The Second Cultural Revolution in Geriatric Medicine
There is general agreement that the distinction between leadership and management is that leadership creates the culture of an organisation and that management works within that culture.
There are many different definitions of culture but the most highly respected writer in the field is Edgar Schein who says: “Culture is the shared tacit assumptions of a group that it has learned in coping with external tasks and dealing with internal relationships.” (Source: Schein, E.H. (1999) The Corporate Culture Survival Guide. John Wiley & Sons (p.186)).
The leadership has to determine the correct belief and assumptions that it wishes to permeate the organisation, and the whole population, if one of the jobs of the leadership is to think of the health of populations as well as the health of individuals.
The British Geriatrics Society (BGS) can be proud of the culture change that it has achieved by providing leadership in the last seventy years. When the BGS was founded, the prevailing beliefs and assumptions of not only the public, but also the medical profession, were that the problems of older people were due to the ageing process and not to treatable disease, and therefore that older people needed “care” rather than accurate diagnosis and effective treatment and rehabilitation.
The first BGS cultural revolution – treatment is possible at any age
The BGS and individual pioneering geriatricians can rightly be proud of their achievements. There has been a revolution in the care of older people with disease. Obviously more needs to be done. Resources have not kept up with population ageing, meaning that many people who would benefit from an intervention by a team under the leadership of a geriatrician, do not do so.
Furthermore, a new problem has arisen, the problem of over-diagnosis and over-treatment, whereas the original problem was under-diagnosis and under-treatment. This is a consequence of what some people call multimorbidity but is actually a consequence of multi-specialty medical care, namely specialists in different disciplines making interventions either unaware of, or not clear of, the consequences of treatments being prescribed for that individual by specialists in other disciplines.
Fortunately this problem is now being understood, for example, through the campaign for Too Much Medicine run by the BMJ and by a growing concern about over-prescribing. This concern, it is true, is derived partly from the preoccupation with costs, but whatever the motive, there is an understanding that treating people with multiple health problems requires the highest level of thought and skill, and is not simply a matter for increased use of technology.
The specialty of geriatric medicine therefore needs to continue with this work to ensure that the change in culture persists, but it is now clear there is a need for a second cultural revolution – the preventive revolution.
The Second Revolution - prevention through fitness is possible at any age
There have been striking achievements in prevention but the focus has been on single diseases, on the prevention of heart disease or lung cancer, for example, but the evidence is already there, and getting stronger, about the potential to “prevent or delay the onset of disease, dementia and frailty”, as set out in the NICE guidelines in 2015. These are however, aimed at people in midlife. We also have the report by the Academy of Medical Royal Colleges on Exercise,The Miracle Cure, emphasising the role that exercise plays, not only in preventing disease but in improving its outcome. This is as applicable to people with long term conditions and multiple long term conditions as it is to people with single-organ disorders. There is also a growing evidence base about the possibility of prevention in older age groups, not so much primary prevention but the prevention of disability and the factors that contribute to frailty. The BGS’s own report on frailty is titled, Fit for Frailty and the key concept that the second revolution needs to promote is that of fitness, so often associated with youth, lycra and sport.
Closing the fitness gap
In the early 1980’s, evidence emerged for the concept of the fitness gap. The fitness gap is the difference between the best possible rate of decline and the actual rate of decline. For most people this gap starts in the early twenties, not because of ageing but because they get their first job which involves that very dangerous behaviour - sitting down. Precisely when ageing has an effect is difficult to determine. Roger Federer is still winning tennis matches at thirty-six and interestingly, came back from injury to regain his winning position. However, for most people life is not like the life for Roger Federer and the stress caused by the modern environment, which is dominated by the car, the computer and the desk job, means that the fitness gap opens up from about the early twenties. When disease occurs the fitness gap gets wider faster, sometimes because of the direct effects of the disease but often because disease changes the beliefs and attitudes of the person affected, and of those who support them, who think it is right and proper that people with long term health problems should no longer have to struggle with the shopping, but that things should be done for them. This accelerates the rate of decline of the actual rate of ability until the individual drops below ‘the line’, namely the line below which they cannot reach the toilet in time and the need for social care is defined.
The evidence for this decline was summarised in a book called, Prevention of Disease in the Elderly in 1985, a worthy book, but the title of which was wrong in two respects. Firstly, the content of the book was much more about the prevention of disability and dependency, and therefore a need for social care than about the prevention of disease and the sweeping generalisation implied in the term “the elderly” was also very misleading. A term like “the elderly” is a figure of speech called metonymy - the identification of one attribute as a basis of generalisations.
