Health Care of the Elderly

Essays in Old Age Medicine, Psychiatry and Services

Tom Arie, Tom Arie

• Publisher: Routledge
• Year: 2022
• ISBN:
  9781000580952
• Edition: 1
• Topic: Medicina
• Subtopic: Geriatria

Originally published in 1981 and edited by a pioneer in psychogeriatric services, this book spans medicine, psychiatry, social work and organisation of services of the elderly, written by eminent authors from several different professions. Chapters include those on stroke rehabilitation, dementia, neurosis, psychotherapy for the elderly and institutional care, among others. The book discusses many issues which remain as pertinent today as when it was first published, not least the problems of providing health services for ageing populations.

1 INTRODUCTION. HEALTH CARE OF THE VERY ELDERLY: TOO FRAIL A BASKET FOR SO MANY EGGS?

Tom Arie

‘Health Care of the Elderly’ is the name of our department in Nottingham. This book’s contributors come from much further afield than just our own department, but a brief word about our department is appropriate, for from it this book takes both its name and its joint approach. The care of the elderly is nothing if it is not a collaborative enterprise. We in Nottingham have tried to go further, by constructing a joint department comprising physicians, psychiatrists and other health workers concerned with the elderly. In short, we have moved from collaboration to unity. I hope that the book will be seen to express the unity of the health care of the elderly.

In Nottingham we each ‘do our own thing’; psychiatrists practice psychiatry and physicians medicine. But we have a common identity and allegiance, we share facilities (including, importantly, a joint building) and much of our nascent research is joint. Supporting our patients and their families is our main business, for our joint approach attempts to ensure that they neither fall between different professions and services, nor get bounced from one to another; but we are very much aware that alongside support for our patients, we have an important job to do in supporting each other.

So we have made a start in making a unity of services for the elderly. We have a long way to go, but already it is clear that this style works, and we enjoy working in this way. Together we serve a defined population in which our services are available to help any old person. There is nothing selective about our clientele: or rather, we do not select them and if there is bias, it is towards the very aged and very infirm. For these are our people: the very aged with multiple infirmities and often with failing brains. Of course, we see many ‘younger’ old people and many with more straightforward medical or psychiatric problems; but at the centre of our concerns are the very infirm elderly. It might be more appropriate to describe our work as the Health Care of the Very Elderly.

The Novel Commonplaceness of Extreme Old Age

It is, of course, the very aged whose numbers are increasing most rapidly in our country, and in most countries similar to our own. It is in them that the now well documented conjunction of physical, mental and social privations is at its most intense; and the most damaging of all these, dementia, rises sharply in its incidence over the age of 80, affecting about one in five of the population of that age. One in five means that four out of five very aged people are not demented, but dementia raises the most taxing issues of medical care, and the most expensive ones — for it is the greatest generator of breakdown, of demand for institutional care and of family burden and crisis. David Jolley and I have together written on these matters on several occasions, and in his chapter in this book he sets out the scale of this problem, which promises to be the biggest challenge to health and social services in all developed countries for the foreseeable future; and he presents approaches which have been shown to work. Kenneth Shulman, also a former colleague, is developing a similar service in Toronto — and in part because of the way care is organised there, in part because of the familiar operation of the ‘Inverse Care Law’, he is seeing far fewer demented patients than patients with functional disorders — a state of affairs which, as he says, he intends to change.

In our teaching we constantly focus on the very aged. The University of Nottingham has provided a full-time attachment of one month’s duration to our department for all medical students; during this time they have an ‘apprenticeship’ to the services of the department, a formal course of teaching, and an opportunity to tackle a particular topic in some depth. We see it as a special responsibility to put this attachment to good use (few medical courses provide as much time for teaching the care of the elderly). We therefore take special pains to avoid merely duplicating the teaching of other departments in medicine and psychiatry, but constantly seek to emphasise the special issues that arise in the elderly. This book should illustrate both the fascination and scientific interest of these matters, and the barriers which stand between old people and effective medical care. Norman Exton-Smith’s chapter illustrates well what have been called ‘the vicious circles of social medicine’ — in this case, the association of maximum biological risk with maximum social disadvantage. Such vicious circles pervade the care of the very aged, and illustrations abound in Grimley Evans’s chapter and, in rather different ways, in Donald Calne’s.

