Social anxiety disorder (SAD), also known as social phobia, is arguably one of the most common mental health problems seen in primary care, only being exceeded by depression; however, it frequently goes unrecognised. It is common that GPs, rather than psychiatrists, face the challenge of making a diagnosis and explaining the treatment options. Evidence suggests that there is a significant need to identify patients with SAD, as it remains under-diagnosed and under-treated. Frequently, patients with SAD present with co-morbid and overlapping anxiety and mood disorders in addition to substance misuse. There are effective treatments for SAD, they include both pharmacotherapy and cognitive behavioural therapy; however, if the condition remains unrecognised there is a strong association with long-term disability and distress. The aim of this article is to increase awareness among GP trainees of this common mental health problem and to shed some light on this disorder and its treatment options.
Read the full article here.
Poisoning and overdose are an increasingly common problem in the UK resulting in approximately 140,000 hospital admissions each year. Substances involved in poisoning including those such as pharmaceutical preparations, household products and pesticides. Patients can experience exposure either deliberately or accidentally in environments such as home, work or school.
Although patients who present with overdose or poisoning may require investigation in the Emergency Department, GPs play an important role in initial assessment of such presentations. This article aims to provide an overview of the management of patients who present with overdose and poisoning. It discusses cases in both adults and children and also considers what to do if a patient declines assessment and or any necessary treatments.
Read the full article here.
The United Kingdom has an increasing aging population. As multiple comorbidity and polypharmacy is common in this age group there is increasing dependence on primary care, social services and the community as a whole. For the majority of elderly people advancing age is associated with a reduction in physical capacity, loss of loved ones, loss of status and physical illness. These psychosocial changes can therefore increase mental health problems. Depression is a significant concern and is often underdiagnosed in the elderly. The overlap of mental, physical and social problems can also make the assessment and management difficult. Many elderly patients and their families may also perceive their change in mood and behaviour to be a ‘normal’ sign of aging and may not present to the GP initially or at all. This article will discuss the prevalence of this condition and outline a framework for assessing, treating and managing elderly patients with depression in primary care.
Read the article here.
This article aims to provide practical information about how to advise and manage patients with substance or alcohol misuse problems who also drive. This can be a bit of a minefield but it is an important public health consideration among society’s overall efforts to maximise road safety. Driving status should also be considered when prescribing therapeutic medication. Patients may ask about the effect on their driving status of taking long term medication. A recent change to the Law has introduced a new ‘drug driving’ offence. The article discusses this change and its implications for patients. Having read it, the GP registrar should feel able to advise patients about the drink and drug driving legislation, have an appreciation of when to consider disclosing information about patients who refuse to stop driving despite advice to do so, and have some helpful resources for managing these sometimes complex situations.
Read the full article here.
Delirium is a common condition that is associated with the potential for markedly negative outcomes. With an ageing practice population, GPs are in many instances the first point of contact for those most at risk of developing delirium. As such, the ability to identify and institute appropriate management is a vital facet for any primary care practitioner, as is recognising the importance of the multidisciplinary team and liaison with secondary care services. This article provides an overview of the multiple causes and clinical features of delirium, with a focus on those that may be encountered in primary care. Recognition of those who require hospital admission is a fundamental skill, but this can only be reliably achieved with a comprehensive assessment, an approach to which is described within the article, referencing national guidelines. This article also discusses the many aspects of managing delirium such as pharmacological and social care, but also considers dilemmas that GPs may face when caring for patients in the community.
Bipolar affective disorder is a potentially life-long psychiatric illness characterised by episodic disturbances in mood between features of mania and depression. The attempted suicide rate in patients with this disorder is about 25-50% with completed suicide in 10%, and therefore accurate assessment and recognition of this disorder is important. In general practice, patients with bipolar disorder may present to their doctor with symptoms for the first time or present with a relapse of their symptoms. There are also a proportion of patients that are managed in the community psychiatric clinics under a shared care protocol with the GP. The article gives a detailed summary about the causes and clinical features of this disorder. It covers how the disorder is classified and how to perform a risk assessment. It focuses on clinical management options in both primary and secondary care including the need for regular monitoring of medications and physical health. There is a case study towards the end of the article to help consolidate learning.
For the full text of this article, including references, visit InnovAiT Online
There are currently 700 000 people with dementia in the UK, and this is projected to rise to over a million by 2025. Dementia can occur at any age, but is most common in older people, affecting one in six people over the age of 80 years. The most common form of dementia is Alzheimer’s disease, other forms include vascular dementia and dementia with Lewy bodies. Behavioural and psychological symptoms in dementia are common. As well as causing distress to the person with dementia, they are a significant cause of distress to carers and are a common factor leading up to institutionalization of the person with dementia.
