Mothers with mental illness experiencing homelessness: a critical analysis.

The experiences of homeless mothers with mental illness were examined from the critical perspective of feminist intersectionality. The purpose of this study was to unveil experiences of oppression and resistance in the lives of homeless mothers with mental illness, while learning from them what is conducive to their health. A qualitative secondary analysis was done using focus group transcripts from a study examining issues related to diversity and homelessness for psychiatric survivors and a study on mental health and housing. A purposive sample of 7 focus groups comprised of 67 participants was used for this study. Findings revealed three overarching themes: (1) discrimination based on intersecting social identities; (2) being stuck: the cycle of oppression; and (3) we're not giving up: resistance through perseverance. The contextual influences of mothering while homeless with a mental illness were emphasized in the results. The findings illuminate the need for increased on ongoing advocacy at individual and structural levels.

The natural history of chronic painful peripheral neuropathy in a community diabetes population.

AIMS: To examine the natural history of chronic painful diabetic neuropathy (CPDN). METHODS: A cross-sectional study of 350 people with diabetes was performed during 1998-1999 to assess the prevalence of CPDN in the community. Fifty-six patients with CPDN were identified and were followed up an average of 5 years later. RESULTS: From the original cohort, 12 patients had died and 14 had moved away or were unable to participate in the follow-up study. Thus 30 patients with CPDN [21 male, mean (SD) age 68.6 years (9.4), mean (SD) duration of diabetes 15.4 years (8.7)] were re-assessed. Seven (23%) had been pain free for at least 12 months and 23 continued to report neuropathic pain of similar quality and severity [total McGill Pain Questionnaire Score median (interquartile range) at follow-up 22 (16-39) vs. 20 (16-33) at baseline, P = 0.3; mean (SD) visual analogue scale (VAS) score for pain over the preceding 24 h 5.3 cm (2.9) vs. 4.6 cm (2.5) at baseline, P = 0.1]. Only 65% had ever received treatment for CPDN despite 96% (22/23) reporting pain to their physician; 43.5% had received antidepressants, 17.4% anticonvulsants, 39% opiates and 30% had tried complementary therapies. CONCLUSIONS: The neuropathic pain of CPDN can resolve completely over time in a minority (23%). In those in whom painful neuropathic symptoms had persisted over 5 years, no significant improvement in pain intensity was observed. Despite the improvement in treatment modalities for chronic pain in recent years, patients with CPDN continue to be inadequately treated.

Memory clinics.

Memory clinics were first described in the 1980s. They have become accepted worldwide as useful vehicles for improving practice in the identification, investigation, and treatment of memory disorders, including dementia. They are provided in various settings, the setting determining clientele and practice. All aim to facilitate referral from GPs, other specialists, or by self referral, in the early stages of impairment, and to avoid the stigma associated with psychiatric services. They bring together professionals with a range of skills for the benefit of patients, carers, and colleagues, and contribute to health promotion, health education, audit, and research, as well as service to patients.

Electrical spinal cord stimulation in the long-term treatment of chronic painful diabetic neuropathy.

AIMS: Electrical spinal cord stimulation (ESCS) is a technique for the management of chronic painful diabetic neuropathy (CPDN) affecting the lower limbs. We assessed the efficacy and complication rate of ESCS implanted at least 7 years previously in eight patients. METHODS: After a trial period of percutaneous stimulation, eight male patients had been implanted with a permanent system. Mean age at implantation was 53.5 years and all patients were insulin treated with stage 3 severe disabling CPDN of at least 1 year's duration. The ESCS was removed from one patient at 4 months because of system failure and one patient died 2 months after implantation from a myocardial infarction. RESULTS: Six patients were reviewed a mean of 3.3 years post-implantation. With the stimulator off, McGill pain questionnaire (MPQ) scores (a measure of the quality and severity of pain) were similar to MPQ scores prior to ESCS insertion. Pain scores (visual analogue scale) were measured with the stimulator off and on, respectively: background pain [74.5 (63-79) mm vs. 25 (17-33) mm, median (interquartile range), P = 0.03), peak pain (85 (80-92) mm vs. 19 (11-47) mm, P = 0.03]. There were two further cardiovascular deaths (these patients had continued pain relief) and the four surviving patients were reassessed at 7.5 (range 7-8.5) years: background pain [73 (65-77) mm vs. 33 (28-36) mm, median (interquartile range)], peak pain [86 (81-94) mm vs. 42 (31-53) mm]. Late complications (> 6 months post-insertion) occurred in two patients; electrode damage secondary to trauma requiring replacement (n = 1), and skin peeling under the transmitter site (n = 1). One patient had a second electrode implanted in the cervical region which relieved typical neuropathic hand pains. CONCLUSIONS: ESCS can continue to provide significant pain relief over a prolonged period of time with little associated morbidity.

