People who have Alzheimer's disease (AD) often experience sleep disturbances due to the nature of the illness. Melatonin has been prescribed for sleep disturbance in individuals with AD, although there is a lack of national guidelines for pharmacological care for this presentation. Prolonged sleep disturbances for individuals with AD tend to lead to poor quality of life for the individual, behavioural challenges, carers' exhaustion and potential placement breakdowns.

The objective of this literature review is to determine whether the available evidence supports recommending melatonin to patients with AD for sleep, along with other benefits and adverse effects.

The hypothesis for this review is that melatonin is beneficial for sleep disturbances and has neuroprotection for individuals with AD.

Literature search on the online electronic database from 2010 to November 2023, using the title of “Melatonin's effectiveness and the side effects on Alzheimer's Disease''. This literature review was done by screening the 125 searched titles. The inclusion criteria included systematic review (SR), meta-analysis, randomised controlled trial (RCT), animals and cell studies. Exclusion criteria included case studies, literature and peer reviews. A total of 12 papers are included in this review.

The three SRs, two meta-analyses and one RCT showed the potential effect of melatonin on ameriolating cognitive decline, improving cognition, quality of life and sleep qualities, with the conclusion that further studies are required. One combined meta-analysis and SR showed melatonin might be an effective treatment for mild AD. One Cochrane review showed melatonin has no evidence of improving sleep for moderate-to-severe AD.

One animal study and two cellular studies showed a melatonin effect in the control progression of AD. One animal study and one cellular research study concluded that melatonin has potential treatment effects.

Adverse effects were mentioned at the higher dose (10mg) with negative reaction times, sedation and confusion.

There is a potential favourable effect of prescribing melatonin for mild to moderate AD, but there is limited evidence for prescribing it for moderate to severe AD. Furthermore, there is emerging evidence on melatonin's neuroprotective effect and potential treatment options for mild to moderate AD; further research is required for both sleep and neuroprotection in AD.

Lithium is a mood-stabiliser with a narrow therapeutic index. Patients are known to be at risk of lithium toxicity if they are unaware of how to recognise its signs. NICE guidelines outline the information that must be relayed to these patients. Furthermore, GMC Good Medical Practice highlights the importance of clear and contemporaneous patient records that contain relevant clinical information.

The aim of this two-cycle audit was to assess the quality of documentation for patients reviewed in lithium clinic and to analyse the consistency of the notes recorded to ensure high quality care provision and communication within the department, in line with the NICE guidelines.

The inclusion criteria were patients over the age of 65, prescribed lithium and were actively reviewed in the monthly lithium clinic at the Older Person's Mental Health Service (OPMHS) at Princess of Wales Hospital in Wales.

A data collection form was created to ensure all the relevant data in line with NICE guidelines was captured including serum lithium level, lithium dose, other psychotropics, side effects, renal function, patient mood, safety netting advice provided including signs of toxicity and awareness of lithium card. A standard of 100% was set for this data to be captured for each patient.

Cycle 1 was completed in November 2023 where a total of 18 patient records were selected (N = 18). Lithium dose, lithium level and renal function were recorded in over 83.3% (n = 15) of the files audited. Details on psychotropics were recorded in 61.1% (n = 11), side effects in 50% (n = 9) and patient mood in 77.8% (n = 14). Safety netting advice was recorded in 11.1% (n = 2). Furthermore, it was noted data recorded varied between clinicians.

The results of this audit were disseminated to OPMHS team. A proforma was introduced to encourage capture of all relevant information and to ensure consistency. Feedback was collected from clinicians using the proformas and relevant changes were made.

A second cycle of this audit was carried out after the proforma was introduced to the subsequent clinic (N = 12). This showed an improvement in record-keeping including lithium dose, lithium levels, psychotropics and side effects of 100% (n = 12). Renal function and mood were recorded in 91.7% (n = 11) of files and safety netting advice provision in 75% (n = 9) of files audited.

Introduction of a proforma is a simple and effective way to ensure relevant and important details are documented. This is not only for good clinical practice, but for medico-legal reasons also.

There is a significant mortality gap between the general population and people with SMI. This is especially prominent in those with psychotic disorders, underpinned by an increased risk of cardiometabolic disease. Identifying patients at risk early in their psychotic disorder is of key importance to reduce this mortality gap. Despite the recognised importance of regular physical health assessments in this group, completion rates are suboptimal. Point-of-care testing (POCT) to screen for diabetes and hyperlipidaemia, providing a result from a fingerprick sample in under 10 minutes presents a potential solution to enhance delivery of physical health checks and improve health outcomes in a proactive manner.

