability

    Muscular tension

    Tension pains

    Physical symptoms

    Fatigue

    Poor concentration

    Sleep disturbances

    Restlessness

    Agitation

    Major depressivedisorder

    American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text revision. Washington DC: American Psychiatric Association; 2000.


    Depression aetiology

    Depression: aetiology

    • Similar to <65

      • Geneticreduced effect

      • Biochemicalamine theory: no consensus

      • Life events

        • Elderly have more of them

        • Bereavements

        • Physical disability & illness

        • Loss of roles/activities


    Depression prevalence

    Depression prevalence

    • Higher than <65

    • 10-20% community prevalence

    • Up to 33% in general hospitals

      • May not be recognised as presents differently

    • Treatable

    • Adverse impact

      • Increased mortality – relative risk 1.6

      • Reduced quality of life


    Depressive presentations in older patients

    Depressive presentations in older patients

    • More somatic complaints

    • Reduced expression of sadness

    • Overlap with physical illness

    • Recent onset of neurotic symptoms

    • “Trivial” self-harm

    • Pseudo-dementia

    • Depression superimposed on dementia

    • Accentuation of personality traits

    • Conduct disorder (behavioural problems)

    • Late onset alcohol dependence syndrome


    Depression detection

    Depression: detection

    • History, examination, informant etc

    • Screening tools

      • Geriatric Depression Scale

        • GDS-30, 15, 10, 8, 5, 1

      • Hospital Anxiety and Depression Scale

        • HAD

      • Brief Assessment Schedule-DEP

        • BAS-DEP


    Depression treatment

    Depression treatment

    • Full range should be available

      • Biological

      • Psychological

      • Social

    • For medication, consider:

      • Side effects

      • Interactions

      • Efficacy

      • Concordance


    Self harm and suicide

    Self harm and suicide

    • 25% of suicides are older people

      • male, living alone, unmarried, physical illness, depression, previous self harm

    • 90% have significant depressive symptoms

    • 60% have physical illness

    • Must be seen by psychiatric services


    Risk assessment management

    Risk Assessment & Management


    Introduction

    Introduction

    Definition

    Why is risk my business?

    What kinds of risk do I need to consider?

    What time frame do I need to consider?

    Risk of suicide?

    To be able to complete it using a scenario

    04/04/2012

    risk training.MK/2012

    78


    Definition of risk

    Definition of Risk

    04/04/2012

    risk training.MK/2012

    79

    “The likelihood of an event happening with potential harmful or beneficial outcomes for self and / or others . . .

    . . . Possible behaviours include suicide, self-harm, aggression and violence, and neglect; with an additional range of other positive or negative service user experiences”

    (Morgan, 2000)


    Why is risk my business

    Why is risk my business?

    Psychiatric patients more at risk than general population

    Recent studies/ surveys: National Service Framework for Mental Health (1999); Our Healthier Nation (1997);National Confidential Inquiry Homicide & Suicide (2001); Avoidable Deaths (2006 http://www.medicine.manchester.ac.uk/suicideprevention/nci/)

    Dictates significant components of overall management plan

    04/04/2012

    risk training.MK/2012

    80


    What kinds of risk do i need to consider

    What kinds of risk do I need to consider?

    Direct self harm

    Harm to others

    Self neglect

    Alcohol/drug misuse

    Vulnerability/exploitation

    Accidental self harm

    Harm to property

    Arson

    Sexual offending

    Risk of harm to children

    04/04/2012

    risk training.MK/2012

    81


    Uk statistics

    UK Statistics:

    Road deaths per annum =

    Annual suicide rate for people with mental health problems =

    People killed annually by intoxicated drivers =

    ??% of people with Schizophrenia will actually succeed in committing suicide

    Annual homicides committed by people with a mental health problem = ?? to ??

    You are ?? times more likely to be attacked or killed by someone WITHOUT a mental health problem.


    Uk statistics1

    UK Statistics:

    Road deaths per annum = 4,000

    Annual suicide rate for people with mental health problems = 1,000

    People killed annually by intoxicated drivers = 400

    15% of people with Schizophrenia will actually succeed in committing suicide

    Annual homicides committed by people with a mental health problem = 35 to 40

    You are 13 times more likely to be attacked or killed by someone WITHOUT a mental health problem.


    What time frame do i need to consider

    What time frame do I need to consider?

