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INSIDE HEALTH

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Programme 7.

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TX:Ìý 04.03.14Ìý 2100-2130

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PRESENTER:Ìý MARK PORTER

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PRODUCER:Ìý ERIKA WRIGHT

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Porter

Coming up in today’s programme:Ìý Over treating older people – I meet a specialist who thinks we are being too aggressive with drugs like statins. And far from improving quality of life by protecting against stroke and heart attack, they often make matters worse.

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Cataracts – we put a listener’s question about the latest developments in lens technology to an eye surgeon. Is it really possible to have your cataracts removed and throw away your reading glasses at the same time?

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And intensive care – the latest research shows that more than half of those discharged from ICU go on to develop psychological problems like depression and panic attacks. We join the team behind a pioneering project to tackle an issue that can leave some patients feeling they would be better off dead.

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Clip

Well I can think of a particular case where a young man was just unable to function, had daily intrusive memories, essentially rendering his life, to him, useless.Ìý And had just completely withdrawn from society, he essentially felt that this was worse than the illness itself and he said he’d rather be dead.

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Porter

More from ICU later.Ìý But first, scarlet fever – a disease that is back in the headlines following the release of new figures showing that the number of cases is on the rise. Schools and parents have been warned to be vigilant. And the latest figures from Public Health England confirm that there were 868 cases last month – up from 591 over the same period last year. And these officially confirmed cases are likely to represent the tip of a much bigger iceberg.

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Scarlet fever is caused by a bacterial infection spread through contact, coughing and sneezing. Most cases occur in children and classic symptoms include a sore throat, high temperature and a spreading red rash that typically starts on the chest or back, and feels a bit like sandpaper. The tongue can be affected too – often starting off with a furry white covering before turning red and swollen and ending up looking like a strawberry. Most cases will settle without treatment but some can go on to develop more serious complications including kidney and heart damage.

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Inside Health’s Margaret McCartney has been taking a closer look at the latest figures. Margaret is this a cause for concern?

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McCartney

Well it depends what you mean by concern.Ìý I think it’s good to know that this is a disease that’s still going around, so we’ve got the kind of idea I think that it’s something that belonged in the 1800s and certainly there were times when in a year it would be quite feasible for 30,000 or 40,000 children to actually die of scarlet fever.Ìý So we’re nowhere near where we were in the 17th and 18th Century, we’re only seeing sort of three or four thousand cases a year in the UK and children don’t die from it anymore, that’s another really important thing to say.Ìý So it’s not a serious illness as it once was but it’s certainly something that GPs are still on the lookout for and it’s something I think that’s good and useful for parents to know about as well.

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Porter

Most cases, as I said, will get better on their own but we do worry about complications in the unlucky few, don’t we, how common are serious complications and can they affect adults too?

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McCartney

Well in the UK I mean nowadays we hardly see any complications from it and the classical, I think, complication from scarlet fever would have been rheumatic fever and there’s still a few people around that maybe had complications of scarlet fever when they were children and they had rheumatic fever and heart valve problems as a result but that’s actually incredibly uncommon the UK and certainly adults can get it as well but it’s much more of a childhood illness.

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Porter

In terms of treatment, if somebody came to you with a sore throat associated with a rash and you thought they might have scarlet fever how would that change your management compared to a normal sore throat?

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McCartney

Yeah, so most sore throats are caused by viruses, we don’t need to do anything particular for them, they’re the kind of things that will get better all by themselves.Ìý And certainly scarlet fever, if you leave it alone, most of the time that will get better by itself as well.Ìý But because there’s a small chance of complications from the bug that causes scarlet fever we are recommended and we usually will give a 10 day course of penicillin afterwards and that’s really to stop the chances of complications from the scarlet fever itself.

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Porter

And presumably that has the added benefit of reducing – making the child or the adult indeed less contagious to others?

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McCartney

Yes, so within 24 hours of starting the antibiotics you’re no longer contagious and you can get back to school or work.

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Porter

So one a few causes of sore throat that GPs will actually want to prescribe antibiotics for. Thank you very much Margaret.Ìý And there is a link to more information on scarlet fever and its treatment on the Inside Health page of the Radio 4 website.

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Most older people take at least one form of medication to reduce their risk of stroke or heart attack - typically a statin to lower their cholesterol, and one or more drugs to reduce their blood pressure.Ìý But there is growing concern among some doctors that the benefits might not be as clear cut as we have been led to believe, and that over-zealous use of these drugs can cause more problems than it solves.Ìý

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Kit Byatt is Consultant Physician and Geriatrician at the The County Hospital in Hereford.

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Byatt

Over the 20 or so years that I’ve been a consultant increasingly I’ve noticed that people that I see coming in to hospital and in clinics are on larger and larger numbers of medications.Ìý Which is understandable in many ways because we’ve had lots of advance in medicine and lots of discoveries of which tablets can help people but we seem to have gone past the tipping point and I spend a lot of my time, both in clinics and in hospital ward rounds, stopping people’s tablets because they seem to be causing problems.Ìý And we know that the more tablets someone takes the greater disproportionately the risk of problems with those tablets.Ìý So roughly speaking about one in 10 as medical emergencies that come into hospital come in because of side effects or interactions or problems with their medication.

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Porter

But conventional wisdom has it that you’re most likely – that age is probably the most important risk factor for having a stroke and a heart attack, the things that kill most of us, and therefore the older you get the more you are at risk and then in theory the greater the benefit of the medicines?

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Byatt

Well you’re absolutely right that the increase in stroke rates rising exponentially, it roughly doubles every 10 years from 50, so it’s very high in the over 80s and 90s.Ìý That said that doesn’t necessarily mean that things that reduce the risk of strokes in younger people will necessarily be just as effective in older people.

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Porter

And by things you mean?

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Byatt

I mean treatments to modify risk factors, such as high blood pressure and cholesterol.

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Porter

But I thought it was accepted wisdom that lowering blood pressure and lowering cholesterol will protect, to some degree, against heart attack and stroke, is that different in the elderly group?

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Byatt

As a generalisation that’s perfectly true but it seems from a lot of studies that if one lowers the blood pressure too much in older people one can cause problems.Ìý So one has to be very careful about which population of patients one is looking at.Ìý For example, just because a large trial done in middle aged people shows good benefit one can’t automatically presume that the same treatment in older people will have the same benefit.

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Porter

Do we have evidence to suggest that this over 80 group respond differently to preventative measures like lowering their blood pressure and lowering their cholesterol?

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Byatt

We do.Ìý I took two landmark trials done in the last few years, one looking at the treatment of hypertension in older people and another looking at the treatment with statin medication to lowering cholesterol in older people and my take on those two trials was that these trial showed modest but really not very dramatic effects.

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Porter

What’s the downsides of being on over-treatment for your cholesterol and over-treatment for high blood pressure, other than that they might not be offering the degree of protection that we think they are, what sort of practical side effects do you see?

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Byatt

I find a lot of people who have been diagnosed in the past with high blood pressure who have been put on medication for that and now some years later find that when stand up or stay standing for too long their blood pressure becomes unduly low and they develop symptoms, either light headedness or actually passing out.

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Porter

Particularly if they’re elderly because falls and resulting fractures etc. are dangerous.

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Byatt

Exactly and in fact something like 10% of people who faint at that age will have no recollection they’ve fainted, so as far as they’re concerned they think they may have fallen.Ìý So we overlook the people who faint because of excessively zealous treatment for high blood pressure because we don’t ask the right questions or we don’t understand the answers properly.

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Porter

Dr Kit Byatt from the Department of Geriatric Medicine at Hereford and listening to that in our Glasgow studio is Margaret McCartney. Margaret what is your take on the evidence for the benefits of lowering blood pressure and cholesterol levels in older people?

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McCartney

I would take the Cochrane Review that was done looking at all the trials relating to people taking medicine to try and reduce their blood pressure and specifically if you looked at people over the age of 60, if you took a thousand people over four and a half years you could cut down heart attacks, strokes from 149 to 106, if you treated those people’s blood pressure.Ìý But if you take people over 80 you could cut down the risk of having a cardiovascular event, like a heart attack or a stroke, but that didn’t actually cut down death rates overall.Ìý And that’s crucial because what it means is that you can lower the blood pressure but what you’re not really doing is lowering people’s chances of death overall, what you’re doing is reducing their risk of heart attack and stroke and the concern is that you might be replacing that risk with risk of a side effect from the medication, such as major fractures caused by falls as a side effect of lowering blood pressure too much.

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Porter

Let’s have a look at cholesterol levels as well because a lot of these people are on statins, is there any evidence that statins work as well in the older people as they’re supposed to in younger people?

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McCartney

Yeah and I think there’s a big issue here about the amount of research that we have and who’s actually being researched.Ìý So there’s a lot of data around younger people – so people in their 40s, 50s, 60s – but not so much data about people in their 80s and their 90s.Ìý And when you ask people who are in their 80s, 90s, even in their 100s, do you want to keep taking this tablet, here’s the pros, here’s the cons, quite often you’ll find people saying to me in return actually I don’t really feel like taking anymore tablets than I need to, can I stop this, it just makes me a feel a bit unwell and I’m not happy to take it.Ìý And very often I think it’s very reasonable not to take it at all.

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Porter

Kit Byatt mentioned there falls in people taking medicine to lower their blood pressure, do you think we underestimate risks like that?

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McCartney

Absolutely and I think one of the problems with the way that we’ve looked at research has been that we’ve been treating blood pressure with the intention to reduce heart attacks and strokes, all very well, but we haven’t looked hard enough, I think, for the complications of that treatment.Ìý And one of them – if you talk to general practitioners, we talk to geriatricians, if you talk to older people themselves – they’ll tell you that feeling faint, feeling dizzy is a side effect that they’ll get quite frequently with the medication designed to lower their blood pressure.Ìý And if you’re creating a group of people who you’re treating for high blood pressure but actually causing a fairly major side effect in terms of falls that is a problem.Ìý Now there was a paper in one of the American journals last week, a journal called Janner Internal Medicine, that looked specifically for this, they looked at what does happen in older people, older people over 70 in this instance, when they’re taking blood pressure medication.Ìý And they found that this increased the risk of fall overall and their concern was very much that we’re not quantifying this well enough and we’re not balancing the risk well enough either.Ìý So we’re not managing to say to people okay we can reduce your risk of a heart attack of stroke but a consequence, a side effect, of that medication might be that it increases your risk of fall with a potentially serious outcome.Ìý What to do then?Ìý And I think it’s very difficult to make decisions but I don’t think we should ignore the problems of side effects.

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Porter

Should we be involving the older people themselves more in this debate, I get the feeling that we’re prescribing at them, rather than with them?

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McCartney

Totally, absolutely and this is the problem that I have with the contract that general practitioners work to.Ìý NICE gives out targets, they tell us to get people’s blood pressure down, over 80s down to 150/90 and the question then for GPs is how can you do this, rather than should we do this.

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Porter

Thank you very much Margaret and there are links to the studies mentioned there on Margaret’s blog – details on our website.

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Now to a pioneering new project aimed at helping people recover from being treated on intensive care. Up until recently the very fact that someone made it home after a life threatening accident or illness would be regarded as a triumph. But there is now a dawning realisation that the psychological trauma of being on an ICU can exact a significant toll in addition to whatever problem put them on the unit in the first place. And while their physical scars may have healed, any mental scars can last much longer. At least half of all survivors are left with flashbacks, nightmares, anxiety or depression and that’s around 50,000 people every year

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A team at University College Hospital in London is training intensive care staff so they can help patients cope with the stress of being on the unit, in the hope that it will reduce the likelihood of long term psychological complications.

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A move that ex-intensive care patient Margaret welcomes. Her problems started with delusions while she was still on the unit.

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Margaret

I could see like my name written in blood on the wall and I was trying to get people in to prove that they were trying to kill me.Ìý I sent a text to my friend and if you were to look at it it’s proper punctuation marks, where I’m asking her to get me help.

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Porter

So it looked like it was written by someone who was lucid.Ìý What were you asking in the text?

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Margaret

For her to get me help because the nurse was trying to extort money out of me and they were going to get me sacked.

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Howell

My name is Dr David Howell and I’m the clinical director for critical care at University College Hospital in London.Ìý Patients can be extremely thought disordered, perhaps some of the most tricky times is when they appear to be coherent and that can be incredibly difficult for the staff to understand.Ìý So patients can have what appears to be completely logic lucid conversation with you but they are completely delirious and this can be very difficult.Ìý Other patients have phoned the police from their beds on a number of occasions, sometimes people think they’re being kidnapped and tortured.Ìý A particularly interesting delusion we had in our clinic recently was a chap who thought he was in World War Two but he was born after the war had started, so he was having delusions about something that he could never even have delusions about.Ìý Some people are fortunate enough to have what they describe as good hallucinations but the vast majority find them troubling.

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Margaret

They got much darker and much worse, where I don’t remember killing the staff but I remember stepping over their bodies.Ìý In my head they had to die so I could live.Ìý I remember feeling that fear.

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Porter

How did you feel at the time?

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Margaret

Terrified.Ìý You can’t really put it into words, it’s more than terrified.Ìý Just this dread that something was going to happen and no one believed me.Ìý And then not knowing whether it was real, that was the worst thing.

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Wade

My name’s Dr Dorothy Wade and I’m a health psychologist in the intensive care unit at University College Hospital.Ìý We wanted to find out how well patients were recovering psychologically after a stay in intensive care.Ìý And there had already been some research showing that patients were suffering from traumatic reactions and depression and other psychological conditions but we were personally actually quite shocked ourselves when we realised the scale of the problem.Ìý So we found out that over a quarter of patients had post-traumatic distress disorder, nearly half of the patients had clinical depression or anxiety and we found that more than half of the patients had one of these psychological problems.

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Porter

And how are these actually affecting the people themselves, what were they experiencing?

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Wade

The patients who were suffering from post-traumatic stress disorder they would be having intrusive memories about intensive care that would keep coming into their mind when they didn’t want them to and they would have flashbacks or really traumatic nightmares.Ìý And we found that they particularly had flashbacks about the very vivid and terrifying hallucinations and delusions that many of them experience while they were in intensive care.

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Margaret

I’d see a lot of lights and I’d see things moving.

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Porter

Were these flashbacks?

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Margaret

Yes.

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Porter

Vivid?

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Margaret

Very vivid, the lights were dark and bright and I was very hyper vigilant. I didn’t like crowds, if I went out to meet my friends, and even my friends said that it must have taken about 18 months to get back to how I was, I was always looking for the closest exit, the nearest…

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Porter

Edgy, anxious.

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Margaret

I was – yeah, very.

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Porter

Were you having dreams at night?

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Margaret

I’d wake up – yeah I’d have nightmares.

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Porter

How long can these problems go on for?

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Wade

Well in our 2012 study we measured it up to three months and found this very high prevalence but actually other studies have followed these patients up to two years or even five years and they’ve still found that the problems persist, that there’s still a very high rate of depression and traumatic stress disorder in this group of patients.Ìý So our new study is designed to address, to try and reduce that acute stress and to try and help patients deal with the frightening hallucinations and delusions that they had.

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Porter

Was there anything about the group of patients, the half or so, who experienced problems when they got home?Ìý Were there any common characteristics, was it something to do with length of stay, how ill they were or….?

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Wade

Well interestingly we found out it wasn’t to do with length of stay or how ill they were, which we were quite surprised at because we thought maybe that’s what explains it.Ìý But actually it was a lot to do with two things – a sort of clinical group of factors and then a psychological group of factors.Ìý So clinically we found that the longer the patients had been sedated for with some powerful psychoactive sedative drugs those patients were far more likely to get post-traumatic stress disorder.Ìý Also patients who’d received a particular type of sedative called benzodiazepines, those patients were actually more likely to have clinical depression as well as post-traumatic stress disorder.Ìý Equally we found that patients who’d received more invasive stressful treatments or procedures they were also more likely to suffer later further down the line.

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Howell

We use drugs which are essentially general anaesthetic drugs, they’re drugs that really were designed to put people to sleep quickly for operations and to wear off quickly when the operation stops.Ìý But of course when patients are intensive care these drugs are administered for far longer time and when people are critically ill and their organs aren’t working as well sadly the side effects is that the metabolise of these drugs tend to accumulate and that’s where part of the problem that we’ve seen with our psychological distress has come from.

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Porter

So it’s possible for patients for days on end to be in some sort of twilight zone effectively, is they’re real and they’re sedated and they might be on strong painkillers as well.

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Howell

Absolutely and it’s a combination of painkillers and sedative drugs that is really – can be very toxic – necessary but very toxic.

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Porter

Has the dawning realisation that some patients suffer psychologically after the discharge affected the way that you use these medicines?

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Howell

We have tried to reduce some of the classes of drugs which we have seen to be particularly potent at causing psychological distress in our unit and…

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Porter

Drugs like?

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Howell

So benzodiazepines particularly.

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Porter

That’s the valium family.

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Howell

Yes things like that, something called midazolam we’ve particularly reduced considerably and in fact rarely use that now.

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Porter

What sort of follow up do you offer at the moment to patients who are discharged from the unit?

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Howell

So in our intensive care unit we’re fortunate enough to have intensive care follow up clinic, which I run with our nurse specialist and a psychologist.Ìý In my experience they’re often - the psychological problems are far more prolonged and can be really, really devastating once the physical problems have got better.Ìý I can think of a particular case where a young man came to our intensive care with pneumonia, was very, very unwell and had received multiple organ support, fortunately got better, came back to intensive care follow up clinic and certainly in terms of every intensive care outcome and parameter was a roaring success – he’d survived intensive care, he’d survived hospital discharge and come back to talk to us and look to all intents purposes completely better.Ìý However, when we explored this further he said he’d rather be dead and had he known the psychological distress that the whole event would have caused him, which he was still suffering from when he came to see us in clinic, he essentially felt that this was worse than the illness itself and life wasn’t worth living.

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Porter

And the sort of things that were plaguing him were what?

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Howell

Just daily intrusive memories, essentially rendering his life to him useless and had just completely withdrawn from society.Ìý He essentially felt that this was worse than the illness itself and life wasn’t worth living.

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Porter

Because traditionally from a medical point of view we’d tick the box saying his lungs were better, he was fine but what you’re actually saying is that he felt worse off.

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Howell

Absolutely and I think that’s the issue that you do hear a lot of patients, general public, sort of say well you’re alive, you feel lucky and I think we’re starting to realise that in fact it’s not all about just living if you feel worse when you’ve survived.

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Margaret

You know there was one nurse who I would just concentrate on, she knew how to calm me down and I think that’s probably the most important part, she knew what to say and she would always try to calm me down and that put me to sleep and tell me how my sats were doing, even though I didn’t really understand.

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Nash

In the first instance we’ll be training all the nurses in a unit in a programme of psychological first aid.Ìý And psychological first aid is something that’s used after earthquakes or other catastrophes, it’s a way to reduce trauma immediately after the trauma.Ìý So it’s all about the way you talk to people, it’s about tone of voice, it’s about using a very non-threatening body language, not crowding the patient.Ìý So if you were nursing a patient like Margaret, who you knew was having really frightening hallucinations and delusions, a very natural thing for anyone might be to say – no, no don’t worry, that’s not true, that’s not happening, you’re fine – but actually we found that that’s probably the wrong thing to do and that the ideal thing to do is not to challenge their delusions, you don’t have to agree with them either but you don’t start to argue with them because then they see you as one of the people that they can’t trust, one of the people that must be part of the conspiracy.

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Howell

Well this could completely transform clinical practice.Ìý This is a new study of which we obviously hope has a positive outcome but if this were to be useful and show that patients do have a better psychological outcome once they recover from a critical illness this would be game changing in terms of how we provide daily support on the intensive care unit.

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Porter

Dr David Howell from University College Hospital in London.Ìý And if that pilot proves successful it will be rolled out across the country as part of a much bigger trial. More details on our website.

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Last week’s item on constipation in children prompted a few of you to get in touch, including Hannah who e-mailed to say that her eight year old son had been having problems but that no amount of explaining, cajoling or bribery would get him to take his medication. But after hearing the young lad talk about his similar experiences on Inside Health Hannah’s son has decided to give it another try. Peer power Hannah! And don’t forget that the medicine he is likely to take does come in a variety of flavours if he still struggles.

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Michael Fardell e-mailed us via insidehealth@bbc.co.uk to enquire about the latest developments in cataract surgery. He asks, can the latest implants really give you perfect vision, correcting issues like long and short sight and even negate the need for reading glasses? If so, are they available on the NHS? And how safe is the operation?

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Well to find out I am joined from our Guildford studio by Consultant Eye Surgeon Rakesh Jayaswal.

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Now Rakesh, first of all, just how good are these latest lenses?

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Jayaswal

The current technology for lenses is very, very advanced these days, we can now virtually any prescription we can treat with lens technology because we have an array of lenses that can pretty much go down to very, very short sight to very long sight as well.Ìý And the way that these lenses are manufactured they are manufactured to such a precise power we can actually get them down to quarter dark to powers, which is incredibly precise.Ìý So they are very advanced, we can pretty much treat any prescription to be honest.

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Porter

Because in the old days the priority right at the beginning of cataract surgery was just to get the clouded lens out, so that you could get some light coming into the eye but now what you’re saying is you can actually perfect someone’s vision potentially?

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Jayaswal

Yes potentially, absolutely.

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PorterÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌý

What about the need for reading glasses though because that’s something that happens to a lot of people as they get older and that’s a slightly different problem, can you get around that by being clever with your lenses?

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Jayaswal

Yes very much so.Ìý I mean this is almost the Holy Grail in terms of trying to perfect people’s eyesight both for distance and near.Ìý But the current technologies do allow you to gain reading as well as distance vision correction all in one go.Ìý So you may have heard of something called the multi-focal lens and there’s also something called an accommodating lens as well which allows people to see distance as well as gaining some degree of clarity for near close up work.Ìý Surgically the technique is very straightforward, it’s very much like putting a traditional lens in.Ìý The difficulties that can arise are more to do with the planning process and the way that the lens is centred.Ìý And actually the most difficult part of the process in trying to rehabilitate someone’s vision is actually to find the right lens for the right person.Ìý And so a lot of the planning process occurs in the consultation beforehand where we sit with the patient and we ask them about their hobbies and their lifestyles and we examine their eyes in great depth to see exactly what lens is the most suitable for their lifestyle.Ìý The actual surgical process of putting a lens into the eye is very straightforward and a multi-focal lens for example essentially it’s trying to do two things at once, it’s trying to give somebody a point of focus at distance and a point of focus at near.Ìý So there’s always a small chance that when it’s doing two things that it can actually create a slight ghosting in certain circumstances.Ìý But if the lens is well centred and well positioned and it’s maintained properly then that risk is greatly reduced but we can never eliminate that risk entirely but the majority of patients who have it done are extremely happy but you have to discuss that with patients about their job, their lifestyle, the things they like to do because in certain conditions they may notice a slight ghosting of image potentially.

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Porter

Looking at what’s available in terms of the NHS and the private sector is this latest technology available on the NHS or is it something you have to pay for privately?

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Jayaswal

Unfortunately it’s something you have to pay for privately.Ìý The purpose of the NHS is to remove cataracts and allow people to see again, so one of the advantages of your standard cataract surgery is that we can use a single vision lens, a single focus lens, and we can correct people’s vision at the same time for their glasses.Ìý Now we don’t guarantee that in the NHS, the principle behind it is to allow people to remove a pathological lens or a cataract within their eye which is limiting their vision and then we give them clear vision and often they go off to the opticians afterwards to get some new glasses made.Ìý So the process of putting in a multi-focal lens or an accommodating lens on the NHS it’s not really achievable for many reasons actually and one of them of course is the cost of the lens which is much more expensive and secondly because to achieve the very best out of these lenses the process of surgery is very straightforward, it’s actually the time spent with the patient trying to find out which is the right lens for them and also even after the process has been done, the surgery’s been done, you have to then potentially do further laser surgery afterwards just to fine tune the lens as well, to get the very best out of it.Ìý So it’s a much more complex process and unfortunately we don’t have the resources to do that on the NHS.

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Porter

In terms of cost if someone was to come and see somebody like you to have this done privately what sort of costs are they looking at?

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Jayaswal

Somewhere between £3-4,000 an eye that is, so people do vary depending on which lens you use but in the ballpark of £3-4,000 an eye is roughly what you’d expect to spend on that.

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Porter

Rakesh Jayaswal,we must leave it there, thank you very much.

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Just time to tell you about next week’s programme when I will looking at new research into the impact of iron deficiency. And learning a few tips from an expert on recurrent thrush. Step one is to confirm the diagnosis, but - as I discover - that’s not always as easy as it sounds.

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ENDS