Is this the world we created….?

I’ve been asked to talk at a Masterclass on Design for Dementia and Ageing at Stirling University this week.  The brief is 10mins on the environment, dementia and acute care. The focus is on the real world aspect rather than reams of data.

So what do we mean by the environment? Type that into Google and you get this:

’the surroundings or conditions in which a person, animal, plant lives or operates’

They often like to provide an example of how to use the word and given the subject matter this one really struck a cord:

‘survival in an often hostile environment’

That is exactly what coming into hospital is like for the person with dementia.

Now before I get into this some more I want to be clear from the start that the people working in hospitals do not deliberately create this nor do we go out our way to make it as horrible an experience as possible.  That said you will frequently hear colleagues talk about how hospitals ‘break people’.  Even in my recent visits to care homes staff would tell me about how residents would seem both cognitively and physically worse after an admission to hospital.

We know that people admitted to hospital are not there because of their dementia but due to conditions associated with it e.g. falls, hip fractures, chest infections, delirium etc.  With that in mind hospitals are perfectly designed to deal with this array of illness. What it was never designed to do was be a place that met the needs of a cognitively impaired person.

Years ago I heard a talk that somewhat poured scorn on the notion of ‘artificial’ dementia friendly environments.  At the time I could understand the frustration – how does a mock 1950s kitchen or living room help?  If they’re well enough to be in a sensory garden should they not be at home recuperating/rehabbing….?

However people with dementia get sick just like everyone else.  So when you need admitted with pneumonia or a fracture then I do think hospitals should do more.  It is not the person’s responsibility to adapt to our broken systems and processes.

There is evidence that if we invest in the environment we can reduce length of stay, falls and violent/aggressive behaviours.  Not to mention the positive effect it can have on staff caring for these people.

The evidence points towards simple, inexpensive measures having a big impact.  Clear signage, quiet, well lit clinical areas.  Ironically the move toward single rooms in new build hospitals has prompted discussion about resurrecting the Day Room as a place for social interaction.

Perhaps one of the biggest challenges is in creating an environment where families/carers are welcomed.  If we are striving to have the person with dementia feel safe and secure then we need them.  They very often point out things that we have become blind to ourselves.

So I would like to see the hostile environment of acute care become a place where the person with dementia thrives and not merely survives….

For more info:

Thanks to Janice McAllister (@janicemcalister) for providing some of the refernecesIMG_4304


True Colours


Our lunchtime meeting this week featured a talk by George (@ilovehermind), one of our junior doctors on health issues in older LGBT people.  It was incredibly thought provoking.  It’s rare that a presentation makes me want to immediately go and learn more. However as I soon discovered there was very little to find.

First up I went to the British Geriatrics Society website and typed ‘LGBT’ into the search facility. No results.  Hmmmm…. disappointing.  I then tried typing ‘Gay’ – nothing again.  In fact despite typing an array of acronyms and looking amongst the various headings I couldn’t find anything.

I tried Health Improvement Scotland. They’re bound to have something I thought.  Eh, that’s a no too.

I was starting to get annoyed….

Eventually I was able to find the articles that George had referenced in her talk.  What I hadn’t really appreciated until now was the range of issues that our older LGBT community faces.  More over how little attention or recognition they receive.

I am also slightly ashamed to say the issues raised had never really crossed my mind.  I guess I have always considered myself to be the type of person who doesn’t pay all that much attention to perceived differences. I will treat people the same whoever they are.

That said over the next couple of days I began to reflect on my own practice.  To my knowledge I have looked after only a few older LGBT people.  I have never asked nor have I made assumptions.

Is this wrong?

I’m beginning to wonder if it is.

I have been corrected on many occasions by the women who I have said hello to as ‘Mrs’ only to be told ‘it’s Miss’.

Then there was the man who I looked after years ago with the low impact hip fracture.  He told us some weeks later that in fact he had been born female but had been brought up and identified as being male.  This was told to us in confidence and I’m very honoured that he felt he could share that.  However when a well intentioned Healthcare Assistant shaved the beard he had been trying to grow for months the devastation felt by all was awful.  He never said not to and she just assumed he would want to look well groomed.  Now I appreciate that’s a very specific story but it has stayed with me.  What could we have done differently?  Each time I come up blank…. The story came back to mind when I read this quote:

‘Coming out’ is an on-going, dynamic process. Every unfamiliar person and place (such as a hospital or nursing home) demands yet another decision about disclosure. (Age UK)

So as we talk about frailty and all the other conditions that occur in old age I don’t recall any conversation about the needs of the LGBT community in old age.

