Deadly drugs still given to the elderly!

Dr Dermot ward



It isn't often as a doctor one receives overwhelming plaudits from the relative of a patient. The story begins about 30 years ago when a longstanding friend of my better half related with distress how her mother had developed a cruel dementia illness. it was not so much memory and other cognitive impairments that so upset that lady’s daughter and other family members but what lately has been neologised as ‘challenging’ behaviour:

She was, I heard, uncharacteristically aggressive, resisting feeding, basic help with personal hygiene, lashing out at professional carers and family alike. They were at their wits end attempting to cope with compassion and kindness.

I don’t think that even though her daughter knew I was a consultant psychiatrist that she was soliciting my advice. But I had known the family over a decade or so and wanted to help if I could though simultaneously aware of the need to avoid intruding where medical angels fear to tread if they have any sense. The mother was of my parents’ generation and I had met her occasionally and more especially had the pleasure of her company while sitting beside her at a family wedding: an older person, of striking appearance, she had an alert mind, a ready wit and oozed competence. In fact , such was her personality that if the family car broke down it was she rather than her husband (a professional man) who would be the one to replace a broken fan belt - when motor cars had such items.

I eventually suggested that perhaps her GP might try a small dose of a particular psychotropic drug and or request a specialist opinion. It was a couple years later when I next met her daughter again. She expressed such great gratitude to me because apparently my mild suggestion had been taken up. Happily it had transformed the patient into a more pleasant, albeit still dementing, person, accepting necessary care with a grace not unknown to her pre-morbid temperament and decidedly without being “chemically coshed”. All I had clearly remembered was meeting her most distressed daughter and hearing the sad tale of her mother’s deterioration. Even now - that older lady is now long dead - when rarely I meet her daughter she still reminds me , with almost embarrassing gratitude, the benefit conferred on her late mother by my proposed micro-psychotropic medication. It seemed to me that I had suggested only averagely competent contemporaneous psychiatric prescribing.

For some years now there has been regular eruption in the public press a mixture of excoriation and righteousness against the misuse of sedating drugs, “chemical coshing,” of the elderly in care homes and hospitals. This happened once more in my Telegraph of July 17, 2012, with the headline I have used in this piece. I don’t disapprove of that: it is merely doing what any good newspaper does. What surprises is the infrequency of any deeper probing of this elder abuse when it is deemed to have occurred. There is the listing of postcode frequency differences, the objection to using ‘antipsychotic’ drugs and of course the  condemnation qualification that “[these drugs] are intended for the treatment of illnesses such as schizophrenia”. It cannot be overstated that prescribing psychotropic drugs needs bespoke management in a manner wholly different to, say, a five or seven day course of antibiotics.

Let me posit some of the reasons why this practise receives such regular ritual exposure. At its most superficial lies a belief that an antipsychotic, no matter how effective it may be, is an inappropriate prescription when given to a patient such as the lady I described above: that she was suffering from dementia not psychosis. Well, when a patient reaches that degree of dementia, such has been, and still can be, described as organic psychosis which immediately preempts any suggestion of automatic inappropriateness in prescribing an antipsychotic in such patient.

Even if such were not the case, experienced doctors in various disciplines have been known to prescribe beneficially ‘off label’ meaning that the product was not originally envisioned by the drug manufacturer as suitable for any condition other than that focussed
in its marketing target. However, regularly experienced physicians may note an unexpected improvement in a separate condition occurring by chance in a patient who is receiving the drug for the labelled illness.  I was already an experienced consultant psychiatrist when I mildly indicated that possible prescription which happily proved so successful. I do not claim any special therapeutic
powers apart from your averagely trained and experienced psychiatrist. It is easy however to underestimate the sweat and tears that go into any medical discipline’s experience and competence. So easily can that happen that you can have a situation today where patients may be assessed by a nurse who works in the consultant’s field and is now allowed to prescribe within that field for a patient who may never have even been assessed by a consultant. This may suit the funding fancy of the NHS but it is not what the medical
profession, when it was self-regulated would have considered consonant with good medical practise.

The barriers erected by government allegedly to improve individual patient treatment and care are numerous but primarily seek cost cutting. This is especially true for mental health services. Remember when joined-up psychiatric and GP teams had an arrangement whereby the family doctor referred a patient to a named psychiatrist who examined that patient, formulated a diagnosis and sent a written report to the GP outlining management and treatment which might or might not involve, hospitalisation, nurse input, or other
member of the multidisciplinary team follow-up. New Roles for Psychiatrists (2003) undermined this medically endorsed primary and secondary cooperative model.

A GP sourced JRSM article titled ‘Referral into a void” (April, 2006) lamented the promoted practise of GPs encouraged to refer individual patients to ‘the team’ rather than a named consultant. And because the patient was not seen by the consultant the GP received no written report on patient diagnosis and management and felt their on-going professional development was thereby impaired. There is even the surprisingly sanctioned situation where one consultant psychiatrist looks after a patient only when he/she is hospitalised while another only sees the patient when he/she is back in the community. Thus is breached that benchmark of good continuity of patient treatment and care. Where I have seen this in operation I am puzzled that it can seem the consultants participating in such practise appear to accept it.

That elderly patients with mental health problems and inpatient critical staffed bed shortages for proper assessment may be inadequately assessed both in and outside hospital hardly surprises. I have but skimmed the surface of service inadequacies making it more likely that headlines such as “deadly drugs still given to the elderly” by GPs and “team” members appear hardly unexpected.

In case you wonder, the drug I advised all those years ago was an antipsychotic, still available and used, with a side effect profile that requires skill and understanding which demands individual bespoke prescribing.