We introduced POCT across EIP teams in Southeast of England and evaluated the impact on physical health check completion rates and the quality of clinician-patient interactions in EIP teams.

A stepped wedge study was performed, introducing Abbot Afinion-2 machines across 30 EIP teams in all eight Mental Health Trusts in South East England (2021–2022). Numbers of completed physical health checks, and HBA1C and lipids blood tests completed in six months before and six months after introduction of POCT were collected from individual patients. Data were compared with those from the South West, which acted as a control region. Data were analysed from National Clinical Audit of Psychosis (NCAP) over comparable date range (2021–2022) to corroborate the findings. Clinician questionnaires were administered at three timepoints (after training, two-months, and eight-months), capturing training experiences, device usability and impacts on patient interactions.

In Southeast England, the rate and quality of physical health checks increased after introduction of POCT HbA1c testing OR 2.02 (95% CI 1.17 to 3.49), lipids 2.38 (1.43 to 3.97), and total completed health checks 3.61 (1.94 to 7.94). These increases were not seen in the Southwest region that did not introduce the machines. A post-hoc review of national audit data also showed a greater improvement of health checks in the intervention group compared with the comparator group over an overlapping timescale. Findings from the questionnaires evidenced improved patient engagement, clinician empowerment and the preference of POCT over traditional blood tests in this setting.

POCT is associated with improvements in the rate and quality of physical health checks, and this study emphasizes the potential of POCT in reducing health inequalities and enhancing holistic care for individuals living with severe mental illness.

Admissions to hospital can be traumatic for a person with dementia due to an inability to cope with unfamiliar environments, faces and routines. The dementia crisis service provides a rapid response and support, in particular to carers and care providers. The team support in managing problematic behaviours to avoid the need for a hospital admission. The team can complete physical examination and bloods in the home environment, reducing the need for involvement of further clinicians.

This project aims to evaluate the effectiveness of the dementia crisis service in reducing admissions to mental health wards.

The pilot for the service began in January 2023. We looked at the number of admissions to Heather ward, an older adult mental health ward in Canterbury, East Kent (the base of the team) over a 5 month period, between August 2023 – January 2024. We compared this to admission numbers a year ago. We looked at what proportion of patients were admitted with behavioural and psychological symptoms of dementia (BPSD), over the same time period to evaluate whether the number of BPSD admissions has changed since the existence of the team.

The number of overall admissions to Heather ward decreased from 43 to 32. The number of detained patients remained the same, 13 patients over the 5 month period. Looking more closely at the nature of some of the hospital admissions, a referral was not made to the crisis service for some of the admitted patients.

The team have been providing this service for just over a year, including the three month pilot. The limited data does not show enough evidence that the crisis service reduces rates of hospital admission. As this is a new service, there is much work to be done to increase the profile of the team. We would like to re-evaluate the admission data after more information has been disseminated to referrers about the service and the support they offer.

There is a bidirectional link between Depression and type 2 Diabetes mellitus (T2DM). Treatment of depression with selective serotonin reuptake inhibitors (SSRIs) may improve glycaemic control and may be beneficial for patients with comorbid depression and diabetes mellitus. The aim of the present study was to assess the effect of escitalopram on C-reactive protein (CRP) and glycaemic control in patients with comorbid T2DM and depression.

A prospective interventional follow up study was conducted in a tertiary health care institute in urban India. Adult males and females who were diagnosed with Type 2 DM, having depression as per ICD-10 and treatment naïve for both the disorders were included for the study. Participants with other psychiatric disorders, on thyroid medication or on any medication that can have effect on CRP levels, having history of any infection/allergic or inflammatory conditions were excluded from the study. Sociodemographic details were collected. The severity of depression was assessed using Hamilton Depression Rating Scale (HDRS) at baseline. Escitalopram was started and titrated upto required doses for each patient. Levels of fasting blood glucose, post prandial blood glucose, HbA1c (Glycated Hemoglobin) and CRP were also measured at baseline. At the end of 3 months, severity of depression scores and blood levels of above mentioned parameters were measured and compared with their baseline values.

