Healthcare Student Journal for Scotland Volume 2 – Issue 2
C o n t a c t I n f o r m a t i o n : S U M J @ d u n d e e . a c . u k
Winter Edition 13
Scottish Universities Medical Journal Team
Acting Editor for the Issue
Lloyd Hughes
Scottish Universities Medical Journal Editorial Board 2012/2013
Kevin Barr
Laura Fraser
Naomi McIlvenny
Lauren Copeland
James Millar
Associate Editors and Consultant Reviewers for University of SUMJ
Professor Sam Eljamel ‐ Consultant Neurosurgeon NHS Tayside, Honorary Professor in Neurosurgery University of Dundee
Dr David Booth ‐ General Practitioner & Doctors Patients and Communities Facilitator, University of Dundee
Professor Jeremy Hughes – Professor of Experimental Nephrology and Honorary Consultant Nephrologist, University of Edinburgh and NHS Lothian
Dr Hannah Lord – Consultant Oncologist. Ninewells Hospital and Medical School
Lloyd Hughes ‐ [Editor‐in‐Chief 2011/12, 5th Year Medical Student; University of Dundee Medical School]
Connecting Physical & Mental Health (Editorial) : Volume 2 Issue 2 Kevin Barr [SUMJ Deputy Editor] As the latest Deputy Editor, I would like to take this opportunity to welcome you to the second issue in the second volume of the Scottish Universities Medical Journal (SUMJ). I am thrilled to be a part of the committee and – most notably – to launch the most recent issue to our readership. A wealth of literature has been published in recent years detailing the growing connection between mental and physical ill health. In this SUMJ issue we are pleased to publish ‘Common Mental Health Conditions in Primary Care’ by Fiona Carver and Fiona Jones (page 13), which highlights the need for primary health care professionals to have the knowledge and skills to deliver person‐centred care to patients with a dual diagnosis1. The authors begin by examining common mental health problems encountered in primary care settings, followed by an in‐depth discussion into the problems faced by mental health patients in such settings. Indeed, the physical health of mentally ill patients is of ascending importance to the healthcare agenda; especially considering people with severe and enduring mental ill health die on average 20 years earlier than the general population, largely owing to physical health problems2. Furthermore, recent research has considered the impact of rumination and psychological processes on the development of mental health of people in the United Kingdom3. The paper suggested that there should be a significant revision of the biopsychosocial model, as psychological processes such as rumination and self‐blame increase the risk of developing depression. These psychological processes in fact, determine the causal impact of biological, social, and circumstantial risk factors of depression3. Therefore, Carver and Jones’s article has a role to play in educating primary healthcare professionals in this topical area. This issue of the SUMJ also puts the spotlight on more sensitive issues in contemporary healthcare. This includes Mandy Barnett’s article ‘Breaking Bad News – Pointers and Pitfalls’ (page 53), which offers an insightful education on the ways in which bad news can be broken to families and patients alike4. Healthcare professionals have frequently been criticised for their approach in dealing with sensitive issues, and Barnett challenges this by offering a step‐by‐step guide to breaking life‐changing news to patients. This raises further questions, and offers our readers an invaluable opportunity to reflect on their own practice – do you consider your patient care to be both person‐centred and holistic, despite organisational and managerial constraints? How can you improve your practice to ensure that your patients will remember you as a supportive and knowledgeable care‐giver? Barnett’s article offers guidance on such questions, and much more. In this issue of the SUMJ we are once again delighted to publish articles from a wide range of disciplines, spanning myriad levels of experience and knowledge. The SUMJ continues to pride itself on publishing the work of Consultants, Doctors, Clinical Lecturers, Medical Students, Nursing Students and all other health professionals, and it is the time and effort of these individuals which ensures the journal goes from strength to strength. We would like to thank all of the contributors who continue to submit articles, and to once again verify that all submitted articles are taken into consideration by the committee. Finally, I would like to congratulate fellow members of the committee on the attainment of their recent positions. I am sure that – as a team – we will devote the time and effort required to ensure the successful publishing of future volumes within the SUMJ. References For full references please see online version of article
Table of Contents
Connecting Physical & Mental Health (Editorial) ................................................ p. 3 K. Barr
Transient loss of consciousness – first ever seizure? Tips for the Acute Receiving Unit............................................................................................................... p. 5‐12 PM Fernandes & RJ Davenport
Common Mental Health Conditions in Primary Care.................................... p. 13‐19 F Carver & F Jones
Approaching Geriatric Patients: The Frequent Fallers .................................. p. 20‐27 N Aly N & IH Malik
How can an academic mentor improve support of tomorrow’s doctors? ...... p.28‐38 F Robertson, C Donaldson, R Jarvis & D Jeffrey
A Child with a Limp – A Clinical Approach.................................................... p. 39‐42 R Humphreys
Regenerative Neurology – The Future ......................................................... p. 43‐46 F Brown
Principles Underpinning the Treatment of Cancer with Drugs...................... p. 47‐52 F Dalgaty
Breaking Bad News : Pointers and Pitfalls.................................................... p. 53‐57 M Barnett
Identification and Treatment of Wearing off in Parkinsons Disease ............. p. 58‐63 JM Fisher & RW Walker
Transient loss of consciousness ‐ first ever seizure? Tips for the Acute Receiving Unit Peter M Fernandes (Clinical Lecturer in Neurology, University of Edinburgh) Richard J Davenport (Consultant Neurologist & Honorary Senior Lecturer) Correspondence to: Peter M Fernandes : [email protected]
ABSTRACT
Transient loss of consciousness (TLOC) in adults is a common presenting symptom to the Acute Receiving Unit, with an epileptic seizure a potential cause. A first ever generalised epileptic seizure is not uncommon, with a lifetime prevalence of approximately one in 20 people. However, as epileptic seizures are only one cause of TLOC, it is important for doctors to be able to distinguish between seizures and the other causes of TLOC. In this article we provide practical advice on how to do this. Key Words: Neurology; Fits faints and funny turns; Epilepsy
Introduction Transient loss of consciousness (TLOC) is a frequent presenting complaint in the Acute Receiving Unit (ARU). The definition of TLOC is, as the name suggests, a loss of consciousness with subsequent recovery. There are many causes of TLOC, but about 10% are due to epileptic seizures1. An epileptic seizure can be defined as a “transient occurrence of . . . symptoms due to abnormal excessive or synchronous neuronal activity in the brain”2. The diagnosis of epilepsy requires a recurring tendency to suffer unprovoked epileptic seizures. Epileptic seizures are common: up to 5% of the UK population will have at least one non‐febrile seizure during their lives3. Epilepsy is less common, with a point prevalence of 4 in 1000 people in the UK; thus a significant proportion of patients presenting with a first ever seizure do not develop epilepsy4. The International League Against Epilepsy (ILAE) divides seizures into focal (arising from a single cerebral hemisphere) or generalised (arising from both cerebral hemispheres)5. Table 1 lists common types of epileptic seizure. The differential diagnosis of TLOC in an adult is summarised in table 2 (as adult neurologists, we will not cover paediatric causes of TLOC but refer readers to SIGN guideline 816). It is important to identify, wherever possible, the correct cause of TLOC; a false positive diagnosis of an epileptic seizure may lead to inappropriate investigations and treatment, and prevent identification of an equally important diagnosis such as cardiac syncope. The diagnosis of epileptic seizure/epilepsy has many implications: it is important to be as sure as one can in making this diagnosis, and therefore this should usually be deferred to an expert. It is better to be uncertain than to reach an incorrect diagnosis – and sometimes it is not possible to make a diagnosis – but provided a careful history is obtained, a correct diagnosis can be achieved in many.
Table 1: Common Types of Epilepsy Syndromes
Generalised seizures (involving whole brain) Tonic‐clonic
Initial sustained muscle contraction/rigidity (tonic) followed by rhythmic muscle contractions (clonic). May be predominantly tonic or clonic
Absence Brief periods of unresponsiveness, with no or minor motor activity (e.g. eyelid flickering)
Atonic Abrupt loss of muscle tone, causing drop attack Myoclonic
Brief muscle contractions causing sudden shock‐like jerks, may manifest as suddenly dropping things or falls
Focal seizures (involving specific areas of the brain, typically stereotyped)
Temporal lobe ‘Rising’ feeling in stomach Unusual smell or taste Intense unprovoked emotion (e.g. fear) Déjà vu or jamais vu
Automatisms such as lip‐smacking, chewing, muttering, fiddling with (imaginary) objects
Frontal lobe Stiffness or twitching of part of the body (e.g. arm) Bizarre patterned motor activity (e.g. .cycling of legs) Parietal lobe Numbness or tingling of part of the body (e.g. arm) Occipital lobe Visual disturbances (e.g. flashing lights) Hallucinations Focal seizures may evolve into a (secondary) generalised seizure and may or may not affect awareness (previously known as complex or simple partial seizures respectively). Total loss of consciousness is unusual in focal seizures Table 2: Other causes of syncope 1‐ Cardiac syncope 2‐ Vasovagal syncope: reflex syncope, orthostatic syncope, and convulsive syncope 3‐ Dissociative attack (also known as: psychogenic non‐epileptic seizure, non‐epileptic attack, pseudo‐seizure) 4‐ Metabolic (e.g. hypoglycaemia)
History A thorough history is of paramount importance in diagnosing what was, or was not, a seizure. Although the patient may be unable to recall all the circumstances of the event, you should ascertain what he/she does remember, and this may require persistence; patients will often say they remember nothing, not realising that there is more to the history than simply the period of loss of awareness. A witness history is essential whenever possible ‐ use the telephone to pursue this if witnesses are not immediately present. Meticulous documentation of the history in the notes will earn the gratitude of the neurologist later, and the most accurate histories are usually those obtained soon after the event, before memories decay. The history of the event should be divided into three segments: before,
during, and after. Case studies 1 and 2 give details of two presentations using this approach (see pages 11 and 12). Before the event The situation may well prompt a diagnosis ‐ where was the patient and what they were doing? For example, most people who lose consciousness in a restaurant, cinema, hospital, GP/dental surgery, bathroom, or on an aeroplane have fainted, whereas TLOC whilst exercising suggests cardiac syncope. Fainting is very unusual in bed (i.e. when horizontal), but is usually the explanation when TLOC has occurred after getting out of bed in the night. Other common triggers of TLOC such as sleep deprivation, alcohol withdrawal, or use of recreational drugs (all suggesting provoked seizure), or intercurrent illness, particularly vomiting and diarrhoea (suggesting fainting) should be identified. Some questions (i.e. recreational drug use or pregnancy) may be best asked out of earshot of witnesses, especially parents – we do this by observing the patient walking down the corridor as part of the examination, and asking them before returning to the clinic room. Does the patient recall any warning before the event? A focal seizure may produce brief (typically less than 60 seconds) sensations that may be difficult for the patient to describe. These sensations vary but common manifestations are listed in Box 1. Witnesses may also provide useful pre‐TLOC information – automatisms such as lip‐smacking/swallowing/chewing, plucking at (imaginary) objects, or trance‐like absence all suggest a focal onset of a seizure. Vasovagal (or reflex) syncope (fainting) usually has a trigger – commonly pain or other unpleasant stimuli – hence the propensity to occur in hospital/surgeries, especially during procedures such as venepuncture. Patients may complain of feeling ‘faint’, sweaty, clammy, and sick, and their vision/hearing may diminish prior to TLOC. Dissociative attacks may also be preceded by a stressful trigger, although not always. Beware of TLOC with no apparent trigger or warning, as this may suggest cardiac syncope. During the attack Generalised epileptic seizures usually start abruptly with tonic stiffening (sometimes accompanied by a ‘tonic cry’) and progress to rhythmic jerking movements. The eyes may be open, the lips may become pale or blue, and patients are unresponsive. The convulsive phase rarely lasts longer than a couple of minutes, although witnesses commonly overestimate duration. Vasovagal syncope may be accompanied by motor activity (stiffening, twitching or jerking) that can mimic an epileptic seizure (known as convulsive syncope), as demonstrated in a series of experiments on German medical students7. These movements are usually brief, lasting for less than a minute, often only seconds. Dissociative seizures are highly variable but there are certain features that help distinguish these from epileptic seizures. Large amplitude asynchronous movements such as arm flailing or pelvic thrusting are characteristic, often waxing and waning over prolonged periods of time. Alternatively the patient may lie motionless, as if asleep. The eyes tend to be closed, and may resist forced opening. Dissociative attacks often have a long duration (10‐30 minutes, or even hours). Patients may be able to recall events occurring during an attack and sometimes report dissociative phenomena such as depersonalisation. Unfortunately witness descriptions may be misleading, so obtaining video footage
(increasingly easy nowadays given the ubiquity of the mobile phone with video‐capturing ability) in recurrent attacks may prove exceedingly valuable. Patients with cardiac syncope often collapse with no warning, and lie motionless, perhaps paler than usual, with rapid recovery thereafter. TLOC during exertion should always prompt consideration of cardiac syncope, and always ask about a family history of young sudden death or heart disease. After the attack After an epileptic seizure patients are typically confused and may even be aggressive (the post‐ictal phase). There is usually a period of amnesia that may be prolonged – patients tend to ‘come round’ in the ambulance or emergency department, even though the witness history confirms earlier regaining of consciousness if not awareness. Patients are often initially unable to recognise partners/friends/colleagues, and this is an important question to ask witnesses (by contrast, people frequently say they felt confused after a faint, but this is not quite what they mean). Patients subsequently complain of generalised muscle ache or headache. Unilateral bite injuries to the side of the tongue are highly suggestive of generalised tonic‐clonic seizures8, as are certain other less common injuries such as shoulder fracture and/or dislocation. Todd’s paresis (post‐ictal limb weakness) may be present, although this is not specific: functional weakness is frequently preceded by a dissociative attack9. Urinary or faecal incontinence are not specific for epileptic seizures and barely worth asking about. Patients with syncope – either vasovagal or cardiac –recover quickly without true confusion or disordered behaviour as seen in the post‐ictal phase, although some patients feel exhausted and fatigued for some time after a faint. Past medical history The remainder of the history should not be neglected, with emphasis on drugs – including over‐the‐counter and recreational drugs – and alcohol. A recent head injury should prompt consideration of subdural haematoma or other intracranial bleeding, especially in patients taking anti‐thrombotic drugs. Recent overseas travel means infections not found within the UK may enter the differential. A history of cancer – particular cancers that metastasise to brain, such as lung, breast, or melanoma10 – is also important. You should ask about developmental and childhood history (in particular, if there were any febrile convulsions), the family history, and any suggestion of previous seizures (e.g. multiple unexplained blackouts or other funny turns). Examination Examination often provides few diagnostic clues (if any) and the history is of far greater importance. Your time will be better spent telephoning a witness than pursuing a rushed neurological examination. Taking the pulse and auscultating the heart are important, especially if the history suggests syncope. Whilst a detailed neurological examination may reveal focal signs suggestive of an underlying structural lesion, you should have decided by the end of the history whether referral to a ‘First Seizure’ Clinic is merited. The presence of persisting abnormalities such as fever, rash, drowsiness, headache, or other focal signs indicate a need for admission for more urgent investigations.
Investigations All patients with suspected seizure should have basic blood tests. The white cell count is often elevated post seizure (and rarely indicates underlying infection), but the CRP is unlikely to be significantly elevated unless there is a concomitant infection11. A 12‐lead
electrocardiogram (ECG) is essential for all patients presenting with TLOC. Table 3 lists mandatory and optional investigations for a suspected first seizure. Decisions regarding specialist investigations such as EEG and brain imaging are usually best deferred to the First Seizure clinic, but occasionally urgent brain imaging (usually CT in the first instance) is warranted (Table 4).
Table 3: Investigations for TLOC Mandatory FBC, U&Es, glucose, LFTs (including gamma GT if suggestion of alcohol excess), calcium 12‐lead Electrocardiogram For consideration Toxicology screen: urinary drugs testing, blood alcohol level Chest radiograph (if aspiration or infection suspected) CT head (see table 4) Pregnancy test 24hr electrocardiogram/ echocardiogram
Table 4: Indications for urgent CT head after TLOC 1‐ Persisting significant focal neurological deficit or confusion/decreased awareness 2‐ Recent head injury (especially if anti‐coagulated) 3‐ Recent diagnosis of malignancy likely to metastasise to brain (e.g. lung, melanoma, breast)
Treatment TLOC with full recovery does not usually require treatment. Defer the decision to commence anti‐epileptic drugs (AEDs) to a specialist; there is rarely an indication for urgent initiation of an AED but if you think this is the case then discuss this with the on‐call neurologist first. Treatment of status epilepticus is beyond the scope of this article12.
