September 2016 – Sparklystar55

Don’t you (forget about me)

September 26, 2016 clcopeland

This week I visited Erskine Care Home where my former colleague Derek Barron (@dtbarron) is now Director of Care. Janice McAlister, Dementia Nurse Consultant Ayrshire & Arran (@janicemcalister) also came along for a catch up and look around. To be honest the promise of cake was an offer to good to refuse…

The main reason for the visit was to chat about staff education with a focus on dementia and delirium.

I’m not sure what the public perception of care homes is but I had very little clue about them until my Registrar training in 2005. At the time we were supposed to go out on domiciliary visits with Consultants, minor problem was that no one was doing them anymore. An interesting development some 10 years later is the emergence of ‘Hospital at Home’ and other parallel rehab/ assessment at home services. Change never stops I suppose….

I had always thought of care homes being filled with people with complex medical and nursing problems e.g. stroke, dementia, Parkinson’s Disease. Frail people.

I also made assumptions that the staff caring for them would know all about their medical history and why they were on certain drugs. Somewhat naively I thought that each resident’s GP would visit on a regular basis.

Now I don’t want people to misunderstand or misinterpret this as a criticism as people were doing the best they could. However the staffing levels and the lack of regular medical input was something that both shocked and baffled me.

So I decided to spend time with a group of GP’s who took over a cluster of care homes in Glasgow. It was hands down the most enlightening experience of my entire Registrar training. I saw first hand the care and dedication of the staff looking after the residents. However the volume of work was huge. The most challenging aspect was in caring for those with cognitive disorders.

In 2013 The Alzhiemer’s Society published a report that indicated that ~80% of people in care homes have dementia or some kind of memory problem (1). This is a significant rise from the previously cited 44% in 2009 in the BUPA report (2).

What is poorly understood is the prevalence of delirium as a complicating factor. Some studies have quoted 8 – 15%. One study however quoted 39.7% as having sub-syndromal and 6.5% having full delirium on admission to nursing home (3). That last statistic really resonated with me. One of the difficulties in recognising delirium in a care home setting is that the tools previously available are actually quite complicated and time consuming. Plus there is little to no training available.

More recently I spent some time visiting care homes in Ayrshire to talk to staff about delirium. I needn’t have bothered in some respects. They knew all about it. What was frustrating though was that they had little in the way of training to articulate the problem or tools to help support the management of it.

There have been attempts to produce resources for care homes – PitStop looks at how (4)

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Going back to the Alzhiemer’s report it’s interesting to note that 44% of people considered the training available to staff as an important reason in choosing a care home.

So with this in mind I would like to suggest we have much more robust training and education available to care home staff. Not only will it help in the care of the people in the homes it may actually drive recruitment in this area. Something that if you read the report published by Independent Age (5) is going to be crucial for the future…

References:

https://www.alzheimers.org.uk/site/scripts/news_article.php?newsID=1498
http://www.cpa.org.uk/information/reviews/changingroleofcarehomes.pdf
Von Guntena & Mosimann 2010 Swiss Medical Weekly
http://ageing.oxfordjournals.org/content/early/2016/05/19/
ageing.afw091.full.pdf
https://www.independentage.org

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It’s all in your head….

September 20, 2016 clcopeland

So as my brain starts to resurface from the blissful cocoon of disconnect I realise my blog is a little late.

So what has been happening this week. Well I took some time off. Actual proper time off. None of that ‘taking a quick look’ at emails even though the out of office is on. No sorting out washing or doing the shopping at home. Most shocking of all was the total lack of tweeting – I know! How did I cope?

During my career I used to ignore all the signs of impending frazzlement until a migraine or panic attack would stop me in my tracks. Worse of all I’d be surprised. Why has this happened? Followed by emphatic ‘this will not happen again – I vow to change’ Until the next time.

There was no learned behaviour. No insight. Also I’m a doctor so that means I don’t get ill right? Especially not in the head *shudders*

At Medical School there was a huge emphasis on the physicality of health. I wasn’t trained to think that there could be a link between mental and physical health. No, if you had a physical ailment it would have a physical cause.

So with this as a foundation it comes as no surprise that doctors are terrible at managing their own mental health and sometimes, those of others.

There is also the stigma to deal with. We in healthcare we are the worst offenders in perpetuating it. We do this by keeping our mental and physical health records separate. Despite all the confidentiality clauses, hippocratic oath taking it is felt appropriate that mental and physical health are separate.

So where do you begin with a person that is showing all the physical signs of illness but none of the organic causes? The so called ‘functional disorders’.

First of all I’d bin the term functional. As many will tell you there is nothing functional about a pseudo seizure or a hemiparesis.

I’ve heard people talk about hardware versus software but that doesn’t really work. Or in the case of the hemiparesis ‘muscles not getting signals’. Ummmm….. no, that makes no sense either.

What I’ve found helpful is first and foremost to believe the person. Their symptoms are real. If you don’t believe this then you will get nowhere and help no one.

The brain is amazing (hence my interest in stroke and delirium) but to assume it only deals with the physicality of the body is ridiculous. What about our emotional selves?

So the second thing I do is actually to say this to people. It seems like you’re stating the obvious but I think sometimes the obvious needs stating.

I also follow up by talking about panic attacks. The physicality of what they can do is real and can be recorded e.g. an increased heart or respiratory rate. I might even talk about blushing where you go bright red in the face. Both though have emotional drivers.

If people believe that physical and mental health are intertwined then you will have started them on a journey to better health. However that journey starts with a healthy doctor – it may just be all in your head but get that right and the rest will follow….

