Saturday, 19 October 2013

Loneliness - a simple problem with complex answers.

Jeremy Hunt has been talking about the national shame of loneliness of the elderly in the UK ( . I feel like I have been harking on about this to anyone who will listen to me for ages. Perhaps even you, dear reader, is getting bored of my fixation with this issue.

But bear with me. Companionship is not just a nicety of civilised living. Loneliness is recognised risk factor for ill health, and it is a bell-weather for how society functions. The way we treat the elderly is a symptom of how fast, and how much, the functioning of modern society has changed. The pattern of our lives has altered so much that we have not yet adapted to deal with an issue that has not troubled previous generations in the way that it currently troubles us.

There are a number of truths that we need to consider: that individuals are living longer, that elderly individuals are often living not just longer lives, but significant periods of their lives in poor health; that families are now smaller and more dispersed. I would encourage you to absorb the impact of those three factors, to get away from the idea that somehow the elderly in our society are lonely because their families and communities have stopped caring about them. It is unhelpful to blame the attitude of families, and communities, in the way they care for the elderly, because it fails to acknowledge that the issue we have with the elderly is not just the result of a change in the way we care, but also of some profound changes in the way we live.

Perhaps your view on the issue is shaped by your direct experience. Perhaps you know of children who travel hundreds of miles each week to check in on their parents who live in a different town. Perhaps you have seen the worry, the stress and the anxiety caused by wanting to help, but not being able to, due to the insurmountable obstacles of the need to work, and the impossibility of moving cities.

Perhaps you know people who take no interest in their parents or grandparents. These people undoubtedly exist, but is theirs an attitude borne out of a habit of our age, or is it more complex than that?

Jeremy Hunt suggests that the start of an answer is simple: take a lesson from Asian families who tend to care for their elderly relatives at home. It might be that easy, but I doubt it.

The issue is underpinned by the impact of social mobility. Where I live, my neighbour was born in the house she still lives in. Her  brother lives across the road, and her son lives three doors away. In this context, it would be possible to take on a care burden. But she is relative rarity. For children growing up in Dorset today, the majority of them will have to move away to further their education, and to seek employment opportunities. In a world of heightened opportunities (recent recessions notwithstanding) the price we have had to pay for greater autonomy and choice in our life patterns has been the requirement to relocate. This won't change.

Add to this the rising reality of prolonged old age, and prolonged dependency in old age, on a scale never previously seen before, and one can really start to question to validity of any assertion that the main solution to loneliness in old age starts and ends at home with the family. That is not to say that it wouldn't be ideal - it is surely preferable to the elderly to be surround by their kin. The issue is that it is not practicable.

Where do we start in the search for practicable solutions? Any approached needs to be many pronged: it starts with consideration of how the frail elderly among us can be afforded the opportunity to interact with the people near us. This perhaps starts with some concept of surrogacy: if you are not supporting your own parents and grandparents, then perhaps there is something that you can do to support the parents or grandparents of someone else, who live near you. With small beginnings, the impact of paying this kind of volunteering forward could really begin to tell.

But the future for modern society needs to consider the impact it can have on stemming the tide of elderly disability: socially engage, mentally stimulated, and physically active elderly men and women accumulate illness and frailty less quickly than those who are not. Embedding not just a role, but a reciprocal obligation of society to accommodate the elderly, and the elderly to take part, heralds a future in which the elderly not just have a role, but a community network that enjoys their input, and then supportively wraps them up, as they become less able to take an active part.

What does that look like? It could be anything, but it to me, it looks like the elderly reading with primary school children, running workshops to teach children about the past, and the skills they developed over time. It involves cross-generational community projects, play schemes, sharing of hobbies, interests and sports through  local clubs. It looks like whatever you want it to look like, because it looks like whatever you make it.

Wednesday, 16 October 2013

A short thought about the way we think

How many people in the UK have mental health problems? What makes the burden of mental illness tangible? How can we make it seem relevant to our lives?

About 10% of the population will suffer from depression during their lives. About 4% have bipolar disorder, just under 1% have schizophrenia. Add in insomnia, addiction, eating disorders and the behavioural problems associated with dementia , and mental illness starts to become the norm - not the exception.

The statistics rarely capture the reality. Throughout our communities there are pockets of expertise, borne not out of education or learning, but out of experience. The sharpest understanding of what it means to suffer, live and cope with mental illness comes from suffering, living and coping with it. The profoundest empathy of the struggles of others suffering, living and coping with mental illness comes from supporting someone you love with their own troubles.

Mental illness in all its forms is so common that these pockets of lived expertise must be everywhere. And yet we live in a society where the perception is that mental illness is the poor relative of physical health problems. Anyone whose life has been touched by these problems knows how profound, disruptive and real mental illness can be; and they also perhaps know how joyful it can be to emerge, for however long, from the shadow cast by psychiatric relapse.

The truths of mental illness are self-evident to all those who live with it. The succour of clinical expertise, loving families and good social support are the cornerstones of happy outcomes. And yet, a great many of the worst sufferers exist in social isolation, without friends, money or families, in communities that pretend they don't exist.

Marcus Trescothick was an international cricketer, whose depression undermined his ability to continue. When he left the England Cricket team during their tour of India in 2006, the team management told the press that he had left on account of personal problems. This wasn't entirely accurate. He left because of depression. He found the obfuscation unhelpful. When he found the strength to be open with people, he discovered a whole world of support, and understanding, both from people he worked with, and people he had never met.

No one wants to have to be an example to others when they are at their lowest ebb, but sometimes, some people find the strength to drive progress. In his own little way, Marcus achieved that: he enabled the people around him to learn about his problems, and to let them demonstrate to him that they care.

And this is the Catch 22 of mental illness. I imagine the majority of people would want to help, to be supportive if someone that they knew was going through a mental health crisis. But we do not know how to broach it. And for the person with the problem, being open about the issue is hard to do, when they are at their most vulnerable, and when they might feel some shame about their problems. You probably wouldn't hesitate to tell me if you'd had pneumonia, but you probably would if you'd been off work with depression.

Society cannot take a lead on changing the nature of its mental health dialogue - it just doesn't work like that. And we cannot place the burden of openness on the people suffering the most.

But perhaps, we can all through our language, and our approach, make it clear that life is tough, and sometimes, the manifestation of illness is psychiatric, and that we get that. Perhaps we can be the people who by being mindful of mental health problems in other people, are mindful and open about our own problems. We may not suffer in the same way as others, but we may also suffer worse. Openness is easier to start when you are feeling strong. Don't wait for your moment of weakness to wish that we were better at talking about mental health. 

Thursday, 3 October 2013

Empiricism in context

In my new role as a community geriatrician, I am exploring how to deliver what I think to be good geriatric care in a new environment. The challenge suits me: I work in nice hospitals, with caring staff, in nice part of the world. It feels like I am doing what geriatrics is all about: doing the right medicine for people who need a lot of care and attention. It is all about balance, judgement, and respect for the individual. 

I have spoken before about the limits of practising geriatrics within an acute hospital setting, and how it is the wrong environment for confused, vulnerable men and women. Increasingly, acute hospitals are factories for technological care. They are busy, fast-moving and bewildering environments. The men and women I deal with often need the best technical care we can offer, but they also need to be in an environment that helps them find their feet again, and helps us decide what issues are really at the centre of their problems: the pattern of symptoms might be easy to discern, but determining their underlying cause takes a bit more nouce.

I said that I like my new job because it gives me the chance to deliver what I think to be good care. This element of subjectivity, of what I think is the best approach, is both the strength and weakness of modern geriatrics. 

However confident we might be that we are acting in our patients' best interests, there is a need for circumspection. The rise of empiricism in medicine is unquestionably a good thing; but it is not without its flaws, and it is not without its areas of poor coverage. Geriatrics is one of these low signal areas: the elderly are often excluded from the big trials, and the application of the evidence base to even common conditions in the elderly is through extrapolation of data sets from younger patients. It might surprise you, but it wasn't until the HYVET trial in 2008 that we could say with any confidence that there was a benefit to treating high blood pressure in the elderly. And even then, the need for circumspection remains, as many of the trial participants were Chinese, and therefore of questionable equivalence to the patients that we deal with.

But let's not get stuck on this. The point I wish to make is that empiricism is an important aspect of modern medical practice. But where geriatrics is concerned, it is only one aspect. Of course, we need to know that the treatments and therapies we use on patients are effective, and not unduly harmful (that is always a question of risk vs benefit). But the care of elderly patients goes beyond the technical questions of the best treatments - it is more complex than that. Of course it is. 

It is these non-empirical aspects of my job that I really love. The variety of approach, and the broadness of it. What I do may not be cutting edge, but I get the chance, as part of a team, to make a difference to the lives of our patients. Go fast, go slow, do nothing at all. Do the test, start the treatment, or hold off entirely. Tackle the physical problem, the mental health problem, or stand back and let the therapists focus on empowering the patient by improving their function and independence. Often, my patients teach me a thing or two about life, from the secret to a successful marriage, to dealing with loss, or what is was like making a dress for the Queen. It's all there if you give it time.

Geriatrics requires knowledge, skill, experience, team play, humility, and usually a clear articulation of what you are trying to achieve - all skills that you can never quite tick off as completed. We might aim to help someone get back to playing golf, or we might try to give someone some peace and dignity in their dying days. Geriatrics normalises normal stuff, and it highlights the unusual. There are themes and trends; there are frustrations and depressing realities. There are disappointments and regrets.

But above all, there is the knowledge that even if we cannot heal the patient, we can help them and their families cope with the reality. 

Sometimes, perhaps quite often, there is the reality that we don't do things terribly well, but we can change that. We have to. 

Moving to community hospitals has helped me to realise that there is a lot we can do to deliver care more suited to the needs of my elderly patients if we are prepared to work differently.  But not everyone shares my view: the question I often get asked is what is the evidence for community-based care. The sub-text is always that they know there isn't really much, and that it is therefore not worth investing in. I smile, I nod, and I acknowledge their point. But I also tell them that we are not really trying to do things differently - we are trying to do the same things better. 

What matters to my patients is not so much about mortality, or length of stay. It is much more about having the right care, the right expertise, good communication, and the best possible quality of life. And we will be content to be held to that account.