Follow‐Up All patients with possible or suspected seizures should be referred to an appropriate clinic, ideally a rapid access First Seizure clinic. The SIGN epilepsy guidelines (SIGN 70) state that the patient should be reviewed by a specialist within 2 weeks13. Different hospitals have different pathways to achieve this, and you should become familiar with the protocol within your own hospital. If there is none, then you should be asking (loudly) why not! Patients with a secure diagnosis of vasovagal syncope do not need specialist referral unless there are diagnostic doubts or the episodes are frequent. Patients with suspected cardiac syncope require an urgent cardiology opinion. Driving regulations are available from the DVLA website14, but anyone who has had a TLOC which is not due to a simple faint is legally obliged to inform the DVLA, and your job as a doctor is to remind them of this legal duty. A first ever seizure will lead to a 6 month suspension for Group 1 licences, but recurrent seizures increase this to 12 months. Group 2 (HGV) drivers have more stringent regulations. Patients should always be informed of the relevant regulations and you must document this in the notes.
Advice to Patients TLOC often causes great concern amongst patients and carers. Therefore you should provide an explanation of your diagnosis wherever possible, with reassurance where appropriate (e.g. fainting). If you are referring on to a specialist, explain why, and how long they might
have to wait (but be realistic ‐ do not say next week if you know this is unlikely to be the case!). Remember that patients may have impaired memory in the aftermath of a seizure – even if they appear alert – and that providing written information is worthwhile (and copying your subsequent clinical letter to the patient will further enhance good communication). Some aspects to consider when speaking to patients are as follows:
• Seizures are common: up to one in 20 people (5%) of people will suffer at least one epileptic seizure in their lifetime
• Having one seizure does not mean epilepsy
• Consider driving advice; if you are unsure, or suspect anything other than a faint, recommend they do not drive until after further specialist assessment
• Avoid situations that could be dangerous: e.g. working at height, using heavy
machinery, or swimming unsupervised Many hospitals have their own information sheets but epilepsy charities also provide leaflets or online information15 16. Patients often have concerns regarding the impact of advice – particularly driving regulations ‐ on their work and home lives. It can help to give the patient a copy of the discharge letter with the advice included so that it can be given to their employer. Patients may ask whether having a seizure means that they have epilepsy. Since epilepsy is defined as a tendency to recurrent seizures then it is clear that a diagnosis of epilepsy cannot be made after a single seizure. About half of patients presenting with a first ever seizure will develop epilepsy within the next 2 years17.
Summary TLOC is a common presentation to the ARU. Most of these patients have benign diagnoses (mainly vasovagal syncope) but some will have had an epileptic seizure. The diagnosis can be challenging and there is often an element of uncertainty, even after an expert opinion has been sought. A thorough history from both patient and witness is the only way to reach as accurate a diagnosis as possible, as investigations rarely reveal what might have happened. It is important to give the patient an explanation of what you think caused their symptoms. Do not make a diagnosis if you are uncertain and remember that epilepsy cannot be diagnosed after a single seizure. If you suspect that your patient has had a seizure, or do not know how to adequately explain their TLOC, then you should refer the patient for further specialist opinion.
Case Histories Case History One An 18 year old girl presented with TLOC. She had gone to bed late the preceding night after clubbing. Her recollection was limited to vaguely recalling going to bed, and then awakening in the Emergency department with a headache, a bitten tongue, and sore arms and legs which persisted for 2 days. Her mother was alerted by a loud ‘thump’ in the morning and found her daughter rigid and unresponsive on the floor with blue lips, progressing to jerking of all four limbs, lasting for about two minutes. Afterwards she was confused, did not recognise her mother, and fought the paramedics when they tried to apply an oxygen mask. On direct questioning, she and her mother agreed that for at least a year they had noted frequent sudden twitchy jerks, usually of her arms, and usually in the mornings. Indeed her
morning “clumsiness” had become something of a family joke, and her mother thought it was simply part of being a teenager who disliked early starts. When seen in the First seizure clinic a week later, it was thought the likely diagnosis was juvenile myoclonic epilepsy ‐ an idiopathic generalised epilepsy syndrome that typically presents with early morning myoclonic jerks (sometimes with absences as well) and eventually leads to tonic‐clonic seizures. The diagnosis was confirmed with an EEG (Figure 1). In this case, the easy part of the diagnosis was recognising the hallmarks of the tonic‐clonic seizure, but equally important was the identification and recognition of the preceding myoclonus, which altered the diagnosis from an isolated seizure to one of epilepsy, with important therapeutic implications.
Figure 1 1A: Normal EEG (with eyelid artefact occurring near start of trace)
1B: EEG from Patient 1, revealing generalised epileptic discharges consistent with generalised epilepsy such as juvenile myoclonic epilepsy (eventual diagnosis in Patient 1)
Case History Two A 70 year old woman presented with TLOC. She had been on a cruise and had contracted “winter vomiting virus”. She recalled getting up from the toilet, feeling hot/cold/clammy and
sweaty, and then waking up on the floor of the cabin and hearing her husband frantically trying to reach the operator on the telephone. Her husband noted her to stagger out of the toilet, and then collapse to the floor, whereupon she briefly twitched and jerked for perhaps 10 seconds. The husband described this initially as a fit and had to be coaxed into providing more detail, which clarified that the events were more like brief asynchronous and short‐lived myoclonic jerking than the rhythmical, more prolonged jerking typical of an epileptic seizure. He said she was “white”, and after the twitching stopped, he thought she had died, as all movement ceased briefly; whilst he was on the telephone she suddenly called his name and regained awareness, before vomiting. She had a bump over her forehead but no other injuries. She was evacuated from the ship by helicopter after the exhausted ship’s doctor thought she had experienced a convulsion secondary to sepsis. Retrospective review of the history suggested that this was most likely to have been a convulsive reflex syncope in association with norovirus infection, which required no further investigation, and she was able to retain her driving licence. It is very useful to extract the suggestion that a witness thought the patient had “gone”; this almost always means syncope not seizure (although witnesses may worry that a patient having a seizure might be dying, it is rare that they think they have actually died as this implies complete lack of movement, which is much more common in syncope). Such questioning requires tact and sensitivity, as it is frequently distressing for both the witness and patient to recall, but constitutes very useful diagnostic information. References Full references for this article can be found in the pdf of the individual article 1 Fitzpatrick AP, Cooper P. Diagnosis and management of patients with blackouts. eart 2006; 92:559‐568 2 Fisher RS, van Emde Boas W, Blume W, et al. Epileptic seizures and epilepsy: definitions proposed by the International League Against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE). Epilepsia 2005; 46:470‐2 3 Sander JW, Shorvon SD. Epidemiology of the epilepsies. J Neurol Neurosurg Psychiatry 1996; 61:433–43. 4 MacDonald BK, Cockerell OC, Sander JW, et al. The incidence and lifetime prevalence of neurological disorders in a prospective community‐based study in the UK. Brain 2000; 123:665‐76 5 http://www.ilae.org/Visitors/Centre/ctf/documents/ILAEHandoutV10_000.pdf 6 The guideline development group. Scottish Intercollegiate Guidelines Network. Guideline 81. Diagnosis and management of epilepsies in children and young people. 2005. 7 Lempert T, Bauer M, Schmidt D. Syncope: a videometric analysis of 56 episodes of transient cerebral hypoxia. Ann. Neurol. 1994; 36:233‐7 8 Benbardis SR, Wolgamuth BR, Goren H, et al. Value of tongue biting in the diagnosis of seizures. Arch Int Med 1995; 155:2346‐9 9 Stone J, Warlow C, Sharpe M. Functional weakness: clues to mechanism from the nature of onset. J Neurol Neurosurg Psychiatry 2012; 83:67‐9 10 Nussbaum ES, Djalilian HR, Cho KH, et al. Brain metastases: histology, multiplicity, surgery, and survival. Cancer 1996; 78:1781‐8 11 Peltola J, Laaksonen J, Haapala AM, et al. Indicators of inflammation after recent tonic‐clonic epileptic seizures correlated with plasma interleukin‐6 levels. Seizure 2002; 11:44‐46 12 Kelso ARC, Cock HR. Status epilepticus. Pract Neurol 2005;5:322‐333 13 The guideline development group. Scottish Intercollegiate Guidelines Network. Guideline 70. Diagnosis and management of epilepsy in adults. 2003. 14 http://www.dft.gov.uk/dvla/medical/aag.aspx 15 Epilepsy Action: http://www.epilepsy.org.uk/ 16 Epilepsy Scotland: http://www.epilepsyscotland.org.uk/
Common Mental Health Conditions in Primary Care Fiona Carver (Lecturer in Mental Health Nursing, Edinburgh Napier University) & Fiona Jones (3rd year BN in Mental Health Nursing) Correspondence to: Fiona Carver : [email protected]
ABSTRACT
Common mental health problems particularly depression and anxiety are frequently found in primary care settings. Depression can range from mild to severe but even in less severe cases can cause problems with normal functioning. Anxiety regularly manifests itself with depression but anxiety disorders, of which there are several, are also likely to disrupt normal life. There are several treatments for these conditions both pharmacological and psychological. Severe mental illness (SMI), generally bipolar disorder and schizophrenia, is also managed by primary care health professionals therefore it is essential these professionals are aware of how these conditions may present and the current treatments available. Bipolar disorder, a serious mood disorder, is often under‐diagnosed in primary care that has implications for the individual’s care and treatment. People with schizophrenia are often monitored by primary care health professionals although liaison and referral to secondary services is recommended for both these SMIs. A holistic recovery focused approach to care is recommended. Key Words: primary care; psychiatry; mental health nursing Common Mental Health Problems in Primary Care Common mental health problems (CMHPs) have been described ‘as extreme forms of ‘normal’ emotional experiences such as depression and anxiety1. Depression, anxiety disorders and mixed anxiety and depression are widespread with a huge burden on society in terms of emotional, social and economic hardship2,3. NICE 4 discusses that although CMHPs will differ in how people are affected, the risk of chronic ill health is possible. It has been found that 90% of common mental health problems are managed in primary care with between 25 and 30% of consultations to GPs related to CMHP5‐8. Depression has been predicted by the WHO to be the second highest cause of morbidity worldwide by 2020 3. Depression Depression is a mood disorder which although is a common mental health problem can be severe enough to endanger life. However, even in less serious cases it is likely to have an impact on all areas of the individual’s functioning. It is estimated that 1,250,000 people living in Scotland will experience depression and that 500,000 Scots are currently enduring varying symptoms of depression9. Depression is likely to occur in people across the lifespan from children to older adults. It is generally accepted that to diagnose depression, the symptoms are classified according to either Diagnostic and Statistical Manual of Mental Health Disorders (DSM) issue IV 10 or International Classification of Diseases (ICD) issue 10 11 (Table 1).
Table 1: Making a Diagnosis of Depression in Primary Care DSM IV
• 5 or more of following symptoms present nearly every day for same 2 week period
• At least 1 of the symptoms is either depressed mood, or loss of interest or pleasure
• Weight loss/weight gain • Insomnia/hypersomnia • Fatigue/loss of energy • Feelings of worthlessness • Reduced concentration • Recurrent suicidal ideation • Psychomotor agitation/retardation
ICD10
• Individual usually suffers from depressed mood, loss of interest and enjoyment, reduced energy
Other common symptoms –
• reduced concentration • reduced self confidence • ideas of guilt/unworthiness • pessimistic views of future • disturbed sleep • reduced appetite • ideas/acts of self‐harm or suicide
Although the cause of depression is unclear, several theories have been put forward12. These can be classed as biological influences – genetics, neurotransmitters, endocrine factors and immune system deficits and non biological considerations – early life experiences, current life events, social isolation, gender and socioeconomic factors. Generally a combination of factors will contribute to someone becoming depressed. Frequently depression and anxiety will be experienced together and even in mild depression anxiety is often present13.
500,000 Scots are currently enduring varying symptoms of depression
Anxiety and Anxiety Disorders Anxiety is common to all human beings and can be seen to be an understandable reaction to stressful life events. At normal levels it has a protective and invigorating function. However it can become severe enough to disrupt normal functioning and at this point can be classified as a disorder14. McManus, Shafran, & Cooper 15 claim that ‘anxiety disorders have a
profoundly negative impact on quality of life and are the most economically costly of all psychiatric disorders’. Although anxiety itself is a generic term, it can be classified into several disorders (Table 2). Table 2; Disorders within the spectrum of an anxiety diagnosis The main conditions are:
• generalised anxiety disorder (GAD) • panic disorder (PD) • obsessive compulsive disorder (OCD) • post‐traumatic stress disorder (PTSD) • social anxiety disorder • specific or simple phobia
Research has shown that suffering from these disorders will adversely affect an individual’s quality of life16. In the general population it has been suggested that one in four people will meet the criteria for an anxiety disorder throughout their lives17. Several theories have been put forward to explain the development of anxiety disorders. These purport to be biological or genetic, cognitive‐ behavioural or that anxiety is a learned behaviour. It has been claimed that anxiety is ‘one of the most common treatable mental disorders’ 18 and there are specific interventions which can be employed to deal with this.
Mixed Depression and Anxiety It is clear that both depression and anxiety have a range of symptoms that are overlapping. Watson et.al 19 would argue that although it has proved difficult to separate the two conditions, both depression and anxiety have distinctly different manifestations. It has been found that within the general population that comorbid depression and anxiety occur in over half those who report symptoms 17 Psychological therapies are being recommended as first line treatment of depression and anxiety 20,4,21
NICE 4 advocates a Stepped Care Model so that people with CMHPs receive the most effective treatment. In this model people will be offered the most appropriate therapy for their problem from low intensity interventions for example psychoeducation or guided self help based on (Cognitive Behavioural Therapy) CBT principles to high intensity one to one psychotherapy. Currently both CBT and Interpersonal Therapy (IPT) are recommended for the treatment of depression 4,21. Depending on the severity of the depression this can be in conjunction with antidepressant medication9. Anxiety disorders are generally treated with CBT, applied relaxation and/or antidepressant medication depending on the specific condition 4.
Severe Mental Illness in Primary Care Sadler 22 discusses that health professionals working in primary care should be as aware of early warning signs of mental ill‐health as they are of signs of chronic physical health problems. As well as CMHPs a significant number of people with severe mental illness (SMI) will be supported within a primary care setting. Both bipolar disorder and schizophrenia are deemed to be SMIs and it is essential that health professionals working in primary care are aware of how these can present and current treatment. Despite SMIs being relatively common in community settings there is a lack of awareness by staff including GPs regarding bipolar disorder 23.
Bipolar Disorder As with depression, bipolar disorder is a mood disorder. It is a serious mental health problem which is distinguished by periods of mania and depression. However in those with bipolar disorder although 90% will have experienced a major depressive episode this does not have to be present to warrant diagnosis to be made 24. According to DSMIV bipolar disorder is classified into types I and II 10. Type I is characterised by having experienced one or more manic episodes (lasting at least a week). Although having a depressive episode is not required for the diagnosis of type I bipolar disorder, the majority of people will experience both depressive and manic episodes. People can experience multiple episodes of disturbed mood. The lifetime prevalence of bipolar I is estimated at 1% of the adult population. The majority of people with bipolar disorder type I will experience episodes of major depression and episodes of mania. Mania is characterised by specific symptoms (Table 3). Mixed episodes where an individual experiences symptoms of irritability and sadness with elation are not uncommon. Misdiagnosis of bipolar disorder in primary care is common as individuals are likely to present with a depressive episode. There is evidence that people with bipolar disorder can have more than one episode of depression before the onset of mania 25. Diagnosis of type II is made if an individual experiences at least one hypomanic episode (not severe enough to be classed as mania however) and one depressive episode 24. Normally symptoms of bipolar disorder will develop between the ages of 15 and 24 years. Establishing the correct diagnosis is important as treatment must be specific to bipolar disorder. There is a risk of inducing a manic episode or causing the person to experience rapid cycling of mood by treating the depression with antidepressants only 23. Smith et.al 26
found that bipolar disorder was under recognised in primary care settings. It has been discussed that the complex nature of bipolar disorder has implications for management of people in primary care 27. When people experience severe mood swings there is likely to be disruption to relationships, employment and subsequent financial difficulties. Substance misuse is common 23. People with bipolar disorder are at higher risk of physical health problems and of suicide 28. The management of bipolar disorder is twofold as people may need treatment for both acute symptoms and longer term therapy to maintain their mood at an optimal level. Acute symptoms of mania will commonly be treated with antipsychotic medication and short term benzodiazepines for agitation. Pharmacological management in the longer term is generally with mood stabilisers ‐ Lithium; antipsychotics – Olanzapine; or anticonvulsants – Valproate 29 These may be used in combination depending on the severity of the illness and would normally be continued for 2‐5 years. As well as pharmacological treatment for bipolar disorder NICE 29 recommends that health professionals advise people with bipolar disorder about self management particularly of early warning signs and lifestyle strategies. There is evidence that psychological therapies (CBT & IPT) and psychoeducation have a part to play in helping people manage bipolar disorder30. NICE 29 makes specific recommendations for primary care health professionals to consider liaison with and referral to secondary services for people with bipolar disorder. Another SMI is schizophrenia, which can present in primary care but is often treated in secondary care.
