health education paper
amberlynn
appropriate_care_for_children_with.pdf
518� British�Journal�of�Nursing,�2015,�Vol�24,�No�10
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Appropriate care for children with eating disorders and obesity
E ating� disorders� are� diseases� of� both� the� body� and� the�psyche.�They�are�characterised�by�poor�control� of�body�weight�and�shape,�accompanied�by�grossly� inadequate� or� irregular� food� intake.�While� young�
women� are� much� more� likely� than� men� to� develop� eating� disorders,�in�recent�years�young�men�have�been�increasingly� shown�to�have�eating�disorders.�The�number�of�children�and� teenagers�seeking�help�for�an�eating�disorder�has�also�risen.� Risk�factors�are�shown�in�Box 1,�while�early�warning�signs� of�eating�disorders�are�shown�in�Box 2.
Screening for eating disorders The� SCOFF� questionnaire� can� be� used� to� screen� for� eating� disorders�(Morgan�et�al,�1999):
�■ Do�you�make�yourself�Sick�because�you�feel�uncomfortably� full?
�■ Do�you�worry�you�have�lost�Control�over�how�much�you� eat?
�■ Have�you�recently�lost�more�than�One�stone�in�a�3-month� period?
A Sahib El-Radhi
�■ Do�you�believe�yourself�to�be�Fat�when�others�say�you�are� too�thin?
�■ Would�you�say�that�Food�dominates�your�life? An� answer� of�‘no’� to� every� question� excludes� an� eating�
disorder.�An� answer� of�‘yes’� to� one� question,� with� the� rest� answered� as� ‘no’� should� exclude� an� eating� disorder� but� suggests�that�the�individual�may�have�some�issues�with�food� or�body�image.�If�the�answer�is�‘yes’�to�a�least�two�questions,� the� test� indicates� the� likelihood� of� anorexia� nervosa� or� bulimia,� and� further� assessment� is� required,� including� medical�assessment�if�this�has�not�already�been�done
Anorexia nervosa According� to� the� Diagnostic and Statistics Manual of Mental Disorders, 4th edition� (DSM-IV)� (American� Psychiatric� Association,�1994),�anorexia�nervosa�is�characterised�by:�
�■ Fear� of� gaining� weight� or� becoming� fat� even� though� underweight
�■ Denial� of� hunger,� preoccupation� with� food� preparation,� obsession�with�calories�and�fat�content�and�dieting�despite� weight�loss�
�■ Refusal� to� maintain� a� body� weight� over� a� minimally� normal�one�for�age�and�height
�■ Purging,�often�using�laxatives�(in�the�binge�type)� �■ Distorted�self-image�of�weight,�size�and�shape. DSM-IV� divides� anorexia� into� two� types:� restrictive� type�
by�rigid�restriction�of�food�intake,�and�binge�eating/purging� type� by� episodes� of� self-induced� vomiting� and/or� laxative� abuse.� Anorexia� nervosa� is� a� serious� mental� illness� with� a� high� incidence� of� comorbidities� and� mortality.� About� 1� in� 250� females� and� 1� in� 2000� males� will� experience� anorexia� nervosa� (National� Institute� for� Health� and� Care� Excellence� (NICE),� 2004;� Engel� et� al,� 2007).There� has� been� interest� in� recent�years�about�the�role�of�sexual�abuse�in�eating�disorders.�
In� contrast� to� post-pubertal� adolescents� and� adults,� pre- pubertal�children�are�at�high�risk�of�rapid�weight�loss�owing�to� low�energy�stores;�rapid�dehydration,�which�may�affect�activity� and�wellbeing;�and�stunting�of�growth�including�height.�With� height� reduction,� weight� loss� will� be� underestimated� if� assessment�is�based�on�body�mass�index�(BMI)�alone.
Clinical�findings�are�mostly�the�results�of�malnutrition�and� include:
�■ Weight�well�below�the�3rd�centile�for�age �■ Cardiac�arrhythmia�or�signs�of�congestive�cardiac�failure �■ Bradycardia,�low�blood�pressure�and�low�body�temperature �■ Excoriation� on� the� dorsum� of� the� hand� as� a� result� of� induced�vomiting
�■ In�females,�loss�of�menstrual�cycles�for�at�least�3 months.
