Delirium is associated with significant adverse outcomes, including prolonged length of hospital stay, increased dependency and increased mortality but there is a paucity of data pertaining to the management of delirium superimposed on dementia (DSD) in dementia specialist services. Here, the authors discuss their results from measuring the current practice in the management of DSD in a UK dementia specialist unit and an older adult community crisis and home treatment team service and the subsequent action plan formulated to improve patient care.

Aims and method To establish whether a dementia intensive support (DIS) service that is part of a crisis resolution and home treatment team for older people is preventing admissions to acute hospital and psychiatric wards. The number of referrals in 2017 to the DIS service was established and those admitted to hospital ascertained. Senior doctors examined 30 sets of notes in detail and reached a conclusion on whether DIS had contributed to admission prevention. This information was then re-examined in two meetings with at least eight senior psychiatrists present. A consensus opinion was then reached as to whether DIS had contributed to admission prevention in each case. Results Over 12 months, 30/171 patients (18%) referred were admitted to hospital. For the subset of 30 referrals examined in detail, DIS contributed to admission avoidance in 21 cases (70%). Clinical implications Our evaluation demonstrates that the DIS service is an effective way of preventing admission.

There is debate as to the most appropriate and accurate description of functional movement disorders (FMDs). In this article, Dr Chalkley and Dr Ruhi discuss the characteristics of FMDs and specifically look at two patients' tremors that were entirely distractible and variable in direction, amplitude and frequency. They describe similar onset and development of their symptoms: hand tremors starting after a traumatic event, which then progressed to the whole body. Despite this, there were multiple differences between the cases; of note, the effect of emotion, exercise and relaxation were completely opposing. They conclude that a traumatic life event may trigger a cascade of somatic symptoms, how personalised approaches to psychological therapy are of importance and crucially that more high‐quality research is needed to make evidence‐based decisions on the management of FMDs.

AimsThe aim of this audit project was to establish the practices in prescribing and de-prescribing of psychotropic medications for patients on a specialist dementia ward.BackgroundThere is a great deal of evidence demonstration high rates of polypharmacy, defined as ≥5 drugs, in older adults in general and in those with dementia more specifically. NICE guidelines recommend a structured assessment of a patient with dementia to exclude other potential causes, e.g. pain or delirium. Psychosocial interventions are recommended as first line. Antipsychotics should only be offered second line who present a risk to themselves or others. These should only be used for the shortest time possible and reassessed at least every 6 weeks.MethodData were collected for patients (n = 20) discharged from a specialist dementia ward between September 2018 and March 2019. The unit has 14 beds caring for patients with predominantly severe behavioural and psychological symptoms associated with dementia (BPSD). The team is comprised of doctors, nurses, a clinical psychologist, occupational therapists, physiotherapists and pharmacists who meet twice a week to review patients. Data were coded by drug class and counts of medication on admission, at the midpoint and at discharge were conducted. Antipsychotic and benzodiazepine dosages were converted into haloperidol and diazepam equivalence.ResultOf the 20 patients, 70% were male and 30% female. 95% of the patient (n = 19) were admitted under the Mental Health Act (1983). 20% were managed on 1 to 1 observations and 80% were on 15 min observations. In general, the results show little change in the overall rate of psychotropic prescribing. The mean number of psychotropic medications prescribed per patient on admission was 2.30, at the mid-point of admission it was 2.30 and at discharge it was 2.05. Mean benzodiazepine dosage in diazepam equivalence reduced between admission and discharge from 3.20 mg to 2.10 mg. Mean haloperidol equivalent dosages increased at the midpoint of admission from 1.11 mg to 2.27 mg before reducing to 0.78 mg at discharge.ConclusionThe results demonstrate minimal change in the overall average number and composition of drugs prescribed. There are differences in the use of regular antipsychotics and benzodiazepines between admission and discharge which are consistent with NICE guidelines. Patients had a structured assessment with regular medicines reconciliation supervised by the team pharmacist. Therefore, the ward environment did allow for detailed discussions about de-prescribing which may not be the case elsewhere.