Love activity but hate exercise? by Erin Archibald

“Drop down and give me 20”…

What do you think about when you hear exercise and strengthening: sweatiness, gyms, Lycra, pain. As a busy mum to 3 children, exercise is something I don’t have much time to do but am I active? Absolutely!!

erin1I am a specialist Physiotherapist within the reablement service STARS ( short term assessment reablement team)- and my main role is to promote exercise and well being in the community- my target audience- not lycra gym bunnies, but over 65 year olds who normally have a long term condition who are recovering from a spell in hospital, and likely do not own trainers or know what a squat entails.  Who am I to advise to join a swimming group, attend low impact exercise classes or complete a rehab programme when I do not complete myself? Instead I walk to the park, climb up woods, I cycle with my children, I chase after them endlessly… so we need to think different about activity.

The benefits of rehabilitation, recovery and reablement support are well evidenced in Health and Social Care interventions.  The support improves a person’s ability to function independently, encourages exercise choices and to take control of their daily activities.

I work closely with 3rd sector and community teams, to encourage and promote active participation socially- tailoring every service users needs with their capabilities and skill sets and I see the patient as an individual not a condition.

  • what are their hobbies ?
  •  what do they enjoy the most in life?
  •  what is meaningful to them?
  •  what matters to them which they are currently not able to do or accommodate?

erin2We support service users to identify their goals through good conversations. We also support them to develop, retain and regain their skills by understanding what matters to them- this may not often happen initially but over the course of the reablement process from our support workers, we build relationships and find getting to know them and their families/carers imperative for helping them identify their goals.

We look at well being plans which can be something as simple as getting to the shop to purchase a daily paper, getting back to social activities, or being able to transfer into a bed or car again so they can visit someone important to them. We promote the benefits to exercise in line with recent evidence via Scottish government 2017.  Many include:

  • Reducing falls
  • Improving strength and balance-
  • Improve wellbeing
  • Reduce anxiety, improve sleep
  • Social Interactions/ reduces isolation
  • Day to Day activities become easier

As a registered practitioner, we document their wellbeing plans and agree this with the service user, enabling our health care support workers to deliver the daily practice of the chosen activity, whether this is a walk to the shop, a spot of gardening, making soup or practising stairs/ steps. This allows us to see progression and plan goals,

As a physiotherapist, I have blended alongside the occupational therapists in our team in the last five years to learn the importance of occupation (activity) led tasks and changing mindsets to linking social interests to exercise. In the time it takes someone to boil the kettle, they can do basic exercises such as the Balance challenge or super 6 exercise programme.  Reactivating “activity” to improve health and well being, Independence and quality of life is based on continuing research carried out at Newcastle University Institute for ageing with Professor Gore (2017). For example being able to reach your feet to cut your toenails, walk 400 yards or maintain heavy housework. (http://www.knowedlge.scot.nhs.uk/ahpcommunity/lifecurve-survey-2017.aspx)

So, lets get more active and promote activity, lets think differently about exercise , and think about What matters to you for healthy ageing?

Erin Archibald is a Specialist Physiotherapist, STARS- Short term Assessment and Reablement service 28th January 2019.

Get up, Get dressed, Get moving by Amy Conley

Amy 1 hippocrates1-2x

Think about an older person, someone in their eighties – let’s say it’s your Granma…

Your Granma lives in her own house; she’s not quite so good on her feet anymore, but she gets about OK.  Stairs are difficult but she manages – and she manages to get up and dressed, make her breakfast and her tea, feed her cat, read the paper, get to Tesco in the car with you.

Then your Granma gets ill – she has say, a chest infection.  She is admitted to hospital.  You pack her bag – nightie, toothbrush, comb.  She is admitted to the ward – she is poorly, needs antibiotics and a drip for a few days. So, on goes the nightie and your Granma is in bed; that’s what you do in hospital – you are poorly and tired and you need to rest in bed.

Your Granma is in bed in her single room.  She needs the toilet but doesn’t think she should get up by herself – she is a patient in a nightie so needs help.  But she can’t see very well or hear very well and can’t find her glasses or hearing aids.  She can’t find the buzzer to buzz the nurses and she can’t hear when they are near.   She thinks maybe she could get herself to the toilet, but she can’t see her walking sticks and is scared she will fall. 

