Warnings over dementia drugs give Copperfield a distinct sense of déjà vu
Oh, fer Chrissakes, not this demented old chestnut again?! GPs are being slated for ‘over-prescribing anti-psychotics’ in patients with dementia, blah blah, déjà vu, overwhelming feeling of boredom and desire to give whoever’s saying it now a buttock full of haloperidol.
As ever, this type of story leaves anyone who knows anything about general practice – that’s GPs, by the way – wondering what the hell these mythical alternatives to anti-psychotics actually are. So, for want of anything better to do, I went in search of this Holy Grail. And I visited, on your behalf, the two most authoritative reports on the subject: ‘The use of antipsychotic medication for people with dementia: time for action – a report for the Minister of State for Care Services’ and ‘The NICE SCIE guidelines on supporting people with dementia and their carers in health and social care’. I’m claiming 10 educational credits just for getting to the end of the titles. But I’ve used them to inform the imaginary conversation outlined below. And if you think I’m making it up, you can check them out here and again here.
Nursing home: Dr C, you’ve got to do something about Mr Smith. He’s becoming increasingly agitated. He burst into the ladies’ bingo session this morning waving his Zimmer in an aggressive manner.
Dr C: OK, well, according to the guidance I have here, you should have a ‘Curriculum to develop skills in non pharmacological treatment of behaviour disorders in dementia.’ Could you use that to fend him off?
NH: We don’t have one of those. And he’s threatening to set fire to people.
Dr C: Right. Well, let’s see, first, I need to exclude a physical cause. Er…like constipation. Is he opening his bowels regularly?
NH: Well, he took a dump in the TV chair during the Jeremy Kyle show, so I don’t think there’s any problem there. And he’s been like this for years so that would make him very constipated indeed. He’s just getting worse.
Dr C: OK, hang on, let me just check the next step…Right, what you need to do is behaviour management.
NH: Which is what, exactly?
Dr C: Well, you have to manage his behaviour…with…wait a sec…a ‘problem solving approach’. Trying being more person centred and…uh…solve his problems.
NH: I know what the problem is, and it’s him. And I am being person centred. I’m representing the distress of all the other inmates.
Dr C: Wait, there’s more. The next stage is multisensory stimulation, bright light therapy, aromatherapy and massage. So turn the TV and radio up to max, shine a light in his eyes and stick some soap up his nose. And then give his feet a rub.
NH: And will that work?
Dr C: Let me just check…er…no. But, they’re interesting avenues to explore.
NH: So how about some quetiapine?
Dr C: 50 mg should do it.
Conclusion? There is no Holy Grail. We’re being asked to reduce antipsychotic prescribing when there is no credible alternative – and without any appreciation that many of these calls are made in a crisis, where advice to distract the patient with a sing-song and a chat about his hobbies simply aren’t going to work. So maybe I can be left to get on with making the best of a bad job. Otherwise, the experts had better be warned. There’s a demented man heading their way armed with a Zimmer frame. And he looks pretty angry.
‘Sick Notes’ by Dr Tony Copperfield is out now, available from Monday Books
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