1 00:00:00,450 --> 00:00:08,440 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, 2 00:00:08,440 --> 00:00:17,010 you've got to have three consultant psychiatrist specialising in old age psychiatry from the local area. 3 00:00:17,010 --> 00:00:24,970 And firstly, I'd like to introduce Wilkinson, who's a consultant at a local mental health trust, 4 00:00:24,970 --> 00:00:32,400 wants to talk NHS Foundation Trust to work in patients with a special interest in depression. 5 00:00:32,400 --> 00:00:37,280 He's been doing some interesting work on transcranial direct current stimulation. 6 00:00:37,280 --> 00:00:44,340 We can talk about that today. So today we're going to talk about some complex clinical cases in the field. 7 00:00:44,340 --> 00:00:51,900 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. 8 00:00:51,900 --> 00:00:56,250 Can you hear me at the back? Thank you. All right. I don't need to raise my voice. 9 00:00:56,250 --> 00:00:59,280 Sounds good in our job. You got used to raising your voice. 10 00:00:59,280 --> 00:01:05,730 And by the end of Friday afternoon, working with older people, you tend to be go home and shout at your family. 11 00:01:05,730 --> 00:01:10,140 Um, so I'm taking a bit of a liberty at Charlotte's earlier invitation. 12 00:01:10,140 --> 00:01:14,190 I'm going to talk for the first 15 minutes or so about a case just to illustrate 13 00:01:14,190 --> 00:01:19,320 clinical complexity in old age psychiatry and the joys really of that. 14 00:01:19,320 --> 00:01:22,920 And then I'm the second half of my half hour. 15 00:01:22,920 --> 00:01:33,330 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 16 00:01:33,330 --> 00:01:42,960 to illustrate the wider problem or the winter challenge of meeting the long term health care needs of the elderly population around the world. 17 00:01:42,960 --> 00:01:55,110 Now for something completely different, this is a whirlwind overview of old age psychiatry in low and middle income countries. 18 00:01:55,110 --> 00:02:03,030 Um, well, why is this important? I understand you've heard something already this morning about the demographics of dementia. 19 00:02:03,030 --> 00:02:13,380 But from a UK perspective, if you're going to go into careers as old age psychiatrist, one of the things you will hear, 20 00:02:13,380 --> 00:02:18,330 I hope more about when you're working in a room long retired is the challenge of meeting the 21 00:02:18,330 --> 00:02:25,260 needs in low and middle income countries or the developing world of people with dementia. 22 00:02:25,260 --> 00:02:28,680 So in a recent report, 23 00:02:28,680 --> 00:02:35,700 the World Health Organisation described this as the UN as a ticking time bomb 24 00:02:35,700 --> 00:02:43,500 with an imagined impact comparable with that of HIV and AIDS in the 1980s. 25 00:02:43,500 --> 00:02:56,310 So two thirds of the, um. Yeah, and Alzheimer's Disease International, which is a collective of research bodies in their 2010 report, 26 00:02:56,310 --> 00:03:02,730 said that two thirds of the economic burden of dementia is already borne by low and middle income countries. 27 00:03:02,730 --> 00:03:11,290 And this proportion is set to increase. Um. 28 00:03:11,290 --> 00:03:18,970 What characterises these countries is the provision is the lack of formal care provision, 29 00:03:18,970 --> 00:03:31,750 so it tends to be family based and informal and not supported by diagnostic services or treatment and support services and medical help. 30 00:03:31,750 --> 00:03:37,150 Seeking for symptoms of dementia in low and middle income countries appears to be unusual. 31 00:03:37,150 --> 00:03:42,580 This may reflect stigma or lack of understanding. 32 00:03:42,580 --> 00:03:49,330 Um, and of course, people don't only seek help for things if they believe there's something to be done. 33 00:03:49,330 --> 00:03:59,410 And we saw a shift here and must be 15 years ago now when the cholinesterase inhibitors became available. 34 00:03:59,410 --> 00:04:06,550 Donepezil, first of all. I mean, I think my my view is that the cholinesterase inhibitors have done very little to 35 00:04:06,550 --> 00:04:11,990 have very little impact on the morbidity associated with dementia in our society. 36 00:04:11,990 --> 00:04:19,270 But what what they have done is focussed attention and focussed attention in society 37 00:04:19,270 --> 00:04:23,560 and politics on the problem of dementia and the needs of people with dementia. 38 00:04:23,560 --> 00:04:32,320 So that will be their legacy. I believe. As yet, there hasn't been such a shift in low and middle income countries. 39 00:04:32,320 --> 00:04:41,380 Some low and middle income countries are in former Soviet states such as the Republic of Georgia, which I'll mention in a minute. 40 00:04:41,380 --> 00:04:51,940 Um, so again, most care in these states is provided by family members associated with significant strain and stigma. 