Language has a major influence on culture and while the concepts of sarcopenia and frailty, as opposed to the concept of frail, have been useful, they also have their downsides. They imply that there are diseases of frailty and sarcopenia, diseases like rheumatoid arthritis and Parkinson’s disease. In fact we are all experiencing wasting of muscle strength from the twenties onwards, except of course for people who keep in training, and we are all losing reserve, not only from ageing but also from loss of fitness. It is important to point out that the key characteristics of loss of fitness, namely a loss of maximum ability levels and of reserve when a challenge is made, are exactly the same as the key characteristics of the ageing process, which is why these two processes are often confused.
The BGS therefore needs to lead a cultural revolution to emphasise that people of any age and with any number of conditions can become fitter and that increased fitness may prevent or delay the onset of the need for social care.
Preventing the need for social care
Promoting fitness has many short term benefits for people in their 60s, 70s, 80s and 90s, for example in the prevention of depression but it is the potential for preventing the need for social care that is of vital importance for individuals, their families, the public services and the public purse.
Of course some people require social care as a result of severe disability caused by, for example a major stroke. Others require it because of dementia but even dementia should now be regarded as a disorder that can be delayed or prevented and the dramatic decline in the prevalence of dementia is only now being appreciated. The BGS needs to continue to promote the culture that is positive in its beliefs and assumptions that people of any age can improve their fitness and maintain a level of ability that precludes the need for social care.
It is clear now that the length of time that people are very dependent can be compressed, as James Fries first argued in 1980.
Leading the second revolution
It is not necessary for geriatric medicine to manage the prevention programme. The resources of geriatricians and their teams are better focused on the increasing need and demand resulting from population ageing - demands which may continue to grow, no matter how effective the prevention programme. The priority for geriatric medicine must be to increase the number of people who are seen and to prevent the harm from overuse being caused by multi-specialty medicine. Nevertheless, by changing the culture, geriatric medicine and the BGS can help to bring about the second revolution – the revolution for the prevention of disability, frailty and the need for social care.
Firstly, the message and the science need to be clear, and the impact of using nouns like frailty and sarcopenia to describe the tail end of continuous distribution curves will need to be debated. The simple model developed in the 1980’s and reproduced in the diagram below, might be one that the BGS could adopt and promote, to help people understand that ageing by itself is not a major problem until their nineties.
The type of work taking place that could be supported by the BGS includes the development of activity therapy, led by organisations including UK Active, the Ramblers and Age UK. Everyone who gets a prescription for a long term condition should also get an activity prescription delivered by GPs at the end of every consultation, reinforced in pharmacies whenever the person calls to collect the repeat prescription.
Linked to the Public Health England One You and Health Check Programmes, people in their sixties and seventies would also be encouraged to be more active - not only to walk more but to address the three other aspects of fitness, namely strength, suppleness and skill, bearing in mind the key determinant for social care is not the inability to walk four hundred metres, but the ability to stand up and go to the toilet when the time available is short.
The message about the benefits of activity is now well received and promoted in care homes, with the bigger challenge being people who are at home. There is scope for increasing activity when older people meet in bridge clubs, bowls clubs, the University of the Third Age or bingo, but a lot of the action has to go into encouraging all older people to be more active every day at home and it is important to remember not only that many older people are getting online, but also that everyone who has a television set is “online”, so the digital approach reinforced wherever possible by encouragement, is key.
In all this, it is important never to lose sight of the broader, social and economic pressures on people which increase for many, as they age. Too many older people are house bound and depressed, not only because of disability but because of low income. The isolation that occurs influences their attitudes and their beliefs, so to change beliefs and attitudes, we need to acknowledge inequality and poverty and continue to campaign to reduce it.
Viva the Revolution
The promotion of fitness in old age requires a cultural revolution that the BGS is well positioned to promote, not only because it led the first revolution but also because geriatricians have already provided leadership, recognising the shift from under-treatment to over-treatment as a hazard older people face. To that end we would like to explore establishing a BGS ‘Living Well’ SIG (special interest group). The aim would be to raise awareness and galvanise action among BGS members and friends about the role of living healthily in order to prevent illness in old age, and thereby, in Lord Amulree’s phrase, to ‘add life to years’. The SIG would work with others, with AgeUK, UKActive and the Ramblers who run the Health Walks and with the other key professionals’ groups, GPs and nurses, occupational and physiotherapists. The BGS has a key role to play because of its understanding of the ageing process and the relevance of The Miracle Cure in people affected by ageing and multimorbidity.
To register your interest in joining the new Living Well SIG, when it gets off the ground, please contact Joanna Gough in the secretariat ()
Sir Muir Gray
BGS Member, Founding Director of the National Campaign for Walking and author of the book Sod 70!