Sleep

There is a science of sleep.

This evening as I was driving home, I heard Peter White discussing sleep disorders in those who are blind or have significant visual impairment.

Unlike our crepuscular cousins, humans are diurnal; we are designed to sleep when it is dark and potter during the day, creating industry, building things.

Central to this system is the function of the pineal gland and the hormone melatonin, which alongside an array of other chemicals regulates our sleep-wake cycle.

Light plays a central role in this which, via our retina which feeds directly into our brains,* makes us sleepy at bedtime and perky in the morning (for those early-birds like me.)

Sleep and wake are of huge importance to patients in hospital and, in particular those who have dementia and related disorders, where their sleep-wake cycle can be turned upside down; inverted. Added to this, reduced exposure to meaningful daylight and monotony, loneliness, immobility and frequent cat-napping and you have a perfect storm for sleeplessness.

The nurses on Mallard know all about sleeplessness; sometimes preceded by sun-downing – the change in behaviour experienced by people with dementia as light fades, cortisol falls and visitors head for home.

I sometimes jokingly refer to this experience as being akin to Night at the Museum – the Ben Stiller movie where the exhibits come to life as the lights go-down.

When my patients sleep during the day and are awake at night all sorts of bad things can happen. At night, with fewer staff, there is less supervision, with lower levels of light, the likelihood of falling increases, with night, shape-shifting illusions come-out of the dark, worsening confusion and disorientation; meals are missed (although we do our best to be flexible), as are tea-rounds; weight-loss and dehydration can ensue.

It is all a jumble. We aren’t designed to be up and about at three in the morning.

We try to rebalance sleep by increasing daytime activities, by talking, joking and engaging with our patients, getting them up and dressed, dancing, singing, drawing, painting.

Hospitalisation as well as being one of the highest risk experiences for older people can also be one of the most boring.

We try to break the monotony, I know however, despite some great work across the country, the standard experience for the average hospital patient – particularly someone who is older and trapped by pathway delays, is one of days that are long and uneventful and tedious.

Your pineal gland doesn’t get a look-in in these situations.

I sometimes resort to sleeping remedies, when the Horlicks hasn’t worked – Melatonin, the recent addition to the pharmacopoeia has shown some promise, but like all drugs, works for some but not others, more often than not the latter.

This is back to the start – it is shining the light on the complexity of care, on what it means to look holistically; to be responsible for the journey, beginning to end. Acknowledging that the old thinking – the doctor see, doctor do, is no longer adequate; only when all the dimensions of night and day, sickness and health are considered, in the round, can we hope to make a difference.

Enough is not good enough.

It is not just what you see that matters, but the hidden, the esoteric pathways of nursing and medicine, pharmacy and therapy, talking and listening. Night and the day; sleep and wake.

robin-williams-in-night-at-the-museum-3-is-heart-wrenching-to-watch-video

*Never realised I was photovoltaic.

UTI

UTI – Urinary Tract Infection.

UTI has become part of everyday language. A meme that represents our changing society.

Twenty years ago, when I was at medical school UTIs existed, they were however still within the rarefied toolkit of doctors.

UTIs have grown and changed, morphed from something specialised, something that you needed a medical degree to diagnose, into a 21st Century commodity like Vapes or cans of Red Bull.

It is not uncommon for a relative to tell me that they think their mum or dad has a UTI.

‘They always behave like this when they have a UTI,’ or, ‘It’s a UTI – you can smell it a mile-off,’ and, words to this effect.

Relatives and carers aren’t to blame for this quick-fix, quick-fire method of diagnosis as the whole health and social care economy has jumped-on the bandwagon of UTIs, not as a panacea, but as an explanation for most that goes wrong with older people – falls, confusion, pain, immobility, fever, non-specific blood-test anomalies; you name it and it can be caused by a UTI.

Or not.

You see, when a scientific approach is taken and the situation analysed, we discover that there is more in the world of frailty and ageing than urine infections.

In reality, UTIs are actually more complicated than an older person smelling of pee.

Smell is not a UTI. Smell is just the smell of pee.

Falls. Older people fall. They also on occasion become confused; this is delirium – a reversible condition akin to dementia which is irreversible and, which can also be experienced by people with or without UTIs.

As we age, our microbiome evolves; the bugs living on our skin, in our bowel and bladder alter. Urine is meant to be sterile, although often, in older people, bacteria get in, but, instead of pathogens causing disease, are either commensals – living in harmony or, tourists in your urethra.

These aren’t UTIs; for this purpose, we invented Asymptomatic Bacteriuria.

Treating asymptomatic bacteriuria is a little like the tactics used by Texas police; Hands in the air. You look iffy… I’m taking you down the station.

Time has fuelled the growth in UTIs in A&E and, in 21st Century Healthcare in general. The numbers of people, seeking assessment, diagnosis and treatment, all, squeezed into a limited window of opportunity encourage quick fixes; botched jobs that take you nowhere;

This is the prescription for Trimethoprim, when, a person is lonely.

It doesn’t work.

Or, when an old woman is poisoned by other drugs prescribed decades before to treat real conditions and which are no longer a risk – statins, pain-killers and blood pressure treatments; the answer, another drug that isn’t needed and compounds the insult.

‘It’s a UTI,’ doctors and nurses become complicit in the scam. Often this is given as a diagnosis when nothing else fits, or, when what fits is not congruent with what is apparent. And then, with more time, more reflection and analysis the diagnosis is undone – de-diagnosed and the medicine de-prescribed, we find ourselves untangling the knot.

The overuse of antibiotics globally is considered by some, to be as great a threat as global warming, international terrorism or avian flu. These are boogeymen that capture the headlines.

Nitrofurantoin – how can that harm you; go on, just a little prescription, just a few tablets;

My request? Well, that is to slow down.

Think UTI by all means, but don’t allow it to overwhelm the senses.

Think linear.

In most instances it is straightforward, and here is the trick.

Stop, look and listen.

When in doubt, don’t UTI.

When in doubt, stop, look and listen.

The patient will almost always have the answer; the befuddlement of dementia or delirium or, aphasia is why we have doctors and nurses – to disentangle the narrative.