    Current/short term risk

    Long term/historical risk

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    Risk of suicide

    Risk of Suicide

    Actuarial risk:

    1% people with deliberate non-fatal self harm will kill themselves in following year - 100x risk of general population

    10% all deliberate self harmers eventually commit suicide

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    Teaching session for gp registrars

    How do I assess risk? I: Suicide iiMore the self harm resembles the following characteristics, greater risk:

    attempt premeditated and prepared for

    Precautions taken to avoid intervention

    Attempt in isolation

    Attempt timed to minimise discovery

    Suicidal intent communicated prior to attempt

    Final acts in anticipation of death, egg. will

    Suicide note

    Violent, active methods used or more lethal drugs

    Person’s belief re drugs

    Person stated aim was to kill self

    Person regrets surviving

    No action taken to obtain help after event

    Numerous suicide attempts with apparent intention to die


    How do i assess risk i suicide iii risk checklist

    How do I assess risk? I: Suicide iii: Risk checklist

    Attempts on their life

    Significant life events

    Expressing high levels of distress

    Believe no control over life

    Use of violent methods

    Helplessness or hopelessness

    Misuse of drugs and/or alcohol

    Family history of suicide

    Major psychiatric diagnosis

    Separated/widowed/divorced

    Expressing suicidal ideas

    Unemployment/retired

    Considered/planned intent


    How do i assess risk i suicide iv assessment

    How do I assess risk? I: Suicide iv: Assessment

    Interview sequence:

    Hope that things will turn out

    well

    Get pleasure out of life

    Feel hopeful from day to day

    Able to face each day

    See point in it all

    Ever despair about things

    Feel it is impossible to face each

    day

    Feel life is a burden

    Wish it would all end

    Wish self dead

    Why feel this way, e.g. be with dead person

    thought s of ending life and how persistent

    Specific method contemplated

    Ever acted on thoughts

    What stopped them

    Feel able to resist thoughts

    How likely to kill self

    Able to give reassurance , e.g. until next appointment

    Circumstances likely to make situation worse

    Willingness to turn for help in a crisis


    How do i assess risk ii safety to others i risk checklist

    How do I assess risk? II: Safety to others I: Risk checklist

    Forensic history

    Previous incidents of violence

    Previous use of weapons

    Misuse of drugs and/or alcohol

    Male gender, under 35 years of age

    Early maladjustment

    Known personal triggers

    Expressing intent to harm others

    Previous dangerous impulsive acts

    Paranoid delusions about others

    Violent command hallucinations.

    Signs of anger and frustration

    Sexually inappropriate behavior

    Preoccupation with violent fantasy

    Admission to secure settings

    Denial of previous dangerous acts.

    Poor compliance

    Inability to engage in treatment plan


    How do i assess risk iii self neglect i sources of information

    How do I assess risk? III: Self Neglect i: sources of information

    History: from patient, informant history, eating habits, security, financial affairs,

    MSE: self care, cognitive functioning

    Informal support networks


    How do i assess risk iii self neglect i risk checklist

    How do I assess risk? III: Self Neglect i: Risk checklist

    Previous history of neglect

    Failing to drink/eat properly

    Difficulty managing physical health

    Living in inadequate accommodation

    Lacking basic amenities ( water/heat/light)

    Pressure of eviction/repossession

    Lack of positive social contacts

    Unable to shop for self

    Insufficient/inappropriate clothing

    Difficulty maintaining hygiene

    Experiencing financial difficulties

    Difficulty communicating needs

    Denies problems perceived by others


    What causes risk

    What causes risk?

    Clinical diagnosis: depression, mood disorders, schizophrenia, organic conditions

    Social circumstances

    Alcohol misuse

    Drug misuse

    Perceived support from formal and informal networks

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    Risk management

    Risk Management

    What’s on your radar?

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    Principles of working with risk

    Principles of working with Risk

    All clinical decisions

    Every clinical situation

    Dynamic variable: think of short and long term risk

    Enhanced by using multiple sources of information, often incomplete

    Identify cause of risk from information

    Screening tools


    Risk rules iii 6 questions

    Risk Rules III: 6 questions

    What is the risk?

    What is the magnitude of the risk?

    What is the imminence of the risk?

    Who is at risk?

    What are the factors to increase risk?

