I’d like to introduce you to Bob. Bob has vascular dementia. Before dementia, Bob knew everyone’s name. He had a hearty handshake, made the best barbecued steaks and loved a good belly laugh. He grew up in a hard-working family in small-town Alberta. In high school, he met Wendy and they were married after graduation. Bob and Wendy had two girls. Bob worked as a sales representative for shoe and clothing companies. He got his amateur pilot’s license and flew to his sales calls. He always took care of his family. He liked to ski – water and downhill. When his kids left home for university, he grew apart from Wendy, and they divorced. He continued to travel with work, but always lived in his home town. His ex-wife, Wendy remained in his life; a consistent and patient support. After a time, they dated a bit again, shared dinners and occasionally vacations. Then, about 4 years ago, on a vacation with Wendy, things went really wrong. Bob pulled over on a remote road in rural Oregon and shouted at Wendy to get out of the car – he didn’t know who she was. Wendy waited and calmed Bob down, and eventually, they drove on. When they returned home, the testing began. Not long after that, a doctor wrote a letter, and Bob’s pilot’s license was revoked. Bob was livid – there was nothing wrong with him and this doctor was using him for career advancement! Incidents of paranoia became more frequent. Wendy couldn’t leave Bob alone, but Bob was starting to get scary. He would demand to see Wendy’s identification; threaten to call the police. Then, after too many uncomfortable situations, came the night he threatened to break her arm, so wisely, Wendy left. Bob went to the RCMP and told them there was an imposter pretending to be his wife; they took him to the Emergency Department. The emergency department doctor sent him to the inpatient geriatric psychiatric facility. Three years have passed, and now Bob lives in a locked long term care unit in his rural Alberta home town. Bob is my dad.
Definition of Health
We are going to have a look at my dad’s health through the lens of MHST601; the Foundations of Health Systems in Canada. Let’s first consider whether Bob was healthy. By the 1946 World Health Organization (Huber, 2011) definition of health: ‘’a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity,” Bob was not healthy: he had chronic hypertension, so bad he once lost vision. He viewed his hypertension as “white-coat hypertension” and didn’t follow his prescribed medication regimen. By some other definitions, the Ottawa Charter for Health Promotion, for example: “Health is…seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities,” (1986) Bob lived a healthy life, for a long time.
Social Determinants of Health
Bob is a white man, able-bodied, with a high school education. He always worked in entrepreneurial sales roles. Bob never worried about how he might afford a meal, he always had a home, friends, and family. He was lucky enough to be born in Canada and have access to a comprehensive health care system. In terms of the social determinants of health, Bob’s educational attainment may have had some influence on his condition (see graphic below), however from the perspective of those things that we are born into having influence on our health, Bob was on the positive side of the ledger for all. Someone with the same conditions, and more of the social determinants in the negative column might well have experienced disability earlier, had more co-morbidities and perhaps premature death. (Mikkonen & Raphael, 2010; & Mohammadi, 2015).
Figure 1: Modifiable Dementia Risk Factors. Reprinted from Mohammadi, D., L. (2015). How lifestyle changes could reduce the risk of developing dementia. (2015). The Pharmaceutical Journal, doi:10.1211/PJ.2015.20200216
Multilevel Approaches to Health - Social Ecological Model
As an individual, Bob experienced hypertension through most of his adult life. This was a direct contributor to his current level of disability (Oxford University Press, 2018). Another individual influence for Bob was that no one could ever tell him anything…he always knew best. This may have made him resistant to information that could have changed his behavior, thus mitigating his hypertension. Bob was never diagnosed as diabetic, but he was not a regular exerciser and had a meat-and-potatoes kind of diet. On the interpersonal level, Bob was well-supported by his wife and family, but his change in marital status resulted in him living alone in mid-life and into his senior years. This may have influenced his adherence to medication, awareness of his disease process and management of it. With respect to community, Bob grew up in a small town, where family doctors were also friends and perhaps less likely to be as frank as might have been beneficial, when explaining to Bob the implications of his under-treated hypertension. Education and self-management programs were less available to him than they would be to urban dwellers. From an organizational perspective, while Bob was an early adopter of technology, information was only readily available online in the last 15 years or so, coming perhaps too late for a lifestyle change to have made a difference. Finally, through the lens of policy, the emphasis on management of chronic diseases and the implications of not addressing these issues have only been a focus for Alberta Health Services for the past 10 to 12 years, thus missing the key window for intervention in Bob’s case. (Unicef, n.d.)
Chronic Disease
While Bob had conditions and complaints come and go throughout his life, high blood pressure was a consistent concern. As described, Bob managed this concern, mostly by ignoring it, denying it, or downplaying it. Essential hypertension is a chronic disease that is very common, and was implicated in $3,229,763,400 in direct health costs in 2008 (Government of Canada, n.d.). Chronic hypertension contributes to hardening of the arteries, damage to the blood vessels throughout the body, and an enlarged heart. It is either a direct cause or a significant contributor to kidney failure, stroke, loss of eyesight, heart disease and heart attack, and – you guessed it – dementia.
