I am just not sure about this

It is clear that the rising number of people with Covid 19, and increasing numbers requiring hospital care, with some going on to death, mean that something must be done.

A lockdown may reduce the spread, the number of cases and deaths for now, but I cannot see that this sort of action can be repeated or extended over and again – And won’t the virus still be there? The hope and belief that a vaccine can be created that will contain Covid 19 seems to me to be far from certain. Sensible public health measures carry more realistic promise – total lockdown is one such – but the benefits in terms of reducing spread of infection have to be balanced against the harm which we see coming from the deprivation of liberties, the stress of endless isolation and denial of comfort from friends and family, faith community and more.

For most it seems right to allow schools and universities to continue their work so that the education and disciplined socialisation of young people is not truncated. It is clear that shops providing essentials must continue to be staffed and to make their goods and services available. What is to be deemed ‘essential’ is not so easy to agree on. Hospitals, care homes and community services must continue their work, though some community services mainstream or voluntary, have been modified or stopped from the beginning of the first lockdown and never reopened. There are huge disadvantages, consequent upon this loss of services, for people with illnesses or disabilities arising from physical or mental disorders, which are often present in combination, and in combination with social disadvantage. Old people and people with dementia and their families are most likely to be affected. The harm is there already, has had its consequences and a return to across-the-board lockdown will surely make it worse.

Agriculture and manufacturing industries have to be allowed to continue – with limits and discipline. Some recreational activities, particularly those where alcohol and other substances are likely to encourage careless and thoughtless behaviour, might be curtailed or stopped. Travel for travel’s sake, cruises and such like, can be delayed for now without great loss other than to the companies which have offered them. But mutual support within families, neighbourhoods and communities, including faith communities, should surely be respected, protected and allowed. Such activities are strengthening at all times, and most particularly in adversity.

The people who will benefit from such an approach are those who are most vulnerable. These include the million people with dementia in the UK

It is good that the leader of the Roman Catholic Church in England and an organisation of imam’s have raised responsible questions Catholic church leader criticises Covid worship restrictions in England

All over the world

This morning I hosted a pre-recorded session for the Alzheimer’s Disease International conference which will be on line in December. The original plan was for a conference in Singapore, but the pandemic ruled that out. Biennial international conference | Alzheimer’s Disease International

We were together courtesy of Zoom and excellent support from the conference secretariat. For me it was a 5am start. For Suhad in Qatar and Li in Taiwan a more civilised time in the day, and for Claudia in Melbourne it was 5pm. But this was our hour together and in synchrony. How wonderful.

It is humbling to see and hear what people are doing in countries around the world.

Suhad, who is by training an occupational therapist, reported on a survey and scholarly investigation of age, infirmity and mental disorders in older people as framed within Islam. The research searched religious texts and collected information and views on beliefs and care practices from families and practioners. The holy texts describe and interpret the characteristics of normal ageing and pathology of late life accurately and with sensitivity.

Claudia – also an occupational therapist described the creation of a tool designed to help people with dementia, their families and professional carers engage in conversations which identify key areas of activity and agree what can be done to enable as full a life as possible. Cue cards – with words and pictures set up consideration of, for instance, mobility: standing, walking, climbing stairs, riding by public transport, riding a bicycle – or driving a car. Conversations are inclusive of all relevant people – and views and comments are written down with an explanation of what plan is agreed, why, and with what awareness of risks. Questions confirmed that this is seen as a potentially useful idea for introduction in other communities. The issue of capacity and how to enable people to contribute as their competence fades, is crucial.

Li has been involved with dementia care in Taiwan for over 30 years. She spoke especially of dementia within Christian communities and the creation and further development of Dementia Friendly Churches. Church communities are large in Taiwan – there are over 4,000 churches and all are now ‘Dementia Friendly’. It is through them that many families receive information about dementia, can obtain training and ongoing involvement in seminars.
There is an annual Dementia Sunday, with special services and worship focussed on dementia and people with dementia. People with dementia and their families may be baptised and are seen to gain relief and pleasure from involvement in worship. Suhad shared observations of the comfort and relief derived from familiar Islamic texts and prayers. These are the added ingredients to support within faith communities.