Are they any different?  In some respects yes but in ways I hadn’t really considered before.  There is a higher proportion who drink alcohol and/or take drugs.  We are also now seeing approximately a third of newly diagnosed HIV cases in the over 50yrs and 5% are >65yrs.

However what I hadn’t appreciated was the issue around social care and loneliness. The combination of family estrangement and/or no children leading to social isolation and lack of support network. Some good news and an attempt to address this lies in Manchester City Council opening the first LGBT care home:

To be honest George’s talk was a real eye opener for me. I became a Geriatrician because I believed that older people were largely the forgotten mass who got a rubbish deal from the NHS. I wanted to be their advocate. I now realise that I have been somewhat blind to a group of people within this. I am delighted that Geriatrics is now front and centre in the NHS.  However I feel we may have some way to go to ensure that all older people receive the care they deserve and are entitled to.

For more info:

health, Leadership

Run the World (Girls)

This week was the Centenary of the Medical Women’s Federation.  Although I couldn’t get to events down in London Izzy Utting, an Edinburgh medical student, had organised an event entitled ‘How to have your cake and eat it….’ With actual cake!196048




I was asked to speak partly due to my role in the MWF (secretary Scottish Standing Committee) but also as someone who has apparently achieved some degree of success as a female doctor.

This I had to smile at that.  ‘Me? You sure about that?’

Preparing for my presentation I couldn’t feel any less inspirational or motivational.  I did seriously debate putting a slide up with:

‘You’ll figure it out’  (drops mic and walks off stage)

Ahead of me were two amazing women Dr Sarah Stock (@evbasedbaby) and Dr Rebecca Heller or Bex (@rebeccalily) talking about their career.  While there were stories of inspirational high achieving women they were both refreshingly honest about some of their life choices and career failures.

Although our talks were prepared independent of each other there was a recurrent theme – Imposter Syndrome.  That nagging irritating voice in your head that tells you are a fraud. The one that causes everyday to be spent in  state of anxiety worrying you’ll be exposed as a charlatan.  I must say I hadn’t actually come across this term until relatively recently but I had experienced all the symptoms.

You see Imposter Syndrome is like a parasite – feeding off your insecurities and self doubt.  It messes with your head so that you are unable to recognise other women going through the same thing. And let me tell you they are.  It’s just it makes you believe that the first rule of Imposter Syndrome is: You don’t talk about Imposter Syndrome.

Bex shared the statistic from an internal report for Hwelett-Packard that men apply for a job when they are 60% ready compared to women who wait until they are 100% ready (Sheryl Sandberg, Lean In). I think this probably tells us all we need to know about its destructive power.  I’m also pretty sure this is why only 24% of Medical Directors are women too (Kings Fund).

So I decided to face mine head on.  A parasite only survives if you feed it. Or in the words of Maya Angelou:


So I stood up and talked about how I had failed. Quite hard to do as a control loving, micro managing perfectionist. That said I made it sound as spectacular as possible – old habits…..

I also talked about what I was lead to believe were terrible career choices.  For example starting a family as a Registrar – something only a handful of people did at the time.  I was also told not to go part time because ‘you’ll never get a Consultant post’.  And for goodness sake what was I thinking about going part time again as a Consultant.  Apparently you’re meant to increase your work load at this point.  Life it seems can wait until you retire.

This is simply not good enough.

So what did I tell these young women:

‘You do what’s right for you at the time’

That means:

  • You will make mistakes – it’s ok you will learn stuff from this
  • You have the right to change your mind
  • Trust your instincts – especially when taking advice.  That person may only have their own interests at heart, not yours.

So can have your cake and eat it?  Yes. Absolutely. And I encourage you to try every single one….


Go with the flow

laxative-articleMonday morning, post weekend on call. It’s not been the best in terms of bed capacity and ‘flow’ but we’re all still here.  Good enough?  Well possibly not. As I started my ward round I was paid a visit to tell me we were minus many many beds.  ‘Was I aware of that? It’s simply terrible. Please do whatever you can to make more beds become available’

‘No problem’ I replied.

There isn’t any point getting annoyed.  It’s not the first time I’ve been interrupted simply to tell me how busy it is.  I’ve even been summoned to meetings to tell me in person. After a fashion you tune out the white noise.

However I have had trainees and nursing staff remark to me;

‘What difference is sending one person home when we are minus 50+ beds?’

‘What I hear is I’m not working hard enough.  What about the times when everything is going well?  You don’t get pulled into a meeting to be told good job’

‘Do they think I’m sat on my arse twiddling my thumbs?’

So reflecting back on the weekend, it had all started so well.  The sun was shining and we had beds.