That is the challenge. That is the effort.

david prowse

 

Me, we, dementia and Donne

This year the Dementia Action Alliance, released a new set of ‘we’ statements relating to dementia.

This was a significant change in the way a disease – dementia is considered. The statements were generated through discussion and consultation with those living with dementia and those supporting them.

Here they are:

      We have the right to be recognised as who we are, to make choices about our lives including taking risks, and to contribute to society. Our diagnosis should not define us, nor should we be ashamed of it.
      We have the right to continue with day-to-day and family life, without discrimination or unfair cost, to be accepted and included in our communities and not live in isolation or loneliness.
     We have the right to an early and accurate diagnosis, and to receive evidence based, appropriate, compassionate and properly funded care and treatment, from trained people who understand us and how dementia affects us. This must meet our needs, wherever we live.
     We have the right to be respected, and recognised as partners in care, provided with education, support, services, and training which enables us to plan and make decisions about the future.
     We have the right to know about and decide if we want to be involved in research that looks at cause, cure and care for dementia and be supported to take part.

Disease, although it primarily affects the individual does not stop with them; it occupies a place central to friendship, family and society.

Dementia is a disease of neurones, one brain cell at a time malfunctions, spreading eventually to the whole person.

None of us can live in isolation (beyond the Aristotle/Nietzschean idyll) – I link to you who connects with me; I become us and we.

Perhaps this is an approach that should be taken to all disease – moving the expectation that whether you have eczema, asthma, diabetes or cancer – the monad of me alone, suffering in silence is not what we are about.

We, evolved to live in groups, societies, collaboratively, supportively – if we allow disease to affect just individuals, to peel them off from society, for whom does the bell toll?

My hay fever affects me; it is me who is sniffing and snuffling through the night, yet, it has affects beyond my person, it reverberates throughout the household.

My arthritic knee, or back or neck, causes me pain, yet, the experience ripples through my family and friends, it changes the dynamic.

Grenfell tower is a representation of me and we; me – the mansion owners of Kensington, somewhere in the world, living it up, their empty houses abandoned yet secure with the latest burglar and fire alarms. And, down the road, the people packaged into minimum square-space existence.

Brexit is another example; I am fine, thank you very much; We isn’t something that is part of the equation – you, you foreign, dark-skinned migrant, refugee, asylum-seeker are not part of we, you are peripheral to us.

The irony of the justification for TM not meeting victims of the fire because of concerns over her own safety.

The irony that so long as I have my car, my holidays, pension and day-time TV, things are alright, don’t bother me with the trivialities of Mogadishu or Damascus.

The we statements represent a shift, a movement away from me to us, from them to we;

Don’t peer too deeply inside; it’s not just about the medicine or the tablet, it is the relationship that counts.

This spills-over into patient safety; when I am considered first, and my patient second, when my troubles or preoccupations are allowed to dominate the narrative, when I forget that my place is to care, I risk forgetting the ‘we’ – I risk not seeing the patient, who by extension is me.

Person-centred care – seeing the person as central is as relevant as seeing that the person you are treating is you, could be you or, your mum or dad, brother or sister.

Once this shift, this change in perspective has occurred, nothing can ever be the same.

We not I.

Us not me.

xxxx

I learned yesterday a little about photons.

Photons are the smallest indivisible particles of light that exist without mass, without occupying space or volume.

Beyond this conception are different species of Photons. Entangled Photons are paired particles that are also indivisible. What makes them stand apart from anything else in the universe is that the two can never be entirely detached.

Stretch the entangled photons to different sides of the universe and what affects one will affect the other, no matter the distance or separation.

Like conjoined twins who share feelings or sensations regardless of distance or geography.

This takes us back to the notion that ‘we’ needs to be considered the smallest unit of society. And, this is not just ‘we’ in the sense of, my family, my town or tribe, but, ‘we’ in the sense that what affects one of us affects us all.

We are indivisible.

This is what makes us human.

photon

Delirium

 

There must be a psychological reason to explain why some people more readily respond by saying yes when asked to do something, compared with others who either reply with an outright no, an evasive, why, what… Let me see, or an oblique, Look at that chaffinch over there.

I fall into the former category every time.

Yes.

I said yes when Nic asked me whether I would like to run a webinar discussing delirium on the 15th of March, to celebrate World Delirium Day.

It could be that the pathways in my brain are unstable, live-wires with inadequate insulation. There you go. Spark.

I was woken this morning at 530 when my phone buzzed with a tweet from a well-known professor of deliriumology who was re-tweeting about the webinar.

You see, the problem is, although I pretty-much live delirium – I have spent more time talking to people with delirium or the relatives of people experiencing delirium than most, I still am not entirely sure I know much about it.

This is because no one really knows or understands. (Except perhaps the professor).

You see, we don’t understand why some people are more likely to become delirious compared with others, that is, why some are more susceptible. People who have dementia, for example, are many times more at risk of developing delirium secondary to relatively minor insults – changes in environment, pain, dehydration, or, constipation, whereas others, require far greater physiological upsets – septicaemia, major surgery, trauma or, an adequate dosage of LSD or Psilocybin.

That is less perhaps of concern, as the more any of us learn , the less we all realise we know.

I should probably offer some reassurance; we do have an idea about some aspects of delirium, at least, we know what works – or at least, what probably works most of the time, although it is so complicated that what works for one person is likely to not work for another.

There are however common themes:

   Person-centred care – I have yet to encounter a patient where treating them as an individual, providing them a sensitive ear, caring touch or individualised plan of care has been harmful.

   Keeping people safe – you can’t argue that when people have delirium they are vulnerable, and, equally, if those vulnerable people injure themselves – fall, trip or otherwise experience harm, they are likely to have a less favourable outcome.

   Ensuring hydration and adequate nutrition – this is, avoiding dehydration or malnutrition, hunger or thirst, these can contribute to a worsening of the delirium.

   Involving family and friends – ensuring that loved-ones have as much access as desired to their delirious mum, dad or grandparent. You are more likely to trust your son or daughter than a stranger in a uniform.