The GP curriculum and management of dementia
Within primary care, GPs admit to difficulties in both the diagnosis and the management of dementia. Statement 9 of the GP curriculum: care of older adults requests an understanding of the special features of psychiatric disease in old age, including an appreciation of the features of dementia. Specifically, GPs must be able to assess brain function and have knowledge of the following:
The prevalence and incidence of disease, including dementia, in the elderly population
The relevant questions in the history and items in the physical examination to the problem presented
The patient’s relevant context, including family and social factors
The structure of the local and national health care system and the role of primary care within the wider National Health Service (NHS), including knowledge of when to refer to secondary care services
The interrelationships between health and social care
The legal issues that may arise
The special features associated with drug treatment of dementia
In addition to the cognitive symptoms of dementia, there are also non-cognitive aspects. These non-cognitive aspects are often referred to as behavioural and psychological symptoms of dementia (BPSD) or ‘challenging behaviours’. Up to 90% of people with dementia will suffer with such symptoms at some point during the illness, but they are generally more common in the later stages of dementia.
BPSD is a term encompassing a variety of symptoms including depression, delusions and hallucinations, agitation or aggression and wandering. Rates are generally similar in Alzheimer’s disease and vascular dementia but may be higher in Lewy body disease because of the presence of prominent visual hallucinations.
BPSD cause distress not only to the patient but also to the caregiver and often result in care home placement in the later stages. Hence, in the community, BPSD prevalence is reported as being highest in the 24 hour care setting and specialist settings such as elderly mentally infirm (EMI) care homes.
This article will mainly focus on symptoms that tend to cause problems in the middle to later stages of dementia. However, it should also be recognized that symptoms such as depression may occur early in dementia, particularly at the time of diagnosis, when the person with dementia may have retained insight.
Detection of BPSD
BPSD will often be identified by those caring for the person with dementia, either family members or care home staff. Detection may also occur through formal assessment performed in a secondary care setting using, for example, the neuropsychiatric inventory.
Depression may be difficult to detect in dementia, especially in the later stages. Validated tools that may be employed to formally assess the presence of depression in primary care include the Patient Health Questionnaire (PHQ-9), which has a possible score range of 0–27. Such tools may be difficult to use accurately in dementia when communication problems often exist.
Aetiology and investigation
BPSD may result from an underlying treatable physical cause, as opposed to the dementia itself. It is important that a history and examination is performed to identify any reversible cause (see Box 1). Many, if not all, of the causes for BPSD listed in Box 1 may also cause a delirium. People with dementia are at greater risk of delirium.
Treatable causes of BPSD
Pain and any underlying causes, e.g. pressure sores, arthritis etc.
Diabetes, e.g. poor sugar control
Medications causing delirium or worsening of cognition, e.g. tricyclic antidepressants and older antipsychotics
Visual or hearing impairment
Inadequate lighting or heating
A history should be taken from the person with dementia where possible but also from anyone involved in the patient’s care, such as family and/or care home staff. Particularly important is the assessment of the perception of the behaviour by the carers.
Blood tests, a urine dipstick and mid-stream urine may be necessary and should be tailored to the individual and findings of the history and examination. Blood tests may include full blood count, urea and electrolytes, random blood sugar, liver function tests, thyroid function tests, calcium and C-reactive protein.
Pain may be difficult to assess in those with dementia as a result of possible altered perception of pain and communication difficulties, sometimes leading to under-recognition and under-treatment. In these situations, there are various observational scales that may be used such as the Abbey pain scale. See Box 2 for a pain management process for people with dementia.
Principle of pain management in dementia
Assess how the person with dementia communicates about their pain from carers, in order to determine relevant background information. This will include current conditions that cause pain, history of pain reactions and previous pain management methods.
Assess for pain using a pain management tool, such as the Abbey pain scale, including physiological, behavioural and body language observations
Record findings and plan care/interventions
Provide analgesia and/or non-pharmacological interventions
Specialist advice from the palliative care team may be helpful if appropriate
In some cases, there may be no underlying reversible cause and the behaviour may be part of the dementia process. It should also be considered that in some cases the challenging behaviour may be multifactorial in aetiology.
