Of Struldbruggs, sugar, and gatekeepers: a tale of our times

Short abstract

Socially isolated, depressed old patients most often end up on the diabetes wards after someone notices their blood sugar is low and all other specialists have lost interest

At the beginning of November Gladys noticed a mild ache in the left side of her chest when she got up to go to the toilet in the middle of the night. The nursing home dialled 999 and she was whisked off to hospital. After six hours of processing in the emergency department, she ended up on the acute admission unit where, despite 72 hours of tests, no cause was found for her pain. Gladys was moved to the cardiology ward but again, despite a further battery of tests (including repeating earlier ones) no one could say for sure what caused her pain. Throughout, Gladys remained befuddled, relatively immobile, occasionally incontinent, and “uncooperative.” She didn't like taking the 16 prescribed tablets each morning. The medicine for the elderly team felt that attempting rehabilitation was inappropriate. Due to pressure of beds Gladys was transferred at midnight to an orthopaedic ward, but because of the need to free up the bed for the next day's waiting list initiative patient, she was moved to urology. After three days it was noted that her blood sugar at the time of admission was 15 mmol/l, so the bed manager felt it appropriate that Gladys should be transferred to the diabetic ward, which had two bays closed because of Norwalk virus. At some stage Gladys lost her specs and bottom set of dentures. She will be having turkey on the diabetes ward on Christmas day.

In the diabetes ward

“Old age is not so bad when you consider the alternatives,” said Maurice Chevalier. It is difficult to share his optimism after completing a general medical ward round, particularly if you are a doctor with an “interest” in diabetes. Nowadays, it is extremely rare to find a youthful inpatient with a diabetes related problem as, apart from an occasional patient with a foot ulcer, beds on the diabetes ward are most often occupied by Struldbruggs.

In Swift's Gulliver's Travels, Gulliver meets the Luggnaggians, among whom lives the immortal race of Struldbruggs. These individuals are destined never to die but continue to suffer the ravages of age and infirmity. Gulliver assumed these people must be particularly wise, given their decades of accumulated wisdom. What he saw was the exact opposite: a most miserable group of socially isolated and depressed ancients suffering from the most awful consequences of extreme senescence.

“They commonly acted like mortals... after which by degrees they grew melancholy and dejected, increasing in both until they came to four score... which is reckoned the extremity of living in this country, they had not only all the follies and infirmities of other old men, but many more which arose from the dreadful prospect of never dying. They were not only opinionative, peevish, covetous, morose, vain, talkative; but incapable of friendship, and dead to all natural affection, which never descended below their grandchildren. Envy and impotent desires, are their prevailing passions... They have no remembrance of anything but what they learned and observed in their youth and middle age, and even that is very imperfect... The least miserable amongst them, appear to be those who turn to dotage, and entirely lose their memories; these meet with more pity and assistance, because they want many bad qualities which abound in the others.”¹

Invariably, in my experience, such individuals are also hyperglycaemic.

Transformation

Why has there been such an expansion in the numbers of Struldbruggs and why do they invariably end up on the diabetes ward? In part this relates to modern medicine's perception that death means failure, to be delayed as long as possible, sometimes to the exclusion of rational thinking: “Nobody wants to be or to look old, everybody wants to live long enough to become old. Any possible measure propagated to increase life expectancy is receiving the utmost attention” (M Berger, lecture to Royal College of Physicians of London, 2002).

Figure 1.

“The least miserable amongst them, appear to be those who turn to dotage, and entirely lose their memor ies”

Credit: MEPL

The transformation from an ancient into a Struldbrugg usually begins shortly after admission to hospital, where a junior doctor, who has no access to previous details of the patient's life or medical notes and who will never see the patient again, orders a huge list of investigations. The patient is initially managed on the admissions unit by the new breed of acute physicians² according to latest guidelines, reinforced by local protocols and driven by fear of litigious relatives. If the patient fails to improve or cannot be discharged, transfer is arranged to the most “appropriate” specialty.³ The superspecialist soon realises that normalising the abnormal result does not make a huge difference. The patient becomes uninteresting and other experts are called in to “help.” The Struldbrugg does the rounds of other specialists, has frequent changes of environment, and experiences multiple, often duplicated, tests. The multidisciplinary medical notes become unwieldy and incoherent, and the drug chart runs to many pages. In the days of old, these individuals would have formed the greater part of the clientele of long stay wards. Today, as geriatricians have metamorphosed into rehabilitation specialists, Struldbruggs are now beyond their expertise and/or their interest.

