Re-labelling (and a bit)

I read this book recently [below].

I am approaching fifty. With age-related sight changes I find that my arms need to be longer!. So if I have misread “Sixty and a bit”  please do forgive me:

Now we are sixty and a bit

This book reminded my of a protocol issued by an NHS Board in Scotland:

4 april 2014 all over 65 MUST

As a doctor who tries his best to follow evidence-based medicine, I argued against this approach. I found that neither this NHS Board nor indeed NHS Scotland shared my concerns:

Brian Robson

With the recent publication of the Care Standards for Older People, the Chair of Healthcare Improvement Scotland confirmed:

Letter4b

It would appear to me that this “screening instrument” has been re-labelled by Healthcare Improvement Scotland

The 4AT was developed and promoted as:

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Recently the 4AT has been re-labelled as:

4AT validated UK Gov

The authors  4AT describe its key features:

(1) “brevity” (takes less than 2 minutes”), and

(2) that “no special training is required”

I should confirm that I use rating scales with patients as part of my daily professional life.

However I would never start out with a rating scale. To me, that would seem most disrespectful.

Rating scales can add to wider medical understanding. This is why, despite my awareness of any intrinsic shortcomings, that I continue to feel that they can be helpful.

The 4AT has recently been re-branded an “assessment test”. The 4AT was promoted for several years, with the support of Healthcare Improvement Scotland, as a “screening tool”. The validation studies, still underway, describe the 4AT as a “screening” tool.

Given that there has been no change to the test itself, I would suggest that this is re-labelling (and a  bit.)

“OPAC tools are working”

It is over a year since I last wrote about delirium. Being aware that the new Care Standards for older people in hospital were to be published this month I had a look on the Healthcare Improvement Scotland web platform for these new standards. As yet these standards have not been published, but I did notice the news that “OPAC tools are working”. I followed the links, read the supporting material, and watched all the associated films:

[The costs of films commissioned from the private sector by NHS 
Healthcare Improvement Scotland has been over £51,000 from 
January 2014 to February 2015]

027Tools

A lot has happened in acute care settings for Scotland’s elders since I last wrote. It is wonderful to see in these films such compassion and dedication to care amongst the healthcare teams: from allied health professionals, nurses and doctors. I agree with Professor Jason Leitch that this demonstrates a caring culture.

It was some years ago that I heard Professor MacLullich give a talk about delirium. I was inspired by his thoughtful presentation which outlined the distressing symptoms that can come with states of delirium and the associated increased risk of mortality.

In this post I will not be considering improvement work undertaken on “frailty”. In what follows I intend to further explore the Healthcare Improvement Scotland strapline: “OPAC tools are working” with particular reference to delirium.

In terms of “working”, only two key figures are given by Healthcare Improvement Scotland. The first confirms that there has been 95% “compliance” with “assessment tools” for delirium.

025Tools

The other key figure demonstrates that length of hospital stay in orthopaedics for older people has been reduced since the introduction of “frailty and delirium assessment tools”:

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In what follows the OPAC tools currently being used in hospitals across Scotland to “identify” delirium will be considered. Two specific issues continue to concern me:

(1) the risk of too great a reliance on any “brief” “tool” rather than this being part of an overall assessment; and
(2) the marginalisation of consent.

(1) Reliance on a “brief” “tool”:032Tools

The 4AT has been revised since I last wrote. It was previously described by its developers as “a new screening tool for delirium and cognitive impairment” (see below):

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The latest version (at time of writing) is version 1.2. The developers “have decided to describe” the 4AT now as an “assessment test”:

Version 1.2 4AT

As an “assessment test” the 4AT requires:

011tools

The 4AT “assessment test” is also noted for its:

009Tools

The 4AT:

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The four questions that comprise the AMT4 are as follows:

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It is important to appreciate that the 4AT test is different from other tools for delirium as it incorporates the AMT4. The AMT4 is a screening tool for cognitive impairment alone. To explain further this test is in effect used to screen for dementia. This is an important point because there has been very wide debate about cognitive screening. Cognitive screening is recommended by neither the UK National Screening Committee nor NICE. Another point is that using brief tests for delirium and cognitive impairment at the same time is an approach novel to the 4AT.

Given that the 4AT test incorporates a test of cognition it is relevant to consider whether our cognitive function can so easily be encapsulated in a “very brief” test. The 95 year old philosopher, Mary Midgley, has said this about “tests”:

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Mary Midgley then goes on to say:

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Cognitive ageing has become an area of great interest since Professor Lawrence Whalley of Aberdeen University began research in this area and some of his findings are summarised in his book, the Ageing Brain.