Principles of assessment
When the person with dementia is living at home, discussing the aetiology and management of the behaviour with carers, and possibly the person with dementia, will be necessary. In institutions a multidisciplinary team-based approach is more appropriate. For example, in the case of wandering, the behaviour can be both beneficial and harmful in dementia. Benefits include exercise, relief of tension and promotion of independence. Potential harm may be physical or associated emotional distress.
It is important to take the behaviour in context. For example, someone who has walked a lot prior to a diagnosis of dementia may continue to do so after the diagnosis. Issues as to what is seen as a risk and who will benefit from management of wandering can be very helpful in supporting the carers but also in planning further management.
An underlying reversible cause, particularly where a behaviour is new, should always be sought and treated appropriately (see Box 1). In primary care, common causes include infection, usually urinary tract or chest infection, constipation and pain. In all cases, an individualized assessment should be carried out examining the nature of the behaviour (frequency, severity and setting) and any provocations. The assessment should also take into account previous medical and psychiatric history, cognitive status and personality.
Principles of management
It should be noted that in around 30% of cases BPSD may be transient and resolve without any medical input. An individualized person-centred approach in managing behaviours should be taken. This will often entail developing a management plan for the person with dementia and monitoring response to the use of particular strategies with regular review. Frequency of review should be agreed by all involved staff and carers and clearly documented in the notes.
Treatment will depend on whether there is an underlying cause. Any underlying reversible cause should be identified and treated. For example, infection may require treatment with a course of antibiotics, and constipation may require ensuring adequate hydration and use of laxatives.
Where pain is present, the treatment will depend on the underlying cause. In the case of pressure sores, appropriate wound management techniques may be necessary. For musculoskeletal pain massage, heat packs, positioning or physiotherapy may be helpful. Analgesia should be selected on an individual basis taking into account any interactions and possible side effects. For example, laxatives should be prescribed with opioids. The World Health Organization (WHO) analgesic ladder for cancer pain is a useful guide for recurring pain of any cause. If pain cannot be controlled, palliative care input may become necessary.
In some circumstances, discussion of the case with all those specialists involved may be very helpful in order to formulate a plan for care. Non-drug approaches to management should be used in preference to use of medication. However, in some cases, and where non-drug approaches have failed to be effective, medication may be necessary.
Specialist advice from the local psychiatric service may be helpful in certain cases. In some geographical areas, there are specialist nurse teams who may assist in the management of challenging behaviours.
The management of BPSD raises various ethical issues. However, the key point to mention is that where possible the person with dementia should receive adequate explanation of any intervention. By the nature of BPSD, this may be difficult. Where the person with dementia does not have capacity to consent to a particular treatment, a decision may be made in best interests in agreement with carers involved. In terms of the practical management of certain behaviours, the least restrictive option should be adopted. In all circumstances, the provision of the Mental Capacity Act 2005 should be followed.
Non-drug approaches to management
Intervention in BPSD will depend on the context and the resources available. Spending the time to develop a simple, practical and clear care plan will include the following:
Exploring routines and identifying and eliminating any possible trigger factors for certain behaviours
Educating carers about the basis for BPSD and methods of improved interaction and communication that may better equip them to deal with certain behaviours
Assessment of environmental factors and possible modifications. This may include looking at room layout, use of signage, examining and facilitating room access, facilitating access to free spaces such as gardens and improvements in lighting of certain areas at night.
There may be limited access to other non-drug interventions but where available these may be tried, although there is little high-quality evidence for clinical and cost effectiveness of such interventions to support their routine use. Such interventions include therapies to reduce distress such as aromatherapy, massage, music therapy, animal therapy or increasing levels of meaningful or enjoyable activities such as walking. ‘Snoezelen’ rooms are environments specially designed to stimulate various senses through the use of lighting, colour, sounds, music and scents.
Assistive technologies such as social alarms, monitoring devices and environmental adaptations and aids can be accessed usually via social services or via certain websites. The website www.atdementia.org.uk brings together information about assistive technology that has the potential to support the independence and leisure opportunities of people with dementia. The site has a database of products, advice on how to obtain assistive technologies and telecare and also has a discussion board.
Monitoring devices include electronic tagging and tracking devices and sensory pads. However, be aware that tagging does require informed consent and the assistance of social services. The ethical conflicts of using such technologies should be weighed up in each individual situation.
