Another Medication Review

Last week we had a follow up medication review with members of the Community Mental Health Team. The nurse on duty was not the one normally present at the reviews, but she had comprehensively assembled what notes there were concerning Rosemarie.

I have written elsewhere about my views on the value of the data they collect. Specifically this time we were interested in changes to her sleep pattern, general emotional state, and the stand up / sit down thing. Data, not subjective, apocryphal impressions. Data.

Well here we were near the end of March. What sleep pattern data did we have? January and most of February. Where was the rest? Probably in another folder. Somewhere. What about the daily notes compiled by the care staff?

"Rosemarie in Lounge."
"Rosemarie changed."
"Rosemarie given drink"

And what about the detailed stand up / sit down notes? No idea. Must be somewhere else.

So we were back to what friends and family had observed and reported to me, what I had seen myself, and what a busy nurse had ascertained from fairly brief occasional glimpses. And the 'notes'.

There was a general consensus that she was less upset generally. although she still had tearful episodes and continued to be distressed by loud and unexpected noises. The stand up / sit down (henceforth SUSD) seemed to have decreased as well but my observation was that she was more often in the wheelchair and this tends to inhibit her ability to stand up.

The sleep pattern data seemed to suggest that she was falling asleep between 10 and 11 most nights, and waking up at about 8. This seemed to be an improvement, but further discussion teased out the extent to which she was tired during the day. Increasingly (but no actual data of course) she was given breakfast in bed and put back to bed afterwards until maybe 11 o'clock.

All the friends and family had seen her when she seemed medicated rather than tired - head dropping to her chest, no response to any stimulus whatever. Then suddenly some switch would seem to click and over the course of a few minutes she would wake up and start interacting.

The doctor thought that this indicated that she was having too much medication - the Donepezil, Zopiclone and Clonazepam had a significant cumulative effect. He suggested that since Rosemarie was sleeping earlier we should stop giving her the Zopiclone unless she was still awake at 11 pm.

The first part of this I agreed with completely, but it seemed counterproductive to give her the Zopiclone at 11. We knew from experience that it takes a good three hours to work (she usually has it at 7) so this would mean it would start working about 2 am. This seemed to be a recipe for making her sleep till late morning. I would have preferred to stop the Zopiclone entirely and observe what happened for a couple of weeks.

We also discussed pain management. Rosemarie has no real way to communicate if she is in pain. She cannot verbalise her condition. She is unable to point. We don't even know how she experiences pain. She regularly gets urinary tract infections and we assume that sometimes this pain or discomfort is the cause of at least some of her SUSD behaviour and possibly some of the tearfulness and agitation. Maybe she gets indigestion, or a sore throat or a headache. How do we know? Being in pain is bad enough, but what must it be like to be in pain and not be able to tell anyone?

So, a trial of regular paracetamol (1g daily) to see if this had any effect. And a regular test for UTI.

Finally we looked at data collection. The Care Home has to provide data to justify the continuing 1 to 1 care funding, and this is normally in the form of detailed SUSD information, though I have tried in the past to get them to include observations of her emotional state. This was now formally requested by the doctor, and with luck the next review in a couple of weeks will have access to more accurate information.

I left the meeting to the soundtrack of the squeaks and grinding noises of slow progress being made.