It was a wonderful early morning session and will be much appreciated by delegates. There must be the possibility that more people than ever will be able to access the ADI conference as an online event, so the messages and learning will spread even further than usual. The drawback is the loss of time away from formal sessions where people get to know each other, ask more questions and explore more ideas. Costs, use of time, and pollution from transport are much reduced. Perhaps a new balance will emerge.

The way people live is important

By David Jolley

We are living with hyperarousal generated by fear of COVID-19. It was uplifting during this past week of escalating tension and conflict reflected by the media to find some oases of calm thoughtfulness.

One was a comment as we compared illness and deaths amongst patients and staff of English mental hospitals from TB during the First World War and residents and staff of care homes during the COVID-19 pandemic. Dreadful at the time, but largely forgotten is the comment from 1917. Lessons learned – none as far as we could see. But this led to the related observation on the present: ‘To listen to some epidemiologists you would think there is only one illness – and that is COVID-19.’ The burden in terms of other physical illnesses and mental disorders is many times greater than that directly attributable to the virus. Much more damage is being done by the gross knee-jerk reactions of government.

The other source of sense came in a letter from Professor Anand an economist from the Open University. His research with colleagues in Oxford, Manchester and New York finds that transmission of COVID-19 is dependent upon people’s living circumstances – shared kitchens and shared accommodation being powerful predictors of spread. This is linked to lower incomes. Blunderbuss reactions which require everyone to stay at home compound this problem rather than alleviate it, and cause additional damage to others who live in other accommodation when they are deprived of chance to meet others and engage in humane, useful social activities and work.

Government ‘really should be engaging with communities about ways in which they can protect themselves rather than handing out overly simple messages that fail to account for important differences in the way people live’.

Time to think and take small steps with humility.

Comfort and inspiration near to home

You can feel we are drowning in the daily deluge of information, exhortations, angst and frequently changing rules about Covid 19.

It is all important – but we need a balance – and most ordinary people, including people with dementia and their families, are grateful for something less frantic, something reliable and lasting.

Pope Francis has provided some blessed assurance rising above the hubbub of sound-bites and one-liners which add up to nothing http://www.vatican.va/content/francesco/en/encyclicals/documents/papa-francesco_20201003_enciclica-fratelli-tutti.html

Elsewhere the newspapers have rediscovered the balm of nature – in small form as in house plants, who’s inclusion in the home, however small and confined, is associated with a greater sense of peace. In hospital the presence of plants encourages and speeds recovery to earlier discharge: https://www.theguardian.com/commentisfree/2020/oct/04/the-guardian-view-on-houseplants-balm-for-troubled-times

In more magnificent proportions, as in trees, we can drink in their presence, shape and, especially at this time of year, wonderful and changing colours. https://www.theguardian.com/environment/2020/oct/06/uk-set-for-burst-of-vivid-autumn-colours-after-sunny-september

https://www.theguardian.com/travel/2020/oct/10/into-the-woods-in-search-of-britains-ancient-oak-trees-wiltshire

You don’t have to go far for this treat. There are examples all around with walking distance, or a short drive Walk back in time: four historic hikes in England’s woodlands

What a wonderful world.

Breaking out

This week has seen the imposition of more restrictions on people’s activities in attempts to reduce the spread of Covid-19 – sensible and well-intentioned but in their extreme and catch-all determination, too much for most people to accept:

Extreme thinking would have all older people restricted in their movements to make them safe: ‘Age-based apartheid’ says the head of NHS England – and most people over 65  https://www.theguardian.com/society/2020/sep/28/asking-over-65s-to-shield-is-age-based-apartheid-nhs-england-boss-says-covid

There are concerns for the safety of residents and staff of care homes, but the ingenuity and resilience of the care home sector internationally is evidenced by the introduction of competitive virtual cycling Out of retirement: the care home seniors chasing global cycling glory

I have been approached by organisations and individuals wanting to find something for people with dementia to do locally. So many activities have been scratched because of the rules of Covid – rules which have changed, varied place to place, and frequently seem less than logical.

