BGS 2014 Spring Meeting Conference Report
Geriatricians who have a bold vision of how things could be better should not listen to people who say it cannot be done because it’s against the rules, the chief executive of the Nuffield Trust told the BGS Autumn meeting in October.
Drawing an analogy between improving health care and the old television programme Scrapheap Challenge where contestants had to build a machine from what they could scavenge from a junkyard, Nigel Edwards added: “That’s your job. You have to build an effective geriatric machine out of suitable components left by the old systems. You have the opportunity to bend things to your shape and it’s time to get on with it.
”In a lecture entitled ‘Redesigning Care’, the head of the research and policy analysis institution said that the system in many hospitals was constructed around the disciplines of medicine rather than the problems of the patient. “It’s about individual events not patient journeys. The sickest patients usually see the most junior doctors because of the batch and queue system. If you arrived from Mars what would you think an outpatients’ department was for? You’d think it was for storage.”
New design principles would be to standardise where possible, centralise where necessary and decentralise where possible and to match needs to services. “How many people here are confident that patients could navigate the systems in which they work? Patients are often in the wrong place.”
An estimated 20 to 25 per cent of admissions, he noted, could be cared for at a lower level of care; 45 to 55 percent of bed days could be in other settings such as intermediate care. It was important to do the jobs necessary to keep someone at home: managing complexity meant that multi-skilled staff needed to be able to turn their hands to all kinds of tasks in order to meet patient requirements. “So, sometimes a highly skilled nurse might have to wash up and sort out the fridge.”
Flow was a key factor with decision making needed at the front of a process. “A senior who delegates is better than a junior who escalates.” Systems should be standardised to ensure coordination, continuity and the anticipation of needs. Networks should enable professionals to share information, work across organisational boundaries and understand the different attitudes and cultures of each discipline. There should also be more discretion over consultant to consultant referral. “We don’t want systems though, that are so big we lose the human perspective. If you can’t get all the people you need to talk to about something in a reasonably sized room, you’ve generally got a problem.”
Rethinking the outpatient model could mean more advice being given via the web and by phone. Although it was not appropriate for those with language, hearing or cognitive problems, it was still estimated that a large number of issues could be sorted by telephone. “You should also use your assets. Find out what voluntary groups are around, what neighbours will do someone’s shopping.”
Above all, patient care should be goal orientated with decision making shared. “And it should not be just a narrow bio-medical model but one with emotional and life based objectives.”
The healing power of being ‘home’
The need to redesign the system to cope with a changing demographic was one of the first themes to be highlighted when the opening session of the conference heard from Maj Pushpangaden that without effective redesign the country would need to build another 22 800-bed hospitals.
Dr Pushpangaden, clinical lead in elderly care in Bradford Teaching Hospitals, was describing the virtual wards system set up in her area to care for patients post discharge. Since its inception in 2012 it has seen 1500 patients. One example was of an 88 year-old woman with osteoporosis who had fallen and broken her arm. She was desperately keen to return home as she helped care for her daughter and her partner, both of whom had learning difficulties. “In the old days she would have gone to an intermediate centre but we elected to let her go home and worked out a care programme which could be handed on to the home team.”
In another case, a 98 year-old woman with soft tissue injury following a fall, instituting a home care plan was quite dramatic. She had been delirious on the ward but after being settled back at home and checked on during the night she opened the door to the health worker the next morning wearing lipstick and smiling warmly.
The Community Geriatrics session had opened with an account by Daniel Lasserson, senior clinical researcher at the Nuffield Department of Primary Care Health at Oxford University, of the work of the Emergency Multidisciplinary Unit, launched as an alternative to acute admission to hospital for frail elderly people. Its aim was to provide a rapidly responsive assessment, aided where possible by modern technology diagnostics: there were now, for example, hand held devices which could give blood test results.
Early diagnosis meant treatment could be started and sometimes continued and monitored at home. Where admission was required it was into a special local unit instead of a main hospital site. “Our approaches tend to be polarised between in patient bed-based hospital care and primary care but we need more in-between systems like this.”
The patient’s perspective
Insights into patients’ viewpoints are always valuable as was proved by a talk on physiotherapy after hip fracture by practitioners Victoria Goodwin of Exeter University Medical School and Louise Briggs from St. George’s NHS Trust in London, who see patients from two days after surgery through into the community. “They’re often very frightened and may refuse help. They might feel it’s too early to get up and fear falling again and harming themselves,” she said.
“It’s important to take time to show them it’s the right thing to do and you can use a hoist on day one if they are very nervous about getting out of bed. It’s also important to put them in control, to choose the right equipment and adapt it to their cognitive abilities. We love gadgets but patients who’ve never seen them before might view them as cages or instruments of torture.”
