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I have known Sarah Towle since my early days of writing. Back before I moved from Nice to New York and she moved from Paris to London. One day we may actually end up living in the same city! We … Continue reading →

Naturally, my greatest reason for inviting an illustrator to be interviewed on Miss Marple’s Musings is because I admire her/his art, but often it is also because I am a little nosy (what writer isn’t?) and I want to find … Continue reading →

to be continued…

By Anayo Akunne

Delirium is a common but serious condition that affects many older people admitted to hospital. It is characterised by disturbed consciousness and changes in cognitive function or perception that develop over a short period of time. This condition is sometimes called “acute confusional state.”

It is associated with poor outcomes. People with delirium have higher chances of developing new dementia, new admission to institutions, extended stays in the hospital, as well as higher risk of death. Delirium also increases the chances of hospital-acquired complications such as falls and pressure ulcers. Poor outcomes resulting from delirium will reduce the patient’s health-related quality of life but also increase the cost of health care.

Delirium can be prevented if dealt with urgently. Enhanced care systems based on multi-component prevention interventions are associated with the potential to prevent new cases of delirium in hospitals. Prevention in a hospital or long-term care setting will lead to the avoidance of costs resulting from patients’ care. For example, the cost of caring for a patient with severe long-term cognitive impairment is high, and prevention of delirium could reduce the number of patients with such impairment. It will therefore reduce the cost of caring for such patients. Prevention could reduce lost life years and loss in health-related quality of life due to other adverse health outcomes associated with delirium.

The multi-component prevention interventions involve making an assessment of people at risk in order to identify and then modify risk factors associated with delirium. Delirium risk factors targeted in such interventions normally include cognitive impairment, sleep deprivation, immobility, visual and hearing impairments, and dehydration. The people at risk of delirium have their risk of delirium reduced through such interventions. The implementation of these interventions is usually done by a trained multi-disciplinary team of health-care staff. This means additional implementation cost. It would therefore be useful to know if this set of prevention interventions would be cost-effective. It was indeed found to be convincingly cost-effective by the UK National Institute for Health and Clinical Excellence (NICE) and was recommended for use in medically ill people admitted to hospital.

It is cost-effective to target multi-component prevention interventions at elderly people at both intermediate and high risk for delirium. It is an attractive intervention to health-care systems. In the United Kingdom the savings for the intervention would spread unevenly between the National Health Service (NHS) and social care providers. The savings to the NHS may be modest and largely accrue through lower costs resulting from reduced hospital stay, whereas the savings to social care are likely to be more considerable resulting from an enduring and diminished burden of dependency and dementia, particularly reduced need for expensive care in long-term care settings. The NHS acute providers may need to invest to implement the intervention and to accrue savings to the wider public sector. The current NHS hospital funding system does not incentivise this type of investment, and this could be a major structural barrier to a widespread uptake of delirium prevention systems of care in the UK.

In the work undertaken as part of the NICE guideline on delirium, the additional cost of implementing the intervention was based on the description of the intervention that required additional staff for delivery. It is possible that the guideline provides an important under-estimate of cost-effectiveness. This is because it might be possible to implement the intervention within existing resources. The intervention is designed to address risk factors for delirium by delivering the sort of person-centred routine c

By Laura Williamson

Early in 2011 the National Institute for Health and Clinical Excellence (NICE) published guidance intended to improve treatment for alcohol dependence and harmful use in England, Wales, and Northern Ireland. The guideline focuses on identifying the clinical interventions best suited to supporting recovery. However, given the influence social factors have on drinking behaviours, NICE also emphasises the need to cultivate environments and attitudes which help to ensure those with alcohol problems feel no “apprehension” about seeking treatment and discussing their alcohol misuse. It does this by identifying principles that should form the basis of treatment: a trusting, respectful relationship between healthcare providers and patients, which acknowledges and seeks to overcome “stigma and discrimination” is crucial, as is the need to support families and carers.

It is vital that individuals can expect to be treated with respect when seeking treatment because only around 5.6% of people in England and 8.2% of people in Scotland who need specialist treatment for dependence actually receive it. Part of the reason for this is that stigma acts as an obstacle for individuals in admitting their alcohol problem and opting to receive therapy. As Schomerus and colleagues stated in their systematic review of stigma and dependence published in the March-April (2011) edition of Alcohol and Alcoholism:

“People suffering from alcohol dependence (and from other addictions) are particularly severely stigmatized. They are less frequently regarded as mentally ill, they are held much more responsible for their condition, they provoke more social rejection and more negative emotions and they are at a particular risk of being structurally discriminated against.”

In the United Kingdom, and internationally, public policy on alcohol has done little to improve attitudes towards dependence. In England, for example, alcohol policy under the New Labour government prioritised the need to persuade people to drink ‘sensibly’. A key aim of the 2004 Alcohol Harm Reduction Strategy for England was to secure “long term change in attitudes to irresponsible drinking”. In his ‘Foreword to the Strategy’, then Prime Minister Tony Blair stated that individuals are expected to make “informed and responsible decisions about their own levels of alcohol consumption.” This focus on “sensible” drinking makes no allowance for the “difficulties in controlling substance-taking” or the “strong desire or sense of compulsion” that are used to diagnose dependence. As a result, it risks implicitly stigmatising the dependent by promoting in the public consciousness the notion that all heavy drinkers, even the alcohol-dependent, are simply “irresponsible.”

Under the coalition government, the stigmatisation of alcohol dependence has worsened and become increasingly explicit in England. In 2010 the government published its new Drug Strategy. The strategy enforces “sanctions” on benefit claimants who are dependent on alcohol (and drugs) if they do not engage with treatment services. This policy sits uncomfortably with the emphasis of the NICE Guidance on the importance of “supportive, empathic

I wrote this last night...

What wonderful news for us and for the world!

WE HAVE A NEW PRESIDENT!

And not just another president, but one who can become a GREAT President.

One who will change the American people, and also inspire the world.

One who can actually give an intelligent and eloquent public speech, full of hope for this great country of ours and for a better world.

One who can unite a nation of different people, of different races, religions, ideals and economic levels.

Hope has just entered the American vocabulary again tonight, with no trace of cynicism.

I am so proud to be an American tonight. I am so proud of my new President.

I am proud to be American in this historic time of change and hope.


Love, Peace, and Hope, to you!

No, seriously...I am. I'm a really nice guy. I'm not saying that I should be given an award or anything, but the fact remains that I am a decent, nice guy. Don't get me wrong, if you want to give me an award, that's fine with me...I won't turn it down.

My wife is a teacher and she moved to a new school this year, and out of the goodness of my heart I designed the schools logo...for free. Want to see it? CLICK HERE. Would a jerk do that? Nope. Would a nice guy? You better believe it bucko!

Not too long afterward one of the students in her class writes something in her reading journal about having trouble drawing noses, which prompts my wife to ask me, "Steven, would you do me a favor and draw some noses in her journal?" So I did. Turns out not only does the girl love the drawing, but the rest of the class does as well and wants me to draw something in all of their journals.

She has 30 kids in her class.

Being the nice guy that I am, I agree. (Not all at once mind, you...but a few a week).

Sound like something a jerk does? I think not.

It feels good knowing that I'm a nice guy. Good, and a little strange, because in all honesty, I wasn't that nice of a kid growing up. Maybe I'm just getting soft in my old age.

NOTE: The above sketch is just something that I'm tinkering with. Trying a different method of computer coloring. I'm still working out the bugs.