A former colleague from another town was in touch last week. He has survived after a life-threatening infection with Covid, including six weeks in intensive care, four weeks on a ventilator and labelled ‘DNR’. He has no doubts that care must be taken to protect the most vulnerable. We agree – but with care and discipline we should be able to engage people in health-giving activities, especially in the outdoors.

Within the government’s rules, and with the oversight of The Ramblers Association, we and other Health Walks have cautiously returned to action. We are including some people with dementia – accompanied by a carer. The pleasure and animated expressions tell the story. We keep apart, but we do talk and look and comment, and appreciate. Today the morning was lovely with sun and colours from the leaves. Another week it may be raining, but we will feel it and be glad.

‘I can’t always get the word I want.’ But knowing you want it, and having a cause is life. Protected silence is death.

Geriatricians released us from cot beds and Buxton Chairs. Prudent activity will do much to save us from Covid-19.

Covid cultures

Restrictions across all age groups and most places are the order of the day to save us all from Covid-19. Cases are rising, and hospitalisations and deaths are also – but these latter are far fewer than when Covid was in its first flush. Deaths from Covid are few compared with total deaths per week. There is a view that a less aggressive and more focussed approach would be more effective and less damaging.

Professor Sunetra Gupta of the University of Oxford, and 26 other highly qualified and respected experts wrote cogently

 ‘Our view is that that the existing policy path is inconsistent with the known risk-profile of Covid-19’.

Current policy they say is predicated on an aim to suppress the virus and anticipate an effective vaccine but: ‘This objective is increasingly unfeasible … and is leading to significant harm across all age groups, which likely offsets any benefits’

‘Instead, more targeted measures which protect the most vulnerable from Covid, whilst not adversely impacting those not at risk, are more supportable. Given the high proportion of deaths in care homes, these should be a priority’

Care Homes – identified as requiring priority attention see the downside of protection which denies families the chance to be together – it takes away the will to live https://www.theguardian.com/world/2020/sep/23/covid-ban-on-care-home-visitors-risks-premature-deaths-experts-warn

And some homes are seeking to counter this by inviting families to live in the home, with their relative, for free https://www.theguardian.com/world/2020/sep/23/relatives-invited-to-move-into-care-homes-in-england-amid-covid-lockdowns

Excess deaths compared with the five year rolling average are now confined to people dying at home 10,000 more deaths than usual occurred in UK homes since June

Commentators suggest that this is because people are even more fearful of the hazards of care homes and hospitals than usual. The concern is that some people are dying who might have been treated successfully from their ailment if seen by competent medical staff. Despite a plethora of automated emails and texts from our own doctors, the experience is of a service determined to keep patients at a long distance.

I hope that Professor Gupta’s group will get a fair hearing.

National Covid Neurosis

The problem may be international – but what I pick up is mainly from the scene in the UK After a couple of weeks with the news giving more prominence to other matters, this past week has been ravaged by fears of the Covid-19 Pandemic. There is no doubt that here, and in other European counties the number of people contracting the disease has increased – mainly younger people, often because of involvement in reckless social activities, oiled by alcohol or other substances, in a culture encouraged and sponsored by government.

This is a hazard for young people, but more so for older people, especially those carrying multiple pathologies, including dementia – and especially those in care homes or hospital. Also at additional risk are the care workers, especially those of the BAME communities. Has anything happened since the first and devastating surge of Covid-19 which will make lives safer in those homes? There are reports already of lack of PPE. The dynamics of hospital to care home transfers may have been tightened up, but maybe. The dynamics of the workforce remain the same as far as I know – Shortages of staff, loss of staff by deaths, self-isolation and illness mean that some homes are dependent on agency staff, who work because they cannot afford not to – even when they are ill and will carry infection from one setting to another.