Very aged people get a poor deal from services; and not all the services which we disburse, often enthusiastically and almost always expensively, have been shown to be effective. Graham Mulley reviews attempts to measure the effectiveness of our rehabilitative services in relation to strokes; James Williamson looks at the value of screening and surveillance, whilst Olive Stevenson attempts both to define the particular task of the social worker in relation to aged people, and to consider some of the reasons why this task is so often not fulfilled. Roy Boyd, from a different point of view, makes an attempt to give precision to, and to make sense of, that often woolly and overworked category, the ‘social problem’.

Nor, as Klaus Bergmann and Felix Post show, are the elderly, and the very elderly, by any means immune from functional mental disorder, often of an eminently treatable kind. Only in recent decades has the importance of affective disorder in old people come to be widely recognised, with massively beneficial consequences for old people, who formerly were too often relegated to the category of the ‘senile’ and thus hopeless. Similarly, the scale of neurotic disorder and maladjustment in old people, including the very old, is now recognised (by contrast with the former comfortable assumption that emotional turbulence becomes extinct with ageing, ‘all passion spent’). This growing clinical and epidemiological understanding, in which Post and Bergmann have been among the pioneers, has already made successful contributions to a rational basis both for treatment and for the planning of services. And such knowledge has also underpinned with facts the debate on the pros and cons of specialised services for very old people which Bernard Isaacs sets out.

I asked Adrian Verwoerdt to write on psychotherapy for the elderly for two reasons: first, because too few people are attempting to think through the issues, such as the ways in which classical psychoanalytic teaching may need to be modified in relation to the elderly, and the scope and limitations of psychotherapy in old people with failing brains. Second, since most psychiatrists who work specially with the elderly are of an empirical disposition, I thought it would be nicely complementary to include a contribution which takes much of its strength from a particiular theoretical framework.

But there is another sense in which the subject of psychotherapy with the very aged is important. For experience with it gives the lie to any impression that the very aged are necessarily without inner turmoil and suffering, or indeed without those dynamics of the psyche which are evident in younger people. The existence of an active inner life in the very old is often implicitly questioned, especially perhaps by those so close to them that the truth could be hard to endure. More light has often been shed on this matter by writers than by clinicians, and in our department we recommend our students to read novels about old people during their period of attachment (and the fact that they take our advice is attested by the constant disappearance of most of these from our library!). Such works include Nell Dunn and Adrian Henri’s love story I Want, Paul Bailey’s At the Jerusalem, a delicate and terrifying account of an old lady’s life in an old people’s home, and that wonderfully restrained picture of two old people’s relationship which is Vita Sackville-West’s All Passion Spent. Simone de Beauvoir’s book on old age, though not a novel, yet has the power (and bitterness) of a work by a novelist herself grown old.

But here I want to draw briefly on two sources, each of them reporting what very old people themselves tell us. It is common to distance ourselves from the very old, to assume they don’t know, they don’t notice, they don’t suffer (indeed, that they don’t hear, for we often assume they are deaf).

Some months ago, following a BBC programme to do with bereavement, the producer received a letter which he passed on to me. I quote most of it here, with the writer’s permission:

Dear Producer,

Bereavement

I missed the first 15 minutes of your last programme but, from what I did hear, you appear to have missed the most poignant cases of bereavement — where it touches the old and the very old. No one seems to want to know about them and assumes that only the middle-aged are involved. The lot of the really old is much worse. I am 81 and 2 years ago my wife, then 77, died. The last 2 years have been very hard to bear. I fell in love with her when I was only 20 and she 18. We were married 4 years later and had 54 years of wonderful life together. The only comfort I am offered is that I must have many happy memories. But that is common to all age bereavement. The younger generation can reconstruct their lives, but at 80, no one can see any use for you and you are expected to retire to the corner of a geriatric ward or home. My home — my wife’s home — means everything to me — I would hate to leave it.

***

I have a good son and a good daughter and good grandchildren.

They would never let me suffer physically but nothing they can do can ease my grief of losing my life-long beloved wife. I happen to be fairly active mentally and physically but, even then, life is now a very empty thing. I receive many kindnesses but can do little in return. I am no longer a useful member of the community — that hurts.

Yours sincerely,

It would be absurd to do more than to let these words stand by themselves. The last two sentences sum up much of the predicament of the very elderly in our society — ‘I receive many kindnesses but can do little in return. I am no longer a useful member of the community — that hurts.’ But there is no escaping the other terrible conclusion of this letter — that even in extreme old age those passions and griefs that we take for granted in younger people, but which we so readily deny in the elderly, are there, and there are fewer distractions or consolations.

