Download this paper in MSWord format

1. Purpose
This document describes the British Geriatrics Society's recommendations for standards of care for specialist services for older people and those with whom they work. It is envisaged the document will be of value to health professionals, primary care groups, NHS managers, general practitioners and voluntary agencies, in addition to geriatricians, old age psychiatrists and specialist registrars.

2. Executive Summary
2.1 Key elements of specialist services for older people

Comprehensive geriatric assessment of older frail people.
The essence of geriatric medicine is to assess and treat the medical and rehabilitative needs of older people. The key expertise of the speciality in assessing the clinical needs of the patients is the comprehensive geriatric assessment. This is recognised as a multidimensional interdisciplinary diagnostic process focused on determining a frail older person’s medical, psychological and functional capability in order to develop a co-ordinated and integrated plan for treatment and long term follow up. (http://www.bgs.org.uk/Publications/Good Practice Guide/compend_3-5.htm)

1. Rehabilitation of Older People - http://www.bgs.org.uk/Publications/Good Practice Guide/compend_1-4.htm
2. Acute Medical Care for Older People - http://www.bgs.org.uk/Publications/Good Practice Guide/compend_3-1.htm
3. The Older Person in the Accident and Emergency Department - http://www.bgs.org.uk/Publications/Good Practice Guide/compend_3-2.htm
4. The Discharge or transfer of care of frail older people for community health and social support - http://www.bgs.org.uk/Publications/Good Practice Guide/compend_3-3.htm
5. Collaboration between Geriatricians and Psychiatrists of Old Age - http://www.bgs.org.uk/Publications/Good Practice Guide/compend_3-4.htm
6. Comprehensive assessment for the older frail patient in hospital – http://www.bgs.org.uk/Publications/Good Practice Guide/compend_3-5.htm
7. Intermediate care - http://www.bgs.org.uk/Publications/Good Practice Guide/compend_4-2.htm
8. The specialist health needs of older people outside an acute hospital setting - http://www.bgs.org.uk/Publications/Good Practice Guide/compend_4-3.htm
9. Geriatric (Medical) Day Care Hospitals for older people - http://www.bgs.org.uk/Publications/Good Practice Guide/compend_4-4.htm
10. Assessment of Older People for Continuing Care - http://www.bgs.org.uk/Publications/Good Practice Guide/compend_4-6.htm
11. Palliative care http://www.bgs.org.uk/Publications/Good Practice Guide/compend_4-8.htm
12. Geriatricians and management of long term conditions - http://www.bgs.org.uk/Publications/Good Practice Guide/compend_4-9.htm
13. Abuse of Older People - http://www.bgs.org.uk/Publications/Good Practice Guide/compend_4-10.htm
14. Interface between primary and secondary medical care in the new NHS in England : the care of frail older people by GPs and consultant geriatricians –http://www.bgs.org.uk/Publications/Good Practice Guide/compend_4-14.htm
15. Hospital Discharge of Older People with Cognitive Impairment to Care Homes - http://www.bgs.org.uk/Publications/Good Practice Guide/compend_4-13.htm
16. Parkinson’s disease - http://www.bgs.org.uk/Publications/Good Practice Guide/compend_6-1.htm
17. Falls – http://www.bgs.org.uk/Publications/Good Practice Guide/compend_4-5.htm
18. Continence Services - (http://www.bgs.org.uk/Publications/Good Practice Guide/compend_6.2.htm)
19. Stroke – ( http://www.bgs.org.uk/Publications/Good Practice Guide/compend_6.3.htm)
20. Orthogeriatrics - ( http://www.bgs.org.uk/Publications/Good Practice Guide/compend_4-11.htm)

3. Introduction
Older people are important and valuable members of society who are entitled to effective and efficient health services to promote health and minimisation of disability in late life. The principles of good medical and social care for older people are:

• Involvement of older people in the management choices of their illness and decisions on future care;
• To promote good health in late life; http://www.bgs.org.uk/Publications/Good Practice Guide/compend_4-1.htm
• The prevention of illness; http://www.bgs.org.uk/Publications/Good Practice Guide/compend_4-1.htm
• Reduction of disability;
• To support older people in their own homes; http://www.bgs.org.uk/Publications/Good Practice Guide/compend_4-3.htm
• Preservation of dignity, autonomy and respect; http://www.bgs.org.uk/campaigns/dignity.htm and
• Although sensory impairment, vulnerability to and delayed recovery from illness may be features of advancing age, old age itself is not an adequate explanation or cause of physical or mental illness.
• Older people in hospital, in their own home and in care homes should be treated with dignity following the recommendations in the Behind Closed Doors Campaign (http://www.bgs.org.uk/campaigns/dignitypress.htm);
• Older people in hospital, in their own home and in care homes should have their nutritional needs recognised as recommended in the Age Concern England Hungry to be Heard Campaign (http://www.ageconcern.org.uk/AgeConcern/hungry2bheard.asp);

3.2 Statutory Service Frameworks for Older People
The NSF in England and similar initiatives in Wales and Scotland set out appropriate standards of care to be provided by the NHS and partner agencies including local councils with social services responsibility. In Northern Ireland , Health and Social Services are integrated to promote collaborative working. Older people throughout the UK can therefore expect:

• Access to programmes that predict and prevent ill health and disability where possible and desirable (Health Promotion and Preventative Health Care http://www.bgs.org.uk/Publications/Good Practice Guide/compend_4-1.htm);
• Full access to the NHS and all its facilities when clinically appropriate regardless of age; http://www.bgs.org.uk/Publications/Good Practice Guide/compend_3-1.htm
• A correct diagnosis at the time of acute illness or loss of independence (Acute Medical Care for Older People - http://www.bgs.org.uk/Publications/Good Practice Guide/compend_3-1.htm);
• Assessment and treatment by a team of appropriate disciplines when recovering from an acute illness or change in health even when recovery has been or is expected to be limited (Rehabilitation of Older People - http://www.bgs.org.uk/Publications/Good Practice Guide/compend_1-4.htm);
• Prompt access to the equipment and aids needed to facilitate recovery and promote independence;
• A supportive multi-agency plan of continuing care where full recovery to independent function is not achieved (Assessment of Older People for Continuing Care - http://www.bgs.org.uk/Publications/Good Practice Guide/compend_4-6.htm); and
• A comfortable and dignified death (Palliative Care http://www.bgs.org.uk/Publications/Good Practice Guide/compend_4-8.htm).

3.3 Delivering High Standards of Care for Older People
Achieving the high standards of care will require:

• Understanding of the needs of older people and a strategic plan to deliver services which address them;
• Involvement of older people, including carers, in service planning;
• Partnership working between primary care, local authorities and NHS trusts, voluntary sector groups;
• Recognition of the role and structure of the interdisciplinary team (defined as a group of nurses, doctors, specialist nurses, therapists, social workers, dieticians and other health professionals organised around the needs of older people or other patient group where leadership and composition of the team may change according to individual patient circumstances); and
• Realignment of hospital based services to develop integrated specialist services for stroke, falls/fractures and osteoporosis, intermediate care support and mental health services for depression and dementia.

4. Eliminating Age Discrimination
The British Geriatrics Society (BGS) opposes discrimination against older people (either direct or indirect) and in particular decisions about health and social care made on the basis of chronological age alone. There is evidence that certain interventions have a greater benefit in older people e.g. thrombolysis after myocardial infarction; hypertension management.

The principle is that health and social care delivery will be based on need rather than age. Age should not be used as a factor in eligibility for health or social care. However, none of these statements should undermine services of established benefit to older people specifically.

4.1 Implications for Specialist departments:

1. Older people must be represented, consulted and involved in local planning and decision making;
2. Local champions for older people are identified at each level in NHS trusts including non-executive director lead and clinical leads. The clinical leads should come from the specialist departments;
3. All clinical policies are regularly reviewed to ensure no age bias;
4. Resuscitation policies are reviewed to ensure concordance with national guidelines;
5. Needs of ethnic and religious minorities are represented and incorporated in departmental protocols and local planning; and
6. Staffs of all types in care of older people units need to be empowered to challenge behaviours and help change attitudes in their own and other departments.

