Psychiatric Focus - In touch with symptoms

Improving the quality of life of patients with schizophrenia was the aim of a recent audit at Kilmallock Day Hospital, writeBridget Falahee and Peter Kirwan

Kilmallock Day Hospital is a rural based setting which provides a comprehensive psychiatric service to a population of 21,940 with an active caseload of 330.

It is staffed by a multidisciplinary team comprising a consultant psychiatrist, senior house officer, social worker, psychologist, addiction counsellor, clinical nurse manager, three staff nurses and a team secretary. Open Monday to Friday, 9am-5pm, services provided include: out-patient clinics, family and individual counselling, anxiety management, relaxation therapy, assessments and diagnosis. Individuals are referred by their GP, assessed at the clinic and referred to the appropriate discipline.

Conducting the audit 

We conducted an audit of patients with a diagnosis of schizophrenia to:
  • Evaluate the negative and positive symptoms they experienced
  • The type of drugs they were receiving
  • Any side effects.

To carry out this audit, we used Eli Lilly’s CARE database which allowed us to monitor demographic and clinical information on a visit-by-visit basis.

The assessments included the Positive and Negative Scales of the PANSS. Patients are rated from 1 (absent) to 7 (extreme) on each of seven positive symptoms including delusions, hallucinations, excitement and hostility, and likewise on each of seven negative symptoms including blunted affect, emotional withdrawal, poor rapport and difficulty in abstract thinking.

Patients were also assessed using the Abnormal and Involuntary Movement Score (AIMS). Tardive dyskinesia is often underdiagnosed and the use of a specific rating tool would allow the team to monitor the levels and severity of these movement disorders (facial, perioral, jaw, upper extremity, lower extremity, neck, shoulders and hips). Subjects are rated from 0 to 4, with 0 indicating absence of that movement.

Global Assessment Functioning (GAF) Scale scores were used to gain a wider understanding of the levels of functioning amongst this group in the community.

Results
At the time of assessment, 46 patients were in treatment for schizophrenia at the Day Hospital, 33 males and 13 females.

The most common diagnosis was paranoid schizophrenia (42 (91.3%)). The average age of patients was 47 years, with a range from 18-77 years. Thirty-six (78.3%) had no children and were unmarried; seven were married; and three were separated.

Of the 46 patients, eight (18.2%) were employed, four full-time, and 36 (78.3%) were unemployed. Thirty-three (71.7%) were living with their families and 13 were living alone. No patient was living in a hostel at the time of the assessments. Six patients had been hospitalised in the last two years (13%). Of these, three had been hospitalised once and three had been hospitalised three times. Among those who had been hospitalised, the range of stay in hospital was from four to 34 days over all hospitalisations in the previous two years, and the average was 16 days.

The GAF scores ranged from 25-85, with an average of 64. This means that on average patients were in the higher half of the scale, 16 (34.8%) patients were scored at 55.

Alcohol abuse was reported in four of 46 patients, and drug abuse in two patients.

The most commonly reported positive symptom was delusions (39%). Lack of spontaneity was the most commonly reported negative symptom.

Following assessment for tardive dyskinesia using the AIMS rating scale eight patients were reported as having tardive dyskinesia. It was more frequent among patients on typical antipsychotics (25% vs 9.5%). There was a significant association between age at assessment and tardive dyskinesia. Patients over 47 years had an eightfold greater risk of having tardive dyskinesia than younger patients (4.6% vs 29%).

In terms of the prescribed medication, we found that 17 (37%) were on one, 20 (43.5%) were on two, six were on three, two were on four and one patient was on five psychiatric drugs. When we limited the analysis to antipsychotic drugs only, we found that one patient was receiving no antipsychotic medication, 43 (87.0%) were on either a typical or an atypical antipsychotic, of whom 25 were on typical and 18 were on atypical antipsychotics. Two patients were on both types of antipsychotic medication

The 10 most frequent medications used by patients in the audit were: biperiden (10 patients); risperidone (8); olanzapine (7); fluphenazine decanoate (7); zuclopenthixol decanoate (7); clozapine (5); alprazolam (4); flupenthixol decanoate (5); benztropine (5); lithium (3); haloperidol decanoate (3); benzhexol (3).

Discussion
The study provides staff with one form of consulting with patients as a means of improving their quality of life.

The results provide quantitative information about patients’ medication and side effects, from which to develop plans for improvement, providing a more consumer orientated system of health service delivery. It also helped patients to be more in touch with their symptoms and side effects and the importance of compliance with services and medication.

Bridget Falahee is a CNM2 and Peter Kirwan, is consultant psychiatrist and clinical director, Kilmallock Day Hospital, Co Limerick

Acknowledgments
We would like to thank the following for their support with this project: D McNamara, Eli Lilly; J Bryne, Boyne Research Institute; M Moriarty; B Malone; J Hinchy; J Leahy; B Tierney; R Cregan; K O’Gready


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