   Sleep – disturbance of the sleep-wake cycle is often a key component of delirium – this as part of my translation of the hospital at night (sometimes trendily referred to as H@N), which in my experience is more like, Night at the Museum, with drowsy, confused patients, fewer staff, strange shadows and the additional impact of sleeping tablets. Establishing good sleep at night and wakefulness by day – that is having adequate stimulus, entertainment and engagement during can all help.

There are many more what we call ‘multi-component interventions’ some of which work, some of which do not, to help a person who is delirious.

We still haven’t figured-out which medicines work for delirium. It seems that although many drugs can contribute to its development, (pain-killers, sleeping tablets, bladder medicines) we haven’t found a pill than can prevent it or even stop it happening.

If only delirium were more like stroke, heart attacks or pneumonia. We could provide the aspirin, thrombolysis or antibiotics and wait for nature to run its course. It is not that simple.

And amidst all this I have offered to say a few words about delirium on the 15th. You are welcome to tune-in; the link is here.

If you can’t or don’t sign-up to listen, I hope what I have written will help to explain some of the morass. It is what keeps me busy. That, and all the other things I am too mentally slow to respond with anything other than ‘yes’.

065_3_alexander_oscilate

1328 and some

On the 22nd of July I posted a blog entitled ‘1328’ – this was the number of days we had been recording (since the opening of Mallard Ward) until the first person experiencing Clostridium difficile was detected amongst our patients.

I had lots of response to that blog, which focused on the impact ‘going back to zero’ had on me and the team.

I thought it appropriate to update those of you who read this blog as to what has happened since then.

Our patient received treatment for the infection, recovered and is now back home.

In the hospital, as part of the assessment to determine why something has gone wrong, we conduct a root-cause analysis (RCA) – specifically for hospital acquired infections within this category – that is usually, C. difficile and MRSA infections, we conduct a more specific investigation called a Post-infection review (PIR).

Our PIR was attended by me, our ward manager, nurse practitioners, matron, the head of infection control and a several others from hospital management and service delivery teams – the focus of the exercise being to determine whether the infection could have been avoided, and, in particular whether there were lapses in treatment or care from which we could learn.

Examples of these lapses could be the doctor prescribing the wrong antibiotic, staff not washing their hands or ensuring a clean environment, not reviewing the antibiotics or other drugs, such as anti-acid treatments which can contribute to increasing the likelihood of infection and other general aspects of care.

Our PIR showed that we did everything that was expected of us – hand washing, prescribing, diagnosing, treating. In other words, there was nothing humanly possible that we the team could have done to avoid our patient contracting the infection – our care was safe, timely, person-centred and consistent with best-practice guidelines.

The outcome of the review was that our patient’s case of C. difficile was ‘unavoidable’.

Within healthcare (at least in the NHS), there is a major focus on avoidable and unavoidable harm. Sure, to the patient who has been harmed, there isn’t much difference – they have a pressure ulcer, fall or infection, but, to the team, to the organisation and likely to the patient and relatives beyond the immediate event, there is a significant difference.

‘Did my dad die because someone didn’t follow policy, didn’t pay attention or, was the outcome inevitable?’ ‘Might my mum have survived the operation if she had a different surgeon or she was at a different hospital?’

It is these heart-breaking questions that relatives sometimes pose the doctors and nurses after something terrible has happened.

In the case of ‘avoidable harm,’ the answer is a possibly maybe, in the case of an ‘unavoidable harm,’ the response is probably not. This can, in some circumstances offer succour, in others not.

It is well established that every day in every hospital patients experience ‘harms’ – it is also very true that virtually all staff go to work with the sole intention of helping, supporting and caring. Things don’t always go that way – for a variety of reasons – some avoidable – whether relating to ‘human factors’ – that is the fallibility that comes with being a human or some other factor such as lack of knowledge, fear of challenging poor practise, limited resources, and so on.

With time and hard work, the amount of harm should reduce, and with this there should be a fall in avoidable harm and any harm that does happen should be unavoidable.

Reflecting on our 1328 days and the impact this had on me, the staff and our patient – going back to zero; on our ‘days since’ sign on the ward we dutifully started counting from zero – it was about 20 days until the review meeting. With the each day, people gained more understanding and acceptance of the new reality and things moved-on; possibly I gained more humility.

After the PIR however some of the staff discussed whether the reversion to zero was necessarily the best thing for our patients and our team. After all, a peer-reviewed meeting had determined that all the care we had provided was excellent, there were no failings or short-comings in the treatment, environment or approach to care.

What was the benefit of going back to zero?

We discussed the semantics of the wording – could we word the sign differently – would this suggest that we were cheating the system, playing games with numbers and data?

We discussed this as a team and this week we raised the issue at our clinical governance meeting – today we even debated the validity of displaying ‘days since’ signs altogether – whether there was a risk of such a reversion to ‘zero’ having a negative impact on staff moral or patient and relative confidence.

The evidence from patient safety literature is clear that the more transparent an organisation, the more it is prepared to bare-all, show the good and the bad, the successes and the failures, the more likely people are to have confidence in the system.

We concluded that a change in the wording from ‘days since’ to ‘days since avoidable’ was reasonable (this is something I have seen used at hospitals across the country), therefore we could come back from zero.

Today, we are therefore at 1374 days since there was a case of avoidable C difficile on Mallard Ward.

What do people think?

To me, the point is, why are we doing this? Why do the staff update the figures daily, consistently; why has safety become a central part of the culture on our ward? Staff connection with patients and their experience of care is fundamental to positive outcomes – when John Donne’s sentiment, ‘no man is an island’ is central to the function of our ward, with each patient and relative and member of staff being part of something bigger than the individual.

When you harm my patient you harm me. Working to protect patients is protecting and maintaining your own wellbeing.

This is the point of the signs, this is the point of sharing the information, this is the point of allowing ourselves to be vulnerable. This is person-centred care – the care I provide is the care I would want provided to me, the experiences of my patients are also mine, the journey we travel is one we share.

This is when care is more than just numbers.

IMG_5362

 

 

 

Medicines, etc.