Time passes.  Your Granma is incontinent in the bed.  She is embarrassed and frightened – what will the nurses think?

Now she is scared to drink and eat because she doesn’t want to need the toilet and be incontinent again.  And she doesn’t want to bother anyone.  The physio comes to see her, tries to get her up.  But she is still embarrassed and frightened.  She has no clothes to wear.  And she has only those foam slippers she got from the nurse.  So it’s best just to stay in bed.

Your Granma stays in bed for longer and longer.  There is nothing to do.  There is a TV but she can’t see it or hear it without her glasses and hearing aids.   She is getting mixed up now; she can’t remember when she came here or why or what day it is.  She thinks she can see cats in the corner of her room.  She still won’t eat, so she has no strength and feels weak. She doesn’t want to get up.  Her bottom and back hurt.  Her leg has swollen up – they said it is a blood clot.

The physios keep coming back.  They try to get her up; two of them struggle to get her to stand.  She is stuck in bed. 

Your Granma’s chest infection has been treated and she has no acute medical illness, but now she is immobile, confused, dehydrated, incontinent, her muscles are weak and she cannot walk anymore, or get herself washed or dressed. 

Your Granma is not going to manage at home anymore; she has to go to a care home.

 

GET UP, GET DRESSED, GET MOVING

At DGRI, we are launching our campaign on Monday 23rd July– the aim is help our patients maintain their function, mobility and independence while in hospital, and for them to return home as soon as possible, as able as possible.

 

WHY HAVE THIS CAMPAIGN?

  • Most patients in hospital are over 65
  • In hospital, older people spend up to 83% of their time in bed
  • 65% of people’s functional ability declines during admission
  • 60% immobile older patients in hospital have no medical reason to stay in bed
  • If you are over 80, 10 days in hospital ages muscles by 10 years
  • 1 week of bed rest equates to 10% muscle loss
  • These changes are “deconditioning” –  “reconditioning” takes twice as long

Amy 5 pjsketch1Amy 7 sliipers sketch 2Amy 6 pjsketch2Amy 8 slippers sketch 4

WEARING YOUR PYJAMAS IN HOSPITAL

  • Affects your confidence and self-esteem
  • Changes how you interact with healthcare staff and other people
  • Is usually unnecessary no matter why you are in hospital
  • Doesn’t feel very dignified when you are trying to eat your dinner

 

STAYING IN BED IN YOUR PYJAMAS

  • Reduces muscle strength
  • Reduces confidence
  • Reduces function
  • Increases blood clots, delirium, pressure sores and infections
  • Leads to reduced appetite, low mood and anxiety
  • Reduces social interactions
  • Lowers pain thresholds
  • Can make blood pressure drop
  • Causes constipation and incontinence

Amy 4 patient in bed

WHAT CAN HEALTHCARE STAFF DO?

  • All of us can and should help patients get moving – nurses, doctors, AHPs, porters, domestic staff, pharmacists…
  • Ask the patients how they normally get about and what they normally do
  • Make sure patients can access buzzers, water, remote controls
  • Encourage patients to get dressed and sit up in the chair

 

WHAT CAN PATIENTS DO?

  • Tell us how you normally get about and get things done and what you need to help you
  • Try to do things that you do at home – wash and dress, eat and drink on your own if able
  • Sit up in your chair and for meals
  • Drink lots
  • If you can’t get out of bed, do little things – wiggle your toes, do a crossword – every little movement  helps

 

WHAT CAN VISITORS DO?

  • Tell us what you do at home
  • Bring in glasses, hearing aids and walking aids
  • Bring in comfortable day clothes and well fitting shoes
  • Encourage you to sit up in the chair and for meals
  • Take you for a walk
  • Bring in photos, books, puzzles, crosswords

Amy 3 nursewalking patient

THE BENEFITS

  • Speeds recovery
  • Reduces time in hospital
  • Encourages patient and carer involvement in healthcare and recovery
  • Helps to retain patients’ individuality and self-esteem
  • Helps patients to quickly return home, mobile and functional

 

If you or your family are worried that it is not safe for you to get up or you might do the wrong thing – ASK US!  We will tell you what is safe and OK for you!

