<p> Minutes of the Exeter Sessional GPs Group at Darts Farm – 4 January 2011</p><p>The meeting was kindly sponsored by: Gary Pullen MSD Alison Earp Galderma</p><p>Attendance: 24 members</p><p>Welcome: Emma Green opened the meeting by thanking the reps for sponsoring. She reminded members to sign the attendance register.</p><p>Emma welcomed Dr Sarah Black, Exeter based Consultant in Old Age Psychiatry.</p><p>Dr Sarah Black – Old Age Psychiatry Overview Overheads attached separately.</p><p>1. Organisation of local services As for other psychiatric services, old age psychiatry is sectorised so patients are cared for by the local team. Team approach very important (this is where private psychiatry can break down) – CPNs, OTs and psychologists are key team members. Note that there are no social workers in the teams so if social worker needed then separate referral to complex care team is required. Exeter team covers all the Exeter practices including periphery –e.g. St Thomas patients at Pathfinder, Pinhoe patients at Broadclyst, patients at Exminster. In patient services very sparse at the moment due to ward closures and admission best avoided as may involve considerable travelling. Single point access so every referral letter is seen in the same place (St Edmunds Court) and prioritised according to need. Triage times are dictated by NHS centrally. All referrals must be made by a GP – previously when this was not a rule there was more risk of inappropriate referrals e.g. confusion due to end stage renal failure. The team require information on physical history, drugs and investigations in the referral letter. Slight anomaly that Crisis Team referrals can come from open access – not just GP – this is in line with crisis team referrals for other age groups. Crisis team cannot see delirium or dementia – only functional psychiatric illness, can only see if urgent (under 24 hours) and only if aim is to avoid admission.</p><p>2. Understanding behavioural symptoms  Delusions often rooted in pre morbid personality – e.g. tending to blame others, angry responses.  Need to consider patient’s perception of environment – e.g. no wonder they are angry if a carer starts undressing them and they don’t perceive that they are in their bedroom at a residential home.  Mood is often the key to altering behaviour – fear can play a big part in behaviour – carer can try to separate the mood from the person – e.g. acknowledge that would be frightening; having acknowledged and separated the mood from the person then it may be possible to say that the brain is playing tricks etc.  People who are very depressed tend to provoke anger in others – e.g. in their carers. This is because they are perceived not to be trying or do not behave as “good patients”. Part of the role of the psychiatrist is to support the staff to understand why they get certain feelings about patients (make their unconscious feelings conscious). Once the staff have understood what is going on they are often able to look after the patient in a better way.  Understanding behaviour as above leads to logical non drug management.</p><p>3. Depression  First line – potent SSRI – fluoxetine more potent than citalopram. If no response to 20mg fluoxetine after 8 weeks then change antidepressant. If some response but not full response then increase dose.  Second line – a dual acting drug like mirtazapine – note that 15mg is more sedating than 30mg due to the different relative inhibition of 5HT and noradrenaline.  If psychotic symptoms then use a separate anti psychotic – the anti psychotic has faster onset before antidepressant starts to work. Risperidone good to use as can start at low dose. Once the antidepressant works, should be able to stop the anti psychotic – except for a very few patients with organic illness – e.g. cerebrovascular dementia. Risk vs. benefit needs to be explained to family as the drugs themselves carry a stroke risk times 3-4.  For agitation use antidepressant – agitation is part of the depression. If a sedative is needed this should only be short term – if still agitated once the depression is treated then need to look why and try to treat – e.g. CBT, different antidepressant.  Patients age over 65 need to stay on antidepressants for 2 years in the dose and form that got them better – if recurrent may need for life.  Avoid benzodiazepines in depression – they work well initially but rapid tolerance and difficult symptoms on withdrawal. They have place only for short term use such as bereavement.</p><p>4. Mania / hypomania  Lithium or valproate (depakote) – both best prescribed by proprietary name.  Olanzapine is less used in older people as mood stabiliser.</p><p>5. Drugs for behavioural and psychological symptoms of dementia (BPSD)  Stop drugs which may be exacerbating  Acetylcholinesterase inhibitors are more effective than anti psychotics – so need early referral of patients with hallucinations as these drugs are available only on shared care and must be initiated in secondary care.  Rivastigmine can help sleep problems which happen in Lewy Body dementia at an early stage before cognitive impairment – so worth referring early.  Memantine is good for use if aggression – more effective than anti psychotic.  Antidepressants are worth trying even if there is only a single symptom of depression.  Anti psychotics – low dose, increase CVE risk times 3-4. use short term and review every 6-12 weeks.  Sedatives can worsen symptoms – the patient who is behaving in a certain way because unable to understand what is going on is even less able to understand when given a sedative.</p><p>6. Extra services  No health care day resources!  Age UK centre in Cowick Street and day care at Arthur Roberts House – both mild to moderate dementia.  Age UK at Cowick Street can help guide people to the right resource.  Some milder dementia / mental health can remain with the day care they already attend.  Age UK organise Neighbourhood Day Care – volunteers receive some training and support then take 3-4 service users in to their own home.  Age UK runs a walking group.  Singing for the brain – a large and active group run by Alzheimer’s Society  Respite care – access residential homes via social services or privately. No dedicated service.</p><p>Housekeeping Emma thanked Dr Black for the talk.</p><p>Future ESGPG Meetings Tuesday 1st February 2011 - Sean Lynch / Mike Jefferys ME team (may be more than one speaker) Tuesday 1st March 2011 – Hazel Curtis – Community paediatrics and child development Tuesday 5th April 2011 – Jane Whitehurst – Hospice update and symptom control Tuesday 3rd May 2011 – Michael Gibbons – Pulmonary fibrosis and new COPD guidelines</p><p>Meeting time Please note that the meetings are now scheduled to start at 7pm with the guest speaker planned to commence at 7.30pm.</p><p>Committee Contacts Dr Hamish Duncan (chairman and LMC link) [email protected] Dr Diane Baker (appraisal support co-ordinator) [email protected] Dr Emma Green (educational co-ordinator) [email protected] Dr Katherine Wood (funding co-ordinator) [email protected] Dr Caroline Burton (treasurer) [email protected] Dr Kathryn Shore (minutes secretary) [email protected] Dr Clair Homeyard (social secretary) [email protected] Dr Francesca Vasquez (social secretary) [email protected] Megan James (LMC link) [email protected] </p>