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Meeting the needs of the most complex patients

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As a specialist provider of mental health support, caring for some of the most clinically complex patients in the UK’s mental health system, St Andrew’s has a team of experts to provide the bespoke support to enable vulnerable patients to recover. Here, NR Times meets consultant neuropsychiatrist, Dr Vishelle Kamath

 

Can you summarise your role and career to date?

I work as a consultant neuropsychiatrist on the brain injury admissions ward. I have worked both in the NHS and at St Andrew’s within the independent sector. I have been fortunate to have the opportunity to have worked both as a clinician and as a manager of clinical services in a clinical director role. 

Aside from my day-to-day job at St Andrew’s, I am an honorary neuropsychiatrist at UCL Queen Square, the National Hospital for Neurology and Neurosurgery. It helps me to keep my skills updated and understand services across the country, which then allows me to use that knowledge to support the team at St Andrew’s and the patients I care for.

Tell us more about the Neuropsychiatry brain injury service at St Andrew’s? 

We support people who have had a recent or long-standing brain injury. These can be acquired either by trauma, like a road traffic accident (RTA) where there is structural damaged to the brain, or through different illnesses, such as encephalitis or meningitis, where the illness itself causes a change in the way the brain functions and leaves people with both physical sequelae as well as psychological and behavioural elements. 

Physical symptoms from brain injury are something you can see – such as difficulties with speech, swallowing, walking, and mobility – but there can be significant psychological and behavioural sequelae of brain injury, not necessarily visible to the eye, which may include the way someone thinks, how they process information, use judgement, plan, and make choices for themselves. 

The impact of trauma can be far-reaching, for example, a brain injury may affect parts of the brain that control appetite – a person can eat excessively as they do not know when they are full – or alternatively, they don’t have any feelings of hunger or thirst so do not eat or drink. 

A brain injury may also affect the way a person perceives other individuals. They may not see them as helpful, and instead see people as persecuting them or harming them, which results in agitation, aggression and resistance or non-compliance with care. 

People admitted into our service may have experienced significant brain trauma and the loss associated with the attendant physical, cognitive and psychological deficits are life changing.  This is aside from the impact that this has on loved ones and families. 

How do you support patients living with these types of brain injury and symptoms? 

Much of the work we do relates to understanding an individual’s specific needs and what has happened to them. Many people come from acute trauma centre or step down neurology wards and have been sedated for long periods or intubated. 

Patients usually come to us at the point when they are beginning to realise what has happened to them and are coming to terms with not being able to care for themselves in the way they had been able to, prior to their brain injury. 

Some individuals come to us with significant memory loss and their ability to learn new things is impaired. Some people have evident mental disorder as a sequelae of their brain damage. They may have developed psychosis, anxiety or depression as a sequelae of their brain injury. We help them to process the environment, situation and the trauma they may have had so they can develop coping strategies. 

During the assessment process we employ many tools and clinical observation assessments to understand what difficulties a person may be experiencing; their ability to function, what they can do for themselves, including simple things such as daily living activities, feeding, changing, recognising the need to go to the bathroom, which can all be affected by a brain injury.

Once we understand this, we can think about interventions that may support a patient to achieve a level of functioning similar to that which they had prior to their injury, and we subsequently develop holistic neurobehavioral and neurocognitive programmes tailored to the individual needs of each person.

A huge part of the service is also about supporting loved ones of the patient, who themselves are often struggling to understand what has happened, and helping them to understand the process. Establishing the pace of recovery, and setting realistic expectations as to what an individual’s journey may be, is part of what we do.

What is the difference between the St Andrew’s brain injury services and those elsewhere?

At St Andrew’s we are able to meet the needs of patients who present with significant behaviours that challenge. With our experience and expertise, we’re able to support people when they have layered complexities; complex physical health needs that are overlaid with significant and complex mental disorders and mental health needs. 