    What are the factors to decrease risk?

    David Hargreaves, 2006


    Risks in clinical management decisions

    Risks in clinical management decisions

    Risks of any action, or no action, e.g. to

    admit to hospital

    detain under Mental Health Act

    allow periods of leave

    liaise with family members

    breach confidentiality

    alter medication

    manage illicit drug misuse

    manage alcohol misuse


    Teaching session for gp registrars

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    What is positive risk management

    What is positive risk management?

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    Teaching session for gp registrars

    Or ?

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    Positive risk taking i

    Positive Risk Taking i

    “Positive Risk-Taking is not negligent ignorance of the potential risks. Nobody, especially service users benefits from allowing risks to play their course through to disaster. Positive Risk-Taking is about collaborative working, based on the establishment of trusting relationships, whereby service users can learn from their experiences, based on taking chances just like anyone else. It is about understanding the consequences of different courses of action; making decisions based on a range of choices, and supported by adequate and accurate information. It is about knowing that support is available if things begin to go wrong, as they occasionally do for all of us. Positive Risk-Taking is also about explicit setting of boundaries, to contain situations that are developing into potential catastrophic circumstances for all involved.”


    Positive risk taking ii principles

    Positive Risk Taking ii: principles

    Weighing up the potential benefits and harm of one choice over another

    More empowering

    Collaboration with service user and practitioner essential

    Focus on positive attributes within service user

    Identifying the potential risks involved when following a clearly defined course of action, with the expressed aim of achieving specific positive gains

    Positive risks need to be measured, defensible, intelligent, documented


    Positive risk taking iii essential requirements

    Positive Risk taking iii: Essential requirements

    Supportive management and policy

    Quality clinical supervision

    Consensus within the team

    Monitor for early warning signs

    Agreed crisis and contingency plans

    Document decisions reached

    Support for service users and carers

    Culture of learning rather than failure.


    Positive risk taking iv some examples

    Positive Risk Taking iv: some examples

    Admission to hospital

    Periods of leave

    Home treatment

    Police arrest

    Home visiting

    Liaison with families

    Discharge from service

    Medication reduction /withdrawal/self management

    Work opportunities

    Independent living

    “controlled” self harm

    Dealing with own finances

    Building a social network

    Moving on from day care facilities

    Going away on holiday


    Should i use screening tools

    Should I use Screening Tools?

    YES!

    FACE risk assessment

    Sainsbury risk assessment tool

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    Clinical example

    Clinical example

    The patient is a 37 year old single woman who is currently cohabitating with an alcoholic male friend. She consumes alcohol, but is not dependent, and smokes cannabis to excess with likeminded friends who follow an ‘alternative lifestyle’.

    She has a six year history of continuous auditory, visual and somatic hallucinations, worsening with alcohol and cannabis. She is erratically compliant with medication, which improves her symptoms. History of depression with psychotic symptoms in the past. Took an overdose and hit her neighbour last year thinking he was a spy who worked for MI5. This led to her being detained under section 2 of the MHA. Recently 3 months ago took an overdose of 30 paracetamol tablets with alcohol. She lost her parents in a car accident nearly a year ago. Her parents were very supportive and lived locally. Has a younger brother and sister who are the only family members she has and when well she keeps in touch with them and engages well with them.

    At times of deterioration in her mental health, her self care and living skills decline, such that she fails to shop for herself, keep her flat clean or attend to her personal hygiene. At the time of her last hospital admission, she argued with 2 MHA assessment teams, that if she wanted to live in squalor with no electricity or running water, then this was her choice.

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    Clinical example contd

    Clinical example: contd

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    Currently feeling down, with poor appetite and loss of weight. She is unemployed and is on benefits. Has mentioned to her friend that she doesn’t want to live anymore and she might buy some tablets from the market and take them on her parent’s death anniversary. 2 weeks ago cut her wrists when she was under the influence of alcohol. Last week pushed a stranger on the street thinking he was spying on her. Police arrested her and released her without charging her. Has hit her male friend who has also hit her back. Her friend is concerned about her. Not engaging with CMHT.

    She is currently non-compliant with medication and has obtained a dog whom she does not exercise and who defecates in the corner of the room .


    In conclusion

    In Conclusion:

    Relationship of risk to mental disorder

    Short and long term risks

    Have a systematic approach in your clinical practice


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