Digest

Abstract News NICE busy on mental health NICE ( www.nice.org.uk ) has been developing several initiatives in mental health. It is to develop new quality standards on social care for people with dementia, autism in adults and self‐harm. These concise statements are markers of high‐quality, clinically and cost‐effective patient care, forming the basis of local indicators to measure the performance of GP commissioning consortia. In addition, NICE has been consulting on a clinical practice guideline on incontinence in patients with neurological disease. Think Family: final report The Social Care Institute for Excellence (SCIE) www.scie.org.uk has published its final report on services for children with mental health problems. Think child, think parent, think family is an evaluation of SCIE's 2009 guidance on parental mental health and child welfare. SCIE found that implementation in 10 UK sites was variable but progress has been encouraging and the report revealed the diversity of approaches to meeting the programme's objectives. Barriers to implementing the programme included an inability to cross reference electronic databases and a lack of performance indicators. Improving access to psychological therapies The number of people referred to or entering psychological therapy is increasing slightly, according to the latest analysis of key performance indicators of the Improving Access to Psychological Therapies (IAPT) programme by The Information Centre ( www.ic.nhs.uk ). In the last quarter of 2011, 218 192 people were referred for psychological therapies – an increase of 1.9 per cent over the previous quarter. A total of 131 066 people entered treatment, an increase of almost one per cent. The Information Centre estimates that 6.1 million people in England suffer from anxiety and depression disorders, meaning that only 2.1 per cent are accessing psychological therapies. The Department of Health is aiming for a minimum of 3.75 per cent per quarter accessing psychological therapies by 2014/15. National Patient Safety Agency warnings The National Patient Safety Agency ( www.nrls.npsa.nhs.uk ) has issued safety warnings about the risk of central pontine myelinolysis (CPM) syndrome after rapid correction of sodium levels and also of respiratory distress associated with buccal midazolam. The National Reporting and Learning System (NRLS) identified 15 incidents of CPM between January 2008 and June 2011, of which three were associated with severe harm. The incidents were caused by errors in the strength, volume or rate of administration of saline infusion administered to correct abnormal blood sodium levels. Healthcare organisations should amend treatment protocols to identify the risk and state the maximum infusion rate for sodium, measure blood sodium every two to four hours, and monitor clinical state, CNS function and fluid balance regularly. Buccal midazolam may cause respiratory distress during the treatment of status epilepticus. Factors contributing to the 132 incidents reported to the NRLS included incorrect dose, inadvertent IV administration and the use of an unlicensed product with a higher midazolam concentration than the licensed alternative. The NPSA recommends that NHS trusts implement treatment protocols with guidance on specifying doses, using oral syringes and opting for licensed products. Wearing off An interactive website, www.wearingoff.co.uk , has been launched for Parkinson's disease patients, their carers and healthcare professionals. Long‐term use of levodopa may give rise to certain symptoms, including tremor, stiffness, slowness and muscle cramping, when the effect of the drug starts to wear off. The website, funded by Orion Pharma, offers support and tools on how to recognise wearing‐off symptoms and provides an online symptom diary to track a patient's progress. Meanwhile, Orion Pharma has launched a new 175mg dose strength of its levodopa formulation, Stalevo. The drug is now available in seven dose strengths making small adjustments of dose easier in Parkinson's disease patients experiencing wearing‐off symptoms. Research Migraine A US analysis of healthcare costs illustrates the value of appropriate treatment for migraine (J Headache Pain 2012;13:121‐7). In 2010, 465 patients in an employer‐sponsored health programme were identified as having migraine or taking an antimigraine treatment. Half had a diagnosis of migraine, of whom 60 per cent were using an anti migraine drug. Patients using antimigraine medication had fewer A&E visits, and allcase medical and total healthcare costs were 42 and 26 per cent lower respectively, compared with those not taking antimigraine drugs. Combinations of drugs may be more effective than monotherapy as migraine prophylaxis, a small US trial suggests ( J Headache Pain 2012;13:53‐9). A total of 68 patients with episodic migraine unresponsive to topiramate or nortriptyline were randomised to continue treatment with monotherapy (with placebo) or with both drugs combined. After six weeks, combined treatment was associated with a significantly lower headache frequency (4.6 vs 3.5 per week) and more patients reported an at least 50 per cent reduction in headache frequency (78 vs 37 per cent). Transdermal sumatriptan is being developed as an acute treatment for migraine. The iontophoretic device actively delivers sumatriptan rather than relying on passive diffusion. Previous studies have shown efficacy to be modest, with pain freedom at two hours reported by only 19 per cent of patients compared with nine per cent with placebo in one Phase III trial ( Headache 2010;50:509‐15). An open‐label extension study now reports that, after up to 12 months' use, 45 per cent of patients reported application site reactions and 1.6 per cent triptan‐associated adverse events. Twenty‐four per cent of patients were pain free two hours after activating the patch for an acute migraine episode, with 58 per cent reporting headache relief and 79 per cent being free of nausea. Cognitive impairment and dementia Canadian investigators have identified a surprising risk factor for non‐adherence to prescribed medication in older people with cognitive impairment ( Int J Geriatr Psychiatry 2012;doi:10.1002/gps.3778). Their study of 339 older people living alone confirmed expectations by showing that memory impairment, previous nonadherence and polypharmacy (at least four drugs) were all associated with an increased risk of nonadherence. However, they also found that higher scores on the conceptualisation subscale of the Dementia Rating Scale (DRS) also predicted worse adherence. The authors suggest that this may indicate deliberate non‐adherence, perhaps to avoid adverse effects. Coffee improves cognitive function due to its caffeine content – but also due to chlorogenic acids, say Swiss investigators ( Psychopharmacology 2012;219:737‐49). They compared mood and cognition in older people after drinking coffee, normal decaffeinated coffee, and decaff enriched with chlorogenic acids. Compared with normal decaff, coffee improved mood and attention functions. The effects of decaff with added chlorogenic acids was less marked but mood and behavioural measures were still improved. Nutritional supplementation may help to improve memory in elderly women who complain of memory loss, an Australian study suggests ( Psychopharmacology 2012; 220:351‐65). A multivitamin preparation improved the speed of response in a test of working memory, though it did not affect performance in other tests of cognitive function. Supplementation was associated with increased levels of B and E vitamins and lower homocysteine levels. Cancer survivors have a reduced risk of developing Alzheimer's disease compared with people without a history of cancer, an analysis of the Framingham Heart Study has shown ( BMJ 2012;344:e1442). Among 1278 people aged over 65 years, 221 cases of Alzheimer's disease were identified over 10 years. The risk of Alzheimer's disease was reduced by one‐third among cancer survivors overall and by three‐quarters in those who survived smoking‐related cancers (though their risk of stroke was doubled). Conversely, people with Alzheimer's disease had over a 60 per cent lower risk of developing cancer than those who did not. The authors note that the inverse association between Alzheimer's disease and cancer is similar to that with Parkinson's disease. Use of psychotropic drugs (antidepressants, antipsychotics and benzodiazepines) is associated with a more rapid cogn

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