The Nuffield Council on Bioethics (2009) recommends that when considering the use of assistive technologies in relation to behaviours such as wandering, a risk-benefit assessment may assist families and professionals in evaluating the gains and losses to the person with dementia. Benefits may include promotion of autonomy, enhancement of safety (e.g. enabling the person with dementia to be found more quickly when lost) and peace of mind for carers. But this must be balanced against perceived loss of dignity, security of individuals with such devices, technical issues and cost. It is important to emphasize that such technologies should be considered in parallel with other services and methods of management and may not be the right solution for all patients.
The benefit of supporting carers should not be underestimated and is particularly necessary in the later stages of the illness. Carers of people with dementia are more likely to suffer with depression, report higher burden and suffer poorer general health than those caring for people with other chronic diseases. Depression in carers has been found to play a key role in determining the point at which the person with dementia is transferred to long-term care. The support of positive coping strategies and promotion of problem-solving behaviour appear to be most effective in reducing depression. Other more formal assistance may be necessary such as arrangement of regular day hospital care or a brief period of respite.
Where the person’s behaviour has caused problems with the police, a card provided by the medical professionals involved with a brief explanation that the person has a diagnosis resulting in certain behaviours may be very helpful in supporting families.
Support from outside agencies such as the Alzheimer’s Society, Age UK and social services may be sought. Help may come in the form of physical and financial assistance but also education and emotional support. In some areas, Admiral nurses are accessible who can provide those looking after someone with dementia with one-to-one support. In some areas, there may also be a carers group that can provide carers with the opportunities to meet and talk with others dealing with similar issues.
In some cases, pharmacological intervention for BPSD may be necessary. A guide to medications that may be considered is summarized in Box 3.
Antipsychotic medication may be described as ‘typical’ (older drugs) or atypical (newer drugs). Side effects of typical antipsychotics such as chlorpromazine and haloperidol include parkinsonism, involuntary movements and cardiotoxicity. Atypical antipsychotic medications, such as risperidone, quetiapine or olanzapine, have less side effects. However, in the UK, the only drug with a relevant licence for use in the treatment of BPSD is risperidone. This is licensed as stated in the British National Formulary (BNF) for the “short-term treatment (up to 6 weeks) of persistent aggression in patients with moderate to severe Alzheimer’s dementia unresponsive to non-pharmacological approaches and when there is a risk of harm to self or others”.
There is evidence that antipsychotic medication can be of benefit for the short-term treatment of aggression, but evidence for long-term use is lacking as many of the trials are of short duration. Hence, patients should not remain on long-term antipsychotic medication without regular review.
However, antipsychotic medication may also have harmful effects. In 2004, the UK Medicines and Healthcare products Regulatory Agency’s (MHRA) Committee on Safety of Medicines issued a safety warning about the atypical antipsychotics risperidone and olanzapine, advising that these should not to be used for behavioural symptoms in dementia because of the increased risk of stroke associated with their usage.
As a result of concerns over the safety of antipsychotics in patients with dementia, the National Institute for Health and Clinical Excellence (NICE) guidelines (NICE, 2007) state that people with Alzheimer’s disease, vascular dementia or mixed dementias with mild to moderate non-cognitive symptoms should not be prescribed antipsychotic drugs because of possible increased risk of cerebrovascular adverse events and death. People with dementia with Lewy bodies with mild to moderate non-cognitive symptoms should also not be prescribed antipsychotic drugs as this group has a particular risk of adverse reactions.
Medications for behavioural symptoms of dementia
Should non-drug approaches be unhelpful, the following medications may be tried:
For mild agitation
Trazodone 50–300 mg
Benzodiazepines, such as lorazepam 0.5–4 mg
Clomethiazole up to three capsules (5–15 ml liquid)
Selective serotonin reuptake inhibitors (SSRIs), such as citalopram 10–20 mg and sertraline 50–100 mg
Also consider sodium valproate 250 mg to 1 g, carbamazepine (50–300 mg), cholinesterase inhibitors (particularly rivastigmine 1.5–6 mg in Lewy body dementia) and promazine 25–100 mg
For severe agitation or if psychosis is present
Quetiapine 25–200 mg
Risperidone 0.5–2 mg
Olanzapine 2.5–10 mg
Aripiprazole 5–15 mg
If depressive symptoms are present
SSRIs such as citalopram 10–20 mg and sertraline 50–100 mg
Mirtazapine 15–45 mg
If severe behavioural problems are present
Consider haloperidol in small doses (0.5–4 mg) and time limited
Reproduced from BMJ, Burns, A., Iliffe, S., 338: p. 405–9 2009, with permission from BMJ Publishing Group Ltd.