Disclaimer

The following narrative is for purposes of information only and offers no specific practical advice on the care or management of patients beyond that which is advised by a trained healthcare professional.

Never stop taking prescribed medicines without the advice of your doctor (or nurse, or pharmacist).

Introduction

When I was at medical school, I am not sure if polypharmacy had been invented, or, if it had, it wasn’t something we discussed much. If you haven’t heard the word, you can probably work-out what it means – ‘poly’ – lots, ‘pharmacy’ – medicines; as to what lots of medicines means is less clear.

I am going to discuss polypharmacy in older people, although with changes in society and healthcare over the past decade, this is likely an issue affecting people of all ages.

Polypharmacy, etc.

Specifically, there are two terms which help narrow-down the definition – they are appropriate polypharmacy – this is when a person is prescribed multiple medicines (anything more than five different types is often a starting point*), all of which are necessary and essential to maintain their health and wellbeing – I will provide some examples later-on, then, there is problematic polypharmacy, where an individual is prescribed medicines which either are unnecessary, ineffective or harmful individually – for example beta-blockers for someone who has asthma, or in combination, e.g. anti-inflammatory drugs and ace-inhibitors (for blood pressure) in someone who is dehydrated.

*This could be as many as 40 tablets a day

Beyond these two definitions, we have oligopharmacy – this is less common, and only something that has become a theme in recent years, where a person receives fewer drugs than they require – either because the benefits are not considered – for example, the use of Bisphosphonates (bone building drugs) in people with osteoporosis or, when there is some other limitation or constraint – perhaps through individual choice – many people dislike taking tablets every day, or through economic pressures – in the UK we are protected by means of subsidised prescriptions; this is not the case in many countries where medicines, specifically those which are proprietary – (often new on the market) can be very expensive.

We also have hyperpolypharmacy which is another term that has only been around a few years and refers to the sometimes extreme numbers of medicines people are prescribed for multiple conditions, which, particularly for older people are becoming the norm – the longer you live, the more time you have to acquire diseases or long-term conditions – asthma, diabetes, arthritis, depression, and the more medicines are available (or often recommended as best practice), resulting in frequent prescriptions of medicines that have never been tested in combination and no one really knows or understands the consequences – even for some drugs that have been available for decades – statins and anti-acid treatments, for example, we really don’t know what the effect of taking them for years in combination with a host of other, potentially newer medicines might be.

Finally, we have deprescribing – this is my favourite activity and probably a major part of my day job as a hospital doctor caring for older people – looking at what people are prescribed and balancing the harms and benefits with a person’s individual preferences and determining what is no longer required – essentially, this means usually stopping lots of medicines people have sometimes been taking for many years, which mostly provides a great sense of satisfaction to me and is appreciated by patients.

The irony associated with deprescribing is that in some ways it is contrary to what it is to be a doctor – up until quite recently, we, alongside opticians, dentists and vets were amongst the only people legally allowed to prescribe medicines; with the modernisation of healthcare in the past ten years, more and more non-medical prescribers – mostly nurses and pharmacists have joined with doctors in becoming accredited with the authority to prescribe. Doctors still however are by far the dominant force (in human society that is) who can prescribe pills, potions and treatments, many of which can do fantastic harm as well as benefit those treated.

I remember my first prescription soon after graduating from university in 1997 – I was working in Raigmore Hospital in Inverness at the time; I remember checking the dose of Morphine in the BNF – the British National Formulary, and watching as a nurse administered this powerful controlled medicine to a patient.

Here is a link to the very recent experiences of a junior doctor in 2016.

Nowadays I get more of a buzz from deprescribing however.

An aspect of this relates to our inability to always get people better.

If you think of the old model of care and treatment – a person might become ill, they would go to a doctor and they would be offered a treatment – whether a leech, poultice or selection of herbs, the act of the doctor using their knowledge and experience to help another was fundamental to the relationship, and often, likely, most certainly in the case of leeches, the patient’s recovery would have been in spite of the blood-sucking; the cured person would however ascribe their recovery to the leech, thank the doctor and get on with their life – reinforcing the good that is medicine.

Nowadays, particularly in the realms of minimally invasive surgery as well as a large variety of disciplines within medicine, studies have demonstrated the objective benefits of tablets, injections, creams and patches; evidence-based medicine has contended with the null hypothesis and supported the use or abandonment of treatments through clinical trials.

It is only in the past few years however that clinical trials have specifically looked to test their products on older people – previously, the standard would have been healthy young adults without any significant health problems – and these, for drugs that would often be then used in much older people with multiple health conditions.

Even once we have adjusted the drug trials for older people, testing the medicines in the ‘field’ reality of complex 21st century lives is more difficult – few studies are conducted with people who forget to take their medicines or who take too many or too few or who sometimes take some of their medicines and at other times forget to collect their prescriptions.

Deprescribing continued…

Sometimes I become frustrated with medicine – as I often see people prescribed medicines that are so obviously inappropriate, I forget that I am not normal – I (that is a doctor specialising in the care of older people), sees the world a little differently to others, fixating on the connections between disease, health, wellbeing, prognosis, outcome and patient preference, rather than say the broken bone or blocked artery.

For example, I cannot see a prescription for a blood pressure tablet in an older person without immediately considering whether it is putting them at risk of falling. I know another doctor, say a cardiologist or renal physician will see these drugs and think about the tremendous good that they are probably doing – allowing the heart to pump more effectively, preventing strokes or kidney failure.

It is true that some drugs have a miraculous effect on disease – to the extent that diseases are changing; for example, thanks to the safety and effectiveness of new drugs to treat rheumatoid arthritis, the numbers of people with cruelly deformed hands and joints are diminishing, to the extent that what was once common is now rare; people dying of heart failure – this condition has changed from being a routine presentation in the accident and emergency department to a chronic disease.

Numbers needed to treat and so on

For every medicine that is prescribed, there will be some people who will benefit, others who will not and some who will experience harm. Within medicine we measure this using statistical calculations called ‘numbers needed to treat’ and ‘numbers needed to harm’, or, NNT and NNH.

