Antipsychotics: person centered care vs roots and branches

When I visit one of the nursing homes in my area, I invariably have specific appointments in mind. Mr Smith or Mrs Brown have been referred, or are already known to community mental health services. Working in an advisory / consultancy / educational capacity other individuals are brought to my attention and this continues the person centered focus - at least at this level.

Keeping things person centered beyond that in assessment, care planing and intervention - is the real challenge. Actually there is another: even where staff are 'trained' and you observe staff -:- resident interactions you often see that (as for us all) there remain key things to learn.

I've visited a few homes to try to jump start an audit of antipsychotics and other drugs that can be so damaging to older adults - potentially fatal in fact as per evidence based findings and reporting in the media:

About 145,000 people with dementia are wrongly being prescribed powerful anti-psychotic medication which causes around 1,800 deaths a year ... The Times

The problem is recognized now as per the Department of Health's (2009) report:

Report on the prescribing of anti-psychotic drugs to people with dementia

The risks, care management and quality of life issues that arise have prompted some homes / organisations to pursue this internally. My manager Christine and I are working to put a 'pack' together and make connections with colleagues working in residential care / nursing home liaison.

It is essential to check that there is consistency, compliance and that reviews are comprehensive. What blood tests have been completed and exactly when? Have next-of-kin been made aware of the potential side-effects? How skilled are staff in dealing with these acute care challenges? Is there a need to 'fix' the care environment? Is this placement - despite being the individual's home - still appropriate? What specific staff awareness is needed to support any shared care protocol that is put in place?

The point here is that it can be surprising the drugs that do come to our attention. People move in from out of area; some individuals are self-funding so they may by-pass formal services; others are seen by locum doctors / out of hours services and subsequent follow-up may be missed. ...

So here it's not about Mr Smith or Mrs Brown in the first instance, even though that's the expectation when I first arrive. Clearly, this is going to take a dedicated approach away from the personal care problem solving - solution finding (fire-fighting!).

The summary care record could be a great help here and I wonder about searches conducted within primary care GP systems. IT systems aside, it's about turning up and engaging with the homes around a root and branches review of their Medication Administration Records Sheets (MARS).

Task driven - person centered care!

h2cm as a 'memory palace' - spatial memory

I've just caught up with BBC Radio 4 Midweek 6 April 2011. I'd heard a trailer that mentioned memory and sure enough Libby Purves and guests discussed dementia featuring Marianne Talbot and her book Keeping Mum: Caring with someone with dementia and memory with Joshua Foer's book Moonwalking with Einstein.

The conversation included the story of Simonides which reminded me of spatial memory and its potential realisation in h2cm:

... Cicero and Quintilian are sources for the story that Scopas, the Thassalian nobleman, refused to pay Simonides in full for a victory ode that featured too many decorative references to the mythical twins, Castor and Pollux. According to the rest of the story, Simonides was celebrating the same victory with Scopas and his relatives at a banquet when he received word that two young men were waiting outside to see him. When he got outside, however, he discovered firstly that the two young men were nowhere to be found and, secondly, that the dining hall was collapsing behind him. Scopas and a number of his relatives were killed. Apparently the two young men were the twins and they had rewarded the poet's interest in them by thus saving his life. Simonides later benefited from the tragedy by deriving a system of mnemonics from it. ...

During the excavation of the rubble of Scopas' dining hall, Simonides was called upon to identify each guest killed. Their bodies had been crushed beyond recognition but he completed the gruesome task by correlating their identities to their positions (loci in Latin) at the table before his departure. He later drew on this experience to develop the 'memory theatre' or 'memory palace', a system for mnemonics widely used in oral societies until the Renaissance.

Source and image: Wikipedia, Simonides of Ceos

Have a listen yourself.

Reading:
Timothy P. McNamara, Spatial representation, Geoforum, 23, 2, May 1992, 139-150.

ERCIM News No.85 Special theme "Unconventional Computing Paradigms"

Dear ERCIM News Reader,

ERCIM News No. 85 has just been published at http://ercim-news.ercim.eu/
Special Theme: "Unconventional Computing Paradigms"

- coordinated by: coordinated by Jiri Vala, National University of Ireland Maynooth (Quantum Computing )
and Giancarlo Mauri, Università di Milano-Bicocca (Molecular and Cellular Computing)

- featuring a keynote by Susan Stepney, Deptartment of Computer Science, and Centre for Complex Systems Analysis, University of York.

Includes: E-services for the Elderly at Home [OLDES]

Next issue: July 2011 - Special Theme: "ICT for Cultural Heritage"

Thank you for your interest in ERCIM News.
Feel free to forward this message to others who might be interested.

Best regards,
Peter Kunz
ERCIM News central editor

Mind & Body in Markup: (Book review to follow)

I am writing up my reading of From A to <A> Keywords of Markup, Bradley Dilger and Jeff Rice, editors, University of Minnesota Press for the Journal of Community Informatics.

In reading the text I noticed how Cartesianism is alive and well not only in Hodges' model but in HTML markup also:

INTERPERSONAL : SCIENCES

SOCIOLOGY : POLITICAL

<HEAD>	<BODY>
narrative	protocol

Yes, I mean 'MIND' really...

Amongst the various aspects of markup dealt with in communication and media, the discussion on narrative forms and protocol also emphasize the SOCIOLOGICAL and POLITICAL (care) domains.

Nursing ideas somewhere between Drupal & Ruby

It's been a busy week:

• getting ready for the Scottish Ruby Conference [SRC] three fascinating days 7 - 9 April.
• checking with the client of the Drupal site, confirming that the following CSS3 adornments are not required: coloured lettering : 3D text : and others. KISS - OK!