A total of 125 patients (females-n = 70, males-n = 55) were included for the study. The mean age of the sample was 63.2 years (SD 10.6). Most of the participants were educated and employed. The mean HRDS score of the participants at baseline and at three months was 20.3 (SD 3.7) and 18.0 (SD 3.9) respectively. The mean HbA1C of the participants at baseline and at three months was 8.4 (SD 1.2) and 7.8 (SD 1.2) respectively. The mean CRP of the participants at baseline and at three months was 4.0 (SD 5.6) and 2.8 (SD 4.3) respectively. There was significant reduction in depressive symptoms (Z score= -6.894, P value <0.05), levels of HbA1C (Z score= -7.936, P value <0.05) and CRP levels (Z score= -6.158, P value <0.05) at follow up after treatment with escitalopram. No significant correlation was observed in these parameters across gender.

Treatment with escitalopram reduces the severity of depression and the ongoing inflammatory process amongst these patients.

Huntington’s disease (HD) is an autosomal dominant neurodegenerative disorder characterised by a pathologically prolonged CAG nucleotide sequence in the huntingtin gene (HTT). Neuropsychiatric symptoms such as aggression, depression, impulsivity and psychosis are non-motor signs of HD. The association between HD and criminal behaviour is debated, and evidence lacking. This is particularly relevant in forensic psychiatry, which focusses on the risk assessment of mentally disordered offenders. This manuscript examines the antecedents of offending behaviour in a male diagnosed with HD during admission to a high secure unit, and the evolution of his risk profile from childhood to post-diagnosis. Additionally, through exploration of psychopharmacological management of psychiatric symptoms in HD, this study aims to further our understanding as to how we can best support people with HD in a forensic mental health setting.

Following review of relevant literature on criminal behaviour in the context of HD, we report the case of a 41-year-old man with a background of dissocial personality traits admitted to a high security unit with symptoms of a delusional disorder; manifesting as paranoia, delusional beliefs and aggression. These were believed to be organically induced within the context of HD, a diagnosis confirmed through genetic testing six months following admission. The patient's symptoms were only partially responsive to first-line antipsychotics; however, good symptomatic control was achieved with clozapine and sodium valproate, enabling step-down to medium secure specialist services.

In HD patients, there may be a challenge of discerning whether offending behaviour relates to prodromal presentation or whether there are pre-existing antisocial attitudes or behaviour; an uncertainty which was present in this case and within the literature. The age of HD onset is inversely correlated with CAG repeat length, and a longer repeat length has been associated with criminal behaviour. This has the potential for use as a marker to determine the time point in which presenting features are attributable to HD. In this case study it was possible to determine through analysis of the CAG repeat length that the delusional disorder was likely linked to the onset of HD; however, dissocial personality traits were not.

A patient's background relating to the life-course persistence of violence, suicidality and psychiatric symptoms in patients with HD informs the process of formulating their risk profile. Changes to the risk profile also reflect the progressing stages of HD. This highlights the need for awareness of how HD may contribute or predispose to criminal behaviour and how interventions could be targeted during critical periods where they benefit most.

1. 1. To evaluate sources and demographics of referrals to the Northwest Surrey Psychotherapy Service, a secondary care service covering Runnymede, Spelthorne, and Woking in Surrey, England. To compare these data with local population data to assess equality of access and whether any groups are underrepresented.

2. 2. To evaluate what diagnoses are most frequent in those referred and the respective characteristics of those whose referrals are accepted for treatment and those who aren't.

A retrospective case note review using SystmOne of all patients referred to Psychotherapy between January 2021 and June 2021. Data were extracted by hand: demographics (age, gender, ethnicity, sexual orientation, marital status, employment status, dependents, caring responsibilities, disability, religion), diagnosis, source and outcome of referral. Reasons for referrals not progressing were correlated with current service inclusion/exclusion criteria. Demographics were compared with local population data available from ONS and Surrey County Council.

Fifty-one people were referred, 10 (19.6%) males and 41(80.4%) females.

Twenty-six (51%) referrals were accepted. Amongst those referred, depression n = 15 (29%), post-traumatic stress disorder (PTSD) n = 15 (29%) and emotionally unstable personality disorder (EUPD) n = 13 (25%) were the most reported diagnoses. Persons with depression or EUPD were most frequently accepted for assessment and treatment. The most common reason for a referral not progressing was the patient experiencing active PTSD symptoms requiring prior stabilisation work n = 9 (17%) or the patient not opting in n = 5 (10%).