Table 3 : Core diagnostic features in Bipolar Disorder Emotional Mood swings such as euphoria/elation to anger/irritability Immediate gratification of wishes Cognitive Racing thoughts, pressure of speech Distractible Flight of ideas Impaired judgement Behavioural Intrusive/demanding/aggressive Impulsive Sexually disinhibited, increased libido
Physical Increased energy/always on the go Decreased need for sleep Appetite changes Lack of attention to personal hygiene/general health Psychotic symptoms in mania Delusions – generally mood congruent. Grandiose in nature – beliefs about being royalty or having special powers but can be persecutory Hallucinations –most commonly auditory, don’t tend to be unpleasant
Schizophrenia Schizophrenia is a serious mental illness that features a cluster of conditions including positive and negative symptoms and schizophrenic thinking. Hallucinations are a positive symptom that are most commonly auditory, but can also be visual, tactile or olfactory related. Negative symptoms are often a lowering of mood, lack of motivation, becoming socially withdrawn and unemotional 31.Schizophrenic thinking refers to a disturbance of normal thought, such as delusions or thought insertion or withdrawal 11. It should be acknowledged that every individual will have different combinations of symptoms unique to them 20(Table 4). Table 4: Core diagnostic features in Schizophrenia
Positive Symptoms Schizophrenic thinking Delusions Hallucinations
Negative Symptoms Lower mood Loss of interest Social withdrawal
There is no definitive cause but it appears to be related to stress vulnerability. Zubin & Spring 32 explain this as people with low tolerance to stress, perhaps due to genetic loading or environmental factors such as childhood trauma, are more likely to develop symptoms. About 1% of the population develop schizophrenia20. According to DSM‐IV 33, it affects males and females equally and different populations equally worldwide. It often first appears in early adulthood. According to ICD‐10 11 classification, there can be a prodromal period of time where loss of interest, self‐isolation and problems with mood appear, most often in young people. However, there is insufficient evidence to conclude that prodromal symptoms should be included in the diagnostic criteria for schizophrenia. Substance misuse should be ruled out before diagnosis as this can cause psychotic symptoms to occur 10. It is also true that people with schizophrenia misuse substances more frequently than the rest of the population, making it difficult to make an accurate assessment. NICE 20 recommends that oral anti‐psychotic medication is prescribed. This is in order to decrease the positive symptoms. Although modern atypical anti‐psychotics don’t carry the same risk of extrapyramidal side effects that typical medication does, they still have
unpleasant side effects, such as weight gain, cardio‐vascular problems and, with clozapine in particular, agranulocytosis20. Clozapine should be offered to people who have not successfully been treated with at least two other anti‐psychotic medications. Any serious side effects may affect compliance with the medication. Where there is difficulty with daily medication compliance, intra‐muscular depot injections may be offered. Some people prefer this, as oral medication will need to be taken every day however depots can be given less frequently. People experiencing distressing hallucinations and delusions may be treated in an acute psychiatric ward in hospital in order to stabilise their symptoms with medication before discharging back to the community. Living in the community can be successful with the help of carers11. Many people with schizophrenia will be looked after in the community by Community Psychiatric Nurses. They may visit to give depot injections, provide emotional support and signpost to voluntary organisations which may run support groups. Having a diagnosis of schizophrenia carries with it a stigma, perhaps due to a lack of understanding by family, friends and the general public. This can mean it is difficult to maintain work or study and relationships may breakdown. The first few years after the person develops schizophrenia can be very difficult, meaning that there can be an increased risk of suicide20. NICE20 also recommends that professionals involved should work in a recovery focused manner, conveying hope and optimism. A holistic care approach should be given, including yearly physical health checks to monitor cardio‐vascular disease in particular. SIGN 34 advises that education on the illness and effects of medication is provided to the service user and carer by an experienced professional. A Family Intervention Programme should be offered to address any relationship difficulties and CBT should be offered to help with distressing symptoms. NICE 20 also suggest art therapies to help with negative symptoms. Psychosis can appear in severe depression and in bipolar disorder as well as in schizophrenia. People with SMIs often are admitted to secondary care during acute episodes of mania or psychosis, more so than depression and anxiety. Community Mental Health Teams (CMHTs) are required to make decisions on when to admit someone to hospital; usually if there are concerns about a person’s safety or others’ safety. However, once the acute phase has settled, people can be discharged back to the community with increased support from CMHTs if necessary. There is evidence that crisis intervention teams can provide care in the home that is more acceptable to both the person and their carers. It has also been seen to reduce repeated admissions to hospital 35.
Conclusion Depression and anxiety are very common mental health problems that are mostly treated in primary care. They have a huge impact on society with people having extended periods of sickness absence from work and can negatively affect relationships. Although they are individual conditions, frequently they are diagnosed together and many of the symptoms overlap, however vulnerability factors may be different. More SMI problems such as bipolar disorder and schizophrenia may be diagnosed in primary care, but acute manic or psychotic episodes are often treated in secondary care. CMHTs help support people diagnosed with these conditions in the community but if people experience acute mania or psychosis they may need to arrange admission to hospital or referral to a crisis intervention team in order to stabilise their symptoms. In conclusion, increased awareness of the symptoms of mental ill‐health is required by health professionals in primary care to maximise appropriate diagnosis and treatment.
References Full references for this article can be found in the pdf of the individual article Scottish Universities Medical Journal NOW Accepting Submissions for Upcoming Issues
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Approaching Geriatric Patients: The Frequent Fallers Nabil Aly (Consultant Physician, University Hospital Aintree, Liverpool) & Inte H Malik (Consultant Physician, Caithness General Hospital, Wick) Correspondence to: Nabil Aly : [email protected]
ABSTRACT
Falls and fall related injuries are common medical problems experienced by older adults. Most falls have multiple causes resulting from a complex interplay of predisposing and precipitating factors in a person’s environment. Recurrent falls, defined as more than two falls in a six‐month period, should be evaluated for treatable causes using effective fall prevention strategies. The frequency of falling is related to the accumulated effect of multiple disorders superimposed on age‐related changes. Multi‐factorial interventions targeting identified risk factors, exercises for muscle strengthening combined with balance training, and withdrawal of psychotropic medication are among the most effective fall prevention strategies.
Key Words: Falls; risk; prevention and intervention.
Introduction A fall, in simple terms, is an involuntary event producing a change in posture resulting in the individual adopting an unplanned supine position. It is defined as 'inadvertently coming to rest on the ground or other lower level without loss of consciousness and other than as a consequence of sudden onset of paralysis, epileptic seizure, excess alcohol intake or overwhelming physical force' . Falls are a major health problem for older people, through both immediate effects such as fractures and head injuries and longer terms problems such as disability, fear of falling, and loss of independence1. In the United Kingdom the national service framework for older people, published in 2001, required the National Health Service (NHS) to establish specialised programmes for fall prevention2. The National Institute for Health and Clinical Excellence (NICE) clinical practice guideline for the assessment and prevention of falls in older people recommended that multi‐factorial risk assessment and individualised interventions should be undertaken3. Such services, including specialist falls clinics, have now been introduced throughout the UK NHS but in the absence of any evidence about the optimum configuration, they have varied in location, skill mix, assessments, and interventions offered4.
Epidemiology Falls are a common and serious problem in older people. One in four adults aged over 70 fall each year and nearly one in two are aged over 80, half of whom fall again in the following year5. Ambulance services are often called as an emergency to assist older people who have fallen6. In some countries all people who call an ambulance are taken to hospital but in others, such as the United Kingdom and United States, between 30% and 50% of such people are not taken to hospital5. An emergency ambulance crew will assess the extent of injury and need for acute medical care, but this service will not assess the underlying risk factors for falling nor attempt to ameliorate them. The policies of the ambulance service in the United Kingdom encourage an increase in the proportion of such people managed at
home to reduce demand on hospital emergency departments7. In England and Wales, trips and falls are the commonest causes of patient safety incidents reported by NHS organisations, according to the figures from the National Patient Safety Agency (NPSA) 8. Figures for England show an increase in reports of incidents, while there has been a decrease in Wales8. They constituted 28% of incidents in England and 39% in Wales; and less than 1% of incidents led to severe harm or death8. Aetiology Most of the falls result from a complex interplay of predisposing and precipitating factors in a person’s environment. One half to two thirds of falls occur in or around the patient’s home9. Environmental hazards are the leading cause of falls, accounting for about 25 to 45 percent in most studies9. Gait disturbance and muscle weakness also are common causes. Dizziness, vertigo, drop attacks, postural hypotension, visual impairment, and syncope also are known to cause falls9. For an individual a fall (or falls) is generally a symptom of underlying problem not an explicit diagnostic sign. That is not to diminish the sentinel importance of falls but to understand that they represent a symptom needing the same clinical approach perhaps as delirium, not presuming to attribute specific cause, blame or remedy but to trigger a careful individual investigation and management plan10. Falls in older people are sensitive to at least 4 spheres of influence10:
1. The physical status of the individual (ranging from disease related disability, physical fitness and nutritional and hydration status)
2. The mental state of the individual ( a range of mental illness, dementias, confidence and (for want of a better term) attention seeking behaviour)
3. The influence of environmental factors (ranging from design of hospital or care setting through to care regime)
4. The impact of medication, adverse or beneficial.
Falls Risk Factors
The risk of sustaining an injury from a fall depends on the individual patient's susceptibility and environmental hazards. The frequency of falling is related to the accumulated effect of multiple disorders superimposed on age‐related changes. Those with recurrent falls, defined as more than two falls in a six‐month period, are sometimes described as “frequent fallers”. The literature recognizes a myriad of risk factors for falls (Table 1)11. The likelihood of falling increases with the number of risk factors12. The falls risk factors can be intrinsic (i.e., age‐related physiologic changes, diseases and medications) or extrinsic (i.e., environmental hazards). It is essential to remember that a single fall may have multiple causes, and repeated falls may each have a different aetiology. Thus, it is critical to evaluate each occurrence separately.
A). Intrinsic Factors
Normal physical and mental changes related to ageing, but not associated with disease, can decrease functional reserve. As a result, older patients become more susceptible to falls when they are confronted with any challenge. Some age‐related changes are not necessarily “normal,” but they are modifiable. When possible, these conditions should be treated. Virtually any acute or chronic disease can cause or contribute to falls11.
B). Extrinsic Factors
In a fall, more active persons are likely to be exposed to high‐intensity forces at impact, whereas the risk of injury in less active persons depends more on their susceptibility (i.e., the presence of fragile bones or ineffective protective responses)13. Frail older persons tend to fall and injure themselves in the home during the course of routine activities. Vigorous older persons are more likely to participate in dynamic activities and to fall and be injured while challenged by environmental hazards such as stairs or unfamiliar areas away from home14. A variety of extrinsic factors, such as poor lighting, unsafe stairways and irregular floor surfaces, are involved in falls among the elderly. Many of these factors can be modified11. The most common aetiologies of falls are listed in Table1.
Table 1 . Most common aetiologies of falls among older adults
Aetiology (s) Examples Gait disturbance &
balance disorders Neurological disorder, muscle weakness,
or pain related to arthritis
Cardiovascular disorder Postural hypotension [Excluding: Severe aortic stenosis, arrhythmia, or carotid hypersensitivity]
Chronic diseases Neurological: Central nervous system disorder, stroke and Parkinson’s disease [Excluding: drop attacks, epilepsy]
Musculo‐skeletal: Arthritis, myopathies. Visual disorders
Acute illness Acute infection Acute metabolic disorder
Cognitive disorder Acute confusion, delirium and significant memory impairment
Medications or alcohol Sedatives, hypotensive agents and hypoglycemic agents
Anti‐psychotics Poly‐pharmacy
Intrinsic Factors
Age‐related changes Loss of mobility, impaired balance
Extrinsic Factors
• Accident or fall from bed • Environmental hazard (uneven pavement, steep staircase or
slippery floor). • Poor lighting • Footwear problems
Clinical Consequences Falls and fall related injuries are among the most serious and common medical problems experienced by older adults. Nearly one‐third of older persons fall each year, and half of them fall more than once15. Because of underlying osteoporosis and decreased mobility and reflexes, falls often result in hip fractures and other fractures, head injuries and even death in older adults. Accidental injuries are the fifth most common cause of death in older adults15. In around 75% of hip fracture patients, recovery is incomplete and overall health deteriorates15. The most consistently proven predictors of fall risk are history of a fall during the past year and gait and balance abnormalities16. Some studies indicated that impaired vision, certain medications , especially psychotropic drugs, decreased activities of daily living and impaired cognition are associated with a higher risk of falls17. The contribution of orthostatic hypotension to fall risk remains uncertain16.
Falls Assessment A single fall is not always a sign of a major problem and an increased risk for subsequent falls. The fall may simply be an isolated event. However, recurrent falls, defined as more than two falls in a six‐month period, should be evaluated for treatable causes. An immediate evaluation is required for falls that produce injuries or are associated with a new acute illness, loss of consciousness, fever or abnormal blood pressure11. 1. History A thorough history is essential to determine the mechanism of falling, specific risk factors for falls, impairments that contribute to falls and the appropriate diagnostic work‐up. Many patients attribute a fall to “just tripping,” but physicians and General Practitioners (GPs) must determine if the fall occurred because of an environmental obstacle or another precipitating factor. The physician should ask about the activity the patient was engaged in just before and at the time of the fall, especially if the activity involved a positional change. The location of the fall should be ascertained. It is also important to know whether anyone witnessed the fall and whether the patient sustained any injuries. The patient and, if applicable, witnesses or caregivers should be asked in detail about previous falls and whether the falls were the same or different in character11. The physician also needs to determine who is available to assist the patient and the duration of being on the floor. A critical element of the targeted history is a review of medications, including prescription, over‐the‐counter, herbal and illicit drugs. Red flags are polypharmacy (four or more prescription medications), the initiation of a new drug therapy in the previous two weeks and the use of any drug known to enhance the risk of falling11. Tricyclic antidepressants and other heterocyclic antidepressants have long been associated with an increased risk for falls11. 2. Physical Examination Physical assessment of patients following a fall should focus on three aspects:
a. Assessment of fall‐related injury b. Identification of fall risk factors, particularly the reversible ones (such as postural
hypotension). c. Identification of falls consequences or complications (such as fear of falling
syndrome) This approach may focus the physician's attention on common problems that are likely to respond to treatment. Most falls have multiple causes and only rarely are all of the causes
fully reversible. Nonetheless, a partial positive impact on one or a few causes often makes a major difference in quality of life for the patients and carers11. 3. Further assessment:
• Home and environmental visit: A home visit is invaluable for assessing modifiable risk factors and determining appropriate interventions. A home safety checklist can guide the visit and ensure a thorough evaluation18. It is particularly important to assess caregiver and housing arrangements, environmental hazards, alcohol use and compliance with medications19.
• Balance and Gait Testing: Several simple tests have exhibited a strong correlation with a history of falling. One‐leg balance is tested by having the patient stand unassisted on one leg for five seconds. The timed “Up & Go” test evaluates gait and balance provides more detailed assessment (Table 2)20. A score of 30 seconds or greater indicates that the patient has impaired mobility and requires assistance (i.e., has a high risk of falling). This test has been shown to be as valid as sophisticated gait testing20. In watching patients perform the test, the physician should also consider the following questions: How safe does this activity appear for this patient? Are there any tip‐offs to remediable causes of impaired mobility? 11.
Table 2: Timed “Up & Go” Test
Components Explanation
Task • The patient gets up out of a standard armchair (seat height of approximately 46 cm [18.4 in.]), walks a distance of 3 meter (10 ft.), turns, walks back to the chair and sits down again.
• The patient wears regular footwear and, if applicable, uses any customary walking aid (e.g., walking stick or frame).