A�Sahib�El-Radhi,�Consultant�Paediatrician�and�Honorary�Senior� Lecturer,�Chelsfield�Park�Hospital,�Orpington
Accepted for publication: May 2015
Abstract Eating disorders are essentially psychological diseases that are characterised by abnormal eating habits. Anorexia nervosa and bulimia are the most common forms of eating disorders. There is an increased recognition of eating disorders among both men and women, and growing numbers of children and teenagers seeking help for eating disorders. Fear of body-weight gain is central to both anorexia nervosa and bulimia. Before the diagnosis of an eating disorder is made, it is essential to exclude organic diseases that may present with similar symptoms to eating disorders. Management initially should focus on correcting the nutritional deficiencies and dehydration at a paediatric or paediatric gastroenterology department, followed by a multidisciplinary approach. At the other extreme, the prevalence of obesity in children is increasing at an alarming rate, and presents a serious public health challenge.
Key words: Eating disorders ■ Anorexia nervosa ■ Bulimia ■ Obesity
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�■ Sleep�disturbance �■ Frequent�and�strenuous�exercise �■ Full�blood�count�(FBC)�often�shows�anaemia�and�leukopenia� �■ Reduced�bone�density�(osteopenia).
Recommended investigations for anorexia The� diagnosis� of� anorexia� nervosa� should� not� be� made� without� excluding� organic� diseases� causing� severe� loss� of� appetite,�such�as�endocrine�disorders�(e.g.�hypopituitarism),� occult�malignancy,�tuberculosis�or�gastrointestinal�disorders� (Crohn’s�or�coeliac�disease).�The�following�investigations�are� recommended�where�anorexia�is�suspected�to�look�for�other� possible�causes�of�weight�loss:
�■ FBC� with� C-reactive� protein� (CRP)� or� erythrocyte� sedimentation� rate� (ESR)� (markers� for� inflammation� or� infection)
�■ Blood�glucose �■ Urea�and�electrolytes�(U&E),�magnesium�and�phosphate �■ Liver�function�tests �■ Plasma�protein�with�fractions�(albumin�and�globulin) �■ Thyroid�function�tests �■ Electrocardiogram� (ECG)� for� pulse� rate,� QT� interval� and� possible�arrhythmia.�
Management of anorexia The�nutritional�management�(Box 3)�of�patients�with�anorexia� nervosa� forms� an� essential� part� of� treatment.� Patients� may� develop� peripheral� oedema� in� the� early� stage� of� re-feeding,� and� this� has� to� be� distinguished� from� cardiac� failure� by� the� absence�of�other�signs�of�cardiac�failure.
All� children� with� features� suggestive� of� anorexia� nervosa� should� be� referred� to� the� local� Eating� Disorders� Service� or� Child� and�Adolescent� Mental� Health� Service� (CAMHS)� for� multidisciplinary� assessment,� which� includes� psychotherapy,� behaviour� modification� therapy� and� dietary� rehabilitation;� medications� have� generally� limited� value� in� management� of� anorexia.�Family�therapy,�particularly�for�adolescents,�is�superior� to�individual�therapy.�Cognitive�behavioural�therapy�(CBT)�is� an� important� therapeutic� intervention� that� focuses� on� how� someone� thinks� about� a� situation,� which� in� turn� will� affect� behaviour.�Admission� to� a� rehab� clinic� is� possible� in� certain� severe� and� moderate-severe� cases.� Recovery� occurs� in� about� 70%�(Keski-Rahkonen�et�al,�2007)�while�the�mortality�rate�is� around�10%—death�is�usually�owing�to�cardiac�arrhythmia�or� electrolyte�disturbance
Bulimia Bulimia�is�characterised�by�an�intense�preoccupation�with�body� weight� and� shape� in� association� with� recurrent� episodes� of� overeating�in�conjunction�with�dieting,�self-induced�vomiting,� and/or� abuse� of� laxatives.� A� non-purging� group� of� patients� prevent�weight�gain�by�fasting�and�exercise�but�not�vomiting� or�other�abuse.�Some�patients�have�both�disorders:�anorexia�and� bulimia.�Patients�who�regularly�engage�in�bulimia�have�a�higher� incidence� of� social� dysfunction,� impulsivity� and� emotional� problems�compared�to�those�without�bulimia.�
The� prevalence� of� bulimia� is� between� 0.5%� and� 1%,� and� about�90%�of�those�who�have�the�disorder�are�females�(Bushnell� et�al,�1990;�Hoek,�2006).�Although�significantly�more�common�
Box 1. Usual risk factors for eating disorders
■■ Socio-cultural (e.g. society’s increased emphasis on thinness) ■■ Family history of eating disorders ■■ Personality disorders including obsessive personality traits ■■ Underlying anxiety ■■ Low self-esteem ■■ Psychological (e.g. bullying, teasing, depression) ■■ Genetic ■■ Child abuse
Box 2. Early warning signs of eating disorders
■■ Patients complain of being fat even when at a normal weight or underweight ■■ Frequent missing of meals ■■ Repeated weighing (of self) or looking in the mirror ■■ Frequent use of ‘slimming’ websites ■■ Repeated claims that they have already eaten ■■ Only eating specific low-calorie foods
Box 3. Recommendation on assessment and management of anorexia nervosa
■■ Assess the degree of dehydration. Weight and height should be measured and plotted on growth chart. Dry mouth mucosa is the first sign of dehydration. Loss of skin elasticity (turgor loss) is a late sign ■■ Assess weight loss (BMI) and muscle wasting: the thigh muscles are affected first; cheek muscles are the last. This can be assessed using the squat and sit-up tests (Table 1) ■■ Examine the skin for breakdown and purpuric rash ■■ Examine the mouth looking for glossitis and loss of sense of taste (caused by iron or zinc deficiency), bleeding of gums, and fissure of the lips (caused by riboflavin B2 or C vitamin deficiency) ■■ Inspect the teeth: recurrent induced vomiting can erode teeth enamel leading to pain and caries ■■ Examine circulation: systolic and diastolic blood pressure, postural hypotension and pulse rate ■■ Measure body temperature: low body temperature is often present, which improves rapidly with improved nutrition ■■ Feed slowly: the amount of food given should be small at first, and be increased gradually ■■ Monitor weight: a weekly weight gain of 0.5-1.0 kg is optimal and an intake of 2200–2500 kcal will achieve that in most patients
Source: Royal College of Psychiatry, 2005
Table 1. Squat and sit-up tests
Squat test Patient squats down and is asked to stand up without using arms as levers. Outcome:
■ Able to get up without using hands at all ■ Unable to get up without using arms for balance ■ Unable to get up without using arms as leverage
Sit-up test Patient lies flat on a firm surface and has to sit up without using his/her arms. Outcome:
■ Able to sit up without using the hands at all ■ Unable to sit up without using arms as leverage ■ Unable to sit at all
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in�women�than�men,�it�is�possible�that�the�general�pressure�on� men� to� become� conscious� of� physical� fitness� and� appearance� will�lead�to�an�increased�prevalence�of�bulimia�in�men.�
Bulimia�is�characterised�by�the�following�diagnostic�criteria: �■ Recurrent�episodes�of�rapid�consumption�of�a�large�amount� of�food�in�a�discrete�period�of�time,�usually�less�than�2 hours
�■ During�the�eating�binges,�a�fear�of�not�being�able�to�stop� eating
�■ Regularly� engaging� in� self-induced� vomiting,� use� of� laxatives�or�rigorous�fasting�or�dieting�in�order�to�counteract� the�effects�of�binge�eating
�■ A�minimum�average�of�two�binge�eating�episodes�a�week� for�at�least�3�months
�■ Self-evaluation� is� unduly� influenced� by� body� weight� and� shape.� The� binge-purge� pattern� may� occur� in� youngsters� who� have� normal� weight� or� are� slightly� obese.� Emaciation� in� patients� with� bulimia� is� most� unusual,� in� contrast� with� anorexia�nervosa. Poor� eating� habits� and� attitude� of� mothers� with� eating�
disorders� may� interfere� with� proper� parenting� and� result� in� negligence,� poor� weight� gain� and� poor� development� of� children�(Stein�and�Fairburn,�1989).
Treatment�(see�also�treatment�of�anorexia�nervosa�above)�in� the�form�of�CBT�is�an�effective�method�of�management�and� often� superior� to� medications� (Royal� College� of� Psychiatry,� 2005).� Medications� such� as� antidepressants� or� fluoxetine� reduce� bulimic� symptoms,� and� are� indicated� if� CBT� fails� (Gorla�and�Matthews,�2005)
Excessive weight gain (obesity) Obesity� in� the� past� has� been� seen� as� a� problem� of� adults,� becoming�more�prevalent�with�advanced�age.�The�prevalence� of�obesity�in�children�is�increasing�at�an�alarming�rate,�and�is� one�of�the�most�serious�global�public�health�challenges�for�the� 21st�century.�The�weight�definition�of�healthy�and�overweight� children� is� shown� in� Table 2.�The� number� of� obese� children� tripled� in� the� 20� years� to� 2006� (NICE,� 2006).� Obesity� in� childhood� is� linked� to� adult� obesity� with� the� potential� risk� of� increased� mortality,� cardiovascular� disease,� hypertension,� type� 2� diabetes,� back� pain,� osteoarthritis,� hyperlipidaemia,� cholelithiasis,� some� cancers� and� sleep� apnoea.� Obesity� can� cause� a� 17%� reduction� in� total� life� expectancy� for� men� and� 10%�for�women�(Fontaine�et�al,�2003).
Obese� children� often� do� not� eat� more� than� their� peers.� Genetic� factors� and� reduced� energy� output� (long� hours� sitting� in� front� of� the� television� and� computer)� are� more� important�causal�factors.�Obesity�usually�results�from�increases� in� the� number� of� fat� cells� (adipocytes)� occurring� during� gestational�months�and�during�the�first�year�of�life.�Any�early� obesity�may�persist.�Other�causes�of�obesity�(Box 4),�including� hormonal� and� endocrine,� are� rare� in� clinical� practice� but� often�considered�to�be�the�reason�by�parents.�
Recommended investigations in obesity �■ Urine:�proteinuria�is�present�in�cases�of�oedema�caused�by� renal�disease
�■ Thyroid�function�test:�for�hypothyroidism �■ U&E�in�blood:�deranged�in�Cushing’s�syndrome�(this�is�rare� but� should� always� be� considered� in� association� with� high� blood�pressure)
�■ Blood� glucose� for� diabetes� and� Beckwith-Wiedemann- syndrome
�■ Calcium�and�parathyroid�hormone�for�hypoparathyroidism �■ Serum�cortisol�levels�for�Cushing’s�syndrome� �■ Bone� age:� normal� in� simple� obesity,� delayed� in� endocrine� causes
�■ Pelvic� ultrasound� scan:� will� confirm� ovarian� cysts� in�
Table 2. Weight definition of healthy and overweight children
Classification BMI (kg/m2)
Healthy weight 18.5–24.9
Overweight 25–29.9
Obesity I 30–34.9
Obesity II 35–39.9
Obesity III 40 or more
Table 3. Differential diagnosis between simple and endocrine obesity
Simple obesity Endocrine obesity
History Long duration Shorter duration
Family history (obesity) Often positive Usually not
Height Average or above Short
Physical examination Otherwise normal Usually abnormal
Fat distribution Diffuse More localised (e.g. truncal)
Bone age Normal or advanced Delayed
Sexual development Appropriate for age Delayed
Striae Pink, appear at puberty Often violaceous, appear early
Box 4. Possible causes of obesity
■■ Simple obesity (genetic and environmental factors) ■■ Infant of diabetic mother ■■ Polycystic ovary syndrome (PCOS) ■■ Endocrine (e.g. Cushing’s syndrome (hypercortisolism), hypothyroidism) ■■ Drugs (e.g. steroids, pizotifen, anticonvulsants) ■■ Insulinoma ■■ Oedema (renal or cardiac) ■■ Beckwith-Wiedemann-syndrome (an overgrowth syndrome) ■■ Cerebral gigantism (Sotos syndrome) ■■ Laurence-Moon-Biedl syndrome (polydactyly, learning disability, retinitis pigmentosa) ■■ Turner’s syndrome
Table 4. Normal ranges of waist circumference (cm)
Age (years)
Boys Girls
10th centile
50th centile
90th centile
10th centile
50th centile
90th centile
2 43.2 47.1 50.8 43.8 47.1 52.2
5 48.4 53.2 61.0 48.5 53.0 61.4
10 57.0 63.3 78.0 56.3 62.8 76.6
15 65.6 73.5 95.0 64.2 72.6 91.9
Source: Fernandez et al, 2004
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polycystic� ovary� syndrome� (PCOS);� or� abnormalities� of� adrenals�in�Cushing’s�syndrome
�■ CT�scan�or�MRI�for�suspected�cases�of�Cushing’s�syndrome The� finding� of� supernumerary� digits� with� obesity� raises�
the� likelihood� of� Laurence-Moon-Biedl� syndrome� (obesity,� polydactyly,�retinitis�pigmentosa�and�progressive�nephropathy) An�uncommon�but�important�physical�sign�in�an�obese�child� is� short� fourth� and� fifth� knuckles� when� the� hand� is� fisted;� a� sign� seen� in� pseudohypoparathyroidism� and� in� girls� with� Turner’s�syndrome�(a�genetic�condition�where�only�one�full� X�chromosome�is�present).
Blood� pressure� should� be� recorded� in� any� child� with� obesity.�It�may�be�elevated�in�those�with�Cushing’s�syndrome� and�Turner’s�syndrome.
Management of obesity Obesity� owing� to� a� syndrome� or� endocrine� causes� is� rare.� Table 3� provides� differential� diagnosis� between� simple� and� endocrine/syndrome�causes�of�obesity.
BMI� gives� no� indication� of� body� fat� distribution� while� waist� circumference� (midway� between� the� 10th� rib� and� top� of�the�iliac�crest)�is�a�marker�for�central�body�fat�accumulation� and� is� more� accurate� than� BMI.� Normal� ranges� for� waist� circumference� are� shown� in� Table 4.� Clinical� intervention� should�be�considered�for�children�with�a�BMI�above�the�91st� centile� and� assessment� for� comorbidities� in� children� with� a� BMI� above� the� 98th� centile� (NICE,� 2014).� NICE� guidance� is� also� available� on� referring� children� to� lifestyle� weight� management�services�(NICE,�2013)�
Much�time�is�wasted�by�giving�unwanted�advice�about�food.� The�child�with�obesity�is�aware�of�that,�often�upset�by�hearing� that� he� or� she� is� eating� too� much,� and� dietary� restriction� is� notoriously� unsuccessful� in� treating� the� condition.� Table 5� shows�evidence-based�treatment�for�obesity.�The�main�cause� of� childhood� obesity� is� not� overeating,� but� genetic� factors� and� decreased� energy� output.� The� latter� can� be� estimated� indirectly� by� the� total� hours� spent� in� the� front� of� television� and�computer�per�day
Non-insulin-dependent� diabetes,� elevated� levels� of� low- desity�lipoprotein�cholesterol�(LDL)�and�low�levels�of�high- density� lipoprotein� cholesterol� (HDL)� occur� in� association� with� obesity� and� are� risk� factors� for� cardiovascular� disease� and�stroke.�
Drug and surgical treatment of obesity Drug� treatment� is� generally� not� used� for� children� younger� than�12�years�except�in�life-threatening�comorbidities,�such�as� sleep�apnoea.�In�children�aged�12�years�or�older,�treatment�with� orlistat�is�indicated�only�if�physical�comorbidities�such�as�sleep� apnoea� or� orthopaedic� or� severe� psychological� problems� are� present,�and�for�a�trial�for�6–12�months�with�regular�review�to� assess� effectiveness,� side-effects� and� adherence.� Orlistat� should� be�prescribed�for�obesity�in�children�only�by�a�multidisciplinary� team� with� expertise� in� drug� monitoring,� psychological� support,�behaviour�intervention�such�as�increased�activity�and� instruction�to�improve�diet.
Surgical� intervention� (e.g.� gastric� banding)� may� be� considered� only� in� exceptional� circumstances� and� after� the� patient� has� received� intensive� management� in� a� specialised�
obesity� service,� been� found� to� be� generally� fit� for� surgery� and�anaesthesia�and�been�found�committed�to�the�need�for�a� long-term�follow�up.� BJN
Conflict of interest: none
This article is part of a series on paediatric care revised from the book Essential�Paediatrics�in�Primary�Care by AS El-Radhi et al.
Table 5. Treatment strategy for obesity
Activity Diet*
■ Encourage enjoyable activities (walking, swimming, aerobics, gardening) part of everyday life
■ Minimise sedentary activity, e.g. watching TV or computer and video games
■ Build activity in the working day, e.g. take the stairs instead of lift, take a walk at lunch time
■ Encourage active e.g. dancing and skipping
■ Be more active, e.g. walking and cycling to school and shops
■ Starchy food (potatoes, rice, pasta, bread)
■ Plenty of fibre-rich diet (oats, beans, peas)
■ Eat at least five portions of fruit and vegetables each day
■ Low fat diet and avoiding increasing fat and/or calorie intake
■ Take as little as possible fried food, drinks and confectionary high in added sugar and food and drinks high in fat (fast food)
■ Eat breakfast ■ Encourage eating high-fibre bread, whole grain cereal, whole-meal pasta, brown rice
■ Children should be encouraged to increase their physical activity even if they do not lose weight as a result because of other benefits such as reducing the risk of type 2 diabetes and cardiovascular events
■ Children should be encouraged to do at least 60 minutes of moderate exercise each day either in one session or several each 10 minutes or more
■ Help children maintain or work towards weight reduction
■ Children should eat regular meals in a pleasant, sociable environment without distraction such as TV watching
■ Parents should eat the same food as their children whenever possible
■ Get children involved at meal times; they are likely to eat what they made themselves
*Any dietary recommendations should form part of a multicomponent intervention
Source: National Institute for Health and Care Excellence (2014; 2015)
KEY POINTS
n■There is an increased recognition of eating disorders in adolescents and young adult women related to an increased pressure in society to diet and to maintain a thin body shape
n■A relationship between eating and personality disorders is established
n■Children and their parents need support and assistance in establishing an effective management plan and nurses play a pivotal role in this plan
n■Forming an adequate management plan for eating disorders requires the collaboration of families, health professionals and mental health experts
n■Cognitive behavioural therapy has become an established method of treating patients with eating disorders, particularly those with bulimia
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Promoting Concordance in Mental Health presents a practical, skills-based approach to concordance. It explores the concepts of concordance and compliance and addresses speci� c challenges faced by health professionals, providing clear methods for overcoming them. The text includes case studies, examples, practical guidance and user-carer perspectives, offering insight into relevant challenges and opportunities.
With chapters on prescribing, psychosis, dementia and psychosocial issues, this title is essential reading for all who want to build better therapeutic relationships and achieve better outcomes.
Aimed at mental health workers, mental health students, carers and service users, this book can be used in a variety of settings.
About the authors:
Glenn R Marland is a Senior Lecturer at the University of the West of Scotland and Vice Chair of the Mental Health Subject Development Group. His PhD explored concordance in medicine taking
Lisa McNay is a Lecturer at the University of the West of Scotland — her clinical background is in community mental health, latterly working as a nurse consultant for people with long term mental health dif� culties.
Austyn Snowden has worked as an RMN in England, the Channel Islands, Saudi Arabia and Australia, mainly in care of the older adult. He is currently a lecturer at the University of the West of Scotland, where he teaches undergraduate mental health nurses and postgraduate nurse prescribers.
ISBN: 978-1-85642-427-1; 210 x 148 mm; paperback; 238 pages; publication 2011; £24.99
Building better therapeutic relationships
Promoting Concordance in Mental Health edited by Glenn R Marland, Lisa McNay and Austyn Snowden
9 7 8 1 8 5 6 4 2 4 2 7 1
ISBN 1-85642-427-8
www.quaybooks.co.uk
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About this book Promoting Concordance in Mental Health presents a practical, skills-based approach to concordance. It explores the concepts of concordance and compliance and addresses speci c challenges faced by health professionals, providing clear methods for overcoming them. The text includes case studies, examples, practical guidance and user-carer perspectives, offering insight into relevant challenges and opportunities.
With chapters on prescribing, psychosis, dementia and psychosocial issues, Promoting Concordance in Mental Health is essential reading for all who want to build better therapeutic relationships and achieve better outcomes. Aimed at mental health workers, mental health students, carers and service users, this book can be used in a variety of settings.
About the editors Glenn R Marland is a Senior Lecturer at the University of the West of Scotland and Vice Chair of the Mental Health Subject Development Group. His PhD explored concordance in medicine taking Lisa McNay is a Lecturer at the University of the West of Scotland — her clinical background is in community mental health, latterly working as a nurse consultant for people with long term mental health dif culties. Austyn Snowden has worked as an RMN in England, the Channel Islands, Saudi Arabia and Australia, mainly in care of the older adult. He is currently a lecturer at the University of the West of Scotland, where he teaches undergraduate mental health nurses and postgraduate nurse prescribers.
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