We have the procedural capability and wide breath of knowledge to support patients whose risk profiles cannot be met in other brain injury environments. 

On our assessment ward, we are able to get patients to a point where they are able to access neurorehabilitation at the earliest opportunity. Until a patient’s behaviour is managed in a way that allows them to engage with and access rehab services, it is unlikely they will achieve the outcomes they want for themselves and return to their premorbid functioning. 

How has your work been affected by COVID-19? 

The pandemic has been a huge learning curve for us. We have continually needed to ensure that patients are risk accessed appropriately in terms of their potential of contracting COVID and the likelihood of them developing a more serious illness. 

Early on in the pandemic, I devised a COVID risk assessment tool and care plan which helped clinicians to systematically think about and understand the risks to other patients with strategies to support all patients and staff safely. This risk assessment is co-produced with the patients and their families, understanding what their views are around escalation of care and any elements of advanced care planning, to reach a shared decision. 

One of the key things in our brain injury service is that we are true advocates of the value of the patient voice and within the context of COVID understanding what the patient wants for themselves, whether we agree or disagree, is a key to the development of these care plans. 

In line with PPE requirements, we all wear masks, we are bare below the elbow, and we maintain a two-metre distance where possible. Staff use appropriate techniques when delivering care during the pandemic. We have hand hygiene audits and are regularly reminding staff of good Infection Protection Control (IPC) measures. We implement periods of isolation and wear scrubs that are discarded/washed appropriately centrally. 

All of our patients are high risk and we undertake four hourly physical health assessments, using a NEWS2 tool to detect any change in physical health, this is especially important for patients who are unable to articulate in the way they feel or report physical health symptoms. We have had to think more creatively, but allow our patients safe ways to access the community, leave and contact with families. Importantly, we have been helping patients and families to understand why restrictions have been put in place.

What are the challenges you face in your role?

I love working in brain injury. As a neuropsychiatrist, I love the interface between organic illness, mental disorder, the layered complexity it has with physical health and various individual elements based on how that person acquired their brain injury and the subsequent physical and psychological sequelae of their condition. 

There is a tendency for brain injury to be seen as a physical disorder and many healthcare settings place all the emphasis on physical rehabilitation, there is limited understanding of neurocognitive and neurobehavioral rehabilitation and this is a challenge across the wider sector. 

Everybody has a different story and some of the obstacles we need to overcome are around how we support patients with high needs, including how we help them to step down into community settings because provision across the country is very limited. 

What do you most enjoy about your role? 

The complexities of individuals and the interface between physical and mental health. Understanding patients in the context of who they are (mother, father, their education and interests, and so on) is integral to any neurobehavioral programme and these are the elements I really love.

Working in a diverse, multi-disciplinary team is also extremely rewarding. I’m very fortunate to work as part of a very skilled team using a comprehensive multi-disciplinary approach and the different perspectives it brings is something I love. 

What do you enjoy doing away from work? 

I love the time I spend with my family and love to cook. 

I also love to travel, exploring different places, enjoying the food and culture. There are so many stories of travel that have enriched my life. I was brought up in South Africa, but explored lots in South East Asia, India, Thailand, America, Europe, Australia and New Zealand. My parents used to love travelling, so I was very fortunate to have travelled when young and when at University. I lived in India for a while, which again was a very enriching experience.

Exploring, cooking and sitting down to a board game or movie with my children and husband are things I really enjoy. The banter I share with them on a day to day basis is the best part of my day.

MND

£1m dedicated to MND research through 7 in 7 Challenge

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A £1million fund has been created to lead new research into potential treatments for Motor Neurone Disease (MND) through the efforts of an iconic challenge by Kevin Sinfeld. 

Kevin, director of rugby at Leeds Rhinos, raised over £2million through his 7 in 7 Challenge, inspired by his former team-mate and close friend Rob Burrow. 

Rhinos legend Rob was diagnosed with MND in December 2019, and Kevin completed seven marathons in as many days to help boost badly-needed research into the condition. 

