Older Mind Matters

Something can always be done

The G8 dementia summit didn’t get the media attention I had hoped to see. One piece in the Guardian made some cogent points and is worth a read (see it here). Richard Ashworth wrote on December 12th that:

“for most people in the UK, at least, a diagnosis is the beginning and the end of the care they get from society and the NHS. Most people get no support at all.”

He goes on to describe how his stepmother was discharged from old age psychiatry after being seen twice, because there was "nothing they could do". What an indictment of old age psychiatrists! I teach my students that something can always be done – we just need to try.

The Prime Minister’s challenge on dementia says on page 8:

“We must ensure that every person gets the treatment and support which meets their needs and their life.”

This is a worthy aim, but one that we are not currently achieving. Continuity of care is a big issue and is one of the key areas where health and social care are failing people with dementia and their families. People living with dementia need to keep in touch with services – their dementia doesn’t go away; their needs don’t go away; and, in fact, over time their needs are likely to change. They and their families may need more treatment, help and support. They and their families may need different treatment, help and support. The full version of our BMJ rapid response to an article by Le Couteur and colleagues on pre-screening people for dementia says:

“At its best, (appraisal of people with dementia) is a living, interactive process which leads to support for the rest of that individual’s life.”

We need dementia services that stay with the people using them for life and there are models of how this can be done. I mention here two that are known to me.

One is the primary care memory clinic service at Gnosall that I wrote about in August 2012. The Gnosall model involves keeping in contact with families and helping them live with dementia.

Another is a Hospice in Ashton-under-Lyne called Willow Wood, which recently won the Innovation in Clinical Practice Award at the 2013 Help for Hospices Awards for "Hospice at the Heart of Care for People with Dementia with Palliative Care Needs". Read about the Willow Wood dementia service here.

If anyone knows any other models providing continuing care and support to families living with dementia, I would love to hear about them.

Happy Christmas everyone and all the best for 2014!

1 comment (Add your own)

1. David Jolley wrote:
Continuity is THE BIG ISSUE

Out of the mouths of Guardian correspondents do we see ourselves as others see us – Yes I am indulging in too many Christmas cracker jokes and mixing the metaphors for a plum pudding response to this last blog of 2013

2013 has been a brilliant year for dementia which has become well recognised and almost over exposed with media interest and concern. Politicians and celebrities have become prepared to share their personal and family stories, cities and towns are proud to be recognised as dementia-friendly, schools use it as a project theme, the police, ambulance and fire services take led roles in identifying and supporting people who are vulnerable because of dementia.
So how can it be that Professor Ashcroft diverts from his scholarly and perceptive analysis of ‘dementia now’ to skewer Old Age Psychiatry and its pathetic response to the needs of his stepmother.
At the moment Old Age Psychiatry’s strongest suit would seem to be in providing services for people with dementia, but here it is revealed as all-but irrelevant when seen from the perspective of the individual with dementia, their family and perhaps their GP who can ‘lend a sympathetic ear to us, but that is all’.

Previous references to Old Age Psychiatry in the newspapers are few:
The Guardian carried stories June 2011, August 2012 and June 2013 on problems of alcohol excess in older people.
Rob Howard featured with comments on the power of music to help people with dementia April 2012 and on the potential of brain training in September this year.
Before that Sube Banerjee was Centre-Fold on dementia as he took us toward the National Dementia Strategy February 2008.
March 2007 included papers and letters on suicide in late life and the models of service which could bring specialty skills close to Primary Care www.theguardian.com/society/2007/mar/21/guardiansocietysupplement3

It is sad and frustrating that our 21 year old Speciality has had such a low profile and is now labelled as useless in one of the areas where it should be strong.

In some ways I think Richard Ashcroft is unfair to the Specialty: we have seen services overall removed from the squalor of underfunded and isolated mental hospitals to work alongside others in the mainstreams of general hospitals and community.
We have seen recruitment of good people of all disciplines to work with old people who experience mental disorders of any and every kind. Our understanding of and confidence in treating mood disorder, paranoid states and a whole range of reaction disorders, including misuse of alcohol and other substances in old age have progressed marvellously over a period of 40 years. Would this have happened without the discipline, enthusiasm and advocacy of the Speciality?
The advances now trumpeted through the Prime Minister’s Challenge have been inspired and directed by Old Age Psychiatrists.
Let us be humble but not self destructive.

A lot has been done. More remains to be done and we are in danger of losing the support of those who need us most if we kowtow to the requirements of ‘management’ and desert or deny the real needs of patients, families and colleagues in compliance with unreasonably restricted budgets and absurdly restrictive ‘standards’.

More shocking and sinister is a short article placed with minimal pomp on page 15 of the Guardian 16.12.13. In this David Brindle draws attention to a report from The Care and Social Care Alliance which found there has been a 25% reduction in the number of people receiving State Funded support between 2007 and now. This equates to 347,000 fewer and computes to 483,000 when changes in the age structure and predictable dependency of the population is taken into account:

More telling still is the detail contained in the excellent original study report from Fernandez, Snell and Wistow of the PSSRU in Kent. This identifies a disproportionate reduction in the number of old people receiving help (down 30%). Some sections, notably people with Learning Disability are actually more likely to revive help now than had been the case in 2007.

While there has been increasing noise and celebration of moves to improve recognition of dementia and its management, services for older people, including those with dementia, have been quietly, brutally decimated.
Perhaps this explains to some extent why Richard Ashcroft and every caring family find early identification and ‘diagnosis’ a present with attractive wrapping but lacking what they had hoped for once the paper is off.

This is something for the Specialty to address in its role as advocate.
Do we still identify with this role?
But it does need fierce attention from all caring people, the voluntary organisations, if they have not been effectively gagged, and by politicians.

In the mean time, as you say, there are models which can make better use of the resources available. These include the Gnosall model of memory (and other) services which bring specialist skills into primary care, and the Willow Wood model which offers palliative care and teaching relevant to people with dementia (and other progressive disorders) and those caring for them.

The key to these successful approaches is respect for the individual and their family and continuity of care based in knowledge of the people and their needs and the availability of local resources.
The Willow Wood service drew on the experiences of an earlier initiative from St Christopher’s Hospice:

Scott S and Pace V (2009) The first fifty patients: a brief report on the initial findings from the Palliative care in dementia project. Dementia 8; 435 DOI:10.1177/14713012090080030705

The Gnosall model is, I think, unique but you may think there is something similar to be found in the model created by the late, great George Ashcroft with the GPs and community hospital of Inverurie.
This was his contribution to thinking and service development after retirement from a distinguished career as an academic General Psychiatrist in Aberdeen. He presented it with clarity and passion at a meeting of the Section in Glasgow. There is a published account:

Ebmeier, K. P., Besson, J. A. O., Blackwood, G. W., Eagles, J. M., Beattie, J. A. G., and Ashcroft, G. W. Continuing care of the demented elderly in Inverurie. Health Bull (Edinb). 46, 32-41. 1988.

I am not sure if the experiment has been continued. Nor am I sure whether Richard Ashcroft is in any way related to George Ashcroft but we must ask.

There is hope in these continuities and we owe it to Professors Ashcroft and all others in the real world to use the knowledge we have to better and more generalised effect

Mon, December 23, 2013 @ 8:11 AM

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