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  • 17th April 2018 | By David Jolley

    This is a major breakthrough: application of the principles identified here will improve life for so many people.

    Shamefully I had not known about the LIFEPATH consortium https://www.lifepathproject.eu/ until I came across a paper in last week’s BMJ from Silvia Stringhini and colleagues: Socioeconomic status, non-communicable disease risk factors, and walking speed in older adults: multi-cohort population based study https://www.bmj.com/content/360/bmj.k1046

    The paper reads as something written by a committee whose languages span the globe – and so it is. They have brought together and ‘harmonised’ the data from 37 cohort studies for 24 countries to examine the hypothesis that socioeconomic status is at least as powerful in determining ability and self-care in later life (and survival), as recognised risk factors.

    WHO is aiming to reduce premature deaths by 25% before 2025 and is targeting: alcohol (did you see front page news on Friday that heavy drinking reduces life expectation? https://www.theguardian.com/science/2018/apr/12/one-extra-glass-of-wine-will-shorten-your-life-by-30-minutes ). This is not a new insight – we have known the ‘alcohol is a self-limiting illness’ for many years.

    Insufficient physical activity, tobacco, high blood pressure, excessive salt intake, diabetes, and obesity.

    The LIFEPATH consortium asks how socioeconomic circumstances compare with these disease risk factors in predicting the onset of disability and death. They find that socioeconomic circumstances are as powerful a predictor as any of the more often cited and targeted risk factors.

    This is so important because it gives the opportunity for countries to manipulate their taxes, services and job opportunities to improve the prospects for the least well off, to produce a healthier population. It seems very likely that we have stumbled on an understanding that it is this measure which underpins all the other rises in risk of impairment in older age: better economic status will reduce the likelihood of excessive use of alcohol, tobacco, salt and food. It will give time and money to take exercise. The incidence of diabetes will be reduced.

    We are reminded of the finding that the incidence of dementia has fallen where economic circumstances have improved, but risen where they have deteriorated. http://www.cam.ac.uk/research/news/new-cases-of-dementia-in-the-uk-fall-by-20-over-two-decades

    ‚ÄčThis is a real breakthrough in understanding… We need now the will to use it.

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    9th April | By David Jolley

    We thought we had quelled all this hoping for a cure and settled for a sensible use of the evidence we have that what works for dementia are preventative approaches and care, so that expenditure on research into possible cures should be rationed internationally and more resources directed to care and health promotion.

    Yet the Guardian carried ‘Humans keep making neurons for learning throughout life’ on Friday. The article and the references it drew on had the virtue of reminding me of the existence of the dentate gyrus, but reading the references I could not be convinced that they were describing the development of new neurons in adult life or old age – to the contrary most of the research seems to confirm that lots of neurons are established at birth and very early life – the number decreases with age. Somehow the alternative story has taken a grip.

    At our weekly seminar we learned that much time of very great men and women is being devoted to consideration of how the NHS will cope when (when) a cure for Alzheimer’s disease via monoclonal antibodies becomes available – at vast expense and with expansion of the need for therapy into decades before the possible/probable emergence of the clinical syndrome.

    I remember being glad that I had not been required to spend my creative years planning for what this country should do in the event of a nuclear war. By comparison this seems a positively reasonable expenditure of a life. The zombie keeps on walking! https://www.researchgate.net/publication/5059675_APOCALYPSE_NO_population_aging_and_the_future_of_health_care_systems

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    Asylum 09 April 2018 | Comments (0)

    2nd April 2018 | By David Jolley

    This week I received a beautiful picture card from a friend who has sought refuge and peace in the beauty ruggedness of North Wales. It carries the sea and sky, land of an island and rain between.