The smaller the NNT and the larger NNH, the better; sometimes people taking medicines for decades have no notion that they are not gaining any benefit. For example, for many years, the use of aspirin as ‘primary prevention’ that is, taking an aspirin a day in otherwise healthy people, was felt to offer protection from heart attacks and strokes. We now know that the potential harms of taking aspirin, specifically in relation to an increased risk of bleeding exceeds any benefit gained from taking the tablet in otherwise healthy people.

Here are some NNT: (this is leaving out some statistics specifically relating to confidence intervals)

  • 18 older people need to be treated with blood pressure lowering drugs to prevent one person experiencing a heart attack or stroke in the subsequent five years, whereas you need to treat 570 50-year-old women with raised blood pressure for five years to prevent a heart attack.
  • 70 to 150 people have to receive statins to lower their cholesterol to prevent a heart attack or stroke in those with no other health problems.
  • 23 people have to receive the flu vaccine to prevent one person catching the illness (this excludes the herd immunity effect).

The numbers are occasionally random and not very personalised – for example, we need to consider all the other factors such as whether prescriptions are filled, whether drugs are taken as prescribed – e.g. on an empty stomach, whether other medicines are interacting – some medicines can either increase or reduce the effectiveness of others.

Essentially, it gets complicated and difficult.

I suspect, this is part of the reason that many doctors do not deprescribe – because of the very inexact and unscientific dimensions related to cause and effect.

Nevertheless, within the dark underbelly of medicine, where geriatricians live, there are some quite stunning effects often, from stopping and sometimes starting medicines.

Stopp and Start Guideline

For example, the Stopp Start Guideline (STOPP: Screening Tool of Older People’s potentially inappropriate Prescriptions. START: Screening Tool to Alert doctors to Right i.e. appropriate, indicated Treatments), published in 2008 in the Internal Journal of Clinical Pharmacology, has become a mainstay for guiding doctors and pharmacists in ways to rationalize medicines.

This guide, a good example of which can be obtained here provides examples of medicines that both potentially harm as well as benefit older people. A more recent review is here.

Much is very straightforward – for example, my favorite, probably within all of medicine is stopping blood pressure tablets in older people. To understand this, you have to know a little about the effect of blood pressure – it follows a curve in association with life expectancy – the lower your blood pressure – to a point, the better, with those with the highest levels having relatively shorter lives, usually, because of cardiovascular disease – that is, strokes, heart attacks, renal failure and so on.

Consequently, those people who survive to be very old – in their 90’s, tend to either have naturally low (but not too low) blood pressure or if they have raised blood pressure, it has been well controlled with medicines for many years.

As people age, there are various changes within the body – the external ones are easy to see – wrinkles and thin skin; inside the body, the process of deterioration is also happening – our lungs and heart become less effective, our kidneys struggle to filter, our eyes to see and our brains to process.

Consequently the effects of drugs become increased – a drug that was ok for a 35-year-old might not be good for someone who is 80, yet, because of practice and traditional approaches to care, people often remain on high doses even when they are either not doing any good or even potentially causing harm.

The biggest harm experienced by older people in relation to blood pressure treatment is falling and the consequent associated injuries – physical, psychological and emotional, or, fractures, anxiety and social isolation.

Determining whether a person no longer requires a blood pressure medicine is quite easy – we can measure their blood pressure; as to whether a blood pressure medicine is outright harmful is also quite straightforward – essentially, we measure a person’s blood pressure when they are lying down then repeat the test with them standing-up; if their blood pressure drops more than 20 systolic or 10 diastolic points and they feel dizzy, wobbly or light-headed, they may have postural hypotension which is caused by their blood pressure medicines; stopping the treatment usually works, although sometimes other treatments are required.

As to why this test is so difficult to undertake either in primary or secondary care I am not clear – on my ward, we have managed to crack the challenge and this is now part of our routine screen for patients who have fallen, for many other areas, probably thousands of people across the UK, this test isn’t done, the people continue taking the potentially harmful medicine and continue falling.

There are a host of other similar medicines which I will list at the end of this document.

I should say, it is important for anyone who is prescribed medicines not to suddenly stop taking them – some drugs need to be withdrawn slowly and others are not the cause of the symptoms – always consult your doctor!

A few specialist areas…

I have already mentioned blood pressure drugs and falls, here are a few other very commonly prescribed medicines that are potentially harmful:

  • Drugs that work on the central nervous system (CNS) – there are a multitude of medicines which affect our levels of alertness and consciousness; whether pain killers such as Morphine and Tramadol, through to antidepressants, anti-psychotics, anticonvulsants or anti-anxiety drugs like Diazepam and Lorazepam; all contribute to a slowing of response time, increased drowsiness, falls, and, potentially dehydration and malnutrition.

This is not to say that people should stop taking their epilepsy medicines, but for those older people who are prescribed regular pain killers for a fracture or sprain they had 10 years before or who have been inappropriately prescribed antipsychotic medicines (ten years ago, these were the mainstay of treatment for people with behavioural symptoms associated with dementia – in recent years we have learned than unless used by specialists in controlled situations, they can cause people to fall and shorten their lives because of heart attacks and strokes) review might be appropriate.

  • Another class of drug that potentially affects the CNS are anticholinergics or antimuscarinics – they stop the chemical Acetylcholine from working in the body, the side effects of which can be beneficial – supporting breathing in people with asthma or COPD, incontinence in those with sensitive bladders or settling symptoms of nausea and sickness.

Unfortunately these medicines all carry with them potential side effects, which in older people can result in confusion.

An anticholinergic scale has been created to determine which medicines have the strongest anticholinergic potential; most people who are prescribed these medicines will not experience any ill effects, some, particularly those who are older and those with dementia or a history of delirium (acute confusion) are at increased risk and should be assessed.

Anticholinergic Burden Scale

A total score of three or more is considered clinically relevant.

acb

Antibiotics

Antibiotics are an entire class of medicine which I have not yet mentioned – discovered by Alexander Fleming in the 1920s and now one of the most commonly prescribed and important medicines in society. Antibiotics have saved the lives of countless people who would otherwise have died and they have transformed modern medicine.