Despite this guidance, antipsychotics are the most common pharmacological treatment of BPSD and up to 50% of those in institutional care receive antipsychotic medications, possibly partly because of a lack of resources for alternative management strategies. The report ‘The use of antipsychotic medication for people with dementia: time for action’ was published in 2009. This report highlighted that of around 25% of people with dementia currently receiving antipsychotics, only about one in five will derive any benefit. The report also emphasized that antipsychotic medications have an associated morbidity, in terms of cerebrovascular events, and mortality. Where the non-cognitive symptoms are severe, and antipsychotic usage cannot be avoided, principles regarding the use of antipsychotics or sedation treatment are detailed in Box 4.
Principles of use of antipsychotic medication in dementia
Communication with carers and where possible the patient regarding risks and benefits
Use only when ‘really needed’
Target symptoms should be identified, quantified and documented
Start at the lowest possible dose
Regular review of the need for medication, every 3 months or according to clinical need
Try to avoid combinations of medications
Medication may only be required short term
Avoid in Lewy body disease, especially typical antipsychotics, due to increased incidence of adverse events
Other groups of medication used for BPSD include anticonvulsants, benzodiazepines, SSRIs and anti-dementia drugs. Of the anti-dementia drugs, there have been trials involving the use of acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine) and memantine showing some benefit in the management of behavioural problems in dementia.
Currently in the UK, NICE recommends the use of acetylcholinesterase inhibitors in people with mild, moderate or severe Alzheimer’s disease who have BPSD causing significant distress or potential harm to the individual, if a non-pharmacological approach is inappropriate or has been ineffective and antipsychotic drugs are inappropriate or have been ineffective. NICE also suggests that people with dementia with Lewy bodies be offered an acetylcholinesterase inhibitor if the BPSD are causing significant distress to the individual or leading to behaviour that challenges. Use of acetylcholinesterase inhibitor medication in these situations should be initiated only by a specialist.
Behaviour that challenges requiring urgent treatment
Although pharmacological intervention should be used with caution, medication for BPSD may be used first line in rare circumstances where the person is severely distressed or in cases where there is immediate risk of harm to the person or others. Choice of antipsychotic should be based on an individual risk—benefit analysis. Once the acute situation has passed, an assessment and care planning approach should be followed as soon as is possible. Staff managing such cases should be well supported and should also have received specialist training. Of equal importance is training in anticipation of certain behaviours and avoidance of certain aggravating factors. As far as possible care should be community based but in certain circumstances psychiatric inpatient admission may be necessary.
The issue of restraint
One particularly difficult issue is the topic of restraint. What is meant by restraint may vary dependent on context. Restraint may be physical but it also encompasses other activities such as use of medication or keypad systems to exit care homes. Section 6 of the Mental Capacity Act 2005 defines restraint as ‘the use or threat of force where an incapacitated person resists, and any restriction of liberty or movement whether or not the person resists’. The Act states that ‘restraint is only permitted if the person using it reasonably believes it is necessary to prevent harm to the incapacitated person, and if the restraint used is proportionate to the likelihood and seriousness of the harm’.
In some circumstances restraint may be necessary and not acting in a particular manner would be considered neglect, for example, if the person with dementia consents, if it is part of a carefully formulated care package agreed by all or if the person lacks capacity but is acting in such a way as to harm themselves or others. The Mental Capacity Act states that restraint can be used when it is believed to be in best interests, is the least restrictive option and is used for the minimum amount of time. It is important to assess and manage risk and by doing so reduce the use of restraint. A particularly useful resource when considering this issue is a publication available online from the Social Care Institute for Excellence entitled ‘Managing risk, minimizing restraint’.
Autistic spectrum disorders affect 100,000 children in the UK, and around half a million family members are directly affected by the condition. They include a number of related medical conditions of which autistic disorder is one. Whilst differing in the severity of symptoms, degree of disability and functionality of the individual they are all life-long persistent complex neurological disorders which typically present in the first 3 years of life and are characterised by a triad of deficits in language and communication, social skills and behaviour. This article focuses on early signs and symptoms, because familiarity with these can facilitate timely recognition and referral. Caring for an autistic child has significant psychological impact on parents and family. GPs are key in coordinating care, particularly at the time of transition from paediatric to adult services. Awareness of available treatments and their risks and benefits is required in order to support parents. A review of pharmacological and alternative treatments for the management of autism and associated comorbidities and information on support groups and local authority assessment processes is included.