BGS Spring Meeting 2017 - Conference Report
Policy makers pay far too little attention to ageing - with serious consequences for both individuals and society as a whole, a leading academic told the BGS’s Spring Meeting in April. “By ageing I don’t mean old age – there’s plenty of policy on that – but ageing across the life course,” said Prof. Alan Walker, professor of social policy and social gerontology at Sheffield University.
The revolution in longevity was all too often portrayed as bad news with phrases like the silver tsunami, the dependency time bomb and the pensions crunch, added Prof. Walker who illustrated his point with a cartoon showing the road sign of old people crossing, but this time loaded with bags of cash and the caption ‘greedy geezers’.
The doom merchants always portrayed increased life expectancy as an economic burden. “Care costs are projected to quadruple by 2045 with the reasoning: more older people, more social care costs, more public expenditure.
“The striking thing though, is how little countries actually spend on social care. The UK spends below one per cent of its GDP but even Sweden, the biggest spender, still spends only four per cent. It’s a similar story with pensions. These are political decisions not demographics.”
Moreover, there were real positive aspects, particularly improved health and functioning and a decline in premature deaths. “The meaning of later life is changing before our eyes. For many people, 70 is the new 50: they are able to do more things and remain more active than previous generations at the same age. To be old is no longer to be poor like it often used to be. Although a fifth of older people do live in poverty, for the majority average income has risen. And there are a million people now working beyond pension age. More older people are also engaged in child care and practical activism.
“You can see cultural shifts just by looking at the colour supplements and the sudden appearance of older people in fashion shoots as well as in art and literature, not to mention the whole anti-ageing cosmetic industry.” There was also a wide range of new and exciting scientific research into ageing.
However, there were still huge disparities and inequalities. “Ageing is inevitable but it is also variable and malleable”, the Marjory Warren guest lecturer told his audience. A person’s genes were obviously key but they were outweighed four to one by extrinsic influences throughout life. These included nutrition, socio-economic status, education, working conditions, air pollution, stress, safety, the built environment and lifestyle choices such as smoking, exercise and diet.
This was why we urgently needed a social policy with a comprehensive strategy for active ageing at all stages of life from maternal and foetal health onwards. There was now, for example, a clear connection between early education and later life cognition. Essentials would include promoting activities which contributed to both physical and mental wellbeing, the prevention of ill health, maintaining or regaining capacity and lifelong learning opportunities. Later life policies might cover maximising activity, maintaining health and autonomy, encouraging engagement in community life and using technology to resist dependency.
We also needed to close the gap between demographic shifts and institutional or organisational responses. Most employers, for example, had not got to grips with the need to find a rejuvenated workforce to compensate for a falling birth rate.
There would be many challenges, he admitted: changing behaviour without making people feel coerced or stigmatised was difficult. Also the neo-liberal ideology that everything was a matter for the individual had been dominant in our society for some time.
“But this has to be a partnership between individuals, organisations and policy makers. If we don’t take collective action it’s not going to happen. But it could transform millions of lives, prevent premature death and save the exchequer money.”
The dying role
The meeting in Newcastle had begun with the first day fully devoted to two special areas: dementia and related disorders and ethics and law. The former included sessions on delirium, screening tools, communication facilitators, cognitive impairment in the acute stroke unit, transition from hospital to the community and insights from families living with dementia.
The ethics and law day began with a morning on transitions of care at the end of life with the first speaker, Prof. Edwina Brown, professor of renal medicine at Imperial College, examining the issues surrounding the withdrawal of dialysis.
The UK Renal Association guidelines were that withdrawal was appropriate if a patient was deteriorating despite it or struggling to cope as a result of the progressive worsening of the underlying problem or there had been the sudden onset of a catastrophic event such as a stroke.
“Dialysis may become a burden. I often get the impression patients feel guilty about wanting to stop it. They feel they’ve let down the medical team who have done so much for them,” said Prof. Brown. She added that some nephrologists gave the impression that the procedure was a universal panacea whereas in fact patients had to be reasonably fit to ensure it.
Ethical issues around the decision included patient autonomy, the use of resources including time and the determining of the ‘ceiling of care’.
By prolonging life unnaturally, a technological society could also deprive us of, what scholars called, ‘the dying role’ and its importance.
With Rembrandt’s picture of Jacob Blessing His Sons on the screen, Prof. Brown added, “Modern medicine often gets in the way of that. Often we don’t have the ability to pass on our wisdom or say our goodbyes. But people want to share memories, pass on keepsakes, settle relationships, establish their legacies, make peace with God. This role, observers argue, is among life’s most important for both the dying and those left behind.”
Such concerns were ever more pressing with the growth in the numbers of older people on renal replacement treatment. There had been, for example, in the last five years, a 50 percent increase in it for the over 85s.
Patients should be offered the opportunity to create an advance care plan which would enable them to discuss their prognosis, ask questions, decide what would or would not be acceptable treatments and what goals they might want to achieve if time was limited.
“I do an annual review with my patients and ask them if they’ve ever thought about what they might want if they reached the stage where the treatment wasn’t going to make them any better. I’d say 60 per cent of people were delighted I’d raised the topic, 20 per cent hadn’t thought about it but were pleased to go away and do so and 20 per cent wouldn’t talk about it then, but would later.”
There were often significant cultural differences. “For instance, truth telling is now the norm in this country whereas it didn’t used to be and in many countries it is still considered more humane to withhold information.”
Similarly there was a difference in the balance between autonomy and beneficence. The West saw the patient as the primary decision maker, many other cultures saw the family.
Take faith seriously
The second speaker Prof. James Beattie, consultant cardiologist with the Heart of England NHS Trust, looked at some of the dilemmas with implanted heart devices towards the end of life. Huge advances over the past 40 years meant there were fewer acute cardiac deaths; instead there were half a million ‘survivors’ living with heart failure.
This was still, he pointed out, a progressive disease but because decline could be lengthy and uneven it was often difficult to recognise when established therapies became futile. “There is a reluctance to discuss prognosis in the face of uncertainty but we have to be able to step back and ask ‘is this still an appropriate treatment’?” Otherwise patients’ wishes might be unexplored or they may feel disempowered by technicalities. “Health professionals need to ensure that treatment is personalised, reviewed openly and regularly with patients and their families, remains appropriate and is held within an ethical framework.”
A plea for doctors to take the faith of patients seriously was made by the third speaker, Prof. Robert Song, professor of theology at Durham University. Although doctors were themselves more likely to be religious than the population as a whole, religion was becoming increasingly estranged from clinical context. “In many contexts that won’t make any difference but in some, particularly at the end of life, it might make a big difference.”
The best way of understanding was not to see religion simply as a set of beliefs but as gut instincts which were felt, lived and practised, a way of being in the world which then emerged into cognitive beliefs.
“This is