This was much in my mind when I was asked to speak recently at a meeting of students on ‘Death and the Doctor’. I asked myself why I in particular had been invited, as someone whose work is with the elderly, for it is generally assumed that both death, and bereavement, are gentler when they come to the very old than in the prime of life. Certainly, there is support for this impression from studies of dying people by workers such as John Hinton on the distress of the dying, and by Colin Murray Parkes and many others on the excess morbidity and premature death which may follow bereavement, and which are both commoner in younger people. But that letter reminds us that relative frequency between groups tells us little about the experience of individuals, and that age extinguishes neither sensibilities nor suffering.

Part of my second illustration is a poem. Robert Graves has said that the essence of good poetry is that it says what it has to say in so few words that one would save little money by turning it into a telegram. I am not sure how well this poem by Walter de la Mare stands up to Graves’s test, but it is moving and eloquent, and it comes in a passage which I have taken from Ronald Blythe’s splendid new book about old age, The View in Winter. An 84-year-old schoolmaster is speaking, and Blythe has recorded the interview:

Old age doesn’t necessarily mean that one is entirely old — all old, if you follow me. It doesn’t mean that for many people, which is why it is so very difficult. It is complicated by the retention of a lot of one’s youth in an old body. I tend to look upon other old men as old men — and not include myself. It is not vanity; it is just that it is still natural for me to be young in some respects. What is generally assumed to have happened to a man in his eighties has not happened to me. The generalisations which go with my age don’t apply. Yet I resent it all in some ways, this being very old, yes, I resent it. I have lost most of my physical strength, and once I was strong and loved doing physical work. I am not used to the loss of my strength and I object when many tasks show that they are now beyond me. I cannot quite believe that I can’t carry this or turn, or hold the other. This old part of me worries the young part of me. It could be that it would be better to be all old. I think that De la Mare’s got the confusion in a nutshell. His poem, ‘A Portrait’, says it all. I read it often now and find that the cap fits. Here it is:

Old: yet unchanged; still pottering in his thoughts;

Still eagerly enslaved by books and print;

Less plagued, perhaps, by rigid musts and oughts,

But no less frantic in vain argument:

Punctual at meals; a spendthrift, close as Scot;

Rebellious, tractable, childish — long gone grey!

Impatient, volatile, tongue wearying not —

Loose, too; which, yet, thank heaven, was taught to pray:

‘Childish’ indeed! a waif on shingle shelf

Fronting the rippled sands, the sun, the sea;

And nought but his marooned precarious self

For questing consciousness and will to be:

To frail a basket for so many eggs —

Loose-woven; gosling? cygnet? Laugh or weep?

Or is the cup at richest in its dregs?

The actual realest on the verge of sleep?

A foolish, fond old man, his bed-time nigh,

Who still at western window stays to win

A transient respite from the latening sky,

And scarce can bear it when the sun goes in.¹

I want to linger for a moment on one line: ‘Too frail a basket for so many eggs’. The image is of a fragile, precarious, inadequate container for a multitude of things themselves fragile — eggs are the symbol of brittleness and fragility. In extreme old age, the inner life may be teeming — ‘so many eggs’ — rather than inert or quiet. Eggs betoken pregnancy, they promise the unfulfilled that which is yet to be; but in everyday life most eggs have their promise aborted: they will be consumed, they won’t ever hatch! ‘I resent it all . . . this being very old,’ says Blythe’s old schoolmaster; in Dylan Thomas’s words, he will ‘not go gentle into that good night’, but rather will ‘rage against the dying of the light’ — a famous phrase which echoes that of the present poem: he ‘scarce can bear it when the sun goes in’.

Well, it is very old people like this for whom services for the health care of the elderly exist; and ‘Too frail a basket for so many eggs’ might itself stand as a gloss on those services, which seem unlikely ever, anywhere, to cope adequately with the spiral of expectations. These expectations themselves derive from those very features of modern societies which have extended the life-span and made extreme old age, for the first time in the history of mankind, commonplace.

Building Confidence

The contributors to this book illuminate with ideas and information the nature and scale of the issues of health, sickness and care of old people which modern industrial (and not only industrial) societies must tackle. They are largely new problems and no previous society can provide parallels or solutions; we have to work them out ourselves. And we must remember that the impact of unprecedented numbers of very aged people raises different issues for different groups: first, there are the old people themselves and the question of what they need from society; then there is society as a whole, and the challenge posed by the vast increase in the number (and proportion) of people of pensionable age; then the families and the other ‘non-professional’ people who provide the bulk of direct support and care; and finally (and often forgotten, though they are a subject of special interest to me), ...