#endpjparalysis

#goinghome

Amy 2 home

Amy Conley is a Consultant in Geriatric Medicine at Dumfries and Galloway Royal Infirmary

‘What I am told I forget…… by the Renal Team

…what I am shown, I remember.

              …what I do, I understand.’

Renal 1

Confucius was credited with many words of wisdom in his 72-years.  I couldn’t vouch for the authenticity of them all – but if he did utter these words he was indeed a man before his time.

The truth behind these words was apparent to me at our recent Kidney Care Planning Education day. The Kidney Care Planning Service has undergone a bit of a re-incarnation in the last couple of years. Formerly known as the Pre-dialysis service, it is simply the care of patients with an eGFR of less than 20mls/min, as they are more likely to progress to end stage kidney failure and need to plan for such an eventuality. However, the term ‘pre-dialysis’ implies that these people are all heading towards dialysis – when in fact many will choose an alternative path. The younger fitter patients should be hoping to get a pre-emptive kidney transplant from a relative or friend, while some of our elderly, frailer patients may well not benefit from dialysis at all and will survive just as long on conservative (nondialytic) care. So when Tanya Harkness took up the mantle of lead Nurse for the pre-dialysis service, she quite rightly felt a new name was required. Many renal units use the term Low Clearance Clinics, but a straw poll of non-renal staff suggested this was more reminiscent of a rehabilitation clinic for inattentive bus drivers… So, after much discussion amongst the renal team, the more accurately named Kidney Care Planning (KCP) service was born.

The aim of the service remains unchanged and while we do take bloods and treat symptoms, easily 80% of what we do is talk. More specifically we provide as much Renal 2information as we can to help every person decide which treatment option is going to suit them best. We do this with clinic visits and home visits. We provide information leaflets, website addresses and even YouTube videos – all with the aim of imparting information. Yet still we are sometimes asked a question that blindsides us – that either leaves us thinking ‘How did you not know that from all the conversations we have had?’  or ‘Crikey- that’s a good question that I have no idea how to answer!’ Because at the end of the day none of us handing out this information have ever experienced what they are going through – the actual treatments, the fear and anxiety, the dread of what their lives will become or the understandable desire to block it all out and pretend it’s not happening.

Which brings me back to Confucius! The subject of teaching is vast, with as many different approaches as there are pizza toppings. Yet 500 years BC, Confucius nailed it with this simple truth – when we actually do something, we come to understand it. So who better to teach our patients, than other patients who have been in the same boat.

We have held education days in the past, usually in a hotel function room with talks given by members of staff. Tanya was keen to resurrect the concept, but made it quite clear from the outset that there was ‘No way on God’s earth’ I think was the phrase that she was ‘EVER’ standing up in front of a room full of people to give a power point presentation. (Why not, I have no idea as I am sure she would be excellent….but there we are!)

So a new format was devised between the whole community team – a less formal approach, like an open day, where patients could turn up and wander at will from room to room – talk to the team leads, watch demonstrations, see the equipment and most importantly meet other patients.

The date was chosen to coincide with a visit from Ewen Maclean, Kidney Care UK Patient Support and Advocacy Office, Scotland. Ewen, himself a renal patient, is a mine of information about the support available to kidney patients, grants and how to apply for them and the political landscape that shapes kidney care in the UK.

We no longer had need of a hotel function suite – if there is one thing we are not short of at Mountainhall it’s space! (And the parking is pretty easy too – sorry!!) So, we sent a personal invitation to all our KCP patients, laid on refreshments and opened up the old pre-assessment unit for the day.

Renal 3The Renal Community Team (Left to right): Fiona Gardiner (Renal Dietitian), Robert McLemon (Transplant) Ian Mottram (Haemodialysis – both home and in-centre), Wendy Brown (Peritoneal Dialysis) Margaret McDonald (Clinic Health Care Assistant & Phlebotomist), Linda Stiff (Vascular Access), & Tanya Harkness (Kidney care planning).

Renal 4As well as written information everyone had something practical for patients who attended and the responses we had were truly illuminating. Ian had a haemodialysis machine with all the lines and bucket of dialysis fluid set up and received the comment ‘Oh, I didn’t realise it would be so small-I assumed it’d be really big.’ And why not –historically dialysis machines took up a whole room, which must be a really intimidating thought if you are going to be hooked up to one- but it has NEVER occurred to me to comment on the size of a dialysis machine in my many dialysis related conversations.