• No physical assistance is given. Requirements • Armchair, stopwatch (or wristwatch with a second hand) and a measured
path Assessment • The physician/Falls‐nurse uses a stopwatch or a wristwatch with a second
hand to time this activity. Time (seconds) Functional rating
< 10 Freely mobile < 20 Mostly independent 20 to 29 Variable mobility
Results
> 30 Impaired mobility
Screening Older patients with known risk factors for falling should be questioned about falls on a periodic basis. Many falls may never come to the physician’s attention because the patient may not volunteer the information Specific inquiry is necessary because of the fears many older persons harbour about being institutionalized. Thus, these patients are unlikely to give falling as a chief complaint11.
Investigations The role of laboratory testing and diagnostic evaluation for fall prevention has not been well studied. It is reasonable to perform tests to determine complete blood count, and thyroid function, electrolytes, blood urea, creatinine, glucose, and vitamin B12 levels. The results can help rule out potentially treatable causes for falls such as anaemia, dehydration, hypoglycaemia, or hyperglycemias. There is an association between falls and syncope, and older persons who fall may not be aware of episodes of loss of consciousness21. Syncope evaluation should be considered in older persons who have unexplained falls, possibly in consultation with their cardiologist21. This could include ambulatory electrocardiography (Holter monitor), tilt‐table test and an echocardiogram. Brain imaging and other relevant studies may be considered based on abnormalities suggested by the history and physical examination.
Falls Management and Prevention Prevention of falls and injuries has been a major focus of research, stimulated by ageing populations and by growing awareness of the mortality and morbidity resulting from falls. Earlier reviews of randomised controlled trials of fall prevention interventions concluded that several types of intervention are effective, including training in strength and balance, modification of hazards at home, and withdrawal of psychotropic drugs22. Multi‐factorial risk assessment of falls followed by targeting of interventions to an individual’s risk factors is an attractive strategy as it could reduce several components of fall risk and would be expected to lead to greater reductions in falls than dealing with risk factors in isolation. Earlier reviews suggested that this type of intervention may be among the most effective, and it is recommended as a primary treatment strategy in the guideline for prevention of falls published by the American Geriatrics Society and British Geriatrics Society22‐24. Several studies have examined single risk‐factor modification and multi‐factorial interventions, and have found that both can prevent falls in older patients, table 3 9. For example, when the assessment indicates gait and balance disturbance, interventions should include management of underlying medical conditions, modification of medication that impairs balance, and referral to a physical therapist for gait and balance exercises and assistive devices9. Patients with orthostatic (postural) hypotension can be helped with the use of compensatory strategies, such as rising slowly or sitting on the side of the bed for several minutes before standing, review and reduction of medications, adequate hydration, and use of elastic stockings to minimize venous pooling in the legs. Liberal use of salt and pharmacologic therapy with fludrocortisone or midodrine can help maintain normal blood pressure9. Cardiac arrhythmias or syncope clearly associated with a fall should be treated with anti‐arrhythmic agents or a pacemaker in consultation with a cardiologist9.
Conclusion Falls are one of the most common geriatric syndromes threatening the independence of older persons. Most falls have multiple causes. Risk factors for falls include muscle weakness, a history of falls, use of four or more prescription medications, use of an assistive device, arthritis, depression, age older than 80 years, and impairments in gait, balance, cognition, vision, and activities of daily living. Physicians caring for older patients should ask about any falls that have occurred in the past year. Assessment should include evaluating the circumstances of the fall and a complete history and physical examination, looking for potential risk factors. Falls are associated with increased morbidity, mortality, and nursing home placement. The most effective fall prevention strategies are multi‐factorial interventions targeting identified risk factors, exercises for muscle strengthening combined
with balance training, and withdrawal of psychotropic medication. Home hazard assessment and modification by a health professional also is helpful. Table 3: Single and multi‐factorial interventions in falls management
Single Interventions
Multi‐factorial Interventions
• Exercise and Physical Therapy. Such programs significantly decreased the number of individuals experiencing a fall over one year when compared with a control group that received no intervention. These include balance retraining, a 15‐week tai chi group exercise
• Home Safety Assessment and Modification. In patients with a history of falling, home hazard assessment and modification by a trained health professional reduced falls.
• Medication Withdrawal. Withdrawal of psychotropic medications, other sedatives or hypnotics, neuroleptic agents, or antidepressants resulted in reduction in risk of falling (for about 14 weeks only).
• Cardiac Pacemaker. Those with unexplained or recurrent falls who had dual‐chamber pacemaker implantation for cardio‐inhibitory carotid sinus hyper‐sensitivity, had a reduction in total number of falls at one year.
• Hip Protectors. They do not reduce the risk of falling, but aim to reduce the impact of a fall, and may help in the prevention of hip fractures for persons at high risk of falls or those living in an institution.
I. Multidisciplinary, multi‐factorial health and environmental screening and intervention programs in community‐dwelling older adults found a significant reduction in falls. The components of this programme include:
1) Exercise programs incorporating gait and balance training;
2) Advice on appropriate use of assistive devices by an occupational therapist;
3) Review and modification of medications; 4) Evaluation and treatment of postural
hypotension; 5) Removal or modification of environmental
hazards; 6) Targeted medical and cardiovascular
assessment and treatments.
II. Multidisciplinary, multi‐factorial health and environmental screening and intervention programs among those in residential care facilities have been successful in preventing falls in these setting.
The components of this programme include: 1) Comprehensive individual assessment with
specific safety recommendations targeting environmental and personal safety (e.g., improvement in room lighting, flooring, and footwear);
2) Wheelchair use 3) Review of psychotropic drug use; 4) Exercises for strength, balance, transfer,
and ambulation; 5) Provision and repair of aids; 6) Providing hip protectors; 7) Facility‐wide educational programs 8) Post‐fall problem‐solving conferences.
Learning Points Key Learning Points
• Falls are a common and serious problem in older people • Falls are the result of a complex combination of several intrinsic and extrinsic factors • For an individual a fall is generally a symptom of underlying problem not an explicit
diagnostic sign • Environmental hazards are the leading cause of falls and most falls occur in or
around the patient’s home • The most consistently proven predictors of fall risk are history of a fall during the
past year and gait and balance abnormalities • The risk of sustaining an injury from a fall depends on the individual patient's
susceptibility and environmental hazards • A thorough history is essential to determine the mechanism of falling and to identify
any contributing risk factor • Recurrent falls, defined as more than two falls in a six‐month period, should be
evaluated for treatable causes. • The most effective fall prevention strategies are multidisciplinary/ multi‐factorial
interventions targeting identified risk factors.
References Full references for this article can be found in the pdf of the individual article
How can an academic mentor improve support of tomorrows doctors? Fiona Robertson (4th year MBChB); Chloe Donaldson (4th year MBChB), Robert Jarvis (Academic Mentor, Dundee Medical School & General Practitioner) & David Jeffrey (Former Academic Mentor, Dundee Medical School & Honorary Senior Lecturer in Palliative Medicine, University of Edinburgh) Correspondence to: David Jeffrey : [email protected]
ABSTRACT Three years ago Dundee University Medical School created a post of a part‐time academic mentor to strengthen support for students. The experience of the first two years of this post is described. Students give their views on aspects of the mentor’s role that they found helpful and describe some of the barriers to seeking support. Finally we look forward with suggestions on how the role of mentor could be developed in future to improve student support. Key Words: Academic Mentoring, Support, Medical Student
Background The modern medical curriculum emphasises self‐directed learning and multiple assessments which tends to result in higher levels of stress among medical students.(1) A student comments: “Getting into medical school is a big enough challenge but what many students don’t seem to realise that once they’re there, there’s plenty more to contend with. This completely new lifestyle and way of learning can come as a shock for many and in such an intense environment, students often feel the pressure. Many students feel inadequate in their studies; as part of our nature we strive for the best. Being surrounded by others with high academic standards may put pressure on ourselves . The reality however is, we’re all in this together. Acknowledging that we are not superhuman and that to work is about not feeling afraid about seeking support. It takes great inner strength and not weakness to do so as there may be more than meets the eye even in the most seemingly well adjusted student. Self awareness of stress is key and the next important thing is doing something about it”. They continue: “Not only do we face great stresses through our course, starting medical school is for many students their first real experience away from home, having to manage their money and time without any guidance from their parents or anyone else. Not only that but we are faced with massive pressure of making new friends whilst we are all out of our comfort zone. Many students have troubles with flatmates they don’t get on with or trying not to succumb to peer pressure to go out drinking every night of the week even when we know the library is calling. It is a challenge to find that “work life balance” everyone tells you about. So along with our studies we still face many of the challenges of day to day life as well as growing‐up. When talking to anyone else with these troubles we are very sympathetic of these challenges however when we begin to struggle ourselves, we feel guilty and embarrassed to go for help because we feel our problems are not worth someone else’s precious time.”
Effective systems of student support are important, but they too have come under increasing pressure2. In January 2010 Dundee University Medical School created a part‐time post of academic mentor to improve student support. The decision to develop this post was driven by a wish to improve support to medical students and was in accord with advice from the General Medical Council (GMC)3. The GMC has moved from a position, in 1993, where it placed responsibility for performance almost entirely on students, to their most recent advice, which recommends the establishment of support for students who have underperformed, in “ a confidential and supportive environment”3,4 The GMC now requires medical schools to have a structured system of student support and that the tutors involved should be appropriately selected and trained3. The Role of an Academic Mentor A student writes “Medical school can be overwhelming in terms of being in a whole new learning, socialising and generally busy hospital environment. Sometimes students feel isolated in the medical school bubble and are unsure who to turn to during times of hardship. In my experience, I was having emotional problems but avoided seeking help for fear of making a fuss. Students had been assigned personal tutors but had I never even met them and since they are also clinicians, I was sure they would be too busy to listen to my problems. This made me feel rather stranded with my problem and unsure who in the university I should turn to. That was when, through word of mouth, I found out about and contacted the academic mentor, someone whose role is to listen to student’s concerns. I believe that knowing that support is out there is very reassuring, even if one does not need it at that moment. Having someone available in case of a time of need can really help make the process of getting through that period much smoother. I felt prior to this that I was being bounced around lots of different people but not actually getting anything done or addressing any of my issues. It is all very well being able to acknowledge and talk through problems, but the most important thing is getting something done about these. That is where an academic mentor can help provide valuable practical information and support to target these issues. Akin to the patient centred approach, a student centred approach is very effective. Although there are also a general University counselling and mentoring services, medical students often face a very different set of problems due to the nature of the course so it is indispensible having a doctor, someone who has experience and a deeper understanding of the medical lifestyle, to discuss issues relating to this. I feel that had I not found the support available, and indeed many others in a similar situation would agree, my problems may have escalated even further. Luckily, having someone in the medical school to listen and even just guide you through a difficult period can really make all the difference.” The academic mentor’s role is to provide an accessible and welcoming face and complement existing personal tutor support .The academic mentor also provides pastoral support to students with social and emotional problems. In the past medical students in the Medical School at Dundee University were supported by a personal tutor scheme which was found to be of variable quality.5 The role of the tutor was mainly to give academic advice and to be available for pastoral support. However, a personal tutor might also have a role in assessing their students. Recent student surveys confirmed that the personal tutor support system was inconsistent. In one survey of 158 students with a 59% response rate only 29% said that they would contact their personal tutor about personal difficulties or health issues6. Sadly, it is often only when a student fails
an exam that problems are identified1. At this point the student may feel solely to blame for the failure and so become further demoralised. A student’s perspective: “I have always worked hard for my grades and any of my non‐academic accomplishments, this has not been without struggles and setbacks however experiencing a marginal fail in an online exam at the end of second year really hit me hard. I knew I had given these exams my all and yet it hadn’t paid off, I felt as though I had let everyone down least of all myself. I have strived for medicine all my life and it felt like everything was falling apart. Everyone else was coping so why couldn’t I? I did not want to speak to my peers who had passed for fear of raining on their parade but I also found it difficult to speak to my fellow resists as I wanted to help them remain positive and not bring them down with me. At the start of second year I had been allocated a personal tutor but I had never met them and e‐mail correspondence throughout the year did not make me feel comfortable about pouring all my worries and fears on to them‐they did not seem interested. Through the medical school we were offered a 15‐minute consultation with one of the doctors involved in the phase 2 teaching. I was genuinely terrified for this and had no idea what to expect. The meeting was formal and worked through a pro‐forma of questions relating to the failure of the exam and what my plans were to improve and if the medical school could do anything extra. I did feel marginally reassured after the meeting that the medical school still had some faith in me but it was not quite the level of personal support I needed in my devastated condition, this doctor was not someone I knew or someone who knew me all they had was my exam feedback graph. On an SSC allocation earlier that year I was lucky enough to meet the academic mentor, who otherwise I would not have been aware of existed. As soon as I received my results, an e‐mail was sent and various meetings followed. The content of the meetings varied from talking through how I was feeling and how to cope, to practice questions to boost my confidence again. Without this support I truly believe I would have had a far bleaker outlook on my resists but having the reassurance from someone who knew my commitment and had been through it all and survived (not without their own blips along the way) was invaluable to my success. This view is shared by many of my fellow students who have also had an array of difficulties through out there medical school careers. This year I have been allocated a new tutor who I have met with on a semi‐regular basis and I know is always only an e‐mail away. They have been fully committed to helping me improve my written submissions as well as improve my confidence about my capability at medical school in general. It has not taken much on their behalf, some constructive criticism on case discussions and a chat every couple of months just to see how I am doing. It may seem trivial but it has made the world of difference to me and I believe my peers would benefit just as greatly from this type of support, or even just the knowledge it is there for them if they need it. I am still very anxious about my up and coming exams but I now feel I have a number of people who know me as a successful student and a struggling student that would be there to advise and support me through any future issues. People who I feel comfortable with and who I know have shared these experiences or similar. I believe the academic mentor should have far greater advertising by the medical school as they are a priceless asset to both the school and its students. I also fully appreciate the time and effort that has gone in to the improvement of the student support scheme through personal tutors, I am aware work still needs to be done but as a student with both positive and negative experiences I can see the progress and feel very encouraged by it.”
The Role of the Academic Mentor in Student Support Services While the academic mentor is part of the ‘package’ of support services on offer to medical students, this role has very specific functions and rules of engagement to make this additional specialist support effective. Mentoring is a relationship in which one person offers help, guidance and support to facilitate another person’s learning or development.7 The mentor should be a source of inspiration and assists in the students’ academic progress. It is a natural and fulfilling way to pass on knowledge and to influence professional development. Both coaching and mentoring are processes that support learning, they differ in emphasis; coaching tends to be directed toward short term goals whereas mentoring tends to be a longer term relationship.7,8
Medical students (like doctors) find it difficult to seek help.9
A student writes “I was reluctant to seek help as I knew as professionals they were very busy so I didn’t want to bother them. I was sure my problems weren’t as deserving as others would be so didn’t feel worthy of their time. If we all thought this way however, no one would seek the help that’s there for us, no matter how big or small our issue is, it is the job of an academic mentor to help us address these. Another reason was the pressure of my own time. I had so much academic work to do already that I didn’t feel my wellbeing was a priority. This ends up being counterproductive as if you are not looking after yourself, this will eventually catch up with you and negatively impact on your work. Many other students may be blinded by their work that they do not wish to acknowledge their surrounding problems inhibiting us from striving to our potential.” There may be many reasons for this, including a fear that any apparent weakness will jeopardise their assessment and future chance of qualification as a doctor. Other barriers to accessing support include a fear of intimidating personalities, a lack of tutor availability and not having information about available tutor support10. It is important to ensure that students are reassured that seeking help is good professional practice and is regarded as a positive step by the medical school. The mentor needs to stress that meetings are confidential and that he is not involved in the academic assessment of students. This enables students to be frank in their discussions and facilitates disclosure of personal issues. While a trusting relationship depends on confidentiality, some matters cannot remain confidential. It is important to define these boundaries with the student from the outset. Behaviours which affect fitness to practice generally will need to be referred to the Medical School. A criminal conviction, drug or alcohol abuse, cheating and fraud are some examples of seriously unprofessional behaviour1. A tension can arise between maintaining confidentiality and accessing appropriate support for the student. If the student feels that information is to be shared they will be less likely to access support2. Support & Advocacy Individual personal support and mutual respect are essential characteristics of a mentoring relationship. It is helpful to remind students that they are good students and that they have been subjected to a rigorous selection process to gain their place at medical school. Mentors need to display some authority to ensure that their advice on behalf of students is consulted
by the medical school. Mentoring is involved in bringing about change not only in individual students but in systems of support for students. Students particularly appreciate having an advocate when they are subject to consideration by the Academic Review Committee considering termination of their studies. They can be helped by having an opportunity to discuss their hopes for their future and to set realistic goals. Advocacy also plays a part if a student is making a complaint about harassment or bullying and in these situations it may be useful for the academic mentor to accompany the student to attend meetings with the university or NHS panels.