The use of antibiotics in the UK remains controlled and all require a prescription, in other countries there is a much looser attachment to regulation and compliance resulting in major limitations in their use – predominantly because of bacterial resistance.

There is a campaign running globally to limit the use of antibiotics in order to control the development of resistance.

Here is a link to a very recent blog by Sally Davies, the Chief Medical Officer on the subject.

Behind these issues, is the heavy reliance within health and social care on ‘bacteria’ as a cause of health problems; in older people in particular, infections are blamed for a whole range of upsets – from falls to confusion, pain and reduced mobility. This is to the extent that there is an inside joke that an older person going to A&E without a cough, who has fallen will be given antibiotics for a urine infection.

Things are even more complicated as many older people have a condition called ‘asymptomatic bacteruria’ – for more details, see here. That is, they have bacteria in their urinary tract but they aren’t doing any harm or causing any disease or symptoms and consequently do not cause confusion or falls and do not require treatment.

That is not to say that urine infections cannot be serious – life-threatening even, just, that their centrality to older people falling is not necessarily as clear.

trimeth

Whether an older person receives a course of Trimethoprim or Nitrofurantoin – the most commonly prescribed antibiotics for urine infections is not specifically my focus, more, as with the discussion above relating to falls and blood pressure – if a person falls at home because their blood pressure is too low (because of unnecessary medicines) and is brought to A&E and receive antibiotics for a urine infection they either don’t have or doesn’t require treating, they will be made no better, indeed they will be exposed to the risks of antibiotics – disrupting the healthy microbiome and potentially causing serious gut infections such as Clostridium difficile. Antibiotics can as also discussed interact with other drugs and increase their toxicity – a common agent being Warfain (which is used less nowadays but still a very common medicine) – most frustratingly however for the person who has fallen, their opportunity for intervention – for the blood pressure medicine to be stopped and their risk of falling reduced, will have been missed and the whole encounter ineffective – a dance macabre of systems, process, health and technology.

Supplements

Another growth area in our society relates to the prescription of dietary supplements – whilst these are not strictly considered medicines or pharmacy, they are ordered on prescriptions.

If you look in the fridge on any hospital ward in the UK you will see a variety of different coloured dietary supplements – most providing increased amounts of protein, carbohydrate or fat, depending on individual need.

supps

I haven’t tried many dietary supplements although I gather some are more palatable than others, some people enjoy them, others dislike any type or consistency.

The usual route for receiving dietary supplements (called ONS, or Oral Nutritional Supplementation by those in the know) is when a person is eating inadequately, or found to be losing weight.

Weight loss can be intentional – through increased exercise or dieting, in older people it is much more often a sinister indication of deterioration, if rapid, potentially indicating severe infection or cancer or when slower and more insidious, the general decline associated with increasing age and frailty.

Ironically, in most of these situations, ONS does little to prevent loss of weight – it does not reverse the systematic process associated with people coming to the end of their natural lives and is really only of benefit to either support people who have an inability to consume adequate calories – for example, after a major operation or recovering from some other trauma or infection, pending a return to wellbeing and ability to participate in normal diet.

Essentially in many instances, we have medicalised the process and instead of doctors and nurses engaging in person-centered discussions about prognosis and the future, it is easier to prescribe the supplements and hope that they will do some good.

Even the Care Quality Commission and the National Audit for Dementia (currently running in 2016 in the UK) are interested in weight and its monitoring – with poor monitoring of the residents in care homes’ weight or those in hospital seen as an indicator of poor care – yet, the issue is much more complex than this.

A common theme to all of the areas so far discussed is effectiveness; writing a prescription and moving-on is not enough; we need to be able to determine whether the medicine has made any difference, whether it has helped or harmed, whether an individual’s quality of life is better now than before. Ironically, a fundamental for determining these changes on a human level relates to ‘continuity of care’ – being able to see the same doctor or nurse throughout the span of treatment or care, interacting with someone who can not only monitor weight, but can also detect subtle changes in behaviour, skin colour, tone of voice, brightness of the eye – these many ineffable characteristics which are still within the realm of people.

Potentially bad medicines…

There are some medicines that are never right, that always cause me consternation when prescribed for older people…

Here are a few of my favourites with explanatory notes:

Haloperidol – this atypical antipsychotic agent was once felt to be a panacea in terms of the treatment of people with dementia; if an older person with dementia was too loud, difficult, non-compliant, aggressive or agitated, a dose of this was felt to work. Over the past five to ten years we have discovered how potentially harmful this drug and other similar agents – such as Risperidone and Olanzapine are in terms of making confusion worse, causing falls, heart attacks, strokes, dehydration and death.

As an antipsychotic this drug can be effective and it is also used very effectively in palliative care, outside of these areas it is best avoided (note – on the Anticholinergic Burden Score it is a ‘3’)

Tramadol – this is a synthetic opiate which is commonly used as a strong pain-killer when simpler treatments such as Paracetamol or Co-Codamol are ineffective; for some people it is effective, for many, particularly for older people and specifically those with any degree of confusion it is likely to cause a significant worsening in symptoms and is best avoided.

Cetirizine – this is a supposedly non-sedative antihistamine – commonly prescribed for allergic conditions as well as sometimes vertigo. In short-term use it is sometime although not always effective; taken longer term its sedative effects can be significant in older people and can also contribute to increased confusion, both of which can result in falls.

Oxybutinin – this drug is sometimes prescribed for irritable bladder – sometimes associated with incontinence in older people. If you ever find a person who is prescribed this drug, ask them if their mouth is dry – this is the most common side effect; more significantly however, for older people, side-effects relating to constipation and confusion and urinary retention (inability to pass urine) can cause significant harm.