Vulnerable Populations
Bob was never part of a vulnerable population until now. Now, he is a senior, and a person living with disability. Dad would never have appreciated being labeled as vulnerable, and I wonder about the use of this term as a descriptor, as it could imply weakness of the group rather than something lacking in our response to that group. This term is used to describe an individual at risk for reduced access to health care services due to population-based attributes and judgments experienced related to those attributes. Bob might have diminished access to certain interventions, such as surgery, if he needed it because he is 1) old and 2) disabled. Fortunately, Bob continues to have family that advocate him to ensure his issues are managed (Waisel, 2013).
Future Health Trends
Dementia is an issue increasingly demanding society’s attention, as the population ages. The numbers we are facing are staggering. Currently in Canada, there are 564,000 individuals living with dementia. Data from 10 years ago tells us we were spending $911,718,500 annually (Government of Canada, n.d.). By 2033, the number of dementia sufferers will be 937,000. The imperative is upon us to better manage this condition. Families take on much of the direct care of their loved ones with dementia. This burden results in diminished productivity, increased physical and mental health challenges, and financial strain for family caregivers (Tew, Tan, Luo, Ng, & Nap, 2011) .
There are exciting trends being incorporated into many models of support for individuals with dementia. These include safe care settings with a neighborhood and home feel, freedom to roam, presentation of natural opportunities for interaction and engagement, use of technology such as robots to exercise, engage and supervise (Grierson, 2018; Liang, Piroth, Robinson, MacDonald, Fisher ... & Broadbent, 2017). While cost/benefit analyses are still needed, use of these environmental and caregiver supports have translated to fewer falls and diminished use of medications to moderate behavior (Grierson, 2018).
Learning
As this course has progressed, I have come to more fully understand how to consider a health issue from a variety of perspectives, how to seek out, manage and share information and how to better explain challenges to stakeholders. I further see how complex and multi-faceted our system of health support is. I find myself better able to appreciate the experiences and frustrations of those accessing the healthcare system, as well as why people might actually avoid pursuing support for their condition, based upon concerns of being judged or misunderstood. When someone like my dad comes to me for support, or when I am in the position of making program or system changes, I believe I am better equipped to thoroughly and effectively address those issues. I notice a significant shift in my way of thinking, and more ways of explaining challenges to help others understand. I look forward to this expanding comprehension of the complex and broad subject of health.
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References
Alberta healthy living program. Retrieved November 5, 2018 from https://www.albertahealthservices.ca/info/page13984.aspx
Chronic disease management. Retrieved November 5, 2018 from https://www.albertahealthservices.ca/info/page11934.aspx
Darragh, M., Ahn, H. S., MacDonald, B., Liang, A., Peri, K., Kerse, N., & Broadbent, E. (2017). Homecare robots to improve health and well-being in mild cognitive impairment and early stage dementia: Results From a Scoping study. Journal of the American Medical Directors Association, 18(12), 1099.e1. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/28974463
Government of Canada, Public Health Agency of Canada. (2013). Economic burden of illness in Canada custom report generator. Retrieved from http://cost-illness.canada.ca/custom-personnalise/national.php
Grierson, B. (2018). Out of the shadows. New Trail, University of Alberta. Retrieved November 26, 2018 from https://www.ualberta.ca/newtrail/featurestories/2018/august/dementia-sets-lives-adrift
Huber, M. (2011). Health: How should we define it? British Medical Journal, 343, (7817), 235-237. https://doi.org/10.1136/bmj.d4163 (link http://www.jstor.org/stable/23051314)
Liang, A., Piroth, I., Robinson, H., MacDonald, B., Fisher, M., Nater, U., Skoluda, N., & Broadbent, E. (2017). A pilot randomized trial of a companion robot for people with dementia living in the community. Journal of the American Medical Directors Association, 18(10), 871. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/28668664
Mikkonen, J., & Raphael, D. (2010). Social Determinants of Health: The Canadian Facts. Toronto: York University School of Health Policy and Management.
Mohammadi, D., L. (2015). How lifestyle changes could reduce the risk of developing dementia. (2015). The Pharmaceutical Journal, doi:10.1211/PJ.2015.20200216
Oxford University Press USA. (2018, June 13). Dementia can be caused by hypertension. ScienceDaily. Retrieved November 25, 2018 from www.sciencedaily.com/releases/2018/06/180613101925.htm
Tew, C., Tan, L., Luo, N., Ng, W., Yap, P. (2011, August 14). Why family caregivers choose to institutionalize a loved one with dementia: a Singapore perspective. Dementia and Geriatric Cognitive Disorders, 30:509-516 DOI: 10.1159/000320260
Unicef. (2015, June 1). Module 1:Understanding the social ecological model (SEM) and communication for development (C4D) [Word document]. Retrieved from https://www.unicef.org/cbsc/index_65738.html
Waisel, D. B. (2013). Vulnerable populations in healthcare. Current Opinion in Anaesthesiology, 26(2), 186-192. doi:10.1097/ACO.0b013e32835e8c17
World Health Organization (1986, November 21). Ottawa Charter for Health Promotion. Retrieved October 6, 2018 from http://www.who.int/healthpromotion/conferences/previous/ottawa/en/