Great. Thank you very much for coming back. So this is our second part of the day, which is the critical part of the day,
you've got to have three consultant psychiatrist specialising in old age psychiatry from the local area.
And firstly, I'd like to introduce Wilkinson, who's a consultant at a local mental health trust,
wants to talk NHS Foundation Trust to work in patients with a special interest in depression.
He's been doing some interesting work on transcranial direct current stimulation.
We can talk about that today. So today we're going to talk about some complex clinical cases in the field.
Thank you very much. Thank you very much, Sophie and Charlotte. And thank you. It's good to see you all here in such a nice sunny autumn day.
Can you hear me at the back? Thank you. All right. I don't need to raise my voice.
Sounds good in our job. You got used to raising your voice.
And by the end of Friday afternoon, working with older people, you tend to be go home and shout at your family.
Um, so I'm taking a bit of a liberty at Charlotte's earlier invitation.
I'm going to talk for the first 15 minutes or so about a case just to illustrate
clinical complexity in old age psychiatry and the joys really of that.
And then I'm the second half of my half hour.
I'm going to talk about some work that I was lucky enough to do in the Republic of Georgia in the Caucasus with a nongovernmental organisation
to illustrate the wider problem or the winter challenge of meeting the long term health care needs of the elderly population around the world.
Now for something completely different, this is a whirlwind overview of old age psychiatry in low and middle income countries.
Um, well, why is this important? I understand you've heard something already this morning about the demographics of dementia.
But from a UK perspective, if you're going to go into careers as old age psychiatrist, one of the things you will hear,
I hope more about when you're working in a room long retired is the challenge of meeting the
needs in low and middle income countries or the developing world of people with dementia.
So in a recent report,
the World Health Organisation described this as the UN as a ticking time bomb
with an imagined impact comparable with that of HIV and AIDS in the 1980s.
So two thirds of the, um. Yeah, and Alzheimer's Disease International, which is a collective of research bodies in their 2010 report,
said that two thirds of the economic burden of dementia is already borne by low and middle income countries.
And this proportion is set to increase. Um.
What characterises these countries is the provision is the lack of formal care provision,
so it tends to be family based and informal and not supported by diagnostic services or treatment and support services and medical help.
Seeking for symptoms of dementia in low and middle income countries appears to be unusual.
This may reflect stigma or lack of understanding.
Um, and of course, people don't only seek help for things if they believe there's something to be done.
And we saw a shift here and must be 15 years ago now when the cholinesterase inhibitors became available.
Donepezil, first of all. I mean, I think my my view is that the cholinesterase inhibitors have done very little to
have very little impact on the morbidity associated with dementia in our society.
But what what they have done is focussed attention and focussed attention in society
and politics on the problem of dementia and the needs of people with dementia.
So that will be their legacy. I believe. As yet, there hasn't been such a shift in low and middle income countries.
Some low and middle income countries are in former Soviet states such as the Republic of Georgia, which I'll mention in a minute.
Um, so again, most care in these states is provided by family members associated with significant strain and stigma.
Old age. The country is not a speciality in many Eastern European states, as it isn't in a number of Western European states and older people.
Services of any sort seem to be quite sparse.
Institutional care can be offered and in some states, but usually seen as a last resort and a sort of one way,
um, step and something else that's described as a sort of hierarchical,
rather hierarchical and doctor centred approach to clinical work with or without a sort of multidisciplinary skill base,
which we're now used to in our services.
Um, as I was looking to do some work on behalf of a nongovernmental organisation called the Global Initiative on Psychiatry,
um, with other colleagues as well, former professor of psychiatry Robyn Giacobbe,
used to be was was involved in setting up a global initiative and used to be on their board of directors.
So I and some colleagues helped with some work in the Baltic states.
And then more recently in Georgia and this is me with a psychologist and psychiatrist who run the Tbilisi office.
Um, for those of you who aren't aware where Georgia is, you probably heard of them.
They were in the rugby last week, I think. I don't know if they won, but I don't know how Georgians came to play rugby,
but normally associated with sort of former Commonwealth with Commonwealth countries.
But, um, so Georgia is there local in red.
So that's Western Europe over there with Berlin and here's the Black Sea.
And that caused a little bit there is the Crimea. So that should be yellow now, I think, to fit in with Russia.
So Georgia sits between in this precarious position between Russia and Turkey, and it's one of the Caucasus.
So you've got Georgia, Azerbaijan and Armenia. So nestled in there between the Black Sea and the Caspian Sea, um, a small country population.
Forty four million. I said my four point four million.
Sorry. Um, and most of whom live in Tbilisi, the capital.
And to get there, you either have to go by Turkey via Istanbul or via Azerbaijan.