SRC started with the charity day a day long tutorial from Chad Fowler author of The Passionate Programmer and Keavy McMinn. They delivered too - indeed it's all great! The venue - The Royal College of Physicians is quite amazing, full of history in its architecture and the portraits of esteemed members. Whether or not I attend a session in there today I must visit the library. The charity day covered:

• Blocks and bindings
• The Ruby object model
• Meta-programming
• Hooks, callbacks, and reflection.

When it came to the exercises I let the experts do their thing and followed the solutions. I missed last year's Ruby bash so it's good to be back.

Swapping to Ruby while tinkering with Drupal is not a help and yet there is overlap. GIT is the must-do within both communities. PHPNW's meeting on Wednesday on OOP with Lorna Mitchell highlighted some common aspects. I'm probably getting a lot of this (as in 'all' plain) wrong but Lorna's mention of $this and static methods sent me on a reverie. ...

Abstract classes are apparently incomplete and $this is not available to them. Suddenly I'm thinking well that's different. In nursing our abstractions on nursing care are complete - in the idealised sense. It's the concrete / practical (dynamic) delivery that sadly falls short.

PHPNW - the conference in October, a Saturday event in prospect and being here in Edinburgh reminds me I have this itch. Dave Hoover's keynote spoke about his career and finding his technical groove from a therapeutic role as a psychologist.

One thing I do know: from the books he mentioned I ain't got 10,000 hours. That's why I am trying to leverage Drupal and in Ruby - the Rails framework. There's an IDE I have just learned of JetBrain's Ruby Mine.

(Despite that) I'm reading Martin Fowler's book on Domain Specific Languages. Not because I'm going to write one (or like rashes), but because I'm totally intrigued and wondering about a research question. What question(s) can I ask that I might also be able to answer (or not)?

method_missing, meta programming and DSLs are still here in Edinburgh. No longer the latest and greatest (Jim Weirich suggested that was c.2006), but then neither are models of nursing. ;-)

In his book, Fowler identifies 'illustrative programming'. Spreadsheets are the key example and quite remarkable in how they are used and the niche they occupy from a programming, DSL, and an everyday tool perspective.

Hodges' model is a spreadsheet; or a decision table of sorts. Basically, does the patient have a problem in each of the care domains? Fowler writes:

The key benefits of a DSL - greater productivity and communications with domain experts - really kick in when you are using an alternative computational model. Domain experts often think about their problems in a nonimperative way, such as via a decision table. An Adaptive Model allows you allows you capture their way of thinking more directly in a program and the DSL allows you to communicate that representation more clearly to them (and yourself). p.116.

I'm really taking liberties with definitions. My domain experts might actually be student nurses.

I know book titles are intended to sell, but I look at the title of Chad Fowler's book above and wonder about the Compassionate Care Programmer and what alternative computational models may be needed to achieve that?

Fowler, M. (2010) Domain Specific Languages: Addison-Wesley Signature Series, Addison-Wesley Professional.

BIG ICT - BIG Society: The big society and HI professionalism

I have a question for you - is there any irony in the matter of a BIG ICT project that was in embryonic form a decade ago - and the emergence now of the UK government's BIG Society?

Well before the 2010 election NHS IcT policy makers recognised once again the importance and value of locally based IcT management and solutions. Over the past decade the NHS has achieved a national infrastructure at great cost. I always wondered about the extent to which a 'national solution' supports innovation and creativity. Having a market, local scope and flexibility, innovation and creativity depends on standards which we can now benefit from.

There is a very timely and interesting article in the BCS's Health Informatics - HI Now newsletter:

The big society and HI professionalism

Professor Stephen Kay and Dr Glyn Hayes discuss how the government’s Big Society programme might affect the state of UK health informatics and look at how BCS and UKCHIP promote professionalism in complementary ways.

Like the dichotomous axes of the health care domains model you wonder whether:

BIG - small : GLOBAL and local

- can co-exist?

Of course they do. In the socio-economic-political realm we now have 'Glocal' stressing the global times we live in - the constancy that is the bigger picture; and as noted above the NHS has re-discovered the mantra of 'Bsmall'.

My role like that of many colleagues is a mixed-bag. Nursing Home Liaison plus training staff in HoNOS and shortly STORM. I have numerous informatics related conversations with students and managers, but for the time being I've let my UK Chip registration lapse.

Having a professional body in occupations with ethical dimensions, safety, accountability and other essential qualities is vital. Amongst many definitions professionalism means important things are anchored; lifting that anchor and subsequent movement needs to be debated, justified and agreed.

Idealism will count for little though if health informatics professionals are tied to the back-office. A chorus that rang out in Trust Boards, project groups in the early-mid '00s was clinical engagement. We can learn a lot now from the background echoes of all that noise. If the reach - risk management of the more adventurous informatics individuals only sees them reach the middle-office; then change in the hyper-contextual-multidisciplinary-person-centered clinical front-office will be difficult and hard to visualize (whatever technology you throw at the problem).

It seems clinically in a great many areas that health informatics has done diddly-squat in terms of non-informatics personnel understanding data, information and knowledge and the relationships between. Little difference in reflecting the questions that clinician's would ask of their case load, wards and department. Yes, with mention of 'dashboards' staff may realise they are all in the same vehicle; but they may not know whether they are in a 2, 4, 8 or 16 wheeler. [A strange and scary phenomena this - when the staff DO know that one or more wheels are in the process of falling off.]

Furthermore, the destination may not be shared, or even identified. Yes, there are centers of excellence and award winners; but there are information deserts out there in the community, public mental health, the nursing homes. You have to ask where exactly are we bound?