Yet we have become aware that there are alternative hazards to people, arising from the responses to this threat, as much as from the physical risks of the infection. It has its grip women and especially within younger age groups, with 30% being anxious. Despite all the changes in the past decade, older people remain more philosophical. https://www.theguardian.com/society/2020/sep/14/uk-has-experienced-explosion-in-anxiety-since-2008-study-finds

Focus in care homes has become the consequences of isolation and loss of personal and meaningful contact even when death is approaching. https://www.theguardian.com/world/2020/sep/14/they-could-die-of-loneliness-how-covid-policies-impact-care-homes

There are calls for improvement to the working conditions for staff – Let us hope this can be achieved, but it will take time and a major review of where money is spent https://www.theguardian.com/commentisfree/2020/sep/18/social-care-workers-living-wage-boris-johnson

We are pleased to have schools and colleges reopened and beginning to function again. We are glad to be able to spend time in church, even if we are told not to sing our praises. We are glad to have health walks recognised as an organised sporting activity and to be cautiously started again. It is essential that families can meet in responsible and caring ways.

My favourite observation of the week has been that of Professor Moin Saleem of The University of Bristol who draws attention to evidence that 35 – 50%of the world population has natural resistance to Covid-19 and another 25% has acquired resistance – to it. This means we may be approaching herd immunity. ‘Is Covid’s end closer than we think?’ https://www.theguardian.com/world/2020/sep/18/is-covid-end-closer-than-we-think

‘Confounding’: Covid may have already peaked in many African countries

The world has lived through previous pandemics without the benefit of so much knowledge and science. Our difficulty – and current failure – is to learn from what is fact – and to balance the risks to physical health, psychological wellbeing, and the economy before taking action.

We need collaborative efforts not competition between ‘for-profit’ mega-organisations, and cool heads, experienced in making clinical judgements.

Thinking with your hands

By David Jolley

I was drawn to the report that the University of Fine Arts in Hamburg is offering scholarships to students to explore the concept of ‘active inactivity’.

https://www.theguardian.com/world/2020/aug/20/bone-idle-german-university-offers-grant-for-best-inactivity?fbclid=IwAR096jOC7R9sM6SHSXVh8HpZNR_sHuS6Fc6NmdGXsn2OSUwBiLzl5fNOPto

The Guardian view on ‘idleness grants’: inspirational thinking | Editorial

‘What do you not want to do? For how long do you not want to do it? Why is it important not to do this? Why are you the person not to do it?

This is an exercise in the virtue of ‘sit still’, which has been lost in the hurry and scurry of modern life, but was valued by the stoics and the Christian tradition of contemplation. A very suitable return for our times when so many of our usual movements – valued and lived with – have been muted by COVID-19 restrictions.

More books are being bought and read. Children’s games, dogs, DIY equipment and more are flying off the shelves, as people fill their time with activities other than commuting and responding to the series of checklists, which routine work has demanded of them. There is freedom to think and use time at your own discretion.

‘Look before you leap’. ‘Don’t just do something – sit there’. My mother had advice for every circumstance – inherited from generations of the wise.

Certainly, a life galloped through from one pleasure venture to another, without a thought for where we are going, or have been, is a nonsense and a waste.

Times at peace, reflecting, planning, being glad or glum, are times well-spent and enrich us. But I know that thought without movement can so easily become empty. Music might move us on. Handling things, making things, cutting, digging, painting, walking – physical activities but they enliven our thinking and feelings to generate more than pure stillness can do.

So it is for us – the more so for people with dementia and similar illnesses. It is a great triumph that we have come to realise the therapeutic power of simple movements, especially when linked with social interactions and fun. This is how people with dementia now live longer and happier lives than was the lot for previous generations.