So it's a bit of a trek, some beautiful country.
So these are the North Caucasus Mountains, which are the sort of natural border between Georgia and and Russia.
And this is the north that you'll be. You're probably aware of territorial disputes in Georgia with the Russians.
So as Abkhazia and South Ossetia, you might remember war breaking out in those regions in recent years, leading to a sort of displacement of people.
This is old Georgian architecture in Tbilisi. Um, it's a very beautiful country, a very warm, hospitable, very warm,
hospitable people with a sort of although it's not a Mediterranean country, but with a Mediterranean sort of attitude, um, religion.
The Georgian Orthodox Church is huge in Georgia.
So while many parts of the world are seeing a reduction in number of people following organised religion in Georgia since the end of the Soviet Union,
the importance of a church is really of a church has really reasserted itself.
And this is a newly built Orthodox Georgian Orthodox cathedral in Tbilisi.
And as the two colleagues I was with on the trip.
Um, this is a hospital called Goldoni Hospital, so it's one of five large old Soviet built psychiatric hospitals in Tbilisi with 212 patients,
and it's a rather sort of generic hospital, a little bit like little more hospital in Oxford was, I think, you know, a generation ago.
So it provides long term care mainly rather than acute care and will admit people
with older people with dementia or chronic psychosis or learning disability.
So that's the exterior of the building. It's rather stark and the interior is very, very stark as well.
This is me with one of the older male patients. You'll see his artwork on his locker.
The Georgians are very artistic people and they a lot of people will draw and paint as a hobby.
And they this is used in the health service to good effect. So art therapy is a real strong feature of the health care system.
And this is generally one of our nurses, whether or not some of the other workers and older older female patients with the
challenge in Georgia for the Global Initiative in psychiatry is to try and engage
the government in a dialogue about the specific needs of older people with mental
illness and to try and help in the stigmatisation of mental illness in older people.
It's very much a family based care model, but as a social patterns, working patterns change in society,
then people women aren't at home any longer as much to look after older people.
So there's going to be there's going to need to be a reliance, increasing reliance on charitable care or state health care.
But still, that theme is seen as a last resort.
The unstable political situation also contributes to the difficulty in organising care for older people.
However, they have managed with some success to set up a good sort of projects trailblazing modern services with younger adults.
So there are new crisis intervention units, some very modern inpatient units, for instance.
So there is hope, but it's just a question of trying to transfer those values to services for older people.
One of the things I got involved in was teaching, um, it's about sowing the seeds and nurturing, also nurturing the next generation.
So this probably doesn't project very well.
But this is me doing a talk about old age psychiatry, what I thought was all sorts of interesting slides and frontotemporal dementia,
PET scans to a group of long term medical staff, most of whom had been there for many years,
some of whom from the Soviet times, very, very hard to entrust to them.
It's a very hierarchical model and they don't welcome debate.
And a couple of them just sort of get up halfway through and walk out or light a cigarette and just turn away.
But it's not all like that. This is a master's programme in mental health,
which the NGO had been part of setting up in this in another another hospital, which is really dilapidated.
But they managed to get some rooms refurbished and get some modern light equipment.
And they're running a very successful master's programme from people with people from a range of backgrounds in mental health of older people.
And I also managed to do a lecture to medical students as well, who have very laperriere,
very little teaching on old age, the country and out in up to top. They were really fascinated by it.
So there is real hope. This was a day which we visited.
So the NGO works in collaboration with this data centre.
So this isn't providing health care as such, but it's providing social care and also home care outreach to older people.
The service is still sort of fairly stigmatised because it's seen to be unacceptable or a last resort to get help with their elderly relatives.
But it's a great positive place. This is the director showing me the home made wine, as well as being very artistic.
They're very much into home grown wines. And so wine is produced and consumed liberally, which is lovely.
So and this is an old lady who you'll see on the video I'm going to show you in a minute.
So watch out for this lady. She was very, very keen to talk and tell us about herself and find out what we were doing and another piece of artwork.
So I'm just going to show you finally just a little video which warms the heart.
So this is in the day centre and a group of mainly ladies, the same situation as anywhere.
So 90 percent women. And then you'll see one poor chap on his own and the other side did you see her?
And just after that, she she made a break and she came over and started shuttling, wants to know who we are, what we were doing there.
So if you want to read any more about that. Yes. That's the address, the web address for.
Global Initiative on Psychiatry and also at King's College, London.
There's 10 66 Dementia Research Research Group websites who are looking at dementia
prevalence and provision of models of service provision in low and middle income countries,
10 to 66, because 60 percent of the burden of dementia is in developing countries, but only 10 percent of the research takes place.
But content? Clever title.