Now, with £500,000 of the money raised through the 7 in 7 Challenge ring fenced for research, that sum has been matched by medical research charity LifeArc. 

The move has created a £1million joint fund established by the MND Association and LifeArc, which will support research projects focused on developing new therapies or repurposing drugs already approved for use for other conditions.

“This is fantastic news and an amazing contribution from LifeArc,” says Kevin. 

“When we set out to complete the 7 in 7 Challenge we hoped to raise awareness and funds to support the MND community but it is so wonderful to see the inspiration it has given people and organisations, like LifeArc, so they too can support the need for more research.

“Our hope, like that of everyone affected by this brutal disease including Rob, is that this money will make a real difference and help find the breakthrough we all desperately want.”

Researchers are now able to apply for a share of the funding, with the criteria that they will be expected to conclude their project within three years and be target driving with set milestones and a credible delivery plan – including a clear route to reach MND patients.

Dr Brian Dickie, director of research development at the MND Association says: “We are so grateful to LifeArc for this generous contribution and are looking forward to working with them to identify projects which have a real chance of making a difference to our community in the coming years.”

Melanie Lee, LifeArc’s chief executive, emphasised that the focus of the new funding is on boosting research around potential treatment options based on the latest understanding of the disease.

“The ambition around stimulating the search for new treatments fits with LifeArc’s approach over the last 25 years to translate early science into health care treatments or diagnostics that can transform patients’ lives,” she says. 

“Our partnership with the MND Association is the latest in a series of strategic partnerships that maximise LifeArc’s expertise in translating strong discoveries from the lab into benefitting patients with conditions with few or no effective treatment options.”

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What causes a stroke?

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Ischemic and hemorrhagic are the two main types of stroke

Over 100,000 people in the UK suffer a stroke each year, with there currently being around 1.2 million survivors living in the country.

Many people note that despite how common strokes are they remain unaware of what the actual causes of a stroke are.

Depending on which of the two types develops, causes and outcomes can differ.

What both have in common is they restrict blood flow to the brain. This leads to a reduction in the brain’s oxygen levels, which can cause tissue damage.

Here, NR Times breaks down why a stroke may occur and what risk factors there are behind each different type.

What are the different types of stroke?

There are two main types of strokes: ischaemic and hemorrhagic.

Ischemic strokes make up nearly 90 percent of all cases and they materialise when an artery which provides blood and oxygen to the brain becomes blocked. 

A hemorrhagic stroke is much less common, but happens when an artery leading to the brain bursts and starts to leak blood around or in the brain.

Causes of an ischaemic stroke

The brain is only able to function properly when its arteries supply it with oxygen-rich blood, meaning any blockages can cause lasting damage.

With a lack of blood flow, the brain is unable to make enough energy to work. If this consists for more than a few minutes, brain cells will begin to die.

This is exactly what happens in an ischaemic stroke, but there are a range of reasons as to why these blockages develop.

One of the main causes is when the arteries around the head narrow, which makes it harder for the blood to pass through.

This can also lead to something called atherosclerosis, which is where substances in the blood (such as fat or cholesterol) stick to the sides of the arteries.

Blood can build up on these deposits, causing a further increase in pressure and a reduction to the brain’s oxygen supply.

There are a number of reasons for these blockages, with the most common ones being around a person’s lifestyle.

For example, smoking can increase the risk of a stroke by up to 50 percent.

This is because nicotine not only narrows the arteries, but it also makes the heart beat faster, causing an increase in blood pressure.

Excessive alcohol intake, obesity and high cholesterol levels are also all listed as major risk factors when it comes to ischaemic strokes.

Problems with the arteries around the heart can also lead to an ischaemic stroke.

Irregular heartbeats, heart attacks and other irregularities around this area can again limit the blood’s oxygen levels.

Causes of a hemorrhagic stroke

Hemorrhagic strokes are most common in people ages 45 to 70, but they affect a lot more younger people than an ischaemic stroke.