Reflection, Feedback and the Learning Cycle Despite evidence that reflection and feedback facilitate learning it is evident from meeting students that many of them feel that they do not receive sufficient feedback.11, 12
A student’ view: “ It is terrifying for us as a whole year of teaching is assessed in a few days of exams at the end of the year. As anxiety can be a big issue, for many brilliant students this may be their downfall on the day and we get no feedback on our results, other than a grade, so are left to ruminate on where we went wrong and why. If we don’t know, then we cannot improve upon our skills and knowledge; a vital skill we need to develop as future doctors. Exams are often tick box exercises that do not truly reflect how good a doctor you will become. This is where the academic mentor helps; they let you reflect on how you have progressed thus far and where you want to go in the future; allowing us to develop these reflective skills early. This will help us in our future careers as we should acknowledge and deal with the good, the bad and the difficult aspects of medicine”. It is disconcerting to discover that many senior medical students have low levels of self‐confidence. The mentoring relationship provides a context in which to build students’ self ‐confidence and demonstrate the use of guided reflection. Where reflection becomes too institutionalised it becomes a burdensome exercise and thus loses all value as a learning tool. Indeed, excessive self‐reflection may reduce insight if it becomes purely rumination on problems.11 The student who lacks insight presents a particular challenge to mentoring. Insight is related to the motivation to engage in reflection but a student will not necessarily gain insight merely by self‐reflection.11 By using strategies such as role modelling and small group work it is possible to move slowly towards a stage when the student, who lacks insight , sets aside blame and begins to take responsibility for their professional development. A mentor needs to understand the range of factors influencing effective learning. The emotional content of the learning process can also be explored within a mentoring relationship. Students need time and encouragement to ask questions such as “How do I feel about this issue?” or “Why do I feel this way?”. With appropriate guidance students can develop their ability to understand their own feelings and those of others.
Role Model Role modelling is a fundamental part of developing professionalism. The mentor should be able to help with the “hidden curriculum”; ethics, attitudes and professionalism. A mentor must have knowledge of the curriculum, clinical competence and an interest in the student’s welfare. As mentoring is a reciprocal relationship, mentors can share their own
vulnerabilities and in doing so the student learns of the uncertainties and dilemmas which are a part of clinical practice. An enthusiastic mentor can inspire a student to learn. Mentors need patience to remember that students who are struggling are often late for appointments and are slow to respond to emails. Students are encouraged to be self‐ directed in their learning and mentoring should support them to move towards this position, and also to be cognisant of the dangers of student dependence.
Personal Tutor Support and Networking A mentor can provide help both for students and personal tutors by establishing good relationships with tutors and to be open to accept referred students. For example, it can be useful, with a student’s consent, to brief a block supervisor of a student’s recent bereavement. Personal tutors can also discuss any student who is causing concern with the mentor so that support may be provided before any possible exam failure. Small group tutorials offering practical tips for new tutors are an opportunity to address tutors’ concerns and to provide training.
Identifying the Struggling Student Support needs be proactive, not simply responding to failure, but preventing academic problems. Mentors can provide continuity of support by tracking a student’s progress. One of the early signs that a student may be struggling is a failure to respond to emails. The mentor needs to be made aware of those students who have failed exams.
One to One Support Students need to be seen in a quiet environment on a one‐to‐one basis. Privacy is essential if students are to feel free to express emotions. Students need encouragement that seeking help is a professional way to behave. An initial meeting that is unhurried and relaxed allows both student and mentor to get to know each other and develop mutual trust and respect. Students often present at the outset of the meeting with a seemingly straightforward academic or learning problem but once trust is established complex issues can emerge. In Dundee Medical school there were approximately 100 individual students seeking help from the academic mentor each year. The following is a brief description of the first 200 students seen.
Findings in Dundee Medical School – The First 200 Students Seen 62 students were male and 138 female, 45 students were referred by university staff and 155 were self‐referrals. There were 17 graduate entry students and 28 international students. The spread of students across the years was as follows (Table 1). Many students presented with a cluster of differing problems: Academic 164, Health 122 and Social 31. (Table 2) Academic The majority of attendances in this category were examination related, either after failing or requests for coaching. Coaching activities included OSCE practice online multiple choice practice, Viva practice, Portfolio advice, learning styles advice and presentation skills. Career advice and questions of attitude or probity completed the academic reasons for seeking mentoring.
Table 1: Students Presenting to Academic Mentor by Year Group
Table 2: Reasons for seeing the academic mentor
Exam Failure It is common for students either to be referred or to self ‐refer after they fail an exam. For many it may be their first experience of ever having failed an exam. Many high achievers have perfectionistic personality traits that may aggravate anxiety in the face of an exam failure. It is interesting to observe that some students do not seek any extra advice or support after exam failure. Exam stress The method of assessing the performance of students can be critical. A student may have an obsession with passing a particular test which can be a block to developing wider understanding of a subject. For instance, many final year students were found to be stressed by a ward simulation exercise which involved them being filmed by a video camera. Considering evidence on social anxiety in medical students, allowed changes to be made so the exercise was perceived as less threatening and more centred on giving constructive feedback.13
0 20 40 60 80 100 120
Premed 1st year 2nd year
3rd year BMSc 4th year 5th year
number of students % of visits
164
31
122 Academic
Social
Health
A small number of students have acute performance anxiety that is manifest by a sudden “freezing” during OSCE or clinical exams where they are being observed. This condition is well known in the performing arts and students can be helped to regain their confidence to overcome “stage fright”. International students International students form a vulnerable group as they have to adjust to a new university and a different culture. English is often not their first language and they may have difficulty integrating and experience loneliness. Graduate students Students arriving with an earlier degree often have a maturity that can be an advantage on the medical course. However, graduate students may become lonely as they do not want to attend the social events catering for much younger students. They may present with a range of social problems related to combining student life with running a home and young family. They may also have difficulties adjusting their learning styles to cope with the self‐ directed spiral curriculum. Coaching Coaching activities, such as practice vivas, may be conducted on an individual basis whilst common problems such as performance/exam anxiety management or the finals portfolio can be helped by tutorials. These tutorials help students to gain confidence by giving them some idea of what is expected of them in the exam and reaffirming their skills and knowledge. Some students may use the group setting to assess whether they feel comfortable in arranging an individual meeting with the mentor. Students also gain confidence in sharing their problems with their peers. In small groups they come to appreciate that others experience the same difficulties as they do. Health problems 90 % of health problems presenting were due to anxiety, depression, low self‐confidence or, bereavement. A small group (8%) had, severe mental health problems requiring specialist psychiatric referral. Physical health problems accounted for about 10% of the students seen by the academic mentor. Social problems These included family and relationship problems, finance, accommodation, bullying or harassment and cultural issues. Psychosocial Support These workload figures confirm the high levels of anxiety and emotional disturbance in medical students found in earlier studies.14 This is reflected later in the high rates of stress related problems, suicidal risk, marital breakdown and alcohol abuse experienced by doctors.15 Students may also have feelings of inadequacy which can be aggravated by loneliness or lack of feedback. As well as course related stress, medical students’ mental health problems are affected by negative life events16. For support to be most effective it is essential for the mentor role to be separated from assessment. One of the most challenging aspects of devising an effective support system is that the students most in need of help often do not seek help. The university works towards
developing a culture of support for medical students that mirrors the patient centred model of care in the NHS. This support culture values professionalism that is not limited to concerns about how we interact with patients but places a high value on how doctors and medical students interact with each other. In such a teaching and learning environment humiliation or bullying of students or doctors, is simply not acceptable. Building the student’s self‐ confidence and self‐ awareness is a core part of mentoring. Students who have appropriate levels of self‐ esteem and confidence tend to be more responsive learners because they are more likely to seize learning opportunities and to take responsibility for improving their performance.7,8
Mental health problems A Norwegian study showed that a third of medical students report mental health problems during their first three undergraduate years and over half do not seek any help.16 Students with serious mental health problems face difficulties not only in their academic progress but also in accessing care. Many students fear the stigma of mental illness. The traditional route of referral to GPs is often not responsive to the timescales of student life 17. Furthermore, waiting times for clinical psychology input are often lengthy. Sometimes students with serious mental health problems are advised to temporarily withdraw from the course. Even when they are withdrawn temporarily to receive treatment, experience shows that support is often ill co‐ordinated and patchy.17 The complexity of tracking students between university, outblocks and home often results in them missing appointments. A tension exists around the transfer of confidential information between various agencies. If a psychiatrist is asked to make a formal assessment of the student’s ability to continue their studies they should not be involved in that student’s treatment.17
A recent report by the Royal College of Psychiatrists recommends closer collaboration between the NHS and Higher Education providers and that students should be seen promptly for help.17 The report also grapples with the adverse impact of alcohol misuse in students and this is particularly relevant since many social events for medical students are based around alcohol.17
Impact of the Mentor on student support “As a medical student you can often feel like you are running a constant treadmill, not getting anywhere. In reality we’re running an amazing marathon, and the academic mentor can act as a sort of coach, spurring us on by showing us just how far we’ve come and help us plan towards reaching our goals the end”. A student Mentoring is about enabling change both in individuals and in systems. It is difficult to measure the outcomes of mentoring as it is only a small part of the total student support system. Mentoring is often informal and often invisible18 . Although there is little evidence of the effectiveness of mentoring of medical students in the literature, it is generally accepted that mentoring develops professional attributes19,20. An American study using such a focus group showed medical students value mentoring in terms of the interpersonal dynamics of the relationship with a particular emphasis on connection and advocacy21 . In the past when students were asked about support they made it clear that the previous system of support, whilst acceptable for some, left others with no support whatever.5 It is a
characteristic of an open supportive culture that their views were taken seriously and helped to develop a more responsive system of support.5,10,22 The practice of medicine is stressful either as a student or a graduate. Seeking help must elicit support rather than stigmatising the student as a failure. Student support should not be viewed as a remedial service but something that every student can access23. Students seek inspirational role models and advisors. In expressing a personal interest in the student a mentor also demonstrates his belief that the student has the attributes to become a skilled caring doctor.24 Mentoring helps students to reflect on their professional development and encourages them to take appropriate risks and to confront their fears.24 More female students than males used mentoring yet subsequently, fewer female doctors are referred to assessment agencies with difficulties25. It is possible that female students are more comfortable than male colleagues with establishing networks of support that then persist after graduation. More students came to the mentor because they chose to rather than being referred. This element of choice to “opt in” is integral to the mentoring relationship.24
Being a mentor is a most rewarding experience as it leads to a greater understanding of younger colleagues. In supporting them and helping them in their academic progress the mentor learns a great deal about teaching and learning and their own professional development.26
Way Forward : New Developments The academic mentor post has now been established following the initial 3‐year pilot scheme. In response to student feedback and the GMC requirements for provision of student support, a restructured personal tutor system was launched this year in the Medical School. It is hoped that students will now feel comfortable about contacting their personal tutors and to have feedback on case discussions and learning portfolios. However, recruitment of personal tutors by the lead for student support has been difficult due to the increasing workload for all NHS clinicians and university staff. The students in Dundee are also in the process of creating their own peer support network with the encouragement of the academic mentor. This system, run by a core group of interested students from across the five years of the curriculum will allow students with issues to contact a central point of contact via text‐message or by online means. The peer supporters will then triage all requests and refer appropriately: for example, issues regarding the process of completion of year 2 work might be referred to a year 3 student for advice; issues regarding applications for the FY programme may be referred to junior doctor contacts or to the postgraduate department. The academic mentor has a role within the medical school to facilitate cultural change. Moving towards a more student centred approach may mean building more effective links between the faculty and the student body which on the face of it may not appear to be ‘student support’ per se. This may involve positive role modelling, but benefit will also arise from healthy discussions with faculty administration, senior academics and clinicians to help improve systems of communication between the students and the faculty. In all contact that the students have they should feel the faculty is available, approachable and supportive; this should be true within the arenas of administration, the VLE, teaching, assessment, remediation and discipline.
The academic mentor may also be in a good place to encourage activities promoting health and wellbeing within the student body. Examples of such activities might include faculty sponsored yoga and mindfulness classes or joint faculty and student charity events. It is vitally important that the individuals appointed to the role of academic mentor have unencumbered access to the senior level of faculty administration. For individual students in difficulty this is often hugely helpful, and for influence on systemic or cultural change it is imperative.
Discussion & Conclusion Students are interested to learn and to take part in supporting their colleagues.6,10,22 They appreciate the presence of an advocate who is not in a position of assessment and value positive feedback. Every medical student should have an opportunity to reflect on the question ‘What kind of doctor do I want to be?’, with an experienced mentor. The mentor can help students in their transitions from school to university and from student to doctor.27
What gives mentoring its particular force and makes it different from teaching coaching or supervision?24 It is the unique facility of having confidential meetings with students, believing in them and helping them to achieve their aims without having to assess them academically. Communication is effective because there is an atmosphere of trust, friendliness and a mutual respect. Mentoring depends on the character of the mentor and the individual student. Support from a mentor must embrace both the professional and the personal self of the student since these are bound together27. Support should be available for all students not just those who are struggling. Respect should be shown for each student with a willingness to work with them to devise a solution tailored to their particular problems. Mentoring which is part of a student support system which is designed to support both personal and professional development has the opportunity to break down institutional barriers and to enhance the learning and development of “Tomorrows’ Doctors”. Ethical approval: This paper does not describe research on human subjects so ethical approval was not deemed necessary.
References Full references for this article can be found in the pdf of the individual article
A Child with a Limp – A Clinical Approach Robert Humphreys (Paediatric Orthopaedic Physician NHS Fife) Correspondence to: Robert Humphreys : >[email protected]
ABSTRACT
Limp is a common presentation in Paediatrics. Fortunately for the majority it will represent a benign problem that settles with minimal or no intervention. It may be as simple as poorly fitting new shoes or a verruca. However, in amongst the self‐limiting problems are relatively rare but potentially devastating diagnoses such as joint infection or malignancy. To have a reasonable chance of picking up on these at an early stage requires a thorough approach to every limping child. This article will review the key points that are important to consider when approaching a child with a limp. Key Words: paediatrics; orthopaedics Introduction Limp is a common presentation in Paediatrics. Fortunately for the majority it will represent a benign problem that settles with minimal or no intervention. It may be as simple as poorly fitting new shoes or a verruca. However, in amongst the self limiting problems are relatively rare but potentially devastating diagnoses such as joint infection or malignancy. To have a reasonable chance of picking up on these at an early stage requires a thorough approach to every limping child. History As with every consultation we start with a good history, but there are some questions that are particularly pertinent to explore: Any recent history of trauma and the mechanism? Trauma is a common cause of acute limp in children. Sometimes parents may try to make sense of the limp by attributing it to a recent fall when the fall may simply be incidental or the child had a tumble because he is unwell. Active children have frequent minor tumbles. There is a danger in attributing a limp to this, missing a potentially significant diagnosis such as osteomyelitis. Equally children do sustain bony injury with sometimes relatively minor falls. Trampolines are often involved when there is bony injury. Plain xrays of the affected area including the joint above and below in two planes are often reasonable in this context. The other complicating factor is that there may have been significant trauma that has not been witnessed in younger children. The spectre of non‐accidental injury should always be borne in mind and advice sought appropriately if there are concerns. Duration and progression of the limp? Time of the day when limp is worse? Has the limp interfered with normal activities? A limp that is not settling within a week or so and a limp that is getting worse or interfering with normal activities requires Specialist assessment to exclude significant pathology. Constant pain unrelated to exercise also suggests significant underlying pathology such as tumour. Mechanical pain experienced only on exercise suggests a more benign diagnosis.
Pain and stiffness in the morning which improves with activity suggests possible joint inflammation and Juvenile Idiopathic Arthritis should be considered. Can the child weight‐bear? Inability to weight bear makes significant pathology more likely, as does the presence of systemic symptoms such as lassitude, fever or weight loss. Any accompanying weakness is also a red flag. With the younger children that present with a limp I often think that this is what it must be like working as a Veterinary Surgeon. An incomplete history and an uncooperative patient pose a significant challenge. This is where your skills of observation come in. Admission to the Ambulatory Unit for a few hours can be very helpful. It allows the child to settle in comfortable surroundings, gives an opportunity to repeat observations and temperature in particular. I tend to have a low threshold for doing bloods and this allows time for the Ametop to work adequately, the play therapist to engage the child and for the lab to process the samples. You may well develop an idea how the child is affected by the joint pain. For example, are they running around while you speak to the mother or still and crying on her knee?
