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  • Therapy? 25 February 2019 | Comments (0)

    25th February 2019 | By David Jolley

    It is refreshing to find an article in the national news which is about older people but does not rehearse the statistics of what a burden we are, and addresses depression, which is something which can affect the lives of people with dementia or without dementia.

    Denis Campbell’s article from February 12th www.theguardian.com/society/2019/feb/12/too-many-older-people-given-antidepressants-instead-of-therapy highlights a systematic review from Rachel Frost and colleagues based in University College London and Bristol University. This considered 1471 papers published since 1806 looking at the issue of how older people who are recognised as being depressed, are managed by primary health care staff. Depression is common in old age and older people are present in ever increasing numbers – So this is a Big Issue. Depression is associated with reduced quality of life and with increased mortality, cognitive decline, functional decline and use of health services (ah – burden finds its way in!).

    The systematic review was limited to qualitative studies and relies on detailed analyses of only 27 papers which were deemed to meet inclusion criteria.

    It is accepted that many people with depression or other mental health problems do not have their condition recognised. Amongst those where primary care recognises their depression almost 90 percent receive a prescription of an antidepressant. This is not deemed good by the authors of the 27 papers, nor the authors of the systematic review. They see depression in older people as ‘understandable’ in terms of the social, physical health and psychological experiences of being old. Therapy should avoid medicalisation of such an understandable condition. Their preferred answer is referral to Improving Access to Psychological Therapies (IAPT) https://www.england.nhs.uk/mental-health/adults/iapt/. The rage is that people age 85 and over are five times less likely to be referred to IAPT than are younger people.

    The healthcare professionals who have contributed views to the 27 papers feel this is wrong. But they are the very people who determine when referrals might be made. Odd isn’t it?

    But there is something strange about the whole paper and the newspaper take on it: No-one can be against supporting practice which encourages clinical staff to listen to patients, gather a proper history and understand who the person is that they have the privilege to be serving, and the factors which are contributing to their difficulties. We do this for people with any symptoms – including those who have dementia. And we use this knowledge in formulating with them and their families, a strategy to try to help them become well.

    The number of older people with depressive symptoms is such that this will always be done in primary care, with referral to specialist reserved for people where symptoms are most severe, dangerous or puzzling. The proposition that the only best practice is referral to a super-specialist, nonmedical service like IAPT is hard to support.

    Toward the end of the systematic review we read:

    ‘When nothing else could be offered, GPs and community nurses tended to provide support themselves to the older person in various ways, or prescribe antidepressants.’

    The only thing wrong with that observation is that ‘or prescribe’ would be better said: ‘and prescribed’. In the management of people with dementia, we should never give up on understanding and working with our knowledge of the patient and their family – but it would be wonderful to have a medication which could be as effective as antidepressants are, to add to our basic therapies.

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    Sunshine 25 February 2019 | Comments (0)

    18th February 2019 | By David Jolley

    Yesterday the morning included frost, but the sky was clear and the colours so intense that a familiar journey home from the hospital felt like a dream into another part of the world.

    Walking westwards along the Bridgewater Canal at Dunham during the afternoon, the water glinted flashes of light and my eyes screwed up to reduce the glare. People approaching were silhouettes without colour until they had passed by. The air was fresh and we walked on easily toward a broad bottomed barge before turning right, away from the towpath to the lane which snakes back and under the echoing under path. The orchard just beyond is full of snowdrops and crocuses at this time of year – Not that I had remembered until we were alongside them – There they rest this year as every year, white and blue and purple with just a few golden cups.

    Clanging over the metal bridge which spans the rushing mill-race we came to the corner which leads to the long straight and narrow road which takes us back to Smithy Lane and on to the entrance to Dunham Park. Either side of that narrow road the hawthorn hedges are bare, their profile spikey and threatening to the unwary. But they were the corridor along which pairs of blue birds flew and flit, over and round, along and back again, thanking the sunshine for such a day and saying joy to all the earth.

    Natalie has been struggling to cope with episodes of ill-health and the loss of a friend who had raised the pleasures of each day to new levels.