Patients with dementia needed special consideration. Those who refuse therapy may be distracted by pain and fear, hunger, thirst or a need for the toilet. Those with short term memory problems may need a lot of repetition or may find it easier to copy movement than be told what to do.
“We need to keep to the same equipment as it may be difficult for them to learn if we keep swopping. And we should always try and train them in an environment which closely resembles the place where the skills will actually have to be used. A gym setting, for instance, might not transfer to a home setting.”
Falls and Fractures
Earlier in the orthogeriatrics session Roger Francis, emeritus professor of geriatric medicine at the Institute for Ageing and Health at Newcastle University, had spoken of the effectiveness of his local osteoporosis and fracture liaison services where a specialist nurse gives advice on treatment for the condition and further falls prevention.
Such prevention was vital with 16 per cent of the population suffering 50 per cent of all hip fractures. The cost to the country of excess mortality – between 17 and 20 per cent – and excess morbidity - up to 50 per cent, leading to loss of independence – amounted to £2.3bn a year. Their liaison services had cut the risk of a second fracture by 40 per cent and the system should be extended throughout the UK.
Antony Johansen, consultant geriatrician at Cardiff Royal Infirmary, highlighted another need for hip fracture patients: prompt and effective rehabilitation. In one survey eight out of ten patients said they would rather be dead than suffer loss of mobility and independence.
He cited a well-known experiment – which would probably be illegal today – where medical students had been confined to bed for a week: even in that time they had lost a fifth of their muscle strength. Yet today physiotherapy and other rehabilitation services were often very limited; there was a great need for improvement.
‘Do you like old ladies?’
A major attraction of BGS meetings is the opportunity to hear from world experts in the field of geriatrics and Brighton was no exception with the Trevor Howell guest lecture being given this year by Kaare Christensen, the distinguished epidemiologist at the Institute of Public Health in the University of Southern Denmark. Prof Christensen who has been conducting a long series of studies of the oldest old took as his theme, the key question of whether we could live better as well as longer.
“There’s no doubt that we are doing very well at surviving. In the last century most countries have increased life expectancy by 25 to 30 years. Every year mortality has been beaten by three months. Up to World War II the decline in mortality was among the young; since then it has been among the old.
“The first question I ask medical students is – ‘do you like old ladies? I then show them the age distribution of people who go to medical doctors. They can then see that most of their professional lives will be spent dealing with old ladies.” To laughter, he added “I never check the drop-out rate afterwards.”
The question he and his team had been trying to address, however, was whether, by improving longevity, we were we simply adding a fourth age which had no pleasure for anyone, not for the people in it, nor for society – did extreme longevity lead to extreme levels of disability - or was there a positive side?
His department had studied two large cohorts. The first were those born in 1905 who were measured at the age of 92 for physical and cognitive abilities. They were assessed as being independent if they could, unaided, get out of bed, out of a chair, walk around the house and use the toilet. A reasonable level of cognition was set at a score of 23 or more out of the 30 questions on the mini mental state examination. The cohort was then re-examined at the age of a hundred. “In one sense, at 92 you are only halfway to being a 100 because it is as hard to get from 92 to a 100 as it is to get from 0 to 92.”
Although half the cohort had died in those eight years, those who had survived to reach their century showed a stable level of independence. “Strength, cognitive functioning and happiness scores were very encouraging. They were not more disabled or unhappy at 100.”
The study then looked at a 1915 cohort. “For every decade another 30 per cent make it into their 90s but would this cohort be frailer?” said Prof Christensen. “In fact they had become cognitively significantly better over those ten years. In the 30 question chart they had increased their score by 1.5 marks and in the activity of daily living they were doing better.” Doctors faced with treating a very old person had to weigh up potential life extending benefits against possible side effects. Two of the main predictors of being in good shape later, the study showed, were the ability to get out of a chair unaided and to have a score of more than 23 on the mental state exam: statistically a third of those who could do that would live to be 100.
Further optimism could be gained from the fact that each successive generation is cleverer than the previous one and that new technological developments could compensate for, say, a lack of mobility or other functions. “I’m not diminishing the extent of depression or suicide but I think we can be positive. If you can keep your cognitive functioning and master some IT, that sounds like a good combination for the future.”
‘It’s not fluffy stuff’
The meeting featured three workshops giving attendees a chance to input their own ideas. In one intriguingly entitled, ‘It’s not fluffy stuff : using the medical humanities to understand the practice of geriatric medicine’, participants were asked to spend as few minutes drawing a cartoon strip of themselves behaving as geriatricians and then to share how that might have illuminated the discipline’s underlying values.
The issues prompted by the exercise included the need to see the whole person, the importance of listening carefully and not making assumptions; and the need to work with other specialists even when they did not understand our speciality.