Examination The examination genuinely needs to be top to toe although undressing the child may have to done in stages to avoid distress. You may have to examine the younger child on his parents lap rather than on the couch. Any abnormal pallor or bruising should be noted and acted on appropriately. A thorough assessment of all joints can pick up on unsuspected other joint involvement in a case of Juvenile Idiopathic Arthritis. The pGALS approach is helpful in this respect.1 Careful palpation of the abdomen is important. Intra abdominal pathology such as an inflamed appendix can cause hip pain and irritability if it lies retrocaecally on the iliopsoas or obdurator internus muscles for example. Hernial orifices and testes in boys need to be assessed as they may be the source of the limp. The spine should be checked to ensure that it is straight and supple.
Investigation, Differential Diagnoses and Management An experienced senior clinician may choose not to necessarily do any bloods in a limping child if he / she is confident that there is no sign of anything concerning. However, as a Junior Doctor it is reasonable to have a low threshold for doing bloods in this context as they can be helpful in excluding significant pathology. A normal blood count and normal inflammatory markers can be very reassuring. About a third of children with acute lymphoblastic leukaemia present with musculoskeletal symptoms such as limp or back pain. A blood film may not show blast cells early on in the illness. A generalized cytopaenia with low haemoglobin, white cells and platelets is concerning and suggestive of bone marrow infiltration. Urgent discussion with Haematology is appropriate. With milder abnormalities such as isolated slightly low neutrophil count (which can often be a post viral phenomenom) repeating the blood count and film a week or so later may be all that is required.
The hip is often the site of pathology in children. The commonest cause of acute atraumatic limp in children is transient synovitis of the hip.2 With hip pathology in children the pain is often referred to the thigh or knee. Younger children may not be able to localise the pain and simply limp or refuse to weight bear. The important differential diagnosis in this context is septic arthritis of the hip. Transient synovitis of the hip is generally a very benign, self limiting problem that responds to rest and analgesia. Septic arthritis on the other hand is a very serious infection requiring early and aggressive management to save the hip joint. “Kocher’s criteria” are helpful in trying to home in on those children that are more likely to have bacterial sepsis causing their hip irritability.3 Significant pyrexia, inability to weight bear, raised white cell count, and raised inflammatory markers are all features that raise the concern about possible septic arthritis in this context. C reactive protein (CRP) is more helpful than erythrocyte sedimentation rate (ESR) or plasma viscosity (PV) as it is often raised within hours of significant infection and also normalises much more quickly as the child recovers / responds to treatment.4 An ultrasound examination will help localise the problem by confirming that there is fluid in the hip joint but it will not be able to tell you whether the fluid is infected or not.5 A suspicion of bacterial infection in this context requires the hip to be aspirated under general anaesthesia to clarify. Finding pus in the joint will require aggressive surgical management to wash out the joint as well as high dose intravenous antibiotics.6
In younger children with an acute “irritable hip” xray examination is generally not needed at initial presenation. Failure to completely settle within a few weeks is an indication to xray in this context to look for other hip pathology such as Perthes disease. In children older than eight years it is reasonable to xray at initial presentation to look for slipped upper femoral epiphysis (SUFE). The radiological signs of a SUFE on a standard AP Pelvis for hips can be very subtle. A frog leg lateral of both hips is also indicated in this age group7 and a SUFE is much easier to pick up on this view. Some centres are now simply doing a frog leg lateral view of both hips and not necessarily doing an AP pelvis to minimise radiation dosage. A common problem that can present with limp in preschool children is a “toddler’s fracture”. This can occur with minimal or no trauma, perhaps just a simple twisting injury during normal play activities. It typically causes a spiral fracture of the distal third of the tibia. The child will be reluctant to weight bear but will be happy to mobilise on his / her knees crawling. There may be tenderness over the distal tibia. The big differential diagnosis here is osteomyelitis. A normal temperature, normal bloods and a well child will help reassure you that infection is unlikely. Xrays may initially be normal. It is a clinical diagnosis. If suspected and infection confidently excluded treatment is with a long leg (above knee) plaster. The child should be reviewed within a few days and if you are right he should be comfortable and confidently mobilising in the plaster cast. All going well the cast is removed at the two week mark. Xrays are repeated at that point. Sometimes the repeat xrays are normal and the child is happy mobilising out of the cast. If the repeat xrays show a fracture line or suggest a healing fracture with periosteal elevation then a further long leg cast should be applied for a further three weeks or so. Plain xrays are poor at picking up early osteomyelitis but should help in excluding significant lesions such as primary bone tumours. Magnetic Resonace Imaging MRI scanning can be very helpful if there is diagnostic uncertainty and is very much the “gold standard” but requires anaesthesia in most preschool children. A skilled Paediatric Radiologist will be able
to help clarify a suspicion of osteomyelitis with high resolution ultrasound avoiding the need for anaesthesia and will be able to tell you if there is any joint involvement or a collection of pus needing surgical drainage. Radioisotope bone scanning is now rarely used because of concern about the total body radiation dosage. It has the advantage over MRI that it can be done without sedation / anaesthesia. It can be helpful in cases where you are struggling to localise the site of the suspected pathology but it is fairly non ‐specific. A hot spot could be inflammation, infection, tumour or trauma. Transient synovitis typically affects the hip. The hip is very rarely the first joint to be involved in Juvenile Idiopathic Arthritis (JIA). A swollen knee with fluid / synovitis on the other hand is less likely to be transient synovitis and you should have a low threshold for urgent Rheumatological referral. The formal diagnosis of JIA is joint inflammation not settling within six weeks but it is important not to wait this long before onward referral! Refer early as specific treatment under the care of a Rheumatologist can prevent significant joint damage. The other important reason to refer early when JIA is suspected is because the child can have a significant asymptomatic uveitis as part of the condition which requires slit lamp examination to diagnose and early aggressive treatment to save sight. The diagnosis of JIA is made clinically. Ultrasound can be very helpful in clarifying joint involvement. In many cases the inflammatory markers can be normal at least initially. Serology such as Antinuclear antibody (ANA) and Rheumatoid factor (RhF) are helpful in the setting of the Rheumatology clinic but should generally not be done as part of the initial work up of a limping child. A frequent dilemma is a limping child with no constitutional symptoms and no localized abnormalities by history or physical examination. Consider using plain films to rule out a fracture, followed by observation and re evaluation in a few days, depending on the severity of the limp and the family situation. Consider checking FBC / film and inflammatory markers to out rule infection. A bone scan may be helpful after two to four weeks if symptoms do not resolve or localize. Conclusion – Key Points To finish, a couple of keypoints: 1) Bone / joint infection and malignancy (bone tumours and leukemia) are fortunately rare but potentially life‐threatening, and should be ruled out as quickly as possible as the cause of a limp by appropriate investigations. For the majority reassurance and rest / analgesia with early review will be appropriate. 2) Hip pathology is notorious for presenting as knee or thigh pain, and must always be considered in patients with these complaints.
References Full references for this article can be found in the pdf of the individual article
Winner of the Essay Prize at the Symposium of the Anne Rowling Regenerative Neurology Clinic 2013
Regenerative Neurology – The Future Fraser Brown (Intercalating Medical Student, University of Edinburgh)
Correspondence to: Fraser Brown : [email protected]
ABSTRACT
The concept of regenerating the nervous system is not a new one‐ one hundred years ago, in 1913, Santiago Ramón y Cajal established the central dogma of the emerging field of neuroscience: “In the adult centres, the nerve paths are something fixed, ended, and immutable.” Cajal himself speculated whether the science of the future would ever be able to reverse this “harsh decree”. It is the aim of Regenerative Neurology to do so. Regenerative Medicine aims to replenish or replace damaged or abnormal cells, organs and tissues to establish normal function. Regenerative Neurology is the application of these principles in the context of neurological disease‐ its application may take many forms, including: implantation‐based techniques; “self‐repair” therapies and generation of diseased tissue models. These three concepts will likely form the basis of the future of Regenerative Neurology. In this essay the current progress and the trajectories they may follow in the future will be explored.
Key Words: Neurology; Regenerative medicine; Neuroscience
Introduction The concept of regenerating the nervous system is not a new one‐ one hundred years ago, in 1913, Santiago Ramón y Cajal established the central dogma of the emerging field of neuroscience: “In the adult centres, the nerve paths are something fixed, ended, and immutable.”1 Cajal himself speculated whether the science of the future would ever be able to reverse this “harsh decree”. It is the aim of Regenerative Neurology to do so. In time this view was challenged; it has been established that neurogenesis occurs in the Central Nervous System (CNS) of mammals, including humans.2,3 Constituitive neurogenesis occurs in the subventricular zone (SVZ) of the lateral ventricle and the subgranular zone (SGZ) of the dentate nucleus of the hippocampus. Neurogenesis has been shown to occur in other areas of the CNS after pathological stimulation.3 Oligodendrocyte Precursor Cells (OPCs) are capable of diferentiation into Oligodendrocytes in response to demyelination.4 Regenerative Medicine aims to replenish or replace damaged or abnormal cells, organs and tissues to establish normal function.5 Regenerative Neurology is the application of these principles in the context of neurological disease‐ its application may take many forms, including: implantation‐based techniques; “self‐repair” therapies and generation of diseased tissue models.6,7 These three concepts will likely form the basis of the future of Regenerative Neurology. In this essay the current progress and the trajectories they may follow in the future will be explored.
Stem cells are central to the approaches described above. They are defined by their capacity for self‐renewal and differentiation into specialised cell types (Figure 1). Many types have potential as therapeutic options in neurological disease.8 Among these are Embryonic Stem Cells (ESCs), derived from the blastocyst; induced Pluripotent Stem Cells (iPSC), genetically reprogrammed from adult cells and adult Neural Stem Cells (NSCs), endogenous populations of stem cells able to differentiate into neural and glial cells, as mentioned above.9‐10
Stem Cell Transplant Therapy Some diseases of the nervous system may be good candidates for stem cell implantation therapies. For example, Multiple Sclerosis involves the loss of one cell type, the myelin‐producing Oligodendrocyte. This condition characterises a disease particularly amenable to stem cell treatment: loss of a single population of cells underlies its pathogenesis.11 This principle of replacing these Oligodendrocytes has in fact been tested, and early research has yielded encouraging observations. Human ESCs and NSCs implanted into a mouse model of hypomyelination showed functional remyelination.12‐13 Recent work by Wang et al achieved remyelination in this mouse model by implanting Oligodendrocyte Progenitor cells, themselves derived from human iPSCs (hiPSCs).14 Multiple Sclerosis is one example, but various other diseases in the CNS involve loss of only Oligodendrocytes.15 Many others have a different monocellular origin, such as Parkinson’s and Huntington’s diseases.8 The Dopaminergic neurons (DN) lost in Parkinson’s have been generated from mouse ESCs, which on transplantation have shown to be functional in an animal model of the disease.16 DNs have also be generated from mouse and human iPSCs.17‐18 On transplantation of the mouse iPSCs in a rat model of Parkinson’s, there was clinical improvement.18 hiPSCs from Parkinson’s patients have been differentiated into DN and transplanted into Parkinsonian rodents, showing a small functional effect.19 The above studies and others constitute growing preclinical evidence for the potential efficacy of stem cell transplants.12‐14,16‐20 Stem cells unfortunately share one of their central properties, the ability to self‐renew, with another type of cell: cancer cells.21 This other side of the double‐edged sword of the so‐called “stemness” of stem cells could lead to tumour formation in transplant patients and hinder attempts to bring these treatments to the clinic.8,22 Primum non nocere (first, do no harm), one of the fundamental principles of medicine, renders it pertinent to evaluate this risk of tumourigenesis. It has been suggested that the ex vivo treatment of stem cells may influence their potential
to form tumours.8 Wang et al’s recent work has shown mice receiving stem cell transplants in their study had not developed tumours at a 9‐month follow up.14 They identified their differentiation protocol as eliminating the potential of the cell population to form tumours; mice engrafted with cells from an early protocol stage formed tumours. A study of undifferentiated ESCs in a rat model of Parkinson’s disease suggests that the level of differentiation of engrafted cells does have an effect on the risk of tumour formation.23 Immunogenicity has also been a concern of researchers in this area, but recent work has established that both ESCs and iPSCs have little impact on the immune system of transplant hosts.24‐25 Virus‐free iPSC reprogramming techniques have also brought this approach a step closer to the clinic.8 This research demonstrates the potential of stem cell transplantation techniques. Given the ethical concerns regarding ESCs and limited availability of NSCs, it seems likely that future research will focus more and more on iPSCs.8 Research should continue to progress to human studies, primarily regarding the safety of transplanted cell populations and developing safe differentiation protocol. Observations of the first iPSC trials in humans are eagerly awaited. Disease Modelling and Drug Discovery Another of the exciting prospects of Regenerative Neurology is the use of iPSCs to develop in vitro models of disease, both to study their pathogenesis and screen possible therapies (Figure 2). This “disease in a dish” approach is appealing, given the lack of readily available neural tissue samples and the limitations of animal models.26‐27
Again, the principles of this method have been shown to be feasible, justifying future efforts to refine the field‐ many disease specific stem cell populations have been generated from patients.28‐30 Recent work in a Motor Neuron Disease (MND) model, derived from hiPSCs (acquired from a MND patient), has provided a unique insight into the pathogenesis of this disease.31 This “disease in a dish” approach may also be able to provide models for drug screening, wherein therapeutic candidates can be tested on an in vitro model of neurological disease. Studies in such a model of Alzheimer’s Disease have elucidated different drug responsiveness in different kinds of the disease.32 Similar work has shown that neurons at different stages of differentiation may react to drugs differently, highlighting the need for tight standardisation of differentiation protocol if these methods are to precede clinical application.33 Work into screening for drugs is in its very early stages, and it is not yet clear how accurately in vitro models will predict in vivo reaction to drugs‐ this should be balanced against the poor predictive value of animal models in clinical translation.34 Additionally, the complexity of some diseases, such as Autism, thought to originate from altered cortical layering, is
beyond current technology.19 Continuing validation and advancement of this technology may yield sufficient evidence to cement iPSC‐based disease models firmly into the repertoire of both those investigating neurological disease and conducting preclinical drug trials. Utilizing endogenous stem cell populations The endogenous stem cell population in the CNS consists of NPCs with the ability to give rise to neurogenesis and gliogenesis, found in discrete areas (see above), and, to a lesser extent, diffusely in the CNS.3 These populations have been shown to proliferate in response to pathogenic situations, such as stroke, in rats.36 Cells arising from this induced proliferation have shown migration towards the ischaemic boundary in stroke.37‐38 Researchers aim to capitalise on this intrinsic ability of the CNS and facilitate functional healing. This approach circumvents the ethical issues regarding the use of ESCs, and the difficulty of establishing safe iPSC lines for transplantation.39 However, recognition of the in vivo incapacity of the CNS to facilitate complete and functional repair has led some to think the complex neural environment cannot be regenerated in this way.40 Conclusion Regenerative Neurology is a complex field, the full scope of which surpasses this essay. I include those areas that may well comprise the future of this field, using illustrative examples throughout, focusing mainly on the CNS. These principles may also be applicable in the Peripheral Nervous System. The ultimate aim is the application of these principles in medicine, and the alleviation of the suffering of many millions of patients. Neurologists currently manage many diseases with no cure; patient need is the driving force of this research and motivates the evolution of Regenerative Neurology into a clinical science. iPSCs may offer the greatest potential for facilitating this‐ research should make them increasingly safe and efficient, and advances in both disease modelling and stem cell transplants will complement each other. This research should run in parallel to the study of endogenous stem cells to elucidate the complex in vivo neural environment. Cajal would scarcely believe what has been achieved since 1913. Now, in 2013, I cannot help but wonder what the next 100 years of Regenerative Neurology research will yield. References Full references for this article can be found in the pdf of the individual article
Principles Underpinning the Treatment of Cancer with Drugs
Faith J Dalgaty (Foundation Year 1 Doctor, NHS Tayside) Correspondence to: Faith J Dalgaty : [email protected] ABSTRACT There are many approaches to the treatment of cancer including radiological, surgical, the use of pharmaceuticals and various combinations of the above. The treatment of cancer is also continually changing with the arrival of new scientific discoveries. Currently the choice of treatment and management is individualised depending on cancer/tumour type, disease staging and treatment aims, such as intent for palliation or cure. There are various types of pharmaceuticals used in the treatment of cancer; these include chemotherapy agents and specific targeted treatments of cancer including monoclonal antibodies and tyrosine kinase inhibitors. Here we explore the rationale behind the treatment of cancer with drugs, by discussing the principles of chemotherapy and the use of targeted treatments in haematological and breast malignancies. Key Words: oncology; chemotherapy
Introduction Cancer is one of the leading causes of death in the UK. In 2008 it was responsible for one in four deaths in England, equivalent to 128,000 people1. As a disease, cancer is difficult to treat as there are numerous types with varying biology depending on tissues involved. Cancer manifests in many ways and has different sensitivities to therapeutic agents. Given these complexities, we are only just beginning to understand the pathogenesis of cancer and how we can treat it. Currently there are a number of approaches to cancer therapy and here we will discuss the principles of treating cancer with drugs, the mainstay of which consists of cytotoxic chemotherapy agents and various targeted treatments. Cancer Cancer is also known medically as a malignant neoplasm. These neoplastic cells display immortality, abnormal regulation of growth, self sufficient growth, resistance to apoptosis, angiogenesis, nearby tissue invasion and the ability to metastasis2. Each cancer is classified according to the tissue it is derived from and the associated cell type, thus making each cancer unique in causation, treatment and prognosis, adding to its complexity. The cause of cancer is thought to be due to a combination of genetic factors and exposure to a wide range of avoidable risk factors. Risk factors for cancer are numerous, the most prominent being tobacco smoking and chewing, poor diet, exposure to UV light, radiation, obesity, hormonal influences, infections (such as Human papilloma virus which is associated with oral cancer and cervical cancer), occupation related (exposure to asbestos causing mesthothelioma) and various chemicals which we are exposed to in our environment3. As cancer encompasses such as diverse collection of disease, a number of approaches to treatments are available. These treatments can be used individually or in combination. Surgery is commonly offered to patients, often with curative intent and occasionally combined with neoadjuvant or adjuvant chemotherapy (before/after surgery)3. Other
options include radiotherapy, hormone therapy, immunotherapy and the newly evolving gene therapy3. Often these approaches depend on tumour type, patient age, life expectancy and the desired quality of life. These therapies can also be used palliatively, to ease suffering in terminal conditions. Principles of Chemotherapy Chemotherapy is the prevention or treatment of disease by chemical substances3. The aim of chemotherapy is to selectively kill or inhibit growth of neoplastic cells whilst preserving normal cells. Chemotherapy targets cells that are rapidly dividing, and therefore affects cell multiplication and tumour growth. As a consequence, agents also target normal tissues with a high growth fraction, such as bone marrow, hair follicles, gut muscosa and skin. This causes alopecia, nausea, vomiting, diarrhoea and infections, such as neutropenic sepsis due to myelosupression. Chemotherapy agents are discovered empirically by screening against chemical libraries. Specificity to cancer types is unknown until after testing4. There are a number of types of chemotherapy agents, which include alkylating agents, nitrosoureas, antimetabolites, anthracyclines and mitotic inhibitors. These have different modes of action, either acting at a cellular level or a cell cycle level. Alkyating agents are activated to expose reactive alkyl groups that make covalent bonds with molecules in the cell5. These have a great affinity to bind with purines and interfere with DNA replication5. Nitrosoureas are similar to alkyating agents, they interfere with enzymes involved in DNA replication and repair6. As they are lipid soluble, they can freely pass across the blood brain barrier and are commonly used agents in the treatment of primary brain tumours.6 Antimetabolites prevent DNA synthesis by inhibiting enzymes involved with the synthesis of nucleotides and amino acids. Antimetabolites are cell cycle specific and damage cells during the S phase of mitosis5. There are a number of anti‐tumour antibiotics called anthracyclines. These bind to DNA and inhibit DNA and RNA synthesis7. Anthracyclines also have an effect on the enzyme Topiosomerase II, whose activity is increased in proliferating cells7. Some chemotherapy agents stop mitosis by inhibiting tubulin polymerisation8. These so called spindle poisons are plant alkaloids derived from natural products8. Table 1 summarises the different drugs and figure 1 notes the cell cycle phases where these medications may exert their effects. Table 1: Summary of Chemotherapy Action Agent Type Method of Action Example Drugs Cancer Rx Examples
Alkyating agents Non cell cycle specific
Chlorambucil Cyclophosphamide Haematological
Nitrosoureas Non cell cycle specific Lomustine Carmustine
Brain Malignancies
Antimetabolites Prevent S phase of mitosis
Methotrexate Cytarabine Fludarabine
Haematological Malignancies
Anthracyclines Cell cycle, non specific Doxorubacin Daunorubacin
Leukaemia, Lymphoma, Breast
Spindle Poisons M phase of cell cycle Vincristine Vinblastine
Lymphoma
Figure 1: The Cell Cycle
Chemotherapy agents can arrest the cell cycle at various stages. M represents the mitosis phase, G1 represents Gap 1, S represents the DNA synthesis stage and G2 is the further gap
stage.