Renal 5Robert had asked 3 transplant patients, with more than 50-years of experience between them to attend. I am not sure if any of them showed their scars where the transplant was placed but they had experienced all the ups and downs of transplantation and immunosuppressants so there was no glossing over the bad bits.

Renal 6Linda was showing patients how to feel  their fistula and what to listen for – explaining how the noise it makes can change if a stenosis is forming – and she was able to give those with a fistula their own stethoscope to involve them in their own fistula care.

Renal 7Our renal dietitian was also on hand to give practical advice on managing fluid balance, as well as providing visual aids on potassium, phosphate and salt restrictions-something that renal patients universally struggle with!

Renal 8One of the biggest successes of the day came from Wendy who had persuaded one of her Peritoneal Dialysis (PD) patients & their families to come and chat so they finally actually knew what the PD catheter looked like when it was inserted and could see for themselves how an exchange worked. But more importantly they could ask someone having the treatment what it felt like, how it impacted on their lives, whether it interfered with their sleep, whether it actually helped! One of our patients who had been set on coming to the hospital for haemodialysis when his time comes, has now changed his mind. We have been sure for many reasons that he would be best suited to PD, but fear was driving his decision. One hour watching a gentleman of his own age performing an exchange and listening to his stories of how life continues almost as normal around PD, has achieved what 5-years of reassurance from us could not…

The feedback Tanya received was overwhelmingly positive, but patients are generally nice, so it is the more subtle signs that have persuaded us this is the right approach. The questions and comments patients have since made in clinic prove that they have valued and retained some of the information they learnt that day. One patient commented how reassuring it was to see dialysis patients who looked well and still lived a normal life. And I hope through this some of the fear for the future has abated.

I expect in the future we will still be blindsided by hitherto unasked questions, but it is not only the patients who are learning, as I finish with yet another Confucius quote:

‘He who knows all the answers, has not been asked all the questions!’

We would like to express our sincere gratitude for all the patients and families who came that day, especially for those who came to share their experiences with patients in the early stages of their kidney care planning journey. We are also grateful for the patients who gave their consent for us to take photographs and use them in this blog.  We hope to make “Kidney Care Planning Education day” an annual event from now on.

 

Other useful renal websites:

Patient focussed resources:

Kidney Patients UK / The National Kidney Federation, the largest kidney patient charity in the UK, run by kidney patients for kidney patients, website provides lots of useful information.

Kidney Care UK – formerly the British kidney patient association, very helpful brochures available online.

Think Kidneys – NHS England’s campaign to raise awareness of the importance of kidney disease. Lots of useful resources can be accessed with just a few clicks from this page.

Clinician focussed resources:

Renal Fellow Network – A USA based website with worldwide contributions distilling vast amounts of renal knowledge into bitesized articles, a great resource to start learning about renal medicine.

UKidney – online education on Nephrology, hypertension and kidney transplant.

#NephJC is a fortnightly Twitter-based Nephrology Journal club with visual abstracts, free access to the articles provided by major journals and regularly includes participation by the authors and other worldwide experts in the field.

 

This blog was written by Dr Alison Almond, Associate Specialist in Nephrology, with contribution from rest of the Renal Team, NHS Dumfries and Galloway.

 

A Yellow Wood by Gill Stanyard

Gill St 1

The 1st June 2018 was my  last day as a  Non-Executive Director for NHS Dumfries and Galloway.  After four years of a potential eight year appointment from Scottish Government, I decided to  leave. I felt I had reached a good and fulfilling end and to stay on for another four year term would have been signing up to endure.  I made a decision I wanted to enjoy. So, I felt happy with my decision to end my time, made when swimming in a shimmering blue sea one early morning, whilst in Greece.

I made a decision. ‘Decision.’ The Latin origin of this word  literally means, “to cut off.” Making a decision is about “cutting off” choices – cutting you off from some other course of action. Now that may sound a little severe and limiting, it’s not. It is liberating. Decisions, they take us onto the next stepping stone, sometimes called  ‘The End’  – two words which tell us a story is over.