Owing to the effects of advanced age on insulin production and action, hyperglycaemia is eventually discovered. As every symptom a patient can experience has the potential to be blamed on high sugar levels, he—or, more often, she—is transferred, usually in the middle of the night, to the diabetes ward, en route to residential care. It is invariably impossible to track down the clinician responsible for making the decision to transfer.

Summary points

Struldbruggs, individuals who are destined forever to suffer the ravages of age and infirmity, appear in Gulliver's Travels

Modern medicine aims to delay death as long as possible, sometimes to the exclusion of rational thinking

Now that geriatricians have become rehabilitation therapists, “Struldbruggs” no longer interest them

Struldbruggs often end up on the diabetes wards when interventions fail and specialists lose interest

Struldbruggs are also expensive in terms of time, effort, and resources. The erosion of spontaneity, incoherence of language, and preoccupation with the demands of bodily functions aggravate staff who are qualified in the physiology and pharmacology of disease but are novices in the skills of humanity. In recent years, because of the demands of the nursing process, nurses have been forced to abdicate from care. Nowadays, patients cannot eat until they have been assessed by a trained therapist, cannot be mobilised until the physiotherapist has pondered, cannot be discharged until they have passed the “home visit” test. When the patient's progress is slow or non-existent, families express dissatisfaction and anger at the care provided for their relative. The friction between relatives and staff is subsequently transferred towards the patient. For staff, feelings are transformed from caring into guilt, self reproach, dread, gratuitously heroic rescue attempts (furor therapeuticus), or a flat, bland, and hopeless attitude.⁴ Surprisingly, asking the relatives to “muck in” or take the Struldbrugg home is rarely offered as a solution.⁵

Treatment

These patients are not in any textbook of medicine. Students are never drawn round their bed for teaching, and examinations avoid their participation. Struldbruggs are always first on the list of exclusions for clinical trials; they rarely appear on surgical waiting lists, nor are they ever an item on the agenda of the clinical governance committee. Their test results are usually abnormal, increasing the risk of iatrogenic disease.

The treatment of the hyperglycaemic Struldbrugg is not straightforward either. Diabetes is no longer considered to be a disorder simply of glucose. In part driven by interests of industry, emphasis has changed to reduction of cardiovascular risk. Consequently, patients are prescribed increasing quantities of expensive pharmacological agents (including combination therapy for hyperglycaemia, two or three agents for hypertension, a cholesterol lowering drug, and aspirin) and are expected regularly to self monitor their urine or blood for glucose. It could be argued that an evidence base does exist for such interventions in older people⁶,⁷; but of the plethora of guidelines for the management of diabetes, many are unrealistic.⁸ In the rush to initiate evidence based treatments, it may be forgotten that adding pills or insulin for high glucose levels increases the risk of falls for old people,⁹ that physical and cognitive disability is positively associated with diabetes,¹⁰ and that tablets may be prescribed but only a minority are swallowed.¹¹ Nevertheless, if Struldbruggs are treated differently from younger people there are invariably shouts of ageism and discrimination.

Modern medicine needs to recognise that absolute benefits from interventions can be modest.¹² Hampton has pointed out that if the aim of medicine is the unthinking application of the results of clinical trials to all patients with the disease, then patient management can pass from doctors to managers. What is important is knowledge of the risks and benefits of treatments and the individual's attitude to illness—the glint in the eye test.¹³

For the time being it looks as if the general physician (usually the one with an interest in diabetes) will have to remain the modern gatekeeper¹⁴ as no one else appears to be interested and, unfortunately, no one can empower Struldbruggs to help themselves.