Archive for December, 2008
Dementia is again a hot topic at present and about to become hotter with the imminent release of the National Dementia Strategy .
One of the aims is to increase public awareness of dementia, so they realise that nanny isn’t just getting old, but actually has a condition for which some help and assistance can be provided. So we can expect lots more elderly relatives to be dragged to the surgery just because they forgot where they put their spec’s. (on your head…) Obviously this is a good thing (mostly).
When granny arrives what do we do with her? Well obviously we listen to the story, and send her for a whole heap of blood tests to rule out anything acute or chronic that may be causing confusion and we do an examination of her mental state.
At best the Mini Mental State Examination (MMSE) is subjective. It has 8 questions with a top score of 30, but I challenge anyone to get 30!
Firstly today’s date…urm, where’s it written… oh yes the display on my phone…I NEVER know what the date is. It does NOT looks great when I’m testing granny, that I have to look around to see if she is right or wrong… (Fair enough if she tells me it’s 1941, and calls me “dad” I have a bit of a hint things may be going badly), but I always think that if I wasn’t working Monday to Friday, I wouldn’t know what day it was.
Recently I did a MMSE and asked what season it was, well it was late September, black as your grandfathers, and it had been snowing. My patient said “Winter”. Of course I didn’t laughed in his face and said, “NO dummy it’s Autumn”.
The question I would struggle on most is “Begin with 100 and count backwards by 7’s”. Holy Carp. I don’t know my forwards 7x table, but if I can’t do it backwards from 100 I score low on the MMSE. It’s OK though, there is an alternative question for this one…
Spell the word “world” backwards. Try saying that to a deaf old lady. It’s not easy to understand let alone do! Incidentally, the answer is not: “W.O.R.L.D.B.A.C.K.W.A.R.D.S. “
I recently heard of an alternative assessment tool. The Clock Drawing test. It is pretty much one of those “It does what it says on the tin” kind of tools. Draw a clock, with numbers and set the time to ten past eleven.
Scoring is out of 5:
1 point for the clock circle
1 point for all the numbers being in the correct order
1 point for the numbers being in the proper places
1 point for the two hands of the clock
1 point for the correct time.
My 4 year old drew her first clock last week, and unfortunately she appears to have early onset dementia, scoring only 1 (scores of 4 or 5 are acceptable)….and I am not sure of the significance if you draw a cuckoo on it!
My highlight from doing MMSE has to be the part of the test where you ask the patient to “write a sentence”. It can be anything…
My patient on this particular occasion wrote: “You’re a funny sort of chap”. No signs of dementia in her case then!
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Interestingly this is a huge part of my job, but something that I don’t think I have written about before. I am a drug dealer (or an Independent Nurse Prescriber, if you want to make it sound slightly more legal!)
Like any good drug dealer, I don’t handle the drugs myself, I simple make sure the right people are getting the fixes they need. Unlike a good drug dealer I don’t get a huge wage for this, nor do I drive a BMW or own a gun…(I’ve got a stapler, but that only shoots about…hold on a second…<clunk-chung!!!>…yeah about 2 foot).
Another difference between me and the gun slinging BMW driving type of drug dealer is that actually I don’t want to give my clientelle any drugs, and I will not issue them just because they ask for them. My clientelle don’t seem to realise this all the time.
This week I have had to clarify that I won’t give sleeping tablets out just because you’ve become reliant on getting to sleep only when you use cannabis. You need to learn how to sleep without drugs, not just exchange illegal drugs for legal ones. Maybe I am a bit harsh. I was going to give her 7 days worth of Zopiclone in conjunction with some self help on insomnia to help her establish a sleep pattern, but she started demanding them and saying she’d make an appointment every day to see me until she got some…so alas she went without…She’ll get bored with it before I do!
Every single day of my working life I have to remind patients that antibiotics do not kill viruses. Antibiotics only kill bacteria. That sniffle that you’ve had for one day, isn’t chronic sinusitis and doesn’t need antibiotics, and just because your Dr prescribed you some last time (just to get you out his room quicker (he said cynically)) doesn’t mean it is clinically indicated this time…
The clinical relevance of it being Friday, Christmas soon, your birthday or the fact your going on holiday doesn’t influence my prescribing (well very occasionally it will – alright you can have some Norethisterone so you can bonk your new husband on your honeymoon and wear a swim suit without sanitary towels hanging out and your tampon absorbing half the swimming pool).
I quite like…this for something other than the sound of me whinging voice…
I also like this for something nice (but it isn’t relevant to the topic)…
In summary I will prescribe drugs, but when I feel it is clinically indicated and not just because the patient thinks it might help…It might help to dive into a vat of goose grease…but I wouldn’t tell you to do it without clinical indication…or a particularly vindictive mood!Read Full Post | Make a Comment ( 1 so far )
This is a bit of a follow up…back in the deep dark archives of this blog, I told of my grandad and his total knee replacement which he had completed privately. Well this is a bit of an update. Since then he has had nothing but trouble with his “private” knee, and so ended up requiring further intervention. Apparently (and I’m not very “ortho minded”) a total knee replacement doesn’t actually replace the total knee… as they used his knee cap, which is apparently what has been causing all the trouble.
So his GP referred him to the National Health Service orthopods.
Grandad (quite quickly) was seen by exactly the same surgeon he saw privately, who said they needed to give him a new knee cap. He then had a speedy date for his op and last week went in for his second bout of knee surgery.
He didn’t pay £10, 000, he didn’t get his own room, he didn’t get a “free” newspaper. So I was waiting for his NHS bashing comments on discharge…
He did get discharged…it’s not like I’m typing this in a black suit wondering what I am going to do with my grandma now! But he DID NOT moan about his hospital stay…
He got 8 hours sleep per night, he said the food was nice (which for my grandad usually means there was plenty of it), he said the staff were friendly and helpful, he shared a bay with 3 other gents who he could spy upon and relay the stories to Grandma, he doesn’t appear to have MRSA. He is happy with his care.
OK so it isn’t a very interesting blog article, and it wouldn’t be a very good story for the press to grab and run with…but it damn well needs saying!!!!
So if you are a friendly NHS worker, I take it upon myself to say thank you from every single patient that didn’t complain! Well done…Keep up the good work…
While we’re talking about my grandparents, I thought I’d share this little story with you…Years ago my grandparents, not wanting to burden the next generations with the issue, decided to buy two plots at the cemetery for “when the time comes…” Cheery.
Recently they have decided that no one much would come to their grave, so decided they’d ask the council for their money back…
“I’ve changed my mind…have you got anything roomier???”
The council (not too surprisingly) had never had this request before, so looked into it and decided to pay my grandparents the current price…
Oh yes….my grandparents made a profit on their own grave and lived to enjoy the money!! Shucks they makes me proud!!Read Full Post | Make a Comment ( 1 so far )