Gill St 2

My friend made the final and shocking decision to end his life at the weekend. A fact I am still struggling to comprehend. Our last communication was a fortnight ago, with me texting him about all the different gins (24 to be exact) that were on the menu at my leaving ‘do.’  He texted me back with a  joke about Rhubarb gin. Then nothing. I didn’t think too much of it, life gets in the way. And then I received ‘The News.’  Yet I have forgotten a couple of times since then, and have gone to text him. Then, with a strange physical ‘flipflop’ stomach feeling,  I have remembered ‘The End,’ which is accompanied by much hurt and sorrow and  strangely, lines from one of my favourite poem’s. – ‘ The Road Not Taken.’ by Robert Frost:

 

Two roads diverged in a yellow wood,

And sorry I could not travel both

And be one traveler, long I stood

And looked down one as far as I could

To where it bent in the undergrowth;

 

Then took the other, as just as fair,

And having perhaps the better claim,

Because it was grassy and wanted wear;

Though as for that the passing there

Had worn them really about the same,

 

And both that morning equally lay

In leaves no step had trodden black.

Oh, I kept the first for another day!

Yet knowing how way leads on to way,

I doubted if I should ever come back.

 

I shall be telling this with a sigh

Somewhere ages and ages hence:

Two roads diverged in a wood, and I—

I took the one less traveled by,

And that has made all the difference.

Gill St 3

 A single decision can transform a life. I always assumed Frost wrote this poem about himself, yet I recently read Hollis’s  biography of Welsh poet Edward Thomas, and discovered that Frost and Thomas were ‘besties.’  Frost had written the lines as a joke about Thomas’s depression induced indecision, which showed up on their long ‘walk and talk’ days together, with Thomas never being able to decide whether to take the path on the right or the left. When Frost sent the poem to Thomas, Thomas initially failed to realize that the poem was (mockingly) about him. Instead, he believed it was a serious reflection on the need for decisive action. At the age of 36, after much wrestling, Thomas felt compelled to enlist as a soldier in the Great War.

Gill St 4

 

He wrote of his decision to his friend Robert Frost  “Last week I had screwed myself up to the point of believing I should come out to America & lecture if anyone wanted me to. But I have altered my mind. I am going to enlist on Wednesday if the doctor will pass me.”  On the first day of the battle at Arras, Easter Monday, 9 April 1917, Thomas was killed by a shell blast.  His poem ‘Adlestrop’ was published in the New Statesman three weeks after his death and has since become a classical favourite of British poetry.

 

Adlestrop

Yes, I remember Adlestrop —

The name, because one afternoon

Of heat the express-train drew up there

Unwontedly. It was late June.

 

The steam hissed. Someone cleared his throat.

No one left and no one came

On the bare platform. What I saw

Was Adlestrop — only the name

 

And willows, willow-herb, and grass,

And meadowsweet, and haycocks dry,

No whit less still and lonely fair

Than the high cloudlets in the sky.

 

And for that minute a blackbird sang

Close by, and round him, mistier,

Farther and farther, all the birds

Of Oxfordshire and Gloucestershire

Life sometimes makes decisions for us. I don’t mean to get all Dead Poet’s Society here, yet I think T.S Eliot had something when he wrote “What we call the beginning is often the end. And to make an end is to make a beginning. The end is where we start from.” (Four Quarters) We get ill and have to take time to rest and get well, and sometimes we don’t always recover, we have accidents,  we don’t get chosen for that job or by that person and we lose people and animals we love and care for.

Where possible, make a decision and choose your ending and make a new beginning, whether it be the end of an unhappy relationship and the start of a happier one with yourself,  saying No to working for extra hours, when you could be saying Yes to spending more time with your family, or your dog or your garden, standing up to a bully and choosing to start being assertive and courageous, speaking out against something which you see is wrong and thus ending corruption or collusion, stopping trying to do everything by yourself and start asking for help -(getting a mentor through NES really helped me with this)  and putting a stop to being taken for granted and drawing new boundaries that put your needs first.

Gill St 5

I have taken a Non-Executive decision to be more accountable to myself in my life, to spend more time outside, to stop watching tv and read more poetry,  to save up to live in a place where I can have two donkeys, chickens and  another rescue dog and to track down some Rhubarb gin.

