This short closing section on “delirium” has taken as a title a few words from Love in the time of Cholera. I have read this book several times and the Fermina Daza’s tea69 always struck me as a metaphor for the best approach to understanding: that we should try and infuse this with real-world considerations. I could see in this tea, the words of Leon Eisenberg, words that have equally mattered to me in my approach to improving health, understanding and care:
“The very success of biomedicine has exacted a price in the way it has narrowed the physician’s focus exclusively to the biology of disease. However, the remedy does not lie in abandoning reductionism where it is appropriate but in incorporating it within a larger social framework to enable the physician to attend to the patient as well as to the disease.”45
Leon Eisenberg was also of the view that “what has hampered progress is too narrow a view of the sciences relevant to medicine.”45
I am going to conclude, that well intentioned as these pathways to “triage” our elderly by mandatory cognitive screening tests most certainly are, there are risks. This process involves reductionist tests, being recommended for use by non-trained staff. The risk is that such shorthands are regarded as more important and robust than overall holistic assessment. I use validated rating scales everyday and when used carefully and ethically they are an important part of overall assessment.
In improvement work such as this might we unintentionally be strapping ourselves to isolated measures that are the “quickest” and perhaps cheapest ways of addressing the needs of an ageing population who may present unwell? Would it not be better, for all concerned, if we trained and provided more frontline staff, doctors and nurses, who take a holistic, scientific and ethical approach to proactive old age medicine?
The Clinical Standards may be 12 years old now, but these words have surely been found prophetic: “Geriatrician involvement in acute care has increased over the years, but the pattern of service provision and the degree of collaboration with other specialists vary greatly across Scotland. Only a minority of older acute sector patients are cared for by geriatricians. Care of older people is now a major task for most acute specialties.”35
I want to very briefly talk about fear. This matter was actually raised by Dr Graham Ellis in his film for Healthcare Improvement Scotland. In talking to the relatives Dr Ellis has become acutely sensitive, as I have, of “the fear that their loved ones have of being admitted to a Nursing Home.”17 In my job as an NHS Consultant in the community I see patients recently discharged from hospital. I am of the view that they are more fearful than ever about being understood for their cognition alone. That they are aware that they will have memory tests whether they like it or not. The line of thought that follows may be subconscious, but it often seems to be: “if they think I am confused they will regard this as dementia (or Alzheimer’s)” – “I will not recover from this” – “I am going to end up in a Nursing Home and die there.”
This is why we need to engage our elders in decisions that may affect them. We can and should ask relatives and carers, but we also need to study wider cultural fears in our ageing population generally so that we improve care as we all wish so to do.
Bettina Piko suggested in a paper now a decade old, that medicine should be viewed as an “integrative, biopsychosocial science,” and that “medical education must involve the study of the biological structures and psychosocial functioning of human beings not as separate systems, but as interactive ones.” Dr Piko suggested in conclusion that the “physician needs to become a sort of neo-polymath in a new Renaissance.”
This week a good example of such an approach was published in the BMJ online pages. It was by a Senior House Officer called Dr Sarah Lois Pinninty. One of the points that Dr Pinninty made was the risk of over-burdening services through well-intended improvements that are based on reductionist and poorly validated tests. The potential situation that may arise is that as services are stretched further, those most in need actually may be less likely to get the level of service they require. We must be wary of faltering steps into a world of inverse-care.
(click anywhere on the picture above to play film)