5. Person Centred Care
Older people should at all times be treated as individuals and offered choice in treatment, discussion and planning of future care. Services need to be modelled so as to be easy to access regardless of the end provider e.g. Health, Social Services or Private provider. This can be achieved through involvement of older people (including users and carers) in service planning, for example:

• Integrated commissioning arrangements between NHS trusts, local authorities and primary care groups or trusts as currently exists in Northern Ireland ;
• Utilisation of the single assessment process;
• Integrated community services to ensure rapid and flexible access to equipment; and
• Ensuring a single point of access to services.

5.1 General Information
Older people may expect from specialist services:

• To be involved in decisions made about their health and future care;
• Adequate numbers of appropriately trained staff;
• Clear and sensitively expressed explanations of their medical condition/illness unless their ill health prevents this, and of the treatment options available, in writing if required;
• If the older person wishes, this information will be shared with relatives, friends and carers;
• That relatives, friends or other advocate may give and receive information on their behalf, if the older person has difficulty in understanding or communicating and gives consent;
• Practical advice on appropriate support services and information to enable them to adapt to illness and disability;
• Written detailed information on local health and social services, voluntary organisations and on benefits;
• That support will also be available to their family and significant friends;
• Access to their health records and the security of knowing that everyone in the NHS is under a legal obligation to keep records confidential;
• Health premises accessible to people with disability; and
• Appropriate and punctual transport arrangements.

5.2 Discharge Planning and Equipment provision

The discharge of older people with high levels of dependency and complex health and social care needs requires careful planning, should be timely and to an appropriate location.

For more information please read The Discharge or transfer of care of frail older people for community health and social support - http://www.bgs.org.uk/Publications/Good Practice Guide/compend_3-3.htm

5.3 Abuse of Older People

Abuse of older people is common, frequently hidden, and insidious in its capacity to deny respect and basic human rights for one of the most vulnerable sectors of society. It is the responsibility of those working in health care of older people to understand risk factors and signs of possible elder abuse, and know the correct way of managing this when suspected. For more information please read Abuse of Older People – http://www.bgs.org.uk/Publications/Good Practice Guide/compend_4-10.htm and the website by Action on Elder Abuse - http://www.elderabuse.org.uk

6. Non-acute Care: Rehabilitation, Continuing Care and Intermediate/Community based Care

6.1 Rehabilitation

The International Classification of Functioning, Disability and Health (ICF) includes body structure and function, but also focuses on ‘activities’ and ‘participation’ from both the individual and the societal perspective. The WHO defines rehabilitation as a wide range of activities in addition to medical care which includes psycho-social care and occupational therapy. It is a process aimed at enabling people with disabilities to reach and maintain their optimal, physical sensory, intellectual, psychological and or social and functional levels.

For more information please read Rehabilitation of Older People - http://www.bgs.org.uk/Publications/Good Practice Guide/compend_1-4.htm

6.2 Intermediate care.

Intermediate Care is conceived as a range of service models aimed at “care closer to home”. The two underpinning aims are, firstly, to provide a genuine alternative to hospital admission for some carefully selected patients and, secondly, to provide rehabilitation and supported discharge.

An intermediate care service should have a clear function (admission prevention and/or post-acute care), incorporate comprehensive (multi-disciplinary) assessment, have an enablement process, offer time-limited contact (to differentiate I.C. from maintenance services) and involve multi-agency working.

For more information please read Intermediate Care - http://www.bgs.org.uk/Publications/Good Practice Guide/compend_4-2.htm and Interface between primary and secondary medical care in the new NHS – Interface between primary and secondary medical care in the new NHS in England : the care of frail older people by GPs and consultant geriatricians –http://www.bgs.org.uk/Publications/Good Practice Guide/compend_4-14.htm

6.3 Community based care

Departments catering for older people in hospital should provide comprehensive services in the community to support general practitioners and primary care teams caring for older people. (The Specialist health needs of Older People Outside an Acute Hospital Setting - http://www.bgs.org.uk/Publications/Good Practice Guide/compend_4-3.htm).