Principles of Targeted Therapies Targeted therapies can be defined as drugs developed against a specific target that is selected for its biological function in the cancer4. Targeted therapies are specifically designed to inhibit an abnormal target, the result of which often prevents downstream signalling, DNA synthesis or microtubule assembly. Haematological and breast cancers are leading examples of how targeted treatments are assisting in the fight against cancer. Breast and Haematological cancers are discussed in some detail, however there are many other examples not discussed here, such as anti‐androgen treatment of prostate cancer. Drug Treatment of Haematological Malignancies Chronic Myeloid Leukaemia (CML) was one of the first malignant disorders where a genetic abnormality was discovered. The Philadelphia chromosome (PH) results from a reciprocal translocation of ABL gene on chromosome 9 and the BCR gene on 22 (Figure 2)9. The resulting effects of the BCR‐ABL fusion gene are abnormal proteins with abnormal tyrosine activity9. This abnormal activity is responsible for the cells seen, with an increased cell count (abnormal proliferation) and immature cells (lack of differentiation)9. The principles for treating CML were previously based on a combination of cytotoxic (Ara‐C) and immunomodulatory agents (interpheron‐alpha)9. The discovery of Imatinib (Gleevec), the first tyrosine kinase inhibitor, revolutionised the way that we treat CML and our approach to cancer therapies. Imatinib is an ABL specific tyrosine kinase inhibitor. This inhibits the ATP binding site in ABL tyrosine kinase which prevents the proliferative effects (Figure 3)9. Imatinib is a very effective treatment as it has been shown that 82% of patients receive a complete cytogenic response. Studies with Imatinib alone, or Imatinib combined with another drug such as interfon, show that the best results are achieved with combinational therapies9.
Tyrosine kinase inhibitors also represent a promising approach to other non haematological neoplasms, as with gastroinstestinal stromal tumours. The targeted molecular approach demonstrated in CML has also been used with other drug classes, as seen in breast cancer. Figure 2: Showing the translocation between Chromosome 9 and 22, resulting in the BCR‐ABL fusion gene, also known as the Philadelphia Chromosome.
Figure 3: Method of action of Imatinib (Gleevec), showing how the drug blocks the ATP binding site, preventing tyrosine kinase function, and the production of the abnormal proteins associated with CML
.
Monoclonal antibodies are widely used in haematological malignancies as a targeted treatment. Rituximab is an anti‐CD20 antibody that are used in haematological conditions, such as Non Hodgkins Lymphoma and Chronic Lymphocytic Leukaemia10. CD20 is an antigen commonly found on the surface of B Cells. Rituximab is combined with cylcophosphamide, doxorubicin, vincristine and prednisolone (R‐CHOP) as a highly efficacious first line
treatment10. R‐CHOP is a good example of a targeted therapy combined with chemotherapy and immunosuppressive agents10. Drug Treatment of Breast Malignancies In the UK, breast cancer is the most common cause of solid tumour death in women11. The incidence of breast cancer increases with age, and ten years post menopause poses the highest risk11. The risk factors for breast cancer include length of reproductive life (difference between menopause and age of menarche), nulliparity (child birth is protective), weight, diet, hormone replacement therapy (exposure to exogenous oestrogen) and it is thought that 10% of breast cancers are hereditary11. The genes BRCA1 and BRAC2 are located on the long arms of chromosomes 17 and 13 and are implicated in the disease11. Breast cancers are superficially classed as invasive or in situ. Cells that do not break through the basement membrane and remain in the terminal ducts lobular unit are non invasive12. The most common invasive breast cancers are ductal and lobular types, corresponding with the affected anatomy12. Patients normally present after noticing a lump, or as a result of the national screening programme detecting an abnormality. For diagnosis and classification most cancers rely on histology, however some cancer classification can be done using other molecular markers. Biopsies from breast cancer tumours are tested for oestrogen receptor status (ER), Human Epidermal Growth Factor Receptor 2 (HER2) and progesterone receptor status (PR). As prolonged oestrogen exposure is known as a risk factor for breast cancer and the identification of the ER receptor provided the first opportunity for targeted anti‐oestrogen therapy13. Tamoxifen is a Selective Oestrogen Receptor Modulator (SERMS) and is a good example of hormonal therapy13. Tamoxifen blocks or down regulates the receptor, and there is resultant inhibition of the proliferative effects of estradiol at the receptor13. Tamoxifen is also prescribed to women at high risk of developing breast cancer. Other ‘indirect’ targeted hormone therapies are also effective. Aromatase Inhibitors block the enzyme which converts circulating androgens to oestrogens14. This is most effective in postmenopausal women as before the onset on menopause ovarian production of oestrogen is too great. Surgical options are often approached with a bilateral oopherectomy or mastectomy to remove sources of oestrogen production and sensitive tissues. New novel therapies have provided other targeted approaches for the treatment of breast cancer. Steroid sulphatases have a role in estrogenic steroid synthesis regulation and, as breast cancers are often noted to have excess synthesis15, inhibition of this activity has been shown to be an effective treatment. The discovery of new therapies in breast cancer is important for additional or alternative therapies if resistance or intolerance is apparent15. HER2 is a member of the epidermal growth factor receptor family receptor (EGFR) family of transmemembrane tyrosine kinases which function is to regulate cell cycle16. Patients with overexpressed HER2 are more likely to have poorly differentiated tumours, with a high proliferation rate, presence of positive nodes (signifying spread) and decreased expression of oestrogen and progesterone receptors(16). Transtuzamab is a monoclonal antibody that has a high affinity for the extracellular domain of HER217. HER2 is commonly combined with cytotoxic agents such as taxanes, vinorelbine and platinum salts. Inhibitors of EGFR are also beneficial in the treatment of other cancers, such as advanced non small cell lung cancer18.
Micro‐array profiling, which measures expression of mRNA, has given us the ability to subclassify cancer19. The information gained from this can be used to screen for those common DNA variants which have increased cancer risk, to help us determine which genes are associated with cancer survival and drug sensitivity18. This genomic medicine approach could be adopted in cancers, for example in breast cancer where they use ER, HER2, PR status coupled with genetic information to subclassify tumours. This could give an indication of prognosis and treatment plans19. Conclusion Treatment of cancer can be approached in many ways: surgically, radiologically and therapeutically. The intervention used is entirely specific to cancer type and the patient. Often, combinations of approaches are used in cancer treatment for maximum effect. Therapeutic approaches to cancer treatment usually encompass chemotherapy or targeted treatments. Both chemotherapy and targeted treatments have a positive influence on treatment survival. Conventional treatment of cancer involves numerous cytotoxic agents, either cell cycle specific or non cell cycle specific. However, more recently targeted drugs have allowed specific treatments to counter act molecular abnormalities. Targeted treatments such as monoclonal antibodies and tyrosine kinase inhibitors have improved survival rates in some conditions. The further development of targeted treatments may revolutionise the way in which some cancers are treated. Yet despite these advances, these drugs are not always a replacement for traditional chemotherapy agents, as the greatest quality of life can often be restored through a combination of both approaches
References Full references for this article can be found in the pdf of the individual article
Breaking Bad News – Pointers and Pitfalls Mandy Barnett (Associate Clinical Professor in Medical Education, Warwick Medical School Honorary Consultant in Palliative Medicine, South Warwickshire Foundation Trust) Correspondence to: Mandy Barnett : [email protected]
ABSTRACT Breaking bad news (BBN) is a frequent and challenging task for clinicians, with the majority of consultants reporting that they do so at least once a week. Whilst discussing a cancer diagnosis or approaching end of life situations is probably foremost in the mind of a medical student or junior doctor, it is unlikely that you will be asked to lead in this type of consultation at this point in your career. However, the definition of BBN is much broader. In this article Dr Mandy Barnett notes a few key pointers that will help you approach BBN consultations in your role as a junior doctor. Key Words: breaking bad news; communication skills
Introduction Breaking bad news (BBN) is a frequent and challenging task for clinicians, with the majority of consultants reporting that they do so at least once a week1. Whilst discussing a cancer diagnosis or approaching end of life situations is probably foremost in the mind of a medical student or junior doctor, it is unlikely that you will be asked to lead in this type of consultation at this point in your career. However, the definition of BBN is much broader, as set out by Ptacek and Eberhardt2
“..pertaining to situations where there is either a feeling of no hope, a threat to a person's mental or physical well‐being, a risk of upsetting an established lifestyle, or where a message is given which conveys to an individual fewer choices in his or her life”. It is information that “...results in a cognitive, behavioural or emotional deficit in the person receiving the news that persists for some time after the news is received.”
Clearly this definition covers a wide range of possibilities; a study of hospital consultants produced a long list of clinical scenarios ranging from heart failure to hearing loss and also of indirect situations e.g. cancellation of operations due to bed shortages1. Hopefully, throughout your undergraduate and foundation training, you will have had the chance to practise breaking bad news in a protected (i.e. simulated patient) environment, and to have observed senior colleagues carry out consultations in practice. This may have given you some ideas about what does and doesn’t work. In this article I would like to focus on a few key pointers that I hope will help you approach BBN consultations in your role as a junior doctor:
Preparation Irrespective of the situation, preparation is fundamental – this means preparing:
1) Yourself 2) The patient 3) The environment
The first point encompasses both intellectual and emotional factors. To break bad news, you need to first make sure you have the facts so that you are able to give the patient correct and consistent information. However you also need to prepare yourself; this involves practical points like ensuring your bleep is turned down or handed over and that you have a clear time window; it also involves clearing your head to focus on the task; occasionally it may mean recognising that you are not the right person (for example if the situation mirrors something in your personal life) and finding a colleague instead. If you feel out of your depth, do be prepared to ask a senior colleague for help. In palliative or end of life situations (irrespective of diagnosis), the Palliative Care Team is a valuable resource3. Preparing the patient is often an on‐going task in the hospital setting, as they may be undergoing a series of tests or procedures to build up the overall picture both diagnostically and prognostically. What is important is trying to ensure that the patient can exercise a degree of choice regarding the timing of a consultation, and also with regard to who hears it. Some may wish to have a significant other present; whilst others will prefer to receive news initially on their own. Remember that family members will have their own concerns and agendas and although they can be supportive they do not have a right to receive confidential information without the patient’s permission. This can be a delicate path to tread, especially when the predominantly North European‐North American model of patient autonomy clashes with other cultural norms. However there is increasing evidence that individual patients value honest information irrespective of their culture4‐5. If in doubt, try to establish early on with the patient on their own, using a professional interpreter if language barriers exist, if the patient is content for the family to receive information on their behalf. Finally, preparing the environment in the hospital setting is not always easy – not all wards have private areas, and if a patient is very unwell it may not be possible to use a separate space6. However little things like getting the cleaners to start in another bay (!), turning the TV off and making sure everyone has a chair all help. Above all, make sure that the patient is comfortable so they can concentrate (and have their glasses on and hearing aid in place!) and that you are sitting near them – this helps them to hear you, creates a more private space and conveys compassion7. If at all possible, take another member of the ward team with you, so that there is a witness who can reinforce support and/or clarify information subsequently.
Starting and Listening Having introduced yourself (and any colleagues) and established who any other people are if you have not met them before (never make assumptions about relationships!), how do you start? If you already know the patient and have been involved with their care to date, your opener is likely to be checking what they understand and have remembered so far. If you are meeting the patient for the first time, it is sensible to take a similar approach, but with a more open question, although it helps to guide the patient to a suitable starting point. E.g. ‘I have read a bit about you in your notes, could you tell me what has happened/what you have been told/what you understand about…since you ..went to your GP/were admitted/had your operation?’ Then listen carefully to their answer, as it will tell you a great deal about where they are up to, what they have actually heard (as opposed to what they have been told) their understanding of information received, their grasp and interpretation
of what this means. This will set the tone for the rest of the consultation, so giving the patient uninterrupted time is important. You can then move on to what you have come to talk about now, checking at this point that they are ready to do so. E.g. ‘we have the results of your scan/blood test/MDT meeting/OT assessment, would you like to go through them?’ Be aware that individual preference for information will vary with time and illness trajectory, not just between individuals8. There is also evidence that whilst patients with a cancer diagnosis seek and prefer information on treatment and prognosis9‐11, patients with other life‐limiting diagnoses such as chronic obstructive pulmonary disease (COPD) may view their illness more as a way of life than as a terminal disease and may resist attempts to broach this possibility10.