Referrals came from a range of sources, mostly general practitioners (GPs) n = 18 (35%) and MindMatters (primary care talking therapies) n = 8 (16%).

Males were underrepresented in referrals to Psychotherapy and reasons may vary. It may be beneficial for referrers to be more proactive in considering and recommending referring males for psychotherapeutic input. Other groups were not significantly underrepresented compared with local population data, including ethnic minorities and those with protected characteristics.

Psychotherapy services frequently declined those suffering acute symptoms of PTSD; there may be a need to educate referrers that this is a likely exclusion criterion. Those who were declined on this basis were signposted to services offering stabilisation work, a positive finding in terms of our service facilitating access to ongoing care.

The sources of referrals suggest that GPs and MindMatters are important partners in identifying those needing psychotherapy services. Some referrals were inappropriate, and clearer referral criteria may be helpful. Some people declined assessments or treatment, which may indicate a need for more outreach or education on the potential benefits of psychotherapy services.

Patients experiencing Medically Unexplained Symptoms (MUS) are some of the costliest in both primary and secondary care. Psychotherapy is one of the most efficacious ways of treating them although the most superior modality is unclear. Cognitive Behavioural Therapy (CBT) has the greatest evidence base, but a growing number of studies have investigated the role of Psychodynamic Psychotherapy (PPT). This is the first study to compare the two modalities concerning their impact on healthcare utilisation and cost to the NHS.

Patients referred to the Oxford Community Psychological Medicine Service in 2021 and who went on to complete a course of psychotherapy for MUS were included. 78 patients were referred, 66 patients were assessed, 16 patients began treatment and 9 patients completed treatment. 4 received CBT and 5 received PPT based on a ‘best fit’ assessment. Their healthcare utilisation (GP appointments, health investigations, A&E attendances, inpatient admissions and outpatient appointments) was assessed during the 6 months prior to their initial assessment and compared with the 6 months after therapy had ended using data from ‘Health Information Exchange’.

Overall, psychotherapy reduced primary care use but our data was insufficiently powered for this to be statistically significant. There was a significant reduction in outpatient appointments after psychotherapy, mostly representing mental health consults.

Significant differences between pre-therapy and post-therapy were only observed for the number of health investigations in the PPT group which, surprisingly, increased with a large effect size (d = 1.19 95% CI 1.12–2.88, P = 0.03). The same trend towards increased utilisation were observed for every outcome measure in PPT besides outpatient appointments. Conversely, all outcome measures showed an improvement after CBT apart from the number of health investigations which marginally increased.

CBT significantly decreased GP appointments at 6 months follow-up compared with PPT with a large effect size (η2 = 0.5, p < 0.05). A similar trend was seen for total cost (η2 = 0.5, p < 0.06) with each PPT patient costing £790 more on average than their CBT counterparts during the 6 months after therapy.

Whilst CBT appears to be efficacious in the short-term, PPT caused significantly increased healthcare utilisation compared with CBT in the 6 months after therapy. This aligns with similar studies that demonstrate a ‘sleeper effect’ in which patients who receive PPT, but not CBT, deteriorate before improving over long-term follow-up.

Additional research is needed to correlate this data with symptoms and capture the long-term benefits of these psychotherapies for MUS.

Recommendations from the NHS and the Royal College of Psychiatrists advise that patients receive a copy of all correspondence that is sent on to the GP. Often, within psychiatric services, letters are not routinely sent to patients.

To improve communication with patients and their carers, the Aneurin Bevan Learning Disability team have been writing letters directly to patients and sending a copy to the GP.

There is limited use of jargon, and the complexity of the language aims to reflect the individual's reading level.

This study aimed to gain feedback from local GPs on the new letter format to ensure effective communication between teams.

We contacted Primary Care Services in the local area to gain feedback on how our clinic letters were being processed, we were informed that letters are reviewed by an admin team and only sent on to GPs if there are specific tasks to action, meaning that many of our letters remain unread.

We identified 16 GP practices in the Torfaen and Monmouthshire area and sent a survey by email to gain feedback on the new correspondence style. The survey was sent out three times within a 12-month period.

Of 16 GP practices just 6 responded, with just 1 GP stating that they had noticed a change in the letter style. 50% of GPs felt they received relevant information in the letters from the CLDT. The comments were largely positive with suggestions reflecting changes that have already been made. There is no feedback that suggests GPs feel they are not receiving adequate clinical information.