6.4 Continuing Care

All older people are entitled to receive a comprehensive geriatric assessment (good practice guide link) prior to placement in a care home or NHS Continuing Care. (The Assessment of Frail Older People being considered for, or in receipt of, Continuing Care - http://www.bgs.org.uk/Publications/Good Practice Guide/compend_4-6.htm). Some individuals will qualify for fully funded NHS Continuing Care, usually still delivered in a Nursing Home, although commissioned by the Primary care Trust. Consultants and departments should be familiar with the criteria for NHS Continuing care under the national framework which commenced in October 2007 -http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_076288

6.5 Acute Assessment and General Hospital Care

Older people benefit as much from appropriate investigation and treatment as younger people and they are entitled to receive equivalent, efficient, timely and effective services as them. They are entitled to be treated with Dignity, compassion and humanity and their human rights should be respected. For more information please read Acute Medical Care for Older People– (http://www.bgs.org.uk/Publications/Good Practice Guide/compend_3-1.htm).

7. Specialist Services: Stroke, Falls, Pressure Sores, Pain, Orthogeriatrics and Continence.

7.1 Stroke
Accurate diagnosis and prompt treatment is essential in Stroke.

Older people are more likely to suffer from strokes and transient ischaemic attacks simply due to ageing.

Prompt investigation (with urgent CT scanning) will allow appropriate acute therapy (i.e. thrombolysis for acute ischaemic stroke) and supportive therapy (e.g. oxygen, intravenous fluids, nutritional therapy (where appropriate) and further therapy as required) to allow maximum recovery to take place.

Guidelines are in place to improve the standards of care and should be followed where appropriate (most should be read and considered by geriatricians and take into account for use in the whole of the UK ).

For more information please read The Royal College of Physicians ( London ) National Clinical Guidelines for Stroke - http://www.rcplondon.ac.uk/pubs/books/stroke/index.htm and also - http://www.bgs.org.uk/Publications/Good Practice Guide/compend_6.3.htm.

7.2 Falls.

Thirty percent of people aged over 65 and forty percent of those aged over 75 fall over each year. Falls are associated with significant mortality and morbidity. Multi- component programmes and comprehensive geriatric assessment have been shown to be effective at reducing the negative consequences of falls .

Falls - http://www.bgs.org.uk/Publications/Good Practice Guide/compend_4-5.htm

NICE Guideline. The assessment and prevention of falls in older people. 2004. - http://guidance.nice.org.uk/CG21

7.3 Pressure Sores

Immobile or frail older people in hospital or in care homes are more likely to suffer from pressure sores. Pressure sores are areas of injured skin and tissue. Sitting or lying in one position for too long usually causes them. This puts pressure on certain areas of the body. The pressure can reduce the blood supply to the skin and the tissues under the skin. When a change in position doesn't occur often enough and the blood supply gets too low, a sore may form. Pressure sores are also called bedsores; pressure ulcers and decubitus ulcers. Prevention will always be better than cure.

For more information please read – NICE Guidance on Pressure ulcers: The management of pressure ulcers in primary and secondary care (September 2005) - http://guidance.nice.org.uk/CG29

7.4 Pain

Any health assessment of older people must include the identification of pain when present remembering that many of them will not acknowledge or report pain. If present standardised intensity rating will help measure severity.

Careful history taking and examination of the older person are essential to identify the location of pain.

It must be remembered that behavioural problems in older people with Dementia may often be caused by pain.

For further information please read The British pain Society and The British Geriatrics Society Guidance on the Assessment of Pain in Older People (2007) - http://www.bgs.org.uk/Publications/Publication%20Downloads/Sep2007PainAssessment.pdf and The Pain Society - http://www.britishpainsociety.org/

7.5 Orthogeriatrics

Fractures are the most significant consequence of falls in osteoporosis currently 75-75000 hip fractures a year in the UK cost the NHS £1.4 billion with numbers set to double by 2050. The outcomes of fractures in older people have been shown to be much better when there is close collaboration between departments of orthopaedics and geriatric medicine.

For further information please read Our historic alliance with the world of orthopaedics, BGS Newsletter October 2007 - http://www.bgsnet.org.uk/Oct07/1_boa_bgs.htm, The British Orthopaedic Association: The care of Patients with Fragility Fracture September 2007and - http://www.bgs.org.uk/Publications/Good Practice Guide/compend_4-11.htm.

7.6 Continence Problems (Bowel and Bladder Control)

Incontinence is a common and distressing condition of later life. Rates of urinary incontinence vary from about 3% to 60%, depending on how incontinence is defined and the type of population studies. Studies have found approximately 2% of the general population and about 60% of the nursing home population to be incontinent of faeces. When ill continence problems are more likely to develop. This may be exacerbated by inadequate history taking and examination as well as lack of attention to their privacy and dignity. Appropriate management will do much to reduce and alleviate distress. (http://www.bgs.org.uk/Publications/Good Practice Guide/compend_6.2.htm).