41 00:04:51,940 --> 00:05:01,480 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. 42 00:05:01,480 --> 00:05:05,380 Services of any sort seem to be quite sparse. 43 00:05:05,380 --> 00:05:12,820 Institutional care can be offered and in some states, but usually seen as a last resort and a sort of one way, 44 00:05:12,820 --> 00:05:19,210 um, step and something else that's described as a sort of hierarchical, 45 00:05:19,210 --> 00:05:26,620 rather hierarchical and doctor centred approach to clinical work with or without a sort of multidisciplinary skill base, 46 00:05:26,620 --> 00:05:31,180 which we're now used to in our services. 47 00:05:31,180 --> 00:05:41,740 Um, as I was looking to do some work on behalf of a nongovernmental organisation called the Global Initiative on Psychiatry, 48 00:05:41,740 --> 00:05:47,650 um, with other colleagues as well, former professor of psychiatry Robyn Giacobbe, 49 00:05:47,650 --> 00:05:53,410 used to be was was involved in setting up a global initiative and used to be on their board of directors. 50 00:05:53,410 --> 00:05:56,380 So I and some colleagues helped with some work in the Baltic states. 51 00:05:56,380 --> 00:06:05,710 And then more recently in Georgia and this is me with a psychologist and psychiatrist who run the Tbilisi office. 52 00:06:05,710 --> 00:06:10,970 Um, for those of you who aren't aware where Georgia is, you probably heard of them. 53 00:06:10,970 --> 00:06:16,870 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, 54 00:06:16,870 --> 00:06:21,160 but normally associated with sort of former Commonwealth with Commonwealth countries. 55 00:06:21,160 --> 00:06:27,850 But, um, so Georgia is there local in red. 56 00:06:27,850 --> 00:06:32,410 So that's Western Europe over there with Berlin and here's the Black Sea. 57 00:06:32,410 --> 00:06:40,150 And that caused a little bit there is the Crimea. So that should be yellow now, I think, to fit in with Russia. 58 00:06:40,150 --> 00:06:50,020 So Georgia sits between in this precarious position between Russia and Turkey, and it's one of the Caucasus. 59 00:06:50,020 --> 00:07:00,220 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. 60 00:07:00,220 --> 00:07:03,520 Forty four million. I said my four point four million. 61 00:07:03,520 --> 00:07:08,680 Sorry. Um, and most of whom live in Tbilisi, the capital. 62 00:07:08,680 --> 00:07:14,590 And to get there, you either have to go by Turkey via Istanbul or via Azerbaijan. 63 00:07:14,590 --> 00:07:20,530 So it's a bit of a trek, some beautiful country. 64 00:07:20,530 --> 00:07:28,270 So these are the North Caucasus Mountains, which are the sort of natural border between Georgia and and Russia. 65 00:07:28,270 --> 00:07:34,570 And this is the north that you'll be. You're probably aware of territorial disputes in Georgia with the Russians. 66 00:07:34,570 --> 00:07:45,430 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. 67 00:07:45,430 --> 00:07:56,590 This is old Georgian architecture in Tbilisi. Um, it's a very beautiful country, a very warm, hospitable, very warm, 68 00:07:56,590 --> 00:08:06,850 hospitable people with a sort of although it's not a Mediterranean country, but with a Mediterranean sort of attitude, um, religion. 69 00:08:06,850 --> 00:08:09,260 The Georgian Orthodox Church is huge in Georgia. 70 00:08:09,260 --> 00:08:19,880 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, 71 00:08:19,880 --> 00:08:24,230 the importance of a church is really of a church has really reasserted itself. 72 00:08:24,230 --> 00:08:28,970 And this is a newly built Orthodox Georgian Orthodox cathedral in Tbilisi. 73 00:08:28,970 --> 00:08:35,220 And as the two colleagues I was with on the trip. 74 00:08:35,220 --> 00:08:48,900 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, 75 00:08:48,900 --> 00:08:56,520 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. 76 00:08:56,520 --> 00:09:02,700 So it provides long term care mainly rather than acute care and will admit people 77 00:09:02,700 --> 00:09:08,550 with older people with dementia or chronic psychosis or learning disability. 78 00:09:08,550 --> 00:09:15,330 So that's the exterior of the building. It's rather stark and the interior is very, very stark as well. 79 00:09:15,330 --> 00:09:21,720 This is me with one of the older male patients. You'll see his artwork on his locker. 80 00:09:21,720 --> 00:09:27,540 The Georgians are very artistic people and they a lot of people will draw and paint as a hobby. 81 00:09:27,540 --> 00:09:35,940 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. 82 00:09:35,940 --> 00:09:43,260 And this is generally one of our nurses, whether or not some of the other workers and older older female patients with the 83 00:09:43,260 --> 00:09:50,340 challenge in Georgia for the Global Initiative in psychiatry is to try and engage 84 00:09:50,340 --> 00:09:54,870 the government in a dialogue about the specific needs of older people with mental 85 00:09:54,870 --> 00:09:59,240 illness and to try and help in the stigmatisation of mental illness in older people. 