The lack of response may highlight how infrequently GPs are reviewing the letters from the CLDT confirming the importance of prioritising doctor–patient correspondence. The limited communication from GP to CLDT emphasises the need for improvement in liaison between secondary and primary care services.

The lack of negative feedback about the letters is encouraging. There is no feedback that suggests GPs feel they are not receiving adequate clinical information and clear feedback that GPs want clear and accessible information, particularly regarding specific actions for GPs.

A clear limitation of this work is the lack of response to our survey. Reviewing these letters from our team is a very small proportion of a GPs workload, more time may be needed to ensure GPs have had contact with our team and are able to provide more detailed feedback.

Emotionally unstable personality disorder (EUPD) is characterized by affective instability, unstable interpersonal relationships, poor self-image and marked impulsivity. Patients may present with a variety of symptoms including impulsivity, suicidal behavior, affective instability and intense anger. This makes the treatment very patient specific.

Treatment guidelines support the use of Dialectical Behavior Therapy (DBT) as the first line treatment of EUPD. Currently, no medications are indicated for the treatment of EUPD which leads to off label use of medicines by clinicians.

More than 90% of individuals receive a variety of pharmacologic treatment with psychotropic medications, especially second-generation antipsychotic drugs for the treatment of cognitive perceptual symptoms and impulse control behavior. Additional psychotropics are usually added leading to psychotropic polypharmacy which should be avoided.

Aim of this study is to assess the frequency of prescription of antipsychotic medications in patients with a primary diagnosis of emotionally unstable personality disorder.

Protocol was registered with the Audit and Quality Improvement project team of the NHS trust and the audit registration certificate was obtained.

Case records of 42 patients with EUPD who attended psychiatric outpatient department from June to August 2023 were collected and screened. A retrospective study was carried out.

Inclusion criteria

Patients above 18 years of age, with a primary diagnosis of emotionally unstable personality disorder.

Exclusion criteria

Patients with comorbid diseases like Attention Deficit Hyperactivity Disorder, Bipolar Affective Disorder and Psychosis where use of antipsychotics is warranted.

All other personality disorders.

After screening 42 case records, 20 cases of EUPD which fulfilled the inclusion and exclusion criteria were found and analyzed. Descriptive statistics were used.

Retrospective data of 20 patients with a primary diagnosis of EUPD were analyzed which included 18 females and 2 males. The mean age of the participants was 27.1.

70% (14) of the patients diagnosed with EUPD were treated with antipsychotics. 20% (4) patients received antidepressants. 10% (2) of the patients received only DBT.

Quetiapine was the most commonly used antipsychotic – 43% (6) followed by Olanzapine – 22% (3), Risperidone – 21% (3) and Zuclopenthixol long-acting injection – 14% (2).

Dialectical behavior therapy is the first line treatment of EUPD. National Institute for Health and Care Excellence (NICE) guidelines do not recommend the use of antipsychotics in the treatment of EUPD. Contrary to the guidelines, antipsychotics are prescribed long term for patients with EUPD who are without any comorbid conditions. This audit has found that 70% of patients with a primary diagnosis of EUPD are being prescribed antipsychotic medication. This needs to be kept in check so that polypharmacy can be avoided.

Mental illness is associated with poorer physical health and reduced life expectancy in comparison to the general population. This is influenced by many factors, one of which is medication related. Antipsychotics can have multi system effects on the body such as increasing the risk of metabolic syndrome and cardiovascular disease. Our objective was to understand current challenges when monitoring patients' physical health and thereby improve overall health outcomes.

Utilising a clinical audit template, the study group was 9 inpatients during cycle 1 and 10 inpatients during cycle 2, who were prescribed antipsychotics on an Old Age Psychiatry ward. Northumberland, Tyne and Wear (NTW) antipsychotic monitoring guidelines were used as criteria which stipulate that blood tests, ECGs, BMI, waist circumference, side effects and lifestyle effects should be recorded at defined intervals. A proforma highlighting these guidelines was created following audit cycle 1 and utilised by the MDT on the ward, the purpose of cycle 2 was to compare findings following the implementation of the proforma. The standard to meet was that 100% of patients should fulfil the guidelines. Data was collected by retrospectively reviewing paper and electronic notes.

