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23 Audit of functional neurology inpatient care on kent ward in 2014/15
  1. Tom Bucknall,
  2. Robert Fung,
  3. Jan Coebergh

Abstract

Aims We aimed to review care of those who received treatment on Kent ward for functional neurological symptoms between 08/02/2014 and 30/03/2015. The type of admission, management, outcomes and other characteristics of patients were highlighted. This information can be used in the development of patient services offered.

Introduction St George’s Hospitals Kent ward is a specialist acute neurological care unit. It is a tertiary regional unit for patients from South West London and Surrey that require treatment for complex neurological conditions. Functional neurological symptoms (FNS) is described as one or more symptoms of altered voluntary motor or sensory function. Symptoms that can lead to admission are for example: weakness or paralysis, abnormal movements, speech symptoms, attacks or seizures, anaesthesia or sensory loss and other sensory symptoms (visual, hearing etc.)1

It has been demonstrated that a specialised multidisciplinary inpatient care programme can be beneficial to patients.2 St George’s Hospital Kent ward has frequent admissions of patients with FNS undergoing inpatient treatment and a dedicated programme for the treatment of these patients is planned.

Methods A retrospective analysis of patient records was performed for patients who were admitted to Kent ward during 2014/15. The patients were selected from a neuropsychiatry database. 26 patient records were reviewed electronically and others in paper form (a transition period in record keeping).

Age, Sex, Length of Stay (LoS), Health professionals involved, inpatient investigations, main diagnosis, secondary diagnoses and other psychiatric diagnoses were recorded for each patient. Diagnoses were categorised into: Functional Motor/Sensory, Non-Epileptic Attack Disorder (NEAD), Pain and Other.

Patient origin, prior LoS in district general hospital (DGH), time taken to transfer from DGH to Kent ward were recorded when available.

Results Out of the 26 patient records reviewed there was a 2.25:1 female to male ratio. The mean patient age was 43 (Range: 20–90). The median LoS was 5 days (IQR: 3,11). The LoS for specific diagnoses:

92% of patients had a co-morbid diagnosis, including neurological, musculoskeletal, endocrine and developmental disorders. 40% of those diagnosed with NEAD had a previous epilepsy diagnosis.

46% of those diagnosed with functional symptoms also had a co-morbid psychiatric diagnosis; a third of these was of depression.

For 15 patients, the patient origin was recorded; Home-40%, A+E-40%, Ashford St Peter’s Hospital-20%.

Discussion The patient characteristics demonstrated fit those described previously: Higher incidence in females, peak age of onset in 4th decade and presence of co-morbid neurological and psychiatric disease as a risk factor.1

The treatment of patients, shown in figure 3, generally involves a multidisciplinary team. This has been shown to be beneficial to patient outcomes.2–5

Patients with functional neurological symptoms frequently have relatively short LoS but do require investigations in an acute inpatient unit.

Expert acute multidisciplinary care provision might be beneficial to outcomes but the role of acute inpatient care and consideration for transfer to specialised physiotherapy based and the role and timing of multidisciplinary specialised care needs to be investigated.

Limitations There may have been a selection bias due to the patient list originating from a neuropsychiatry database although they do see almost all patient with functional neurological symptoms.. This may have affected results.

No data on outcome were routinely available.

Conclusions St George’s Kent ward receives a wide spectrum of patients with different FNS and virtually all also have co-morbid diagnoses. Length of stay is acceptable and investigations are often needed. Future research regarding best pathways for diagnosis and treatment is needed.

References

  1. . American Psychiatric Association, American Psychiatric Association, editors. Diagnostic and statistical manual of mental disorders: DSM-5. 5th ed. Washington, D.C: American Psychiatric Association; 2013. p. 947.

  2. . Demartini B, Batla A, Petrochilos P, Fisher L, Edwards MJ, Joyce E. Multidisciplinary treatment for functional neurological symptoms: a prospective study. Journal of Neurology 2014 Dec;261(12):2370–7.

  3. . Saifee TA, Kassavetis P, Pareés I, Kojovic M, Fisher L, Morton L, et al. Inpatient treatment of functional motor symptoms: a long-term follow-up study. J Neurol 2012 Sep;259(9):1958–63.

  4. . Nielsen G, Stone J, Edwards MJ. Physiotherapy for functional (psychogenic) motor symptoms: a systematic review. J Psychosom Res 2013 Aug;75(2):93–102.

  5. . McCormack R, Moriarty J, Mellers JD, Shotbolt P, Pastena R, Landes N, et al. Specialist inpatient treatment for severe motor conversion disorder: a retrospective comparative study. J Neurol Neurosurg Psychiatry 2014 Aug 1;85(8):895–900.

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