Gill St 6

Sorry if I did not see you to say Goodbye. I wish you well in your decision making and hope that your sigh is a happy and fulfilled one.

 

 

 

 

 

 

I

Summer of Celebrations Part 1 by the SPSP Team

SPSP 1

Reflections from Improvement Advisor, Paul Sammons

As an improvement advisor with no clinical background, I work closely with people who want to change things for the better, and who know their teams and roles well, but who don’t always have the skills to structure improvement work.  They may not have the capability to use the ‘model for improvement’ – a proven methodology that helps focus aims, identify change ideas and to measure what difference if any, a change actually makes.  Having completed the Scottish Improvement Leader programme (ScIL) in 2015/16 I do have that capability which, when brought together with practitioners who have a will and an urgency to change things for the better, can be very powerful.   I enjoy the privilege of working alongside, enabling, and learning from some fantastic individuals and teams who strive to improve services of their patients and service users.

Some of these moments will be with me forever – I recall working with Dr. Grecy Bell to motivate and enthuse a group of primary care staff about Medicines Reconciliation – not the most lively of topics, but Grecy created the ‘med rec fairy’ concept – a local champion in each GP practice who would carry the ‘wand’ to ensure their team saw med rec as a vital part of their work.

SPSP 2

Another great memory for me was working alongside Dr. Mark Colwell – we teamed up to lead a local dental improvement collaborative, creating a structure around better decision making and treatment planning for patients on high risk medication.  Mark showed me how ceding power to his team enabled a flat hierarchy where all team members were able to critically observe each other’s practices, and contribute towards a more collaborative approach to patient care.   With the practices involved we improved much – starting even before patients arrived for their appointments – maximising the use of text messaging, moving through the patient’s journey. The work involved reception staff to engage with patients to obtain highest quality patient histories, and enabling dental nurses to observe and to prompt their bosses into even better patient conversations.

SPSP 3

I have observed people in health and social care who once invigorated with a little QI magic, will stop at nothing to deliver better care, and who seem to have the energy to drive improvement forward in the most unlikely circumstances.  I spend time with Julia Hutchison in DG Smile dental practice, and I leave with a real spring in my step.  What is it about these people and all of the others that I get to support that is courageous, different and special?  I do reflect on a wee video that helps me answer that question.  You might like it too.  It is available on YouTube and can be viewed here.

I believe that attention to QI capability and capacity is key to improving services, and that we will see this develop through our local ever-expanding network of QI capable practitioners.  In the near future we will expand our practitioner level QI education and training – to ensure managers and leaders are well equipped to support, coach and supervise improvement projects.  In 2018/19 I plan to focus improvement efforts into the Women’s and Children’s teams as they settle into their new DGRI home.  I contribute to the improvement force field that is growing stronger across Dumfries and Galloway in health care and in social care.  I work as part of a small but wonderful team of hand-picked curious and quirky individuals – who quietly and tirelessly support each other, creating a synergy of support to our customers.  Perhaps you are close to that growing network of improvers – perhaps you feel the force like I do?  Well I do, and as I work with a widening spectrum of fabulous people I can honestly say that there is much joy in my work.  Long may it continue…

SPSP 4

 

Cathy’s Journey by Amy Conley

van gogh

Friday night, admissions unit is where we first met Cathy……

I say met; we heard her before we met her – Cathy was shouting out, incoherent, clearly agitated. In her room, we found a tiny lady lost in a huge nightie, scrunched up on the bed, clinging onto the bedrail.  Cathy was 95, frightened and distressed.

Cathy had been transferred from another hospital, for assessment of pain.  It was impossible to know if Cathy was in pain or not – she couldn’t tell us.

We looked at her notes…

With a diagnosis of dementia and arthritis, Cathy had been living fairly independently with carer support, hadn’t been in hospital for some years.

A few weeks before, carers worried that Cathy may have fallen, an ambulance was called.  Cathy went to ED – no broken bones, but concern that Cathy couldn’t mobilise safely resulted in admission.

Over the next 6 weeks, Cathy was moved seven times between three different hospitals, from community to acute and back; staff worried about pain, falls and possible injuries, worried they were missing something, worried that more tests were needed…

Over this time, staff reported increasing difficulty with Cathy’s behaviours and confusion; she was distressed, agitated and uncooperative. Other patients were frightened.  Staff felt unable to manage.  Cathy was prescribed sedation.