Explaining If and when you move on to explaining a diagnosis or discussing management options, remember to Keep It Simple, and less is definitely more if you want your main points retained. Tailor your language according to the patient’s own – some patients will have learning difficulties and a very basic vocabulary13, whilst at the other end of the spectrum you may meet patients with long‐standing chronic or progressive conditions who know more about it than you do. The key is to give information in small chunks and to allow time for the patient to process it and respond – this may involve sitting in silence for a time that feels long to you, but is rarely perceived as such by the patient.
Answering Questions – Know Your Limitations Always invite questions, and try to answer them as clearly as possible, but don’t get drawn into discussing areas that you either don’t know about (such as specialist treatment options) or timeframes that are speculative (such as when they can start treatment/go home). It is not being evasive to say that you don’t know, as long as you indicate who will provide answers and/or when that information will be available. One of the major underlying causes for complaint is when patients receive inconsistent or contradictory explanation. Ironically it is more likely to occur when the patient is more anxious and the clinical team are trying hardest as this may lead to information being presented early when it is incomplete or the picture is changing. Handling Emotions – yours and the patient’s Emotional reactions are often the area doctors feel least adept at handling14 (Cantwell & Ramirez, 1997). If the discussion is more emotional, try to avoid talking to cover any discomfort on your part. If a patient or relative becomes tearful, allow time and don’t be afraid to offer silence. If it feels appropriate, a supportive touch such as patting a hand may be appreciated, but don’t do it if you feel uncomfortable15. It is alright to express sadness ‘I am so sorry…’ as long as your feelings are genuine16. Equally, it is important to remain professional and not to allow your sadness for the patient’s situation to become confused with your personal feelings. A potentially more difficult situation to handle is if the patient or relative becomes angry in response to the news. The key here is not to take it personally, and, unless you perceive a
real physical threat, try to allow the person to vent their feelings while you listen. If you are not already seated (which you should be if you have prepared your environment), sit down as soon as you can. It is difficult for someone to maintain aggression if they are sitting down and talking to someone who is listening calmly. In most BBN scenarios anger usually reflects someone’s fear or frustration with a situation beyond their control. If there are genuine grounds for complaint, apologise for the failings of the system, but do not assume individual fault. If you think the person concerned is likely to make a formal complaint, let your consultant know.
Finishing the BBN consultation When it comes to closing the consultation, how you do so will clearly vary enormously with the situation. If the patient and/or family are calm, you may wish to recap on what you have talked about, check for any questions and agree on what happens next. If the situation is more emotional, you may need to state gently that you are finishing at this point ‘...I am going to have to leave shortly…’ if they are in a private area, make it clear that they can stay ‘...please take your time’ and check if they want anyone to remain with them (this is when an accompanying colleague is invaluable) or to be alone for a while. Documentation and Follow‐Up Action Ensure you update relevant clinical colleagues verbally but most importantly, document your conversation in the medical records and check that an entry goes into the nursing Kardex if this is maintained separately. Documentation of significant conversations is key to good professional care but is often inadequate17‐18. If you need to put other plans into action as a result of the meeting e.g. referring to the Discharge Co‐ordinator, try to address this while it is still a priority. Self‐Awareness Once you leave the room or area, pause for a moment to check on yourself. Breaking bad news is stressful for juniors19, but it remains emotionally draining no matter how experienced you become20‐21. It may be helpful if you can debrief with colleagues22. An easily overlooked point is to be aware around the hospital too. Hospital canteens are often public areas, so take note of who is around you if you go for a break with colleagues shortly after a BBN consultation – uproarious laughter may be a release for you but will appear at odds with your previous professional demeanour to a family member standing behind you in the lunch queue.
On‐ Going Patient and Family Support Breaking bad news is often a continuing process. Whilst it is important not to offer unrealistic hope (whether that relates to prognosis, treatment options or the likelihood of coping safely at home) it is equally important that patients and families can discuss and consider options and come to terms with limitations without feeling abandoned by the health professional team23. If you are involved with the patient’s on‐going care, be sure to indicate when you will be back to see them again, especially if they have decisions to make. If they are being handed over to another team, make sure the patient knows you will document your meeting and any outcomes from it. If a patient is going home and has unstable medical needs, try ringing the GP directly, not only to update them on the medical
situation, but also to let them know what the patient and/or family has been told, as the GP is likely to be the first point of contact once the patient is home. Conclusion Bad news is what the hearer perceives it to be, and conditions or situations that become routine to you during your career will still be unique to the individual patient and family. You will not always find it easy to deliver patient‐centred care within the constraints of busy departments, pressurised team members and less supportive senior colleagues24. However, remember that patients will forgive you for not knowing all the facts (as long as what you do tell them is consistent), but they will always remember your attitude and whether or not you cared16.
References Full references for this article can be found in the pdf of the individual article
Identification and treatment of wearing off in Parkinson’s disease Authors: James M Fisher (St5 Geriatric Medicine) & Richard W Walker (Consultant Physician and Honorary Professor of Ageing & International Health) both at Northumbria Healthcare NHS Foundation Trust/Newcastle University Correspondence to: Richard Walker: [email protected] Abstract: Parkinson’s disease (PD) is a neurodegenerative disorder classically characterised by motor symptoms. In recent years there has been increased recognition of the non‐motor symptoms of PD. ‘Wearing off’, worsening of a patient’s symptoms before the next dose of their medication is due, may be seen with advancing disease. Management of wearing off may include modification of a patient’s levodopa medication regimen or prescription of an additional agent. The onset of such motor complications may be delayed by the use of levodopa‐sparing agents or by keeping levodopa doses to a minimum. Wearing off may be evaluated via patient histories, diaries, rating scales or questionnaires. The efficacy of these assessment methods is however limited by recall bias and their inherent subjectivity. A number of potential objective methods of symptom assessment in PD have been explored, with body‐worn accelerometers showing the most potential. The application of advanced computational algorithms to the data captured by accelerometers may enable the complexity of human movement to be appreciated. Such technology may, in future, allow objective identification of wearing off and thus provide the clinician with vital additional information on which to base clinical decisions. Key Words: Parkinson’s Disease; Wearing off, Motor Fluctuations
Introduction Parkinson’s disease (PD) is a progressive neurodegenerative disease with selective loss of dopaminergic neurones in the basal ganglia. When there has been loss of 70 – 80% of neurones the motor features of PD, resting tremor, cogwheel rigidity and bradykinesia, become evident. This is generally when the condition is diagnosed. There are currently no proven disease modifying agents and treatment for the disease is aimed at alleviating the symptoms. Generally, patients respond well to treatment early on in the disease but as more and more of the dopaminergic reserve in the basal ganglia is lost they develop motor side effects. These include dyskinesia which manifests as choreiform jerky movements which can involve the limbs, trunk and face and are usually worse at peak dose. They also include wearing off, whereby the patient’s symptoms deteriorate before the next dose of medication is due so, for example, the tremor may increase and they may slow up. It is now increasingly recognised that patients with Parkinson’s disease suffer from non‐motor symptoms as well as motor symptoms. These include constipation, drooling, pain and neuropsychiatric symptoms including hallucinations, anxiety and depression. All of these
symptoms can also occur as a manifestation of wearing off, and not necessarily at the same time as the motor symptoms.
What causes wearing off? As demonstrated in Figure 1, as the disease progresses the buffering effect of the patient’s own dopamine decreases, and they become more dependent on the drugs they take[1]. The short duration response (SDR) to each dose of drug decreases and the therapeutic window narrows such that the time spent controlled, with neither wearing off or peak dose dyskinesia, becomes shorter. In addition to the SDR there is also a long duration response (LDR) which can last for days to weeks but over time the LDR decreases more than the SDR thus leading to fluctuations[2]. Figuure 1: Development of Motor Fluctuations with Advancing Disease (adapted from Obeso et al.[1])
Treatment Pulsatile delivery of traditional Levodopa leads to pulsatile stimulation of dopamine receptors making motor complications more likely, whereas continuous delivery of Levodopa by infusion reverses motor complications by maintaining the patient for a longer time within the therapeutic window[3]. Treatments aimed at continuous delivery of Levodopa, such as duodenal infusion with Duodopa, do produce improved symptomatic control but are very expensive. Generally, when a patient who is on Levodopa presents with wearing off, options include increasing the dose frequency, changing to a controlled release preparation but these have variable absorption and an unpredictable effect, rescue therapy with fast acting agents such as dispersible Madopar (a form of Levodopa) or adding in other agents. Standard Levodopa includes a dopamine decarboxylase inhibitor (DDCI) which prevents breakdown of Levodopa in the peripheral circulation, but which does not cross the blood brain barrier, thus allowing breakdown to dopamine once inside the brain. Dopamine agonists, such as Ropinirole, Pramipexole and Rotigotine (given as a patch), directly stimulate the post synaptic receptor and can reduce off time by approximately 20%, or 1 and a half hours per day. Monoamine oxidase‐B (MAOI‐B) inhibitors such as Selegiline and Rasagiline have also been shown to decrease wearing off as have the catechol‐O‐methyl transferase (COMT) inhibitors, Entacapone and Tolcapone. These drugs act by slowing the breakdown of dopamine and therefore prolonging the action of Levodopa.
Prevention Ideally, motor complications should be prevented or, more realistically, delayed by appropriate management. Levodopa doses should be kept low, generally not higher than 600mgs per day. Levodopa sparing agents such as dopamine agonists, MAOI‐Bs and COMT inhibitors should be utilised. There is evidence from previous drug trials, and the recently published PD MED study, that initial treatment with dopamine agonists compared to Levodopa leads to less motor side effects at 5 years, at the expense of poorer symptomatic control otherwise (PD MED 2011). There are now once daily preparations of both Ropinirole and Pramipexole available.
Identifying Wearing Off Since wearing off can include such a variety of signs and symptoms it is thought that the condition may be under‐recognised by clinicians[4]. It is therefore imperative that patients are educated about wearing off and are regularly asked about, and given ample time to describe, symptoms that may suggest wearing off. Reliance on patient recall of symptoms (perhaps with relative/carer input) is prone to recall bias which may be exacerbated by the duration of time between appointments and the fluctuant nature of the condition itself. A common description given by patients that should alert clinicians to the possible onset of wearing off, is that the duration of effect of their medications no longer lasts until their next medication is due. Direct observation of wearing off by clinicians is simply impractical, given the long duration of time over which such fluctuations occur. Various attempts have therefore been made to improve the detection and measurement of wearing off. One of the most commonly used and simplest methods is a patient completed symptom diary. A symptom diary requires patients to record their current disease state, be it on, off or dyskinetic, usually at hourly intervals. Patients are typically asked to complete symptom diaries for a period of several days whilst at home, thus enabling prolonged recording of disease state and its fluctuation. Wearing off may be recognised by increasing amounts of off time occurring before the next dose of medication is due. Central to the validity of diaries is patient compliance with their completion and accurate disease state recognition by the patient. The nature of symptom diaries is such that they are open to recall bias. Evidence suggests that patient self‐assessment, when compared to clinician assessment, often results in incorrect identification of their disease state, particularly when their disease is fluctuant[5]. In attempts to provide more objective, valid measures, a variety of clinical rating scales are in use for patients with PD. The most well known and widely used is the Movement Disorder Society‐sponsored Unified Parkinson’s Disease Rating Scale (MDS‐UPDRS)[6]. This is an extensive assessment used widely in clinical research that includes both clinician and patient completed sections. The MDS‐UPDRS consists of four sections, part four of which is designed to capture data on motor complications. Specifically relating to wearing off, the MDS‐UPDRS has only two questions. Firstly it asks the patient, with clinician supervision, to quantify off time as a percentage of time spent awake in a typical day in the last week. Secondly it asks patients to categorise the functional impact of off time in terms of its impact on their activities and social interactions. Whilst this assessment method standardises the question asked and the choice of possible responses, it is ultimately limited by recall bias and inherently subjective.
Questionnaires have been specifically designed to detect both motor and non‐motor symptoms of wearing off; the 32 item wearing off questionnaire, WOQ‐32[4] and its abbreviated form, WOQ‐9[7] (Table 1). Evidence suggests these tools may be more sensitive in the detection of wearing off when compared to clinician assessment; they are however limited by relatively low specificity[8]. Table 1: The Wearing Off Questionnaire (adapted from Stacy et al.[7])
COLUMN A
Experience symptoms? COLUMN B
Usually improves after my next dose Tremor
Any slowness in movement
Mood changes Any stiffness Pain / aching
Reduced dexterity
Cloudy mind / slowness of thinking
Anxiety / panic attacks Muscle cramping
Moving towards more objective methods of assessment Ultimately patient recall, questionnaires and even clinical assessment remain inherently subjective methods of assessment. As such they are limited by recall bias and the fact that symptoms may not be apparent during the brief period during which clinical assessment occurs. One might also argue that the very act of observing a patient in a clinical environment may in fact influence the signs and symptoms exhibited. There is therefore great need for a more objective method of symptom assessment capable of capturing data, unobtrusively, whilst the patient goes about their normal activities of daily living. In attempts to objectively assess symptoms in PD, a wide variety of methods have been explored including lasers[9], electromagnetic sensors[10] and optoelectronic systems[11]. These systems have shown promise in a highly‐controlled research setting but their clinical use has been restricted as a result of their complexity and expense. Frequently they are only capable of short‐lived assessment and evaluation of a patient in their own home has not been possible. The field that has seen the most work undertaken is that of accelerometry. Accelerometers are sensors that are capable of detecting and measuring acceleration, such as that generated by human movement. Accelerometers have been in existence for many years but recent advances in nano‐technology have seen the development of micro‐electromechnical systems (MEMS) accelerometers that are often less than a millimetre in size[12], an example of which is seen in Figure 2.
Figure 2: A typical MEMS accelerometer (adapted from [13])
Hoff et al[14] used continuous ambulatory accelerometry in an attempt to identify on and off disease states in 15 patients with PD, all of whom exhibited fluctuations. Their system comprised 7 separate accelerometers located on the sternum, wrist and thigh, worn for a 24 hour period whilst patients simultaneously recorded a symptom diary. The objective measures generated by the authors’ analysis showed inadequate sensitivity and specificity to consider this system an appropriate method of automated on‐off detection. In this work human movement exhibited by participants was, for the purposes of analysis, mathematically described using small numbers of simple variables (e.g. mean acceleration). It is likely that the simplicity of such variables will fail to capture the complexity of human movement, hence the poor results seen in this work. Keijsers et al.[15] collected data in a similar manner, with accelerometers placed at 6 sites on the body, but explored the use of more sophisticated analysis methods, neural networks. Artificial neural networks (ANNs) are mathematical models inspired by biological neural networks, capable of adaption and ‘learning’ as data are presented[16]. ANNs are capable of considering huge numbers of variables and, critically, can weigh up the complex interconnections between each. Their use in the field of speech recognition has proved extremely successful in improving it’s accuracy. Keijsers’ work showed that ANNs were able to distinguish the presence of dyskinesia from voluntary movement with high levels of sensitivity and specificity. Accelerometers and analysis methods like ANNs have huge potential to provide a new, objective method to assess the symptoms exhibited by PD patients. This method may enable wearing off to be identified sooner and more accurately, thus more fully informing treatment decisions. The authors of this article are currently involved with research exploring the use of similar analysis methods to accelerometer data, derived from wrist‐worn sensors worn by patients with PD for prolonged periods at home. Looking further ahead, Rodriguez‐Molinero et al[17] hypothesised that in the future, body‐worn sensors could be used in conjunction with drug infusion pumps to provide dynamic real‐time dose adjustment in response to both the patient’s disease state and their level of activity.
Conclusions Wearing off is a major problem in later stage PD and has a significant impact on quality of life. Judicious use of drugs can help to delay the onset of wearing off and adaption of the drug regime can help to treat the motor symptoms but has less effect on the non‐motor symptoms. In order to identify the problem healthcare professionals, patients and carers
need to be aware, and scales and diaries can help. In the future it is likely that unobtrusive monitoring devices will become available clinically to guide management.
References Full references for this article can be found in the pdf of the individual article