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Game Day

September 12, 2016 clcopeland

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You know autumn is just around the corner when the NFL kicks off. Throw in an episode of Strictly and you’re all set.

I love the NFL. I’ve been a fan of the Pittsburgh Steelers since 1985. No, I’ve not been to Pittsburgh but I have seen games both Stateside and in London. And no I don’t have pressure sores from sitting watching a game that lasts ~3hours.

My love of the sport dates back to when I used to watch with my Dad on Channel 4. At that time Pittsburgh was the worst team in the league. We would have bets on how much they would get beat by that week (I didn’t realise that they’d won 4 Superbowls in the 70s so assumed they’d always been crap). I also used to listen to the games on the Armed Forces radio. Usually it would drift out at a crucial 4th and goal so I’d be left shouting at the radio in frustration.

So why American Football? I think initially it was the physicality of the game. It’s much more heavily regulated now but some of the tackles are quite spectacular.

The ‘plays’ are like little set pieces – so I guess that kind of appeals to my sense of organisation.

I think the main reason though is the team ethos. I’d never really seen or heard much about the concept of the ‘team’ in British sports. That’s not to say it doesn’t exist but the NFL has always stressed/celebrated its importance much more openly. While there may appear to be a gazillion players on an NFL team all doing different things, they all know why they are there and what role they play.

So I guess this is what was in the back of my mind when our stroke team started the Aston OD (Organisation Development) work this week.

http://www.astonod.com

Like many specialty teams in the NHS we are pretty small but high performing. Stroke care is usually delivered by Geriatricians but unlike other aspects of Geriatric Medicine we are held to account by the Scottish Government through a series of targets. Something that adds to the pressure of working in such a small team.

So we decided to take a timeout. Of sorts. The plan is to continue delivering high quality stroke care whilst striving to meet our targets. However over the next 3 months I have the job of leading the team through the Aston journey.

I’ve never done anything like this but I’m excited. Every session will be like game day (in my mind anyway). They’ll be planned out meticulously. The game plan will be shared ahead of time so the team is prepared. We will leave everything on the field. In short we will ‘get it done’.

Whilst we may not win the Vince Lombardy trophy of Aston OD I am hopeful that Team Stroke will emerge stronger, more cohesive. More awesome!

Now. Let’s do this……!!!!!

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We have all the time in the world….

September 5, 2016 clcopeland

It was my birthday this week. Whoo-hoo!! In recent years I’ve tended to kick the backside out of a week long celebration. Last year I excelled myself and turned it into a year long event (it was a significant birthday so I figured that was ok).

Birthdays are a sensitive topic for some people. I’ve never really understood why to be honest. I’ve also not been able to pin point the exact age that it becomes an issue. As a kid you look forward to birthdays and getting older is exciting. There is an allure to being ‘grown up’. For some though it stops and the pursuit of youth becomes all consuming.

I remember watching TV when Natalie Imbruglia was advertising a well know skin care product. I became enraged when she said ‘facing your thirties?’ She was 28 at the time. ‘Are you kidding me? I’m still in my twenties and you’re saying I should be stressing about turning 30! P*** off Natalie!

At the time I only really thought of age in superficial terms. I had no real reason to think about it in any other way. I may or may not get married. I was pretty sure I wanted to have children but that could wait until I was ready. Being ready was loosely defined as finishing my Registrar training, getting a Consultant post and generally being settled. I was also pretty confident I would know when the right time would be.

What I would not know was that time would have other plans.

So I continued on – I got married, had a beautiful daughter and took up my Consultant post. I was 35.

Now anyone who has started a new job, especially at a higher level of seniority will know how stressful it can be. Every minor ailment gets put down to stress – headaches, insomnia, mood swings, an inability to conceive. This is what I believed and so I blindly continued with my personal mantra of ‘what will be will be’.

At age 38 I found myself crying uncontrollably at my desk at work over the most ridiculously insignificant thing. Feeling a mixture of embarrassment, frustration and lack of control I frogmarched myself to my GP.

I was diagnosed with Primary Ovarian Failure or Premature Menopause (honestly the mere mention of the phrase makes me shamefully recoil in horror).

After repeating the bloods my GP phoned me with the results to confirm the diagnosis. I went into all out fixing mode. I wanted referred to someone. I didn’t know exactly who or why but still, I should see someone about this surely?

I was told that there wasn’t any point and did I want to start HRT?

Eh, no – thank you very much! I want to have another baby. I want to know why this has happened. I want to know was it my fault? I want to know how to fix this. And no I do not want bloody HRT!

I was eventually referred to an amazing female Consultant in Glasgow. There was no changing the fact that I had shut up shop – I was technically the same age as a woman in her mid 50s physiologically speaking. This woman listened to me and answered my questions with enormous sensitivity.

Over the next year I made my peace with it. It turns out there is virtually no information out there for women <40yrs dealing with POI so I started a journal. While it was more for my own personal sanity I also wanted something I could refer back to for my friends in the future. Most importantly though I want to make future conversations with my daughter easier.

I did find the Daisy Network (@thedaisynet) very useful. I was however quite taken aback by the reaction Kirstie Allsopp received in this article. She came under fire a couple of years ago for her ‘anti feminist’ views on fertility.

https://www.theguardian.com/tv-and-radio/2014/jun/02/kirstie-allsop-young-women-ditch-university-baby-by-27

I absolutely agree with her that these conversations are hard. However we need to be honest and educate young women about their own health and fertility.

So as I turn another year older I will continue to celebrate ageing in all its wonderful, wrinkly glory. Beyond the superficial however is a knowledge to be shared so that my daughter can make decisions like she has all the time in the world……