Muna Al-Jawad, consultant in elderly medicine at the Royal Sussex County Hospital, launched the workshop with examples of her own amusing and cleverly drawn cartoons, including those with the super hero character, Old Person’s Whisperer, which she uses both as teaching aids and to illustrate her own research.
The other half of the workshop led by Kate Wardle, consultant geriatrician at the Salford Royal Foundation Trust, focused on how film could illuminate the experience of ageing with clips from Up, Iris and Amour. Audience members were then asked how they would deal with some of the issues raised. Film, she said, could cut across time and across social and cultural settings and be a powerful tool for unlocking and managing emotions.
Deprivation of liberty
A second workshop dealt with palliative care and a third with mental capacity. In the latter Premila Fade, consultant in geriatric medicine at Poole Hospital and Dawne Garrett, professional lead in the care of older people at the Royal College of Nursing, looked at the implications of a Supreme Court ruling earlier this year in three test cases on the question of deprivation of liberty.
The decision that Article 5 of the European Court of Human Rights must be judged objectively, i.e. in comparison to a person with capacity and without disability, and not subjectively, meant there was a whole new cohort of people who fell outside Deprivation of Liberty regulations and therefore needed authorisation by the Court of Protection.
These included minors aged 16 to 18 and incapacitated people living in their own homes or assisted living who require continuous supervision and control where care is provided by the state. This was going to mean a huge rise in applications going up from the current 13,719 to an anticipated 176,000 in the next couple of years, swamping social services and the Court of Protection.
Early dementia diagnosis
Another approach to exploring current issues at Brighton was a debate on the timely topic of dementia diagnosis. The motion “This house believes that earlier diagnosis of dementia is good for patients and their families” was proposed by Jill Rasmussen, clinical champion of dementia for the Royal College of General Practitioners, who argued that research suggested most people would want to know provided it opened the door to evidence based treatment and support. Although the initial feelings on hearing the news included shock, anger and grief these could be balanced by a sense of reassurance and empowerment.
“Early diagnosis allows people to plan ahead while they still have the capacity to make important decisions” she told the meeting. “It allows them to get timely practical information, to consider drugs and non drug treatments and to participate in research.”
It would also, she argued, reduce stigma which often contributed to people’s reluctance to discuss symptoms and raise awareness generally. “People often think cognitive decline is just normal ageing so patients and relatives don’t seek medical advice. They often wait until the illness is so advanced it cannot be ignored.”
There was also an economic cost of delaying diagnosis. “We need cost effective packages of medical and social care for people with dementia and their carers across the course of the illness. We need multi targeted interventions, pharma and non pharma, plus support and training and respite care.”
Opposing the motion Surrey GP Martin Brunet maintained that it was screening by the back door, that memory clinics could be swamped by the worried well and that giving doctors financial incentives to make diagnoses was ethically unsound. “It’s good that the government initiative Dementia Challenge is putting it on the map but there are a lot of people benefiting from it including politicians and pharma: there are lots of vested interests here.”
Evidence about effective ways of preventing the progress of the disease following early diagnosis was still thin and money spent on finding cases might be better spent on research and support for patients in hospital or at home. There was also the danger of false positives and the over-enthusiastic use of drug treatments. “A dementia friendly society is basically just a caring society. I want to see nurses and doctors showing interest in and respect for patients irrespective of their cognition.”
An electronic vote before the debate showed 62.5 per cent of the audience in favour of the motion, 22.7 per cent against and 14.8 per cent abstaining or undecided. Afterwards it was 59 per cent for, 36 against and 5 abstentions or undecided.
ICU’s and the older patient
Technological advances have led to dramatic changes in intensive care units over the past ten to 15 years but there are still big questions over their suitability for older patients, as a session devoted to the subject heard on the second day of the meeting.
Andrew Bentley, consultant in intensive care medicine at the University of South Manchester, told his audience that there was a significant mortality rate among such cohorts but that age was only one factor. Others included co-morbidities, frailty, severity of organ dysfunction, infection and inflammation and timing of discharge. There was, however, no difference in the pattern of the use of resources. “We are treating them the same as younger groups.”
The eventual outcome – only 40 per cent were able to return home, the others having to have residential care - was determined more by functional reserve and by what happened during the whole stay in hospital.
One of the big problems in ICUs is delirium defined as disturbances in attention, awareness and cognition not explained by pre-existing states or conditions. The condition could be hypo- as well as hyper-active, which made it difficult to diagnose in patients who were in a stupor, according to Valerie Page, consultant in intensive care at Watford General Hospital.
Evidence suggested that both mortality and functional outcome including memory impairment and poor concentration, were both affected by delirium, the risks increasing with the longer a patient suffered, but it was still severely underestimated. “If in doubt, assume everyone has it”, was her message.
