SECOND OPINION:Research on elderly provides better guidelines for all ages, writes DES O'NEILL
A DELIGHT in the counter-intuitive is a defining characteristic of those who enjoy working in geriatric medicine. Indeed, the very high quality of the trainees attracted to the intellectual and care ferment of the specialty might strike the general population as counter-intuitive in its own right.
The attraction lies with engaging with people at an age when they are at their most complex: as we say in the trade, we are born copies, but die as originals. Any two 85 year olds are much more different from each other than any two 45 year olds: yet up to recently the health system tended to over-simplify the care options for older people.
The process of rethinking old age starts with stripping away unhappy and lazy myths that have encrusted this most remarkable of social advances.
The most deadening myth is to caricature later life almost exclusively in terms of a miserable trajectory of decline and disease: of course, bad things happen as we age, but people also grow and develop into later life.
In fact, given that the meek and weak in their cohorts have died at younger ages, older people display an extraordinary mixture of toughness and frailty.
A further surprise to many is that older people show better outcomes to many medical procedures, such as urgent angiography for heart attacks, than younger people – a longevity dividend even in therapeutics.
Such counter-intuitive data assists in combating ageism. Barriers to getting sophisticated medical treatments because of age become a double-whammy, in the first instance in terms of diminished citizenship, and in the second instance because we are hampering access to those who stand to benefit most from them.
This culture of thinking against the flow has helped me greatly in steering a new departure for Ireland, the development of guidelines for medical fitness to drive.
This project, sponsored by the Road Safety Authority and the Royal College of Physicians of Ireland, represents a late catch-up by Ireland to develop comprehensive guidelines for doctors and drivers on how to manage driving in the face of illnesses that might affect ease and safety of driving, such as epilepsy, problems with vision and alcohol dependency.
There is a silver lining in starting this process relatively late compared with many other countries. Not only can we learn from their experiences, but much of the research upon which we should aim to base our decisions has only developed in the past 25 years.
And indeed, there are surprises aplenty in the research which can help us to shape our guidelines in ways that are counter-intuitive to doctors and the lay public alike.
A problem with driving is our familiarity with it, which not so much breeds contempt but dulls our critical thinking, exemplified by the collective obsession that older drivers represent a hazard to other road users.
Yet all the data suggests that older drivers, despite what is clearly an increased burden of illness and disability, are among the safest drivers on the road.
Indeed, a recent study showed that serious injury was halved for children in car crashes where a grandparent was the driver compared with a parent, despite less rigorous use of child safety measures.
This research frees us from a mechanistic view of driving where reaction time is all important, and move to models where behaviour, particular strategic and tactical approaches (when and how I drive) assume greater importance.
In addition, a small but growing body of public health research indicates how important access to driving and transport is to health and wellbeing, an important counter-balance to a larger body of work focusing on safety.
The new guidelines will apply to drivers of all ages, and for certain illnesses may in fact be of most relevance to younger populations of drivers, such as those afflicted with alcohol and substance misuse.
It is reassuring that the RSA has endorsed an enabling approach for the new guidelines, which are unlikely to alter the numbers driving on the road but will provide more security and reassurance to drivers and doctors alike.
That we have gained critical insights from research on older people to provide better guidelines for all ages should not really be a surprise: if you design for the old, you include the young, but if you design for the young, you exclude the old.
Prof Des O’Neill is a consultant in geriatric and stroke medicine. He will address the annual conference of the Irish College of Ophthalmologists on Thursday.