Chronic painful peripheral neuropathy in an urban community: a controlled comparison of people with and without diabetes.

AIMS: A cross-sectional study has been performed in order to estimate the prevalence, severity, and current treatment of chronic painful peripheral neuropathy (CPPN) in people with diabetes in the community. METHODS: Using a structured questionnaire and examination we have assessed these factors in a community sample of people with diabetes (n=350) and compared them with 344 age- and sex-matched people without diabetes from the same locality. RESULTS: The prevalence of CPPN was estimated to be 16.2%[95% confidence interval (CI): 6.8-16%] in people with diabetes compared with 4.9% (95% CI: 2.6-7.2%) in the control sample (P < 0.0001). Diabetic subjects with and without CPPN did not differ in age, sex, type and duration of diabetes, body mass index, smoking status and glycaemic control. However, CPPN diabetic subjects had significantly higher Visual Analogue Scale (VAS) scores for pain over the preceding 24 h [median (interquartile range) 3.5 (1.5-6.7) cm vs. 0.7 (0-3.9) cm, P < 0.0001]. Also, the total McGill Pain Questionnaire Score (a measure of pain quality and severity) was 18 (13-31.5) vs. 10 (4-16) (P < 0.0001). Of patients with diabetes and CPPN, 12.5% (7/56) had never reported their symptoms to their treating physician and 39.3% (22/56) had never received any treatment for their painful symptoms. CONCLUSIONS: CPPN is common, often severe but frequently unreported and inadequately treated.

A survey of the views of geriatric psychiatrists in the United Kingdom on the use of electroconvulsive therapy to treat physically ill people.

BACKGROUND: One of the main concerns about ECT is its use for people with concurrent medical illnesses. Geriatric psychiatrists are more often likely to encounter this situation in working with older age groups. Drawing on the collective experience of all UK geriatric psychiatrists may allow a better understanding of the use of ECT for people with major medical illness. METHODS: A postal questionnaire was used to seek the views of all consultant geriatric psychiatrists in the UK on the use of ECT in the presence of major illness. The questionnaire was developed from previous literature on the subject, a previous pilot study, published guidelines and clinical experience of the authors. RESULTS: Geriatric psychiatrists most often favour bilateral ECT. They are likely to carry out physical examination, chest X-ray, ECG, haemoglobin estimation, urea and electrolytes, thyroid and liver function tests in medically ill people before considering ECT. They are more likely to change their ECT assessment procedures when dealing with medical illness, rather than any other aspect of treatment, and are unlikely to change any aspect of ECT treatment in someone of advanced age. CONCLUSIONS: Geriatric psychiatrists see their roles in relation to ECT as primarily that of assessment, and rely on others to advise on anaesthetic drug use, treatment technique, concurrent drug treatment and post-ECT management. It is important that the ECT consultant and ECT anaesthetist are aware of their role and prepared to offer appropriate advice. The role of the ECT consultant in relation to the responsible medical officer requires clarification.

Brittle diabetes in the elderly.

