The Tao of Dementia & Delirium (part 1)

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‘Do not prescribe anti-psychotics!’

I usually include this phrase when inducting new doctors into my department.

In recent years there has been a great deal of discussion about the potential harms of anti-psychotic medications, when used inappropriately to sedate or tranquillise people who are either living with dementia or experiencing delirium.

The old standard, in particular before Professor Sube Banerjee wrote his 2009 paper ‘Time for Action,’ when an older patient disagreed with the intentions or management plan of a doctor or nurse in hospital, was to reach for the prescription chart.

Atypical antipsychotic drugs – were developed in the 1990s to help people experiencing major psychiatric illnesses – schizophrenia and bipolar disorder.

Soon after these medicines became available their use became widespread in primary and secondary care; older people with symptoms that others found difficult or distressing were often prescribed these drugs.

Banerjee’s report brought together evidence that the use of these drugs in older people, with dementia, whether those living with Alzheimer’s disease, vascular, fronto-temporal dementia or any of the other types, frequently resulted in worse outcomes – significantly worse outcomes – falls, dehydration, malnutrition, stroke, heart attack and death.

So – what to do when do when a patient is upset and their behaviour is causing a risk to themselves or others? (This itself is subjective – what is risk?)

If you ask anyone who has experience of Person-Centred Care, their first response will be – talk! Engage in a conversation; approach the person as an equal, and listen to what they have to say – do not objectify!

How much can be done by providing hearing aids and glasses; by switching on lights and reducing background noise; a reassuring touch, by not shouting, but talking calmly, ideally in the local dialect (where my Glaswegian ‘doctor’ becomes ‘daughter’ and the miscommunication in remedied)

Sometimes this doesn’t work, very, very occasionally, we need to do more – as to what more, that is the Tao.

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