Example of appropriate polypharmacy

This is an example of an imaginary 85 year old man who is living independently in a town in the UK. In the past he has experienced a heart attack and a stroke, he also has diabetes, high blood pressure, an enlarged prostate, chronic obstructive pulmonary disease (COPD), arthritis and constipation. Here is what he might be prescribed:

Clopidogrel 75mg once in the morning To prevent blood clots
Atorvastatin 40mg at night To lower cholesterol
Bisoprolol 5mg twice a day To protect heart
Ramipril 5mg twice a day To lower blood pressure
Bendromefluthiazide 2.5mg once a day To lower blood pressure
Spironolactone 25mg once a day To protect heart
Amlodipine 5mg once a day To lower blood pressure
Gliclazide 80mg twice a day To control blood sugar
Metformin 500mg two tablets three times a day To control blood sugar
Tamsulosin 400mcg once a day To help with prostate
Paracetamol 500mg two tablets four times a day Pain relief
Lactulose 15mls twice a day Treat constipation
Movicol Sachets one twice a day Treat constipation
Spiriva inhaler once a day COPD
Symbicort inhaler two puffs twice a day COPD
Salbutamol inhaler as required COPD
Ibugel cream three times a day Pain relief

I think this would qualify as polypharmacy – this would add up to approximately 30 medicines a day, excluding his inhalers – and think, what might happen if he falls and hurts his back and requires more pain relief or needs to take antibiotics…

Example of deprescribing

Imagine another patient – she is a 91-year-old woman living in a nursing home. She has limited mobility, only able to walk with assistance of two people, she is doubly incontinent. She needs help with dressing, eating and drinking; she has a past medical history of Alzheimer’s type dementia, Diabetes, falls, asthma, depression, stroke and she broke her left hip three years ago.

Initial medicine chart:

Donepezil 10mg at night For Alzheimer’s
Zopiclone 3.75mg at night To help sleep
Gliclazide 80mg on the morning For diabetes
Metformin 500mg twice a day For diabetes
Cinnarizine 5mg once a day For ?dizziness
Co-Codamol 30/500 two tablets four times a day For pain
Movicol 2 sachets a day For constipation
Salbutamol inhaler as required For asthma
Seretide inhaler two puffs a day For asthma
Atrovent inhaler two puffs four times a day For asthma
AdcalD3 two tablets a day For bones
Alendronate 70mg once a week For bones
Lansoprasole 30mg once a day For indigestion
Amitriptyline 25mg at night For depression
Citalopram 40mg once a day For depression
Amlodipine 5mg once a day For blood pressure
Aspirin 75mg once day For stroke
Dipyridamole 200mg twice a day For stroke

A narrative rationalisation of these medicines is:

Is she gaining any benefit from Donepezil in terms of her Alzheimer’s which is likely to be advanced; this could be causing her side effects – agitation or insomnia – discuss with relatives or carers or Older People’s Mental Health Team about stopping

She might not need the Zopiclone if the Donepezil is not required and preventing her from sleeping. In general sleeping tablets are ineffective with long-term use and significantly increase the risk of falls in older people. Consider stopping.

Gliclazide and Metformin – there is little evidence that tight control of blood sugars in older people, particularly those with dementia in nursing homes benefit, check HbA1C and consider reducing and stopping; aim for random blood sugars below 11 mmol, move away from a stringent diabetic diet which may encourage her to eat more. You might want support from the diabetic team in the community. Too low blood sugars can cause confusion, falls and brain injury.

Cinnarizine – often left on repeat prescriptions, most people taking this don’t know what it is for and it isn’t doing them any good – it can also worsen confusion and contribute to falls. Stop!

Co-codamol 30/500 – this is very strong codeine with paracetamol, she may require pain relief – this needs to be regularly reviewed, it is likely that this dose contributes to worsening confusion and constipation, also the high regular dose of paracetamol might be too large for her body weight, risking liver injury. If she does need pain relief, would paracetamol alone be adequate? Would a topical preparation be better? What is causing the pain? Could her laxatives be reduced if she is no longer taking codeine?

Inhalers – clarify the severity of her chest symptoms – it could be that she no longer requires inhalers given that her exercise tolerance is now so poor, even so, check that she can use them – if she is unable to coordinate her breathing, it is likely that the medicine is not working on her lungs, instead contributing to a dry, sore throat. Alternative inhalers are available for people who struggle with the technique, or, they might not be needed at all.

Adcal D3 – it is likely that she does not experience any exposure to daylight and her dietary intake of calcium and vitamin D is poor – these could contribute to falls and there is mixed evidence as to their benefit. For some patients they are difficult to swallow and a daily chore – is this something the patient wants?

Alendronate – given the patient’s previous fall and broken hip, it is likely that she has osteoporosis which this drug can successfully treat in combination with calcium and vitamin D – in order to benefit from this drug and not experience significant side effects, it needs to be taken when standing or sitting very upright, for thirty minutes, on an empty stomach with ‘plenty of water’ (plenty is the scientific measurement used by the British National Formulary) – can she achieve this? Is the medicine likely to cause her stomach upset? Is her life expectancy (which is somewhere in the region of one to two years) adequate for the medicine to have any effect? Could she stop taking the antacid medicine Lansoprasole if she doesn’t take this?

Amitriptyline – this is a tricyclic antidepressant with powerful anticholinergic properties, sometimes used to help with chronic pain or insomnia. This dose is likely too high and it probably shouldn’t be prescribed to her. This needs to be withdrawn slowly. Note, she is also prescribed a too high dose of Citalopram, another antidepressant – you might want to consider speaking with her mental health team before reducing this to the recommended dose, if it is needed at all. The combination of the two drugs increases confusion and can increase risk of falling.

Amlodipine – check her blood pressure; is this required at all? Is it doing any good? Is it doing any harm? Suggest to stop.

Aspirin and Dipyridamole – this is the old treatment for stroke prevention; we nowadays use one tablet instead of three, which are difficult to swallow and have side effects of stomach upset and headache; did she actually have a stroke in the past? What is the evidence for this? What will be the benefit in terms of her quality of life and life expectancy if she is not prescribed the alternative (Clopidogrel) at all?