Audit cycle 1 revealed 0 of the patients met the physical health criteria. 0 had the full set of required bloods in the correct timeframe, 0 had waist circumference checked and 2 and 1 patients had side effect and lifestyle effects documented respectively. By comparison, ECGs and BMIs were recorded well. Audit cycle 2 demonstrated significant improvement in all areas. 9 patients had bloods accurately measured. 3 and 6 had side effect and lifestyle reviews respectively. ECGs and BMIs continued to be monitored well. However, waist circumference remained poor with 1 patient recorded. Qualitative feedback when presenting these findings to the MDT highlighted an interest debate into the cost/benefit of measuring waist circumference with the main point being not wishing to cause undue anxiety to the patient.

The use of an accessible proforma clearly outlining the criteria to meet for each patient proved valuable in improving the monitoring of physical health parameters. This study highlighted a need for increased awareness of metabolic syndrome and the importance of empowering patients with knowledge regarding their healthcare to help tailor a patient-centred approach to physical health monitoring. Our presentation aims to encourage discussion among attendees around measuring waist circumference and raise awareness of metabolic syndrome.

The National Drug Treatment Centre in Dublin is the longest established treatment service for drug users in Ireland. Led by Addiction Psychiatry teams, it provides specialist multidisciplinary input for patients with complex medical and psychiatric needs secondary to substance use. Many patients attending the centre engage poorly with other healthcare services in the community. The aim of this audit was to improve physical healthcare engagement in a caseload of 60 patients, through improving GP registration rates and possession of medical cards (providing access to free public health services).

The comparison standard for the audit was the Irish Health Service Executive (HSE) Clinical Guidelines for Opiate Substitution Therapy: 2016. These stipulate that all drug users entering treatment and rehabilitation should have a care plan based on assessed need. Specific domains covered include: Drug and Alcohol use, Physical Health, Psychological Health and Social Functioning.

During the initial audit cycle, electronic care plans in a caseload of 60 patients were reviewed for information on their GP and medical card status.

Intervention: Following the initial cycle, results were presented and discussed at a multidisciplinary team meeting. A combined MDT effort was made to discuss medical card and GP status with patients during each interaction. Patients were referred to social work for support in application/renewal of medical cards and GP registration where required.

Results following re-audit:

The percentage of patients with GP registration clearly displayed on their care plan increased from 66% to 93%.

The percentage of patients with an up to date medical card increased from 12% to 45%.

The percentage of patients whose medical card status was unknown reduced from 72% to 44%.

The percentage of patients with their medical card number displayed on their care plan increased from 25% to 55%.

There was a significant improvement in the number of patients with GP and medical card information documented clearly on their electronic care plan. This has assisted National Drug Treatment Centre staff in supporting patients' physical health needs more effectively, through close liaison with primary care providers and onwards referral to other services where required. It was noted that further efforts were required to build upon these results and reach 100% compliance. Recommendations and an action plan were developed to ensure ongoing improvement in standards.

Patients with serious mental disorders like psychosis may pose a significant risk to themselves and others when they drive. The DVLA has set out guidance for driving for patients with psychiatric disorders, substance use disorders, and for those taking psychotropic medications. It's good medical practice to identify risks associated with driving, discuss, advise appropriately, and document the same in the clinical notes.

To assess the compliance of the mental health professionals at Rathbone Rehabilitation Centre (RRC) with DVLA guidelines regarding patients about driving restrictions, documenting this appropriately and to increase awareness of the DVLA guidelines.

Data of all the discharged patients from RRC over a 12-month period was collected following a standardised process and assessed for 6 parameters.

A total of 51 discharges were identified and audited against the DVLA guidelines.

51 (100%) patients had a mental health diagnosis documented on patient electronic records (Rio).

9 (18%) of patients had their driving status documented. 42 (82%) did not.

Of the 9 patients whose driving status was recorded, 6 did not drive and are thus labelled not applicable for subsequent criteria. The type of vehicle driven was not documented in any of the cases and therefore was 0%.

Of the 3 patients who drive, 2 (67%) had been informed that their condition may affect their ability to drive.

67% had documented evidence of receiving advice on driving restrictions.

67% had documented evidence that the practitioner has informed the patient that they have a legal duty to inform the DVLA about their condition.

An action plan was designed to improve compliance with DVLA guidelines for practitioners managing inpatients.

• • On admission all patients should be asked for their driving status and the result documented on Rio. This could be done on the clerking admissions proforma on Rio.

• • For all patients that do drive, the types of vehicles they drive should be documented–this can also be included in the clerking admissions proforma on Rio.