86 00:09:59,240 --> 00:10:06,330 It's very much a family based care model, but as a social patterns, working patterns change in society, 87 00:10:06,330 --> 00:10:11,670 then people women aren't at home any longer as much to look after older people. 88 00:10:11,670 --> 00:10:20,910 So there's going to be there's going to need to be a reliance, increasing reliance on charitable care or state health care. 89 00:10:20,910 --> 00:10:24,120 But still, that theme is seen as a last resort. 90 00:10:24,120 --> 00:10:30,830 The unstable political situation also contributes to the difficulty in organising care for older people. 91 00:10:30,830 --> 00:10:40,960 However, they have managed with some success to set up a good sort of projects trailblazing modern services with younger adults. 92 00:10:40,960 --> 00:10:45,690 So there are new crisis intervention units, some very modern inpatient units, for instance. 93 00:10:45,690 --> 00:10:52,290 So there is hope, but it's just a question of trying to transfer those values to services for older people. 94 00:10:52,290 --> 00:11:00,180 One of the things I got involved in was teaching, um, it's about sowing the seeds and nurturing, also nurturing the next generation. 95 00:11:00,180 --> 00:11:01,650 So this probably doesn't project very well. 96 00:11:01,650 --> 00:11:08,280 But this is me doing a talk about old age psychiatry, what I thought was all sorts of interesting slides and frontotemporal dementia, 97 00:11:08,280 --> 00:11:13,530 PET scans to a group of long term medical staff, most of whom had been there for many years, 98 00:11:13,530 --> 00:11:17,850 some of whom from the Soviet times, very, very hard to entrust to them. 99 00:11:17,850 --> 00:11:22,680 It's a very hierarchical model and they don't welcome debate. 100 00:11:22,680 --> 00:11:30,120 And a couple of them just sort of get up halfway through and walk out or light a cigarette and just turn away. 101 00:11:30,120 --> 00:11:34,110 But it's not all like that. This is a master's programme in mental health, 102 00:11:34,110 --> 00:11:41,670 which the NGO had been part of setting up in this in another another hospital, which is really dilapidated. 103 00:11:41,670 --> 00:11:45,540 But they managed to get some rooms refurbished and get some modern light equipment. 104 00:11:45,540 --> 00:11:53,190 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. 105 00:11:53,190 --> 00:11:59,880 And I also managed to do a lecture to medical students as well, who have very laperriere, 106 00:11:59,880 --> 00:12:04,360 very little teaching on old age, the country and out in up to top. They were really fascinated by it. 107 00:12:04,360 --> 00:12:10,120 So there is real hope. This was a day which we visited. 108 00:12:10,120 --> 00:12:13,350 So the NGO works in collaboration with this data centre. 109 00:12:13,350 --> 00:12:20,580 So this isn't providing health care as such, but it's providing social care and also home care outreach to older people. 110 00:12:20,580 --> 00:12:27,960 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. 111 00:12:27,960 --> 00:12:35,790 But it's a great positive place. This is the director showing me the home made wine, as well as being very artistic. 112 00:12:35,790 --> 00:12:43,650 They're very much into home grown wines. And so wine is produced and consumed liberally, which is lovely. 113 00:12:43,650 --> 00:12:47,730 So and this is an old lady who you'll see on the video I'm going to show you in a minute. 114 00:12:47,730 --> 00:12:57,510 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. 115 00:12:57,510 --> 00:13:01,500 So I'm just going to show you finally just a little video which warms the heart. 116 00:13:01,500 --> 00:13:06,810 So this is in the day centre and a group of mainly ladies, the same situation as anywhere. 117 00:13:06,810 --> 00:13:19,180 So 90 percent women. And then you'll see one poor chap on his own and the other side did you see her? 118 00:13:19,180 --> 00:13:27,510 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. 119 00:13:27,510 --> 00:13:33,970 So if you want to read any more about that. Yes. That's the address, the web address for. 120 00:13:33,970 --> 00:13:38,860 Global Initiative on Psychiatry and also at King's College, London. 121 00:13:38,860 --> 00:13:48,550 There's 10 66 Dementia Research Research Group websites who are looking at dementia 122 00:13:48,550 --> 00:13:54,100 prevalence and provision of models of service provision in low and middle income countries, 123 00:13:54,100 --> 00:14:02,890 10 to 66, because 60 percent of the burden of dementia is in developing countries, but only 10 percent of the research takes place. 124 00:14:02,890 --> 00:14:05,551 But content? Clever title.