    Walking with a trusted support, through the world as it still is, with memories, pains and possibilities may provide therapy beyond words.

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    Still water 11 February 2019 | Comments (0)

    11th February 2019 | By David Jolley

    Wolverhampton does not have a river of any significance, but it does have canals. One of the pleasures of life there was to live on the bank of the Staffordshire and Worcester Canal at Newbridge. The Midlands has a network of canals, Birmingham bizarrely boasts a harbourmaster. These man-made channels were constructed to ease the transport of freight in the 18th Century. After many years of disuse and neglect they have been reinvented as a leisure facility for boaters, walkers and others; and affordable homes for more and more people. Currently there is real interest in returning freight to the canals of Salford, London and Leeds.

    The problem is that while bodies of water mean there is the possibility of floating along in one dimension, there is a block to those who want to cross to the other side. In some instances the lock system allows passage for people on foot, but for bigger canals such as the Manchester Ship Canal, something different is needed: Hulme’s Ferry continues an ancient tradition to help people across from Irlam to Flixton – at some times in the year https://irlamandcadishead.net/locations/hulmes-ferry/ . Cars and other vehicles need roads and bridges for their journeys. Traditional canal bridges are almost always narrow – not allowing the passage of larger vehicles and requiring their drivers and Satnavs to find another route.

    At Warburton a toll bridge crosses the Manchester Ship canal – using this cuts out many miles of main road and motorway travel when heading from Altrincham towards Warrington, Wigan, Liverpool and other North West towns. The cost is wonderfully 12p for a single journey and 25p for a day pass. I love the interruption of the flow to be part of this ancient ritual – but not everyone feels the same: https://www.manchestereveningnews.co.uk/news/greater-manchester-news/warburton-toll-bridge-queues-complaints-14817403

    So what is all this about? Well I think it is about finding your way – as in Pathfinders rather than Pathways. For there are some routes which suit some people and others which suit others. There are recent and modern routes, older and ancient ways. Beyond roads and canals there are railways, rivers, tramways and so on. Individuals will often want to go ways which use different modes in sequence, rather than stick to one. Sometimes you have to go a long way round to get where you want to. Sometimes you can use an older way and get there – but it may take time and research to learn about it.

    So it is with trains of thought or feelings – what is causing puzzlement, confusion or fear just now may be based in old times, old losses or mistrusts. Know about them and proceed gently. There will be a way.

     

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    Rant Control 04 February 2019 | Comments (0)

    4th February 2019 | By David Jolley

    Through the week we have exchanged thoughts about the learning from Gnosall’s successful memory service in Primary Care. That service, successful and sustained after more than 12 years, has generated international interest and added to enthusiasm for care of people with dementia and their families within Primary Care. Unhappily three attempts to extend the principle to other Primary Care services in Staffordshire and Shropshire have foundered.

    During this month we have been told that greater use of electronic technology for and by patients will make for much better use of resources and knowledge https://www.england.nhs.uk/2019/01/long-term-plan/ . This is something which one of our discussants has supported strongly. The problem is, I might venture, that much of healthcare need is amongst older people, some with dementia, and many of them are not computer-savvy.

    The Gnosall models brings clinical expertise directly to patients and families and that expertise remains available in the Practice throughout the life of individuals with dementia. The experience of the roll outs has been that everyone has liked the principle but that organisations have been unable or unwilling to accommodate them within gigantic, rule-ridden protocols which do not want to know about continuity of clinical responsibility or clinical freedom.

     ‘Large organisations cannot allow autonomy as it may affect the integrity both of the organisation as a whole but also the individual divisions.’

    And in that we have the essence of the problem: the health and wealth of the large organisations such as NHS Trusts or private sector providers has been allowed to become the first priority. What is best for patients, families and the health and wealth of the nation as a whole has been set aside.

    So we have an understanding. So we rant. Can we please regain control!

    Better use of technology may have advantages for some, but old-fashioned, person-centred good practice has so much more to offer.

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