Severely unstable, or brittle, diabetes can be disruptive to patients, carers and diabetes care teams. The peak age-group for brittle diabetes is 15-30, but there are reports of its occurrence in much older patients. To explore the characteristics and cause of brittle instability perceived by diabetologists in elderly patients we circulated a questionnaire to all UK hospital diabetic clinics for adults. 130 (56%) of 231 replied. Reports were obtained on 55 patients fulfilling our criteria for 'elderly brittle diabetes'--namely, age > or =60 years, on insulin treatment, and experiencing life-disrupting glycaemic instability of any kind associated with frequent or long admissions to hospital. Further information was obtained by a research nurse who visited the relevant clinics. The mean age of patients was 74 years (range 60-89) and 71% were female. The brittleness was classed as mixed glycaemic instability in 22 (44%), recurrent ketoacidosis in 16 (29%) and recurrent hypoglycaemia in 15 (27%). In 2 cases there was insufficient information for classification. The diabetes care team judged the brittleness to have multiple origins in two-thirds of the cases: problems with memory or behaviour were rare, and in only 4 cases was deliberate manipulation of therapy considered a possibility. 84% of the patients were living independently. In younger patients the principal manifestation of brittle diabetes is recurrent ketoacidosis. The present survey, though possibly subject to ascertainment bias, indicates that the patterns of instability and their causation may be different in elderly patients. With the growing use of insulin in the elderly, brittle diabetes is likely to be encountered increasingly often in this age-group.

Institutional dietary provision for diabetic patients.

We compared the diet of residents with diabetes with current British Diabetic Association (BDA) recommendations, and the nutritional adequacy and content of the diet using 3-day food diaries. We studied 52 residents with diabetes and 48 age- and sex-matched controls from 37 nursing, residential and elderly mentally infirm homes in one city. The daily intake of fat, protein, carbohydrate and fibre of the group with diabetes did not comply with current BDA guidelines, and 52% of diabetic residents and 46% of controls had a lower daily energy intake than currently recommended. The diet of diabetic residents did not comply with current recommendations. Undernutrition is common in both groups.

Elderly people with hypothalamic-pituitary disease and growth hormone deficiency: lipid profiles, body composition and quality of life compared with control subjects.

OBJECTIVE: In healthy adults the secretion of growth hormone (GH) and insulin-like growth factor 1 (IGF-1) declines with ageing and body composition alters, particularly with an increase in total body fat. In elderly people, hypothalamic-pituitary disease can cause GH deficiency (GHD), compared with age matched controls. This study aimed to clarify whether GHD in the elderly is associated with differences in body composition, circulating lipid levels and quality of life (QOL) compared with control subjects. SUBJECTS: Twenty-seven elderly patients (14 males, mean age 71 years, range 65-83) with hypothalamic-pituitary disorders (23 pituitary tumours) and GHD (mean (SD) peak stimulated GH response 1.6 mIU/l (1.03) range 0.6-5) were studied. Twenty-five patients had been treated surgically (six cranial surgery, 19 transsphenoidal) and eight patients had received external cranial irradiation. Twenty-seven control subjects (14 males, mean age 72 years, range 65-86) were also studied. METHODS: Weight, body mass index (BMI), total fat mass (FM, bioelectrical impedance), waist to hip ratio (WHR), serum IGF-1, fasting blood glucose and lipid profile were measured. QOL was assessed in both groups using five interviewer administered self-rating questionnaires: The Nottingham Health Profile, Short-Form 36, Hospital Anxiety and Depression Scale, Mental Fatigue Questionnaire and Life Fulfilment Scale. The GHD group also completed the Disease Impact Scale. RESULTS: The data (mean (SD)) from males and females were analyzed separately. The male patients had a higher BMI than controls, 28.9(4.5) vs. 25.2(2.3) kg/m2 (P = 0.01) but the BMI in the female patients and controls was similar. In the female patients compared with the controls, FM was higher 39. 4(6) vs. 33.1(8.3) % (P = 0.02), WHR was also higher 0.9(0.08) vs. 0. 83(0.09) (P = 0.03) and serum IGF-1 levels were lower 10.8(6.4) vs. 18.2(6.5) nmol/l (P = 0.01). However, in the male patients, FM, WHR and IGF-1 levels were similar to the controls. Fasting blood glucose was similar in both male and female patients and the controls. Two female patients and one male control subject were taking lipid-lowering agents and were therefore excluded from the analysis of lipid profiles. Total cholesterol, triglyceride, LDL cholesterol, HDL cholesterol and total cholesterol/HDL cholesterol ratio were not significantly different for both male and female patients compared with the controls. The 27 patients with GHD reported significantly less energy (P < 0.05), mobility (P < 0.05) and personal life fulfillment (P < 0.01) than the 27 controls. There were significantly more problems with emotional reaction (P < 0.01), social isolation (P < 0.05) and mental fatigue (P < 0.05). Additionally the GHD group reported more impairment in areas of social functioning (P < 0.05), general health (P < 0.05) and mental health (P < 0.05). The GHD group reported a modest degree of disease impact (mean score of 14.1). There were no significant differences in the domains of material life fulfillment, pain, sleep, physical functioning, vitality, anxiety, depression, self-esteem or role physical functioning compared with the controls. CONCLUSION: Compared with control subjects, the elderly female patients with hypothalamic-pituitary disease and GHD had a significantly higher total fat mass, with the WHR indicating a more central fat distribution and lower female serum IGF-1 levels. In contrast, elderly male patients had similar total fat mass, WHR and IGF-1 levels compared to the controls. There were no significant differences in the lipid profiles between male or female patients compared to controls. However, many of the male patients were receiving androgen replacement which might have influenced these results. Low HDL cholesterol concentrations are probably a better predictor of future cardiovascular disease than raised LDL cholesterol levels in the elderly population and these were similar in patients and controls for both