There was nothing especially remarkable about the case mix or the volume coming in.  This continued on into Saturday but by lunchtime it became apparent there was a problem.  No one was moving out of the acute assessment unit.  By teatime things were stuck.

It was clear that we were experiencing a severe case of constipation.  Every attempt to discharge precipitating colicky pain in the system. It was just too hard. By Sunday we had some flow but not the good kind.  It was the kind of overflow flow that goes into all the wrong places.

So how do you manage a bowel impaction secondary to constipation?  Well sometimes you need to decompress the situation through a naso gastric tube.  It doesn’t clear the blockage but it does make you feel better and able to cope with the pain.

So how do we achieve this in the NHS?  Well, we don’t really.  We just remind people how uncomfortable they are and imply it’s their own fault as they aren’t trying hard enough to move things along.

I think we should instead allow people to ‘decompress’ naturally. I’m talking about listening and acknowledging how hard it is. Allow people to vent. Once rid of all that hot air and bile you might find people are much more willing to offer practical help and suggestions.

Now that of course still leaves the constipation blocking the natural flow of things. I would recommend a variety of laxatives for this.

There’s the gut stimulant – perhaps the multi disciplinary team (MDT) in this situation.  Get more physio and occupational therapists. Or perhaps offer a targeted and focused MDT to get people up, help them with their walking, offer adaptations and support at home.

We have the stool softener – making the journey out that bit more pleasant. Our ward teams including pharmacy are key here.  Taking the time to explain to the person and their families what has happened and what to expect on discharge.  All of this neatly packaged into an immediate discharge letter and sent to their GP.

You also need to tackle things from the other end through a high phosphate enema.  To me that’s social work.  Get the assessments done, secure funding and either get the person home with the care package or into a care home as quickly as possible.  You will get an almost immediate result with this.

Employ all these strategies, flow returns, pressure is relieved and everything is that much better.  Ah…..

Of course as many of my older patients tell me, it’s best not to get constipated in the first place.  I am constantly being told that prunes are the answer. They are tasty, effective and cheap.  I guess that’s what integrated health and social care aspires to be (just not as cheap).

So will tomorrow be any better?  Marginally.  Will I do anything different to what I already do? No. Sometimes it’s best to just go with the flow…..

Dementia, education, Uncategorized

All that matters to me


This week I was invited to talk to care home staff at Erskine.  It was part of a series of talks to raise awareness about delirium, mobility issues in those with cognitive problems and dementia.  In addition to these clinical talks were two from a relative and carer perspective.  One was Tommy Whitelaw (@tommyNTour) talking about his mum Joan.  The other was given by a family member of a current resident.

I must say when I saw that relatives were speaking I thought: ‘Wow! That’s quite a brave thing to do.  I wonder how the staff will react?’

I’m all for putting my head above the parapet but not many others are.  It can be incredibly difficult to hear feedback, no matter how constructive, without first putting it through a defensive filter.

That said I found what they had to say both incredibly moving and challenging. I don’t mean that critically either.  When you work in your own tiny eco system of healthcare you can desensitise or even forgot how a simple turn of phrase can inadvertently upset a person. To hear that your mum is ‘too good’ for a care home after you’ve spent months anguishing over the decision can bring back feelings of guilt.

We were also reminded to take the time to remember that this person is a mum, a dad, a brother, or a sister.  This person will never be a resident or a client to a family.  They are people with stories and lives of their own.

It was these talks that had the greatest impact for me.

You see we talk a lot about being person centred but if feels like being in an echo chamber at times.  What do I mean by that?  Well, it tends to be people working in the health service talking about the need to be person centred.  I rarely hear the patient or relative perspective in these meetings.  It’s also started to feel a little competitive:

‘And the prize for person who talks the most about person centredness goes to…..’

I personally feel that it you were you wouldn’t feel the need to go on about it so much. You would just be.

So what makes the difference then?  Tommy and I spoke about some of the people he’s met over the past few years.  It’s quite a list although I got the impression that those who have affected him the most are those on the ground, so to speak.  For all the pledges and promises of funding from on high it seems to get stuck on the way down to those who need it most.

As Tommy said caring is not seen as a career to aspire to. Even those working in the care home sector will struggle to get access to adequate training and education.

We have created this culture so we alone are responsible for changing it. I don’t want to hear people talking about what they should do.  I want to see them actually doing something!

I’ve always been a believer in the concept of small steps of change. You are however investing time and effort in a very distant future so it does require patience.

Looking around the room after Tommy spoke and seeing many in tears, it was clear that a difference had been made.  And that’s all that matters……