I know people might think I am exaggerating – below is an example of the actual prescription of a different patient who has dementia and lives in a nursing home – see if you can spot the ‘dodgy drugs’

meds

By the end of the day, the patient’s medicines can be potentially reduced dramatically – she might feel better, be less confused and eat more. All of this is difficult and potentially time-consuming, but very worthwhile for the patient; in patients who are older it is important to explain why you are stopping the medicines that another doctor has told them are critical to their wellbeing – the vast majority of people are aware that they are a poison and doing them harm and delighted to stop; for those frailer patients who perhaps lack insight or mental capacity, a discussion with their next of kin is very important – it is also important to explain your rationale which is solely to improve the quality of an individual’s life rather than save money.

Drugs, side effects and hospital admission

A 2004 study at two hospitals in the UK over a six-month period showed the frequency of admissions associated with adverse drug reactions – these totalled over six per cent of all admissions (there are over five million emergency hospitals admissions each year in England).

Many of the associated side effects are potentially avoidable.

  1. NSAIDs including aspirin 29.6%
  2. Diuretics 27.3%
  3. Warfarin 10.5%
  4. ACEI/A2RAS 7.7%
  5. Antidepressants including lithium 7.1%
  6. Betablockers 6.8%
  7. Opiates 6.0%
  8. Digoxin 2.9%
  9. Prednisolone 2.5%
  10. Clopidogrel 2.4%

 

IMG_5751

Gut microbiome, antibiotics and older people

There has been a massive swing to the proactive, early use of high dose antibiotics in those people attending accident and emergency departments in the UK with suspected infection; specifically, something we call ‘sepsis’ – this is a condition where we are at risk of being overwhelmed by infection, usually by bacteria although other organisms can cause this.

Warning signs are raised temperature, dropping blood pressure, high breathing rate, drowsiness.

In an attempt to treat early – something that has been shown to reduce the numbers of people dying from infection (that is, treatment within the first three hours of arriving in hospital or seeing a doctor or paramedic), the Sepsis Bundle has been created and rolled-out across the country.

This bundle, which is in effect a list of instructions to follow when sepsis is suspected has improved compliance with guidelines, early treatment with antibiotics and other measures to support people and, hopefully, has reduced the numbers of people either dying or becoming critically ill.

This is all very good.

There is another side to this… It relates in some ways to the models of care I described in the last blog – the medical, older people and palliative models – the medical, being treat and investigate at all costs, and, for older people, aid recovery and care, and, the palliative, which is care, support and ensure that the person’s subjective experience is given priority.

When an older person attends A&E, the most common cause in our society, being, a fall at home; the receiving doctor or nurse has a dilemma – they need to find-out if the person is OK – do they need urgent treatment? Oxygen, intravenous fluids, antibiotics, or, can the team move on to the next phase and try to determine why they have fallen – was it a stumble relating to reduced muscle strength in an older person with arthritis, did they lose consciousness, are they harbouring an infection?

And, it is to the last of these that the system often defaults, with an older person who has fallen, becoming an older person who has a urine infection.

The science, or rather the practice of treating urine infections in older people can be patchy.

For this, I have (my own, non-evidence based) rule of thirds; one third of people you suspect to have a urine infection have one, one third of the time the antibiotics use to treat the urine infection, if present, are ineffective as the bacteria are resistant and one third of the time the antibiotics you use work.

This is not very scientific, but some people appreciate rules of thumb.

There is an empirical method for determining the presence of urine infections – examining a sample of urine under the microscope. If bacteria are present or there are signs of bacteria present, then the likelihood of infection increases; it is only after those bacteria have been grown in a lab and tested against different antibiotics, which often take 48 to 72 hours, do we know if there is definitely and infection and what treatment to give.

I have talked previously about asymptomatic bacteruria (& Bear Grylls) – my point here is the frequent use of antibiotics in situations where the evidence for bacterial infections is small.

In older people these are falls and confusion (delirium).

The usual philosophy with respect to the use of antibiotics is that they might work, they don’t do much harm and we need to do something.

It is this thinking that has resulted in the many cases of Clostridium difficile we see reported nationally – this is, where toxic gut bacteria are allowed to flourish because the normal balance of beneficial bacteria is affected by the use of antibiotics.

Clostridium difficile diarrhoea is a horrendous condition which can make people very ill, necessitate their isolation and can become chronic – being a risk every time they subsequently take antibiotics.

I am less concerned here about Clostridium difficile, but instead the unfathomed gut microbiome that exists within all of us. The unimaginably complex density of bacteria that control many aspects of our health and wellbeing – supporting digestion and metabolism, the control of hormone levels, function of the liver, and even, potentially our response to stress and levels of neurotransmitters.

We, the homeostatic organisms that have evolved over the past four billion years, exist in a state of serenity when well, but things can be thrown out of kilter by disease.

Separately, we know that the numbers of antibiotic resistant bacteria are increasing globally – this is another issue.

What I wonder is whether there is harm in using antibiotics?

Like all aspects of medicine, particularly in relation to treatment, there is always a balance, between harms and benefits – if the treatment I offer kills the bacteria or cancer but also kills the person I am treating, I haven’t done a good job.

What if the treatment I give is wrong and potentially harms?

This is my question relating to the third of the third of the third (or some other numerical mixture of facts and figures) – what happens when we treat an older person with antibiotics when they either don’t have an infection or the bacteria present are not causing any harm (and might even be helping us)

I don’t want to knock my fellow Scotsman, Fleming – his discovery of penicillin has resulted in unimaginable benefits to the entire human race. What, however have the harms been?

The explicit harms are easier to determine – they are, Clostridium difficile, MRSA, ESBL, MDRTB, and a host of other acronyms and Latin phrases.

My message, or perhaps my question is whether enough thought is given towards the use of antibiotics every time they are used or prescribed; enough thought about the benefits and the potential harms. In the UK we are relatively protected from the abuse of antibiotics, in many countries, antibiotics are unregulated and sold directly.

What is the good we are doing and what is the harm? Do not consider everything we don’t understand to be caused by bacteria – sure, bacteria are out there, in numbers we cannot imagine, yet, only a few are harmful and only a few are the cause of harm – for, there are other dangers which are not always related – pain, fear, anxiety, depression, isolation and loneliness, lack of physical fitness, poor diet, right-wing politics, and so on.

Antibiotics are great and I am an advocate, but, before using them think homeostasis, think cause and effect and consider evolution.