• • At their first ward review/discharge meeting and whenever relevant, patients should be informed whether their condition affects their ability to drive and if so, what the restrictions are. They should be informed of the legal requirements regarding informing the DVLA and documented.

• • To consider driving status when assessing risk.

To study the risk factors for burnout among doctors in a tertiary general hospital in Singapore. We hypothesized that burnout would be associated with singles, young age, females, foreign born staff who had recently moved to this country unaccompanied by family, and those showing less resilience. We hypothesised perceived support and satisfaction with leisure would mitigate against burnout.

An anonymised survey was carried out, with questionnaires sent to all staff via email. Survey instruments included the Oldenburg Burnout Inventory, Connor Davidson Resilience Scale, Brief Form of Perceived Social Support Questionnaire, Patient Health Questionnaire-4 items (PHQ-4), Leisure Time Satisfaction Survey and the Demand Control Support Questionnaire (DCSQ). Descriptive statistics for normally-distributed numerical variables were presented as mean (SD or standard deviation), and for categorical variables, median and n (%). One-way ANOVA was performed to determine differences in total burnout scores across categorical variables and simple linear regression was used to assess for binary and numerical outcomes in terms of resilience, PHQ, DSCQ, satisfaction with leisure time and perceived social support, with significance set as p < 0.05.

A total of 129 doctors responded to the survey. Over half were male, and nearly 70% were married. Nearly half were below age 40 and only about 5% had no immediate family living in Singapore.

Burnout was associated with young age (p < 0.004) and those with anxiety 2.39 (2.13 to 2.64) p = 0.038, and depressive symptoms 2.71 (2.44 to 2.97) p < 0.001. Psychological demand was positively associated with burnout (1.52 (1.32 to 1.71) p < 0.001; whereas decision latitude −0.69 (−0.85 to −0.52), social support at work −1.35 (−1.49 to −1.21), and high resilience −0.56 (−0.63 to −0.48), were negatively associated (all p < 0.001).

Satisfaction with leisure time was negatively correlated with burnout (p < 0.001). Contrary to hypothesis, singlehood, gender, overseas staff recently joined with no accompanying family were not associated with burnout (p > 0.05). In addition, perceived social support from outside work did not mitigate against burnout (p > 0.05).

Young age, anxiety and depression, and psychological demands were risk factors, whereas resilience, decision latitude, satisfaction with leisure, and social support at work were protective factors against burnout. Reducing workload, improving work schedules, promoting self-management, teaching physical, mental, and emotional self-care, and other stress management activities are among the effective techniques shown to reduce burnout. Interventions should be made available for all staff, but specifically focusing on those at greatest risk.

The Institute of Mental Health is the only tertiary Psychiatric Hospital in Singapore. It has two 29 bedded inpatient wards which provide acute care for the elderly with severe mental health conditions including dementia. Restraints are one of the methods employed in managing agitation in patients with dementia. The physical consequences of restraints are reduced mobility resulting in decreased muscle tone and mass, bone demineralisation, orthostatic hypotension, and atelectasis. This results in patients who are more prone to falls, aspiration pneumonia, deep vein thrombosis/pulmonary embolism and ulcers. The psychological consequences include aggravating agitation, feelings of humiliation, negative emotions like anger and despair. Hence, we embarked on a program to reduce the use of physical restraints in the management of agitation in patients with dementia.

Baseline restraint hours were collected from 7am to 9pm for all dementia patients who were restrained for agitation for a period of 5 months. Patients on Geri chair with seatbelt used primarily for fall prevention were not included. The Pittsburgh Agitation Scale was used to measure agitation.

The nursing staff were trained on the Enriched model for targeting behaviour and on the VIPS (Valuing people, Individualised care, Personal perspectives, Social environment) framework for person centred care. Restraint hours were collected post intervention as well as benzodiazepine usage data over both periods to monitor any changes in the usage.

The baseline data (preintervention) over a 5-month period determined that patients with dementia who were agitated were being restrained on an average for 3.33 hrs per day from the period of January to May 2021. Following the training of nursing staff on the enriched model of care and the use of VIPS framework for person centered care the restraint hours reduced to 1.48hr per day over 5 months from January to May 2022. Benzodiazepines usage went down from 0.34mg at baseline to 0.17mg per dementia patient per day post intervention.

Nonpharmacological interventions (enriched model and VIPS framework for person centered care) using a multidisciplinary team approach is effective in the management of agitation resulting from dementia and should be used as a first line in the management of such conditions.