Managing delirium in everyday practice: towards cognitive-friendly hospitals

SummaryProviding optimal healthcare for increasingly elderly hospital populations who have high rates of cognitive disorder is a great challenge. Using delirium as an example, we describe how improved management of acute cognitive problems through a multifaceted hospital-wide programme can promote cognitive-friendly hospital environments. A specific plan of action is described that spans interventions in day-to-day clinical care of individual patients all the way to wider organisational practices.Learning Objectives•Understand the concept of cognitive friendliness and how addressing the problem of delirium can contribute to this in our healthcare system.•Become more aware of specific aspects of a cognitive-friendly programme and how these can be implemented in practice.•Explore the key outstanding issues for research that can further enhance our awareness of cognitive-friendly practices.

Balancing risk requires a balanced approach: Commentary on… severe and enduring eating disorders: recognition and management

SummaryPaul Robinson's article provides an excellent summary of some of the challenges faced by clinicians working with patients with severe and enduring eating disorders (SEED) and outlines a robust approach to the recognition and management of this complex group of patients. This commentary expands on some of the points raised, adds some further views and suggests a tailored approach to establishing a therapeutic alliance with patients and carers.

Evaluating malingering in cognitive and memory examinations: a guide for clinicians

SummaryCognitive and memory testing are a common part of clinical practice, but professional concerns are sometimes raised that the individual being tested might be feigning deficits. Most clinicians have limited experience and training in detecting malingering in such cognitive testing, and the very issue raises considerable ethical dilemmas. Nevertheless, psychiatric work faces ever greater potential for legal scrutiny, and failure to appropriately evaluate potential malingering risks professional embarrassment and distress. There is a need for clinicians to make themselves aware of the ways in which malingered behaviour might be evaluated through the clinical history, the use of routine psychometric testing and, particularly, the use of symptom validity (‘malingering’) tests. This article describes these factors and gives guidance on the appropriate reporting of findings.Learning Objectives•Better understand the complexities in cognitive assessment where malingering is suspected.•Understand the types and limitations of the major symptom validity tests.•Be better prepared to produce documentation and reports stating test findings.

Severe and enduring eating disorders: recognition and management

SummaryPatients with severe and enduring eating disorders (SEED) may constitute a specific group. It is proposed that patients with anorexia nervosa (SEED-AN) or bulimia nervosa (SEED-BN) that requires the regular attention of a multidisciplinary team and is of a duration known to have a low recovery rate should be included in the SEED group. These patients present with a combination of severe symptoms and long-term illness, and may experience serious chronic physical sequelae (e.g. osteoporosis and renal failure), marked social isolation and stigma. Their carers suffer from the stress of caring for them over a prolonged period. Symptoms, treatment and crisis management of SEED-AN are discussed. SEED is a relatively recently described area of eating disorders psychiatry that requires research and service development so that patients and carers are helped to cope with very serious chronic, but not incurable, conditions.Learning Objectives•Understand the definition of SEED-AN and SEED-BN.•Be able to assess the physical and psychological state of patients with SEED-AN and SEED-BN.•Be able to plan the monitoring and treatment of patients with SEED, involving their carers and families.

Crossing the Rubicon? Legal developments in assisted suicide

SummaryUK law on assisted suicide and euthanasia is very clear: it is unlawful. However, there have been successive proposals for changes to legislation in this area (in England and Scotland) and a series of individual challenges to current legislation in the courts. This article does not seek to debate the profound ethical arguments that surround this emotive subject, but instead to portray how the law, through court judgment and legislative proposals, has wrestled with opposing views, particularly over the past decade or so, as the impact of the Human Rights Act has presented unique challenges. Some of our closest European neighbours have diverse legislation that could influence our own legislature, and, from across the Atlantic, the Oregon Death with Dignity Act is being mirrored in proposals to change the law in the UK.Learning Objectives•Be able to recognise the impact of the Human Rights Act on challenges to legislation relating to assisted suicide.•Understand proposals for statute.•Appreciate how certain other countries legislate in this area.

Mindfulness-based training in residential settings: rationale, advantages and obstacles

SummaryThe past few decades have witnessed the synthesis of Buddhist mindfulness practice with the Western psychological paradigm, leading to the development of a variety of mindfulness-based interventions. These are delivered to various populations to treat a wide range of physical and psychological disorders, and several protocols have been implemented and evaluated, mostly, if not exclusively, in open or out-patient treatment settings. Little attention has been given to the definition of criteria, guidelines and protocols for the use of mindfulness in residential settings such as in-patient psychiatric wards, secure and forensic services, prisons, nursing homes and hospices. In this article, we discuss the rationale, advantages and obstacles to delivering mindfulness-based interventions in residential treatment settings, with specific reference to forensic settings. We also discuss the problem of developing robust outcome data and recommendations for future research.Learning Objectives•Understand the advantages and challenges of introducing mindfulness-based interventions in in-patient settings.•Understand how mindfulness-based interventions can be adapted to accommodate individual patient psychopathology.•Understand how mindfulness-based interventions can be adapted to specialist clinical settings such as forensic units.