Royal College of Physicians ( London ) Management of Continence Care - http://www.rcplondon.ac.uk/college/ceeu/coop/index.asp

NICE Guideline. Urinary incontinence: the management of urinary incontinence in women (October 2006) - http://www.nice.org.uk/guidance/CG40

NICE Guideline. Faecal incontinence: the management of faecal incontinence in adults (June 2007) - http://guidance.nice.org.uk/CG49

8. Mental Health Services
Good mental health underpins the well being of older people. Older people with mental health problems are entitled to have a diagnosis made and appropriate treatment initiated as recommended in the following guidelines.

BGS Delirium guidelines- http://www.bgs.org.uk/Publications/Clinical%20Guidelines/clinical_1-2_fulldelirium.htm

Collaboration between Geriatricians and Psychiatrists of Old Age - http://www.bgs.org.uk/Publications/Good Practice Guide/compend_3-4.htm

Hospital Discharge of Older People with Cognitive Impairment to Care Homes - http://www.bgs.org.uk/Publications/Good Practice Guide/compend_4-13.htm

Delirious about Dementia http://www.bgs.org.uk/Publications/Publication%20Downloads/Delirious-about-dementia.pdf

NICE Guideline. Dementia: Supporting people with dementia and their carers in health and social care (November 2006) - http://www.nice.org.uk/guidance/cg42

9. Medicines and Older People.

Medication offers older people the opportunity of enhanced life expectancy, enhanced functional independence and quality of life.

Older people are more likely to suffer from multiple diseases and hence be prescribed multiple medications increasing the likelihood of poor compliance and adverse drug reactions.

When prescribing for this group consideration must be given to risks and benefits.

For more information please read The Royal College of Physicians (London) National Sentinel Audit of Evidence based prescribing in Older people (EBPOP) (1999/2000) - http://www.rcplondon.ac.uk/college/ceeu/ceeu_ebop_summary.htm

10. Palliative Care.

All older people at the end of life, wherever they are living, are entitled to holistic person centred palliative care equivalent to that provided to people suffering from cancer.

Palliative Care - http://www.bgs.org.uk/Publications/Good Practice Guide/compend_4-8.htm

11. Further Information

11.1 NHS Publications:

• NHS Scotland. Adding Life to years. Report of the expert group on health care of older people. 2002
• NHS Wales. National Service Framework for Older People in Wales 2006
• NHS Wales. When I'm Sixty Four and more. Report from the Advisory Group on a Strategy for Older People in Wales 2002
• NHS England. National Service Framework for Older People 2001
• NHS England. A new ambition for old age: Next steps in implementing the National Service Framework for Older People 2006

11.2 National Institute of Health and Clinical Excellence (NICE) Guidelines:  

• Urinary incontinence: the management of urinary incontinence in women (October 2006) - http://www.nice.org.uk/guidance/CG40
• Faecal incontinence: the management of faecal incontinence in adults (June 2007) - http://guidance.nice.org.uk/CG49
• The assessment and prevention of falls in older people (November 2004) - http://guidance.nice.org.uk/CG21
• Pressure sores: Pressure ulcers: The management of pressure ulcers in primary and secondary care (September 2005) - http://guidance.nice.org.uk/CG29
• Dementia: Dementia: Supporting people with dementia and their carers in health and social care (November 2006) - http://guidance.nice.org.uk/cg42/?c=91523
• Cardiovascular: Management of chronic heart failure in adults in primary and secondary care (July 2003) http://guidance.nice.org.uk/CG5/?c=91497
• Parkinson’s disease: Parkinson's disease: diagnosis and management in primary and secondary care (June 2006) - http://guidance.nice.org.uk/CG35
• COPD: Chronic obstructive pulmonary disease - Management of chronic obstructive pulmonary disease in adults in primary and secondary care - http://guidance.nice.org.uk/CG12/?c=91527

Review date October 2010.

Authors: Dr J Morris, London and Dr D Beaumont
for BGS Policy Committee