Cathy by now was very confused, unable to communicate what she needed, not eating, not drinking.  She had become incontinent.

Back to Friday night…….

The sight of Cathy was heart-breaking; crying out, unable to tell us why, unable to understand what we were doing. She was dehydrated, in pain and encumbered by various medical contraptions.

We talked to Cathy’s family.  We decided that Cathy didn’t need any more interventions or hospital moves.  We did our best and made her comfortable.

Cathy died six days later…

 

Cathy, like many people admitted to hospital, was frail; she was frail before she came to hospital that first time.

If we had recognised her frailty at the hospital’s front door and intervened, well, perhaps Cathy’s story might have been different – different conversations, different interventions, different decisions and different plans made.

We talk a lot about frailty but it’s not always easy to explain or to understand.  Frailty is one of those words that get bandied about but what do we mean when we call someone frail?

The dictionary definition is “the condition of being weak and delicate”, something we all feel at times, but not really helpful in identifying frailty in our patients.

Within medicine, after years of vagueness and uncertainty, we have defined frailty as “the reduced ability to withstand illness without loss of function”.

 So……

A minor illness or injury, that would be no more than troublesome to you or I, affects a frail person more profoundly, leaving them struggling to walk, to wash or to dress, to eat or to communicate.

In reality though, how do we recognise the frail patient?  Does it matter?  Does it make any difference?

Age alone does not make people frail – people don’t become frail simply because they live too long.  Frailty doesn’t come with a diagnostic test, but there are signs we can look for – older people, with cognitive problems, mobility problems or functional problems, people on many medications or who live in care homes.  People who present to us with falls, incontinence or confusion.

“Frailty is everyone’s business”

The population is getting older and frailer, particularly here in Dumfries and Galloway.

Older, frail people have higher demands on health and social care services and more unplanned hospital admissions.  Once admitted, frail people are more susceptible to hospital-acquired infections, delirium, nutritional problems, falls and skincare issues.

In comparison to other patients, frail elderly patients are more likely to have prolonged hospital stays, to lose their mobility and functional abilities; they are more likely to be admitted to residential care, more likely to die.

I am a geriatrician.  I’m not at the glamorous end of medicine and I don’t have a bag full of fancy equipment, tests and treatments.  But within our medical specialty, we do have one intervention that has been shown to improve outcomes for the frail elderly –Comprehensive Geriatric Assessment

CGA means that frail older people are much more likely to be well and living at home 12 months after admission, and much less likely to be admitted to care homes or to die within those twelve months.

CGA is a multidisciplinary assessment of a patient and their physical, psychological and functional needs.  It allows us to develop a personalised, holistic and integrated plan for that patient’s care, now and in the future.  We think about how patients walk, talk, eat, drink, see, hear, think, remember, socialise, mobilise, and take their medications.  We think about how we can make all of those things better and easier for frail elderly people and their carers and families.

We all need to understand and recognise frailty.  Think about it, see it and talk about it, and allow a person’s frailty to influence decisions for their care and future.

Over 18 months we are working collaboratively with other health boards and Health Improvement Scotland to improve recognition of frailty at the front door.

Hopefully, if we get it right we can influence a better outcome, one that recognises and considers the specialist needs of our frail elderly people, one that supports them to continue to live happily and safely in a place that they can call home…

 

“We’ve put more effort into helping folks reach old age than into helping them enjoy it…”

Frank A. Clark, American Politician 1860-1936

 

If you have an interest in frailty and want more information or to become involved in our project please contact   amy.conley@nhs.net or lorna.carr2@nhs.net

Amy Conley is a Consultant in Geriatric Medicine at Dumfries and Galloway Royal Infirmary.

 

 

 

 

Take Two Bottles Into The Shower? Not me, I’m a Clinical Health Psychologist by Ross Warwick

image1Because you’re worth it

Bang! And the dirt is gone!

Eat fresh

I’ve been thinking a lot about advertising these past few weeks as September is a significant time for my team in Clinical Health Psychology. This month we will be making a concerted effort to promote our service, raise our profile and increase our contact with the people we aim to help.