What happens post-ITU is vitally important according to Carl Waldman, consultant in intensive care medicine and anaesthesia at the Royal Berkshire Hospital in Reading where he also runs a follow-up clinic. Problems could include nightmares, hallucinations, loss of taste, poor memory and sexual dysfunction. “It can be similar to post trauma stress disorder,” he said.
Adverse effects could be mitigated by keeping patients as awake and interactive as possible, preferably in natural light, and talking to them while they were actually in intensive care as well as appropriate referrals and rehab later. “You need intensive after care after intensive care.”
At the opposite end of the spectrum of care are conditions which do not involve highly sophisticated equipment but mastery of more basic techniques. This was the theme of the talk given by Alison Hopkins, chief executive of Accelerate CIC which provides complex wound management services to the NHS.
The extent of venous ulcers among older patients was shown by the number of audience members who raised their hands in response to her question of whether this was a problem they had to deal with.
“These patients have a terrible quality of life and have had for years,” she said.” They have often not had their pain managed properly but their coping mechanisms like sleeping in a chair have made matters worse.”
There was hope though, as she explained with photos showing extreme examples of ulcers which had subsequently been cured or greatly improved by the right amount of compression and skilled bandaging. “We ask patients to rate bandagers. It’s a way of empowering them and it ups the game of the nurses.”
It must be a UTI
If ulcers have been widely under-managed then, conversely, urinary tract infections have perhaps been over-managed according to Sean Ninan, ST6 in geriatric medicine at Hull Royal Infirmary. “Many doctors feel that all acutely ill old people must have a UTI,” he said, citing cases where a stroke and an epileptic fit were misdiagnosed as UTIs. Over-prescribing of antibiotics was contributing to the possibility of an antibiotic apocalypse as well as putting patients at risk of possible side effects.
He was followed by Keith Hawkins, consultant geriatrician at the University Hospital of South Manchester, who outlined various treatments for UTIs and the prevention of their recurrence.
Other sessions at the meeting included ones on respiratory medicine, neurology, management and leadership and peri-operative care. There were platform presentations of papers on rheumatology, anti-coagulation and pain management. The subjects covered by more than 60 posters included research into clinical effectiveness, diabetes, epidemiology gastroenterology and Parkinson’s Disease.
On the social side there was a drinks reception in the Skyline bar at the conference centre and a dinner and dance at the Brighton Hilton.
Abuse and neglect
The last afternoon in Brighton looked at the abuse and neglect of older people when Jackie Morris reminded the audience of the Society’s long involvement with the problem: the first professional conference on the subject was organised by the BGS in 1988.
The definition of abuse was the violation of an individual’s human and civil rights by any person or persons. As well as physical, it may be verbal, psychological, emotional, financial and sexual. It could be an act of neglect or a failure to act. It could be committed by a friend, a family member or a stranger; it could happen at home or in an institution. “It happens when we forget to be humane, when we stop seeing patients as people and start seeing them as numbers.”
Dr Morris then provided examples of case histories and asked attendees to confer with a partner to see what each illustrated. Themes which emerged included recommendations to embed geriatricians in the system, the importance of dispassionate whistleblowers, the importance of knowing the Mental Capacity Act and the need for procedures to protect staff against malicious allegations. Supporting staff generally was fundamental. “Unless they’re treated with dignity and respect, it’s very hard for them to treat their patients with dignity and respect.”
Examples of institutional abuse could include ignoring requests for assistance to go to the toilet, scolding or humiliating incontinent patients, not helping with eating or drinking, not offering hand washing facilities, no privacy, no access to personal possessions, infantilisation, dehumanising language, restraints and abuse of medication.
Signs of physical abuse included cuts, scratches, bite marks, fractures, sprains, bruises and poor hygiene. Psychological abuse could be indicated by anger, excessive fear, passivity, confusion, by changes in mood, attitude and behaviour, by changes in sleep patterns and by a hesitation to talk openly.
Combating abuse involved raising awareness, ensuring people felt able to complain without fear of retribution, nurturing both the receivers and givers of care and assisting older people to maintain confidence and self esteem.
The event concluded with an address by Stephen Bowen, director of the British Institute of Human Rights who spoke about the interface between health care and human rights. “The idea that every member of the human family is equal in dignity and worth even if they’re old or their behaviour is difficult underpins everything.”
The NHS was in fact founded in the same year as the Universal Declaration of Human Rights was made and there was a natural linkage between the two. The principle of autonomy, for example, and informed consent were key principles of both. The second great UDHR principle was about the right to regulate the relationship between those with power and those over whom they have power which had relevance to the doctor/patient relationship.
Human rights provided the lens through which to view the world. “People say it’s utopian but in fact it is very much an attempt to find a balance between idealism and realism.”