Professor Whalley reminds us that the brain is such an incredible biological wonder. Each of us have 100 billion neurons in our brains, and whilst this may change with ageing, it is still the case that our neurons, even on our last day in life, amount to:

The shock of the fall (9)

Recently this lead Editorial was published in the Lancet:

004Tools

It repeats the reminder of Professor Whalley that:

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To many it appears counter-intuitive that something so complex as human brain function can be reliably assessed in a test that takes less than 2 minutes. In a follow-up post I will look at the work currently being undertaken to evaluate the 4AT.

(2) Marginalisation of consent:
“Compliance” with the 4AT “assessment test” is being measured in Scotland by Healthcare Improvement Scotland. My concern here, that I have expressed before, is that such an approach marginalises the right of the individual to consent or otherwise to this assessment.

I have become aware through my own clinical practice that even brief cognitive tests can be distressing to patients and can leave them fearful (the following quote is from a patient undergoing a short cognitive screening test but not the 4AT):

039Tools

Another reason to be concerned about consent is that our cognitive abilities tend to follow a parabolic distribution through life. It would be a mistake to disregard this when undertaking complex diagnostic considerations.

In March of this year the UK Supreme Court judged that it was for patients to decide whether the risks, benefits and alternative options of assessments or medical interventions have been adequately communicated:

014Tools

Treatments may bring harms as well as benefits. This is why explanation of risk should be an ethical underpinning in our interactions with a patient.

The Scottish Delirium Association (SDA)  has issued delirium pathways for use across NHS Scotland. The “OPAC tools” are generally the starting point in these pathways. The SDA Comprehensive pathway states very clearly:

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This pathway outlines environmental and general measures, alongside medical and nursing approaches to manage delirium which has been identified using the 4AT test. If these measures are not in themselves sufficient to improve the state of delirium, the Comprehensive Pathway outlines further interventions:

041Tools

A recent audit of Haloperidol prescribing in NHS Scotland has confirmed the findings of the Scottish Government that in our acute hospitals prescribing of antipsychotics has been rising year on year.

To try to identify how much of this rise comes from prescribing for those aged 65 years and over, the 0.5mg capsules and 1mg/ml liquid haloperidol are likely to be indicative.

In one Scottish NHS Board (see table below), we find that haloperidol prescribing in those aged 65 years and over in the acute hospital has nearly doubled since cognitive screening was introduced and monitored at NHS Board level.

042Tools

This is a recent study published in the Lancet:

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The authors of this study argued that:044Tools

Summary:
In these films Healthcare Improvement Scotland outlines that “OPAC assessment tools work, and are working in hospitals across Scotland”. There is no doubt that delirium is a condition associated with significant morbidity and mortality. It is also clear that we have a long way to go in understanding such a complex condition. Given this, my concerns about the over-reliance on brief tools used at outset and the marginalisation of consent are unchanged.

In a follow-up post I will look at the work currently being undertaken to evaluate the 4AT.

Update, 5th October 2016. The following was published on the 
front page of the Scotsman newspaper: 

"Mental health prescriptions hit ten-year high"

prescriptions-for-mental-health-drugs-10-year-high-nhs-scotland-2016-a prescriptions-for-mental-health-drugs-10-year-high-nhs-scotland-2016-b

The figures are from the Scottish Government and can be accessed here.

“Packaging up old myths”

Last week the Association of the British Pharmaceutical Industry (ABPI) held its Annual Conference:Annual Conference 2015The Pharmaceutical Industry are concerned about an “affordability conundrum”:Affordability conundrum1The affordability conundrumThis BBC Report from November 2014: “Pharmaceutical Industry gets high on fat profits” documented that:Pharmaceutical industry gets high on fat profits (2b)There will be many companies around the world who would like to be dealing with this kind of “affordability conundrum”.

Another area of concern to the industry was discussed at the 2015 ABPI Conference:Aileen Thompson 2aileen_thompsonThe closing session of the 2015 ABPI Conference was focused on the reputation of the pharmaceutical industry:  Industry as a credible partner A panel discussion was part of this:      Sponsored by concentraI wonder if the panel considered this:Pharmaceutical industry gets high on fat profits (3)Andrew McConaghie of PharmaPhorum recorded this passage:wrong1 wrong2 wrong3My view is that if the Pharmaceutical industry are concerned about their reputation then they should avoid such obvious scapegoating. Dr Goldacre has been and continues to be a world pioneer for scientific objectivity and it does the “reputation” of the British Pharmaceutical industry no credit to distort his work in this way.

Here is the view of the World Health Organisation:Pharmaceutical industry gets high on fat profits (4)

One and the same

In this short film I will explain to you why I have come to understand that case-finding and screening are actually one and the same.

One and the same from omphalos on Vimeo.

All around us national clinical leads and disease champions argue that early detection policies are exercises in ethical case-finding. They insist that such policies are not screening. This is important because criteria have been set for the introduction of any national “screening” programme. It appears that by calling any programme “case-finding”, these criteria can be ignored.

In this film I will briefly look at the historical development of case-finding and screening. This provides clear evidence that these terms have been consistently used one and the same. This film will argue, along with Dr James Maxwell Glover Wilson, that the ten principles that are considered necessary by the World Health Organisation for screening, should also apply to case-finding. One and the same.

As an approach, case-finding emerged in the first few years of the 1930’s: “to designate the pre-clinical stage of a tuberculous pulmonary infiltration, when it is demonstrable by x-ray examination but does not yet manifest itself clinically by symptoms or signs perceptible to the patient or by the usual methods of classical physical examination.”

The success of this case-finding approach led to its use for detection of other diseases. By 1968 the World Health Organisation had listed ten requirements necessary for the introduction of a public health screening programme. Note that this list refers to case-finding. Screening and case-finding are one and the same.

  1. The condition sought should be an important health problem.
  2. There should be an accepted treatment for patients with recognized disease.
  3. Facilities for diagnosis and treatment should be available.
  4. There should be a recognizable latent or early symptomatic stage.
  5. There should be a suitable test or examination.
  6. The test should be acceptable to the population.
  7. The natural history of the condition, including development from latent to declared disease, should be adequately understood.
  8. There should be an agreed policy on whom to treat as patients.
  9. The cost of case-finding (including diagnosis and treatment of patients diagnosed) should be economically balanced in relation to possible expenditure on medical care as a whole.
  10. Case-finding should be a continuing process and not a ‘once and for all’ project.

Into the next decade and case-finding moved into many other areas.

In 1970 diabetes was considered as one area that might benefit:
“Many are truly asymptomatic, even on direct questioning. Despite this, diagnosis of the diabetes is not usually difficult, for random or post-glucose blood sugar levels are sufficiently high to allow of no doubt. Nevertheless, when screening by blood sugar level is employed for case finding, diagnosis becomes more problematic.”

As the 1970’s progressed case-finding of hypertension became a priority.

Hypertension in general practice
21 April 1984
“SIR, I support Dr John Coope’s comments on the lamentable state of management of patients with hypertension, benefits can be achieved from treatment. The practical answer surely lies in case finding.”

Into the 1980s and case-finding methods are underway to detect dementia:
Do general practitioners miss dementia in elderly patients?
Oct 1988

Some of the difficulties of this were discussed at this time and reveal that the Wilson & Junger principles for screening were considered necessary:

“We have made some progress with the problem of assessing mild dementia. However, there are as yet no widely accepted criteria for mild dementia, nor are there any clinically useful biological markers. Consequently, whether normal ageing, benign senescent forgetfulness and mild dementia lie on a continuum, or whether mild dementia is categorically distinct, is uncertain.

Thus, prospective longitudinal studies using a range of reasonably standardised diagnostic criteria are imperative, as they may show which of the existing criteria most effectively distinguish those cases which progress from those which remain stable.”

Those who know me and my writings will realise that it was with the early diagnosis of dementia where my interest first started in case-finding and screening, one and the same thing. It was clear to me that early diagnosis of dementia could not just side-step the ten principles as established by the World Health Organisation. However it took the support of doctors like Dr McCartney, Heath, Brunet and Cosgrove (the Grassroot doctors) to reason why a timely approach to the diagnosis of dementia would be a better, and less harmful approach than case-finding or screening, one and the same.

The UK National Screening Committee have been approached by policy advisors to tabulate similarities and differences between screening and case-finding. Having looked at these carefully it is clear to me that the majority of differences are in fact interpretational and demonstrate that case-finding has been, in recent years, wrongly separated from screening. The main cost of this is that the ten principles need not to be followed.

For example with screening one is generally invited and formal information of benefits and harms are shared. This generally does not happen with case-finding.

For example with screening there is generally formal quality assurance whilst with case-finding this is generally not so.

Time to finish but first let me dispel a myth. It has been argued that for case-finding one has already “symptoms” but with screening generally one does not. This is a false divide. Symptoms are not all or nothing and may or may not be experienced. Dr Wilson and Jungner made no distinction here and the World Health Organisation agreed.

Screening and case-finding are one and the same thing.