    This is not the North Wales of beach, pebbles, running tides and friendly shops and cafes which I remember from our childhood. It is something more grown up and powerful. There are parts of the country where people find retreat, healing is a local industry. Generations of children from the North West and the Midlands spent days and months in the cold sanatoria which cared for them and their tuberculosis in North Wales. My first appointment as an SHO in psychiatry was at the North Wales Mental Hospital, Denbigh. Built a short distance from the town and its castle, its creation was to counter the disadvantage being experienced by Welsh speakers who were admitted to English Mental Hospitals http://northwaleshospital.btck.co.uk/

    ‘Denbigh’ is now closed, abandoned and its remains damaged by fire. I spent only three months there before moving to South Manchester. They were months which burned, maybe scarred, memories which I will never forget. The staff were impressive, caring, well-educated local people. Healing was a major local industry, alongside farming which was perhaps less dominant than had been. Doctors at the hospital base were an assortment of long-serving individuals with characteristics and limitations of their own. Consultant Psychiatrists ranged from the young and ambitious to the older ex-military, and were often away from the hospital at clinics dispersed across the wide territory of the whole of North Wales – as far down as Aberystwyth. Life and therapy in the attractive villas with in the hillside grounds was good enough and encouraging for recent admissions. Living and dying for old people within the bowels of the old part of the hospital was as dark as anything I have ever seen. Cot beds, contractures, reflex use of antibiotics, forty bodies to every single sex dormitory, a cockroach run at night time.

    A review of budgets told how little was being spent on people here in comparison to nearby general hospitals. There was less heating, less food and fewer staff. We did the best that could be done.

    This is a component of the changing scene which it has been my privilege to be part of. I look back in horror but not regret. This was the base from which marvellous changes have been made and we have been part of. Some of these advances have come from better medicines, but much more has come from greater awareness and wider involvement of caring people of all descriptions. Much of this has gone on and continues to be conducted, in the places where people live their working and family lives. Part of the movement saw mental illness become included within the general hospitals, first of the North West, and then throughout the UK. https://www.cabdirect.org/cabdirect/abstract/19702701868

    There is much more to be said about this and where it has led us. But for now, to reflect that even now we find help and therapy in the physical environment of North Wales and other blessed landscapes. Neither approach need be exclusive of the other.

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    27th March 2018 | By David Jolley

    Having gone through the final iterations to agree a version of our chapter on carers’ needs for George Tadros’ coming handbook on liaison psychiatry, I am saturated with the facts and arguments for good practice. It all seems so familiar, so much common sense and so widely known that I was wondering if it needs saying again.

    I met Marlene on Sunday. She was hardly recognisable for the anxious, thin, uncertain figure that I have known these past 18 months. She looked taller, fitter, and her hair a fountain of curls above a confident, smiling, caring face. George’s struggle through the last stages of dementia has been completed and she has her life, her home and her involvement with friends and the world outside to be lived again.

    She has memories of their long and happy years together, and reminders of them around her. Unhappily there remain the memories of the very last weeks which were spent in a general hospital ward where the regime and individual nurses were ill equipped or disposed to understand and provide for his needs and hers.

    ‘In those weeks he ate hardly anything. They gave him chips and sandwiches – things he could not cope with. I took him treats myself but they were not enough.’

    Then two new nurses came to the ward.

    They had worked on a unit which specialised in people with eating problems.

    ‘This is no good.’ They said out loud – and went off to their previous unit and obtained suitable supplements and preparations which he could manage. He ate and drank them all.

    ‘They took time with him – and in those last days I knew he would be OK. I thank God for those nurses’

    So it may be common sense to many, and it may have been said before, but it needs repeating over and over.

    Writing a chapter is all very well, but how widely will the handbook be circulated and read?

    Could we have a poster prepared which would be placed on every ward?  People with dementia and their carers are to be found on nearly every ward in every hospital.

    Can we worked toward a system where every ward is supported by/owned by a Friends Group – who will monitor what goes on – and contribute to the quality day by day by their presence and modest contributions?

    It would be a good thing to do but there is likely to be resistance in many places – Just the places where the arrangement is most needed

    I wonder if we can muster person-power to do this in our local hospital. Would it be the first priority for people’s time and energies? Mostly it would be something that needed experience of caring for a loved one living with/dying with dementia. It could not be taken on by current carers – they have more than enough to do already.

    Maybe it is something to think of in the life after the death of the individual who had dementia – for immediate carers or other whose lives were affected.

    We keep thinking, and saying, that if we get it right for people with dementia, it will be right for everyone else too.

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