As part of this, Ken has kindly allowed us to take over the blog for a few weeks. I’m kicking things off with an account of what the service does and I thought I would take inspiration from psychological tricks used in the world of advertising to help draw you in and get the message out there.

image2I’ll start, then, with a summary of the service that follows the advice of a Professor of Experimental Consumer Psychology at the University of Wales, Jane Raymond. Prof Raymond advises that rather than bombard the audience with information I should break it into chunks to allow the brain time to process each component:

  • Chunk 1: The Clinical Health Psychology service helps people who have a psychological problem that is caused and maintained by a physical illness.
  • Chunk 2: These problems usually involve unpleasant feelings and unhelpful thoughts about the illness that keep someone from doing things that matter to them.
  • Chunk 3: This can cause distress, affecting overall well-being, medical treatment, self-management and health outcomes

An article in a social psychology journal showed that a wide range of people respond well and are persuaded by stories (Thompson and Haddock, 2012). So to illustrate chunks 1-3 here’s a fictionalised case based on real events:

Jane is a young teacher who has type 1 diabetes. Her condition and the things she must do to keep on top of it are often accompanied by feelings of shame, anger and loneliness. She has frequent thoughts that her condition means she is abnormal and that it must be hidden from others. Because of these unhelpful thoughts and feelings she avoids testing her blood, guesses her insulin levels, is inconsistent with her diet and keeps problems to herself.

She has been absent from work and in and out of the DGRI several times within the past twelve months. Because of this she believes friends, family and colleagues are annoyed with her for not taking proper care of herself and landing them with more responsibility. As a result, she avoids seeing people and has become more and more isolated.”

The next steps for Jane are chunked below:

  • Chunk 4: In therapy we would work with Jane to live well with her condition by addressing her unhelpful thoughts, feelings and avoidant behaviour
  • Chunk 5: As therapy is all about collaboration, Jane’s most likely to have a good outcome if she’s motivated to participate and make changes to her life
  • Chunk 6: Jane can be referred to Clinical Health Psychology by anyone who is involved in her care, be it her GP, Practice Nurse, Dietician, Diabetes Specialist Nurse or Consultant.

In Jane’s story, she’s in and out of DGRI because thoughts and feelings stop her from acting in a way that would help keep her well. So psychological therapy would add value by reducing her distress and unplanned contact with services (and by highlighting that sentence your attention has been focused on a key message about how psychology makes a difference to both the person and the hospital; Pieters and Wedel, 2004).

But would you believe that individual therapy expertly delivered by members of our experienced, compassionate, and, yes, attractive, team is but one feature of our service? In Clinical Health Psychology we also provide training, teaching, supervision and consultation because you don’t need to be a psychologist to provide psychological care (worth mentioning because (a) it’s completely true and (b) according to Goodman and Irmak, 2013, audiences are likely to prefer multi-featured products).

Already the Diabetes and Cardiac Teams are benefitting from increasing their psychological knowledge and skill through participating in Emotion Matters training, and a group of local GPs have recently completed training to introduce CBT techniques into their routine consultations. Recruitment of a second cohort will be underway soon.

Time for pictures of the product:

headshotsBy now thanks to my evidence-based and scientifically informed techniques of persuasion, you will no doubt want to know how you can benefit from working with our wonderful service.

You can contact us by email or by calling us at the psychology department to talk about matters psychological, be it complex cases, potential referrals, or training your department. Find out more about making referrals by consulting our service leaflets which are available absolutely FREE through Beacon by searching for ‘Clinical Psychology’ or looking under ‘Documents’ after following the link below. And as the Patient Information Leaflet can also be found there, you enjoy a 2 for 1 bonus!

http://hippo.citrix.dghealth.scot.nhs.uk/sorce/beacon/?pageid=Sitesearch&searchCriteria=clinical%20health%20psychology

Keep your eyes open for opportunities to attend training events we’re delivering this month and enjoy the blog posts written by the Clinical Health Psychology team over the next few weeks. Finally, to eke this advertising ruse out just a little further, comment below to be part of a Clinical Health Psychology virtual focus group.

Just do it.

Ross Warwick is a Consultant Clinical Health Psychologist and Lead for Clinical Health Psychology at NHS Dumfries and Galloway