These are caused after the arteries around the brain burst and cause bleeding.

Depending on where the artery is can affect the outcome of the hemorrhagic stroke.

If the bleeding occurs within the brain, blood shooting out at high pressure can kill some cells.

Bleeding on the surface increases the pressure in the protective layer between the brain and the skull, potentially causing more cell loss.

This bleeding is normally caused by chronically high blood pressure. In many cases, the increased pressure can cause the arteries to expand and weaken, meaning a split in them is more likely to take place.

A rarer cause of hemorrhagic stroke is where the blood vessels around the brain are connected abnormally, causing further stress on the brain. These are congenital (present at birth) but the reason for their occurrence is currently unknown.

Again, the best way to reduce the risk of an hemorrhagic stroke is to make healthy lifestyle choices.

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NHS pilots video service for epilepsy diagnoses

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A new clinical video service which supports epilepsy diagnoses and management in the era of coronavirus and beyond has been launched in the UK.

vCreate Neuro allows registered patients and carers to share smartphone-recorded videos of potential seizures or unknown movements with their clinical team via a secure, NHS-trusted system.

The data and footage act as a visual aid to assist clinical teams with rapid precision diagnostics, creating a digitised clinical pathway that minimises the need for face-to-face clinic appointments and invasive tests.

The system is currently being piloted across Scotland and, following its initial success, across England including Great Ormond Street Hospital, Evelina London and Sheffield Children’s Hospital.

The system is available to families who are concerned that they, their child or loved one may be experiencing seizures or unexplained episodes including epilepsy.

Since May 2020, more than 2,000 families have shared over 5,000 videos with their clinical teams across the platform.

Dean MacLeod was referred to the service when her seven-year-old daughter, Olivia, began having unknown movements in May 2020.

Dean uploaded videos of Olivia during these episodes as Olivia’s seizures grew more frequent.

The videos were reviewed by Paediatric Neurology professionals at the Royal Hospital for Children, Glasgow, and, supported with telephone appointments, Olivia was diagnosed with a form of epilepsy and quickly started on treatment.

Speaking about her experience, Dean said: “I’ve found vCreate to be invaluable in Olivia’s journey since she started having seizures last summer.

“We live in a remote location on the Isle of Lewis, Scotland, and we have a very limited paediatric service on the Island. The service has made it easy to access the specialist clinical knowledge needed by sending recordings of various seizure events to the Paediatric Neurology team at Glasgow.

“Since the diagnosis, I have kept in regular contact with the clinical team through the platform, sending videos and typically receiving advice from a Consultant within 24 hours which is fantastic. Between the vCreate service and telephone discussions, our family have not needed to have face-to-face consultations which has been hugely beneficial during the pandemic.”

Professor. Sameer Zuberi, consultant paediatric neurologist at the Royal Hospital for Children, Glasgow, said: “vCreate Neuro has transformed how we use carer-recorded video in our service. We are diagnosing epilepsy more rapidly, preventing misdiagnosis and saving unnecessary investigations. Families feel in more control and better connected to the service.

During the Covid-19 pandemic, many people experiencing seizures and seizure-like episodes, including children, have been unable to see a clinician.

Create Neuro aims to help by empowering patients to use asynchronous video technology for self-management, reducing the need for physical appointments. 

Founder Ben Moore said: “We’re passionate about family-forward care, and worked closely with clinical teams, patients and carers to develop the vCreate Neuro service.

“The system aims to improve patient care, reduce the number of clinic investigations – and resulting costs to the NHS – and digitise the patient pathway. We want families to be in control of their healthcare journey and have a direct link to their clinical team despite the pandemic restrictions.”

The vCreate platform has been independently assessed and approved by Information Governance teams in over 100 UK NHS Trusts.

 Within the platform, a clinical database is available as a learning resource for clinicians to study seizure types, events, and other symptoms.

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