Challenging the stigma of Alzheimer's disease.

Changing Minds--Every Family in the Land is a national campaign launched by the Royal College of Psychiatrists which aims to reduce discrimination against people who suffer from mental disorders. One of its target areas is dementia. What is the stigma associated with Alzheimer's disease and how can hospital doctors challenge it in everyday practice?

Stigma and Alzheimer's disease: causes, consequences and a constructive approach.

The term 'Alzheimer's disease' has entered the vocabulary of ordinary people. This has been useful, encouraging patients and families to seek medical help for conditions that were previously neglected as inevitable consequences of old age. Yet Alzheimer's itself can carry negative connotations. Some people who believe they have Alzheimer's disease are suffering from less sinister and more easily treated conditions. Even when the diagnosis is confirmed, many months of happy and worthwhile life continue for most patients and families if they are given appropriate information and support. It is important that neither families nor clinicians see life with presumed Alzheimer's disease as of no value.

Prescribing. Short rations.

A national survey of old-age psychiatrists showed patchy and generally low prescribing of the Alzheimer's drug Donepezil. Most health authorities had 10 patients, or fewer, on the drug last year. The ethics of the present position should be examined by a third party.

Gender, isolation, work patterns and stress among old age psychiatrists.

OBJECTIVE: To investigate work patterns and stress in consultant old age psychiatrists over a period of 1 week and to attempt to identify areas amenable to change. DESIGN: Postal survey. PARTICIPANTS: Full-time old age psychiatrists on the list held by the Faculty of Old Age Psychiatry, Royal College of Psychiatrists. MAIN OUTCOME MEASURES: Hours spent on different work activities during a period of 1 week, Stress Checklist score, stressors perceived by respondents. MAIN RESULTS: Men and women doctors did not differ in numbers of hours worked. Consultants working with colleagues worked similar hours to single-handed consultants. Community activity was greater among consultants working with colleagues than among single-handed doctors, whose work was based more in outpatient clinics. For the whole group, time in acute ward rounds correlated positively with stress score and time spent on research at home correlated negatively with stress score. CONCLUSIONS: Doctors spending more than 50 hours at work might be advised to review their work pattern. Excessive time on administrative activities should be reduced. Peer support should be encouraged. Consultants and managers should be sensitive to work patterns and possible sources of stress.

Painful diabetic neuropathy.

Chronic painful diabetic neuropathy causes symptoms that can last for many years and severely impair the quality of life of affected patients. This review describes the epidemiology, pathophysiology and treatment of chronic neuropathic pain. Particular emphasis is placed on a comprehensive review of the management of painful symptoms through a detailed review of the published literature using a variety of databases particularly Medline and EMBASE.

Painful diabetic neuropathy.

Chronic painful diabetic neuropathy can cause a variety of challenges, particularly in successful treatment. The pain, which can last for years, can severely impair quality of life. Management is difficult, although the careful use of drugs can be significantly beneficial. Tricyclic and anticonvulsant drugs may be effective, with a variety of drugs available as second line agents. Newer non-drug systems such as electrical spinal cord stimulation represent exciting possibilities for the future management of this most difficult diabetic syndrome.

Burnout: current knowledge and relevance to old age psychiatry.

OBJECTIVES: To review the literature on burnout and consider its relevance to old age psychiatry and the role of the consultant. DATA SOURCES: Medline and PsychLit computerized databases. DATA SYNTHESIS: Burnout is a syndrome of emotional exhaustion, depersonalization and decreased sense of personal accomplishment which is recognized in people working in the human service professions and can have adverse effects on the workforce. There is little evidence of unique stressors related to care of elderly mentally ill people. Burnout is likely to be modified by workplace interventions. Relevant areas for intervention are political and social, organizational and management, training and personal issues. Support to consultants and their continuing professional development need to be radically reviewed.

The role of the old age psychiatry consultation liaison nurse.

OBJECTIVE: To assess and describe service changes when a psychiatric consultation liaison nursing service is introduced. DESIGN: Prospective collection of basic service data before and after implementation of the service change. SETTING: A newly established comprehensive old age psychiatry service. PATIENTS: People on medical and surgical wards aged over 65 years referred for psychiatric assessment. OUTCOME MEASURES: Numbers of referrals made and patients seen, details of psychiatric diagnoses made and follow-up offered before and after the change in the service. RESULTS: Within 6 months there was an increase in liaison referrals to the service. The proportion of people offered follow-up showed little change and delay before assessment decreased substantially with the PCLN service. CONCLUSIONS: A psychiatric consultation liaison nursing (PCLN) service was successfully initiated. Numerous difficulties were encountered but this is a useful model for old age psychiatry services to consider researching and developing further.

Diabetic peripheral neuropathy and quality of life.

The quality of life (QOL) of 79 people with type 1 and type 2 diabetes and 37 non-diabetic controls was assessed using the Nottingham Health Profile (NHP). The NHP consists of six domains assessing energy, sleep, pain, physical mobility, emotional reactions and social isolation. Symptomatic diabetic neuropathy was present in 41 of the patients. The neuropathy patients had significantly higher scores (impaired QOL) in 5/6 NHP domains than either the other diabetic patients (p < 0.01) or the non-diabetic (p < 0.001) controls. These were: emotional reaction, energy, pain, physical mobility and sleep. The diabetic patients without neuropathy also had significantly impaired QOL for 4/6 NHP domains compared with the non-diabetic control group (p < 0.05) (energy, pain, physical mobility and sleep). This quantification of the detrimental effect on QOL of diabetes, and in particular of chronic symptomatic peripheral diabetic neuropathy, emphasizes the need for further research into effective management of these patients.

Smoking habits and painful diabetic neuropathy.

In order to assess the relationship between chronic painful diabetic neuropathy and current--or lifetime--smoking habits, the smoking history of 49 diabetic patients was investigated and compared with that of 23 diabetic patients without chronic pain (age 51.0 +/- 1.9 years, mean +/- SEM). Current level of nicotine intake was measured using urinary cotinine (a nicotine metabolite), and expressed as cotinine/creatinine ratio (COT/Cr), and lifetime smoking load by pack years (20 cigarettes per day for 1 year equals 1 pack year). Current pain intensity was evaluated using a visual analogue scale (VAS). The presence of chronic painful diabetic neuropathy was based on clinical history and examination. Of those patients with painful neuropathy, 26% were current smokers (age 54.2 +/- 3.2 years, mean +/- SEM), 31% ex-smokers (age 57.0 +/- 2.9 years), and 43% lifelong nonsmokers (age 58.0 +/- 2.9 years). Pain duration and intensity were similar in all three groups. COT/Cr levels were similar in current diabetic smokers with pain [5.0 (0.2-10.6) micrograms/mg] and the diabetic control group of smokers without pain [6.8 (1.8-13.3) micrograms/mg, NS]. There was no relationship between VAS and either COT/Cr levels or pack years in current smokers, or between duration of pain and pack years in diabetic current or ex-smokers. In conclusion, we found no relationship between current or previous levels of smoking and severity or duration of chronic painful diabetic neuropathy.