So too for all of us.  We may come to bless this time, when the world stood, or sat, still and began to think again. But thoughts are better when linked to careful movement.

Starting Early

By David Jolley

Still buoyed up by the good news from the Lancet Commission that up to 40% of dementia worldwide could be avoided if policies are adopted to counter known correctable risk factors, news of growing inequalities in the UK makes me angry. We should not let this happen:

the educational attainment gap between richer and poorer students has been widened by the stresses of lockdown. Figures reveal differences which are exacerbated by Covid but were already marked: disadvantaged students are 18 months behind the average by the time they will be taking GCSE. Gypsy/Roma youngster are 34 months behind, while Chinese youngsters are 2 years ahead of the average. Persistent poverty in the UK is now affecting 36.7% of school children.

https://www.theguardian.com/education/2020/aug/26/attainment-gap-between-poor-pupils-and-their-peers-widening

So almost 40% of children in the UK are being disadvantaged for life by poverty and lack of education – the two go together. The demands placed on services and families by the COVID-19 emergency, is making things worse – the poor getting poorer, unless action is taken to help achieve a better balance. Lost education in childhood and youth will have long lasting effects – including a greater likelihood of developing dementia later in life.

A related observation is that children living near to green spaces make better progress with their education: children living in greener boroughs perform better:

https://www.theguardian.com/environment/2020/aug/24/children-raised-greener-areas-higher-iq-study#:~:text=Growing%20up%20in%20a%20greener,an%20average%20of%202.6%20points.

The images of treeless streets and high-rise flats, with little access to parks or the countryside, come easily but uncomfortably to mind. The COVID-19 crisis has seen parks heavily used and appreciated, though abused and misused by some Parks in a pandemic: a glimpse into the future?.

Education (lack of) is identified as the second most powerful predictor of cognitive loss and development of dementia late in life which can be corrected. Correction will reduce incidence of dementia by 7%.

The COVID-19 emergency is teaching lessons – but we need to take note and turn the learning into action. For the health of all across the age groups, we need to build in greater equality – with special stress on education for disadvantaged people throughout their lives. We need to invest more in achieving a balance of available public green spaces.

Physical fitness and health in later life

By David Jolley

Professor Archie Young died in March this year, but I did not see his obituary until this week.

https://www.bgs.org.uk/policy-and-media/remembering-professor-archibald-young

I met him during a visit to the small and wonderful rehabilitation hospital in Hampstead. which he ran with Nori Graham. It was one of the most spectacular demonstrations of the benefits of Physicians and Psychiatrists and their teams working together for the benefit of patients. Would it be that there be more. Why is this not routinely part of how services for older people are configured? Why are nurses forced to choose whether to be ‘adult’ or ‘mental’ early in their training, when so many patients have mixed pathologies?

Archie Young was the son of Archie Young – an anatomist in Glasgow, and grandson of Archie Young – Professor of Surgery in Glasgow. A family tradition of excellence – sealed in a name. In addition to his medical studies our Archie Young was an extreme athlete – excelling in sports from swimming to rugby and eventually ice-climbing. Bringing these attributes together his research and clinical interests focussed on improving and maintaining physical fitness and strength in late life. He showed that it is not inevitable that older people lose muscle strength – exercise can reverse the decline – with benefits to general health, including mental health. He co-authored ‘Physical activity for patients: an exercise prescription’ for the Royal College of Physicians 2001 – his chapter 5 (p31-42) addresses health in old age.

Sad to learn that his last years included life with Lewy Body Disorder – despite which he remained active. Lewy Body Dementia was not recognised when I began to practice but was identified in the late 1970s by researchers in Nottingham and Newcastle.

Living with Lewy body dementia

There is no recognised association with previous athleticism – on the contrary – physical activity is held to protect against the development of Parkinsonism and Lewy Bodies characterised by accumulation of alpha-synuclein. The mix of physical and mental symptoms can be ameliorated by regular exercise.

So much to learn. So many good people to be grateful for.