George: Schizophrenia, Cognitive Decline & Antipsychotics

11.11.08	George admitted on a Section 117.  George is sixty-three with a long history of schizophrenia having being diagnosed in 1969 (24yr old).  Revolving door patient although mainly inpatient.  Usual stuff (in some cases) believing he was well (if discharged) and stopped meds resulting in re-admittance.  Intractable auditory hallucinations which seem to govern his thought process.  Well educated and apparently his life fell apart after university and his first employment being his last.  Physically well (statins and senna).   No known NOK.   Stayed in his room, appears distracted, unresponsive to communication.
12.11.08.	George has remained in his room again this AM.  Does not initiate conversation but appears to welcome it, smiling and holding out his hand for you to take it.  He is a very pleasant man with a seemingly gentle disposition.  Distracted this PM, quite haunted appearance.  Will not communicate or make eye contact. OK by teatime.
18.11.08	George appears well settled.  Stays in his room most of the time but will venture into the lounge occasionally. Other residents appear to have accepted him into the fold and include him in conversation to which he enters – although still does not initiate same.   Often distracted by auditory hallucinations to which he does respond, often angrily.  Other residents seem to tolerate this, some amused by it, others ignore it and the rest by nature of experience, understand it.
09.12.08	George very well settled.   He has been designated his own chair by his circle of friends!  Goes out each morning for his newspaper accompanied by staff.  Remains fully compliant with meds.   Does not initiate conversation but readily responds.  Auditory hallucinations continue.
18.03.09	Section 117 terminated – George now free to leave the building without supervision.
21.01.11	George returned to the home (by the police) for the third time in succession after apparently getting lost.  No evidence of cognitive decline when in the home – but perhaps too subtle?  Monitor.  George now to be accompanied by staff whenever he leaves the home.
26.08.11	Cognitive decline continues.  Defecates and urinates inappropriately.  Manually evacuates bowel smearing contents in room.  Very hostile during interventions, always verbally, often physically.   After re-referral to psychiatry, depot discontinued and ‘given’ as oral meds.  Donepezil initiated.
23.02.12	Further decline evident.  Needs assistance in all aspects of daily living.  No longer able to feed himself.  No longer mobilises.   No longer speaks bar that of responding to his voices, but this being of a bark.  His psychiatrist continues to decrease and reduce (the amount of) his antipsychotics.  We don’t understand why!  Donepezil stopped.
17.10.12	Apart from a rare moment when he smiles that smile and offers his hand for the taking, George appears to exist in a permanent state of torment (hell!), he appears distracted to the point of being haunted most of the time, haunted by his voices that he no longer understands.  Every intervention becomes a battle – how horrific his life must be for him.  We have requested his GP refer him (urgently) to psychiatry; he is on the lowest dose of one med only; how can this be right?
14.11.12	Accompanied George to see his new psychiatrist  - always seem to be temporarily filling a post before they move on elsewhere  - who despite explanations refused point blank to visit him in the home.  I suppose one benefit of him not doing so allowed him to see George at his most agitated.  But benefit it wasn’t.  He (the psychiatrist) was adamant that George’s problems/behaviours’ lay with his ‘dementia’.  He has ordered that George’s remaining antipsychotic be reduced across the next fortnight then stopped.  I am horrified and dare question his judgement.  His response: We both know of the dangers associated with antipsychotics and dementia, don’t we?  WHAT ABOUT HIS SCHIZOPHRENIA?
14.11.12 -present	George’s existence must be pure hell.  Psychiatry will not have a re-think – so this is George’s lot until the day he dies.  The rare smile continues, lost as it is amidst his continuous torment as he barks in response to his voices and lashes out at all those who go near him. He has ‘dementia’ but his voices haven’t. Perhaps his psychiatrist is following the ‘wisdom’ here, but perhaps he should visit here where it is concluded that most elderly patients remain symptomatic and impaired. Perhaps I don’t know what the hell I am talking about as I am not a psychiatrist – but what I do know, what is so horribly evident to me, is that George is tormented by his voices and psychiatric services will do naught to alleviate his obvious distress.   How can this be right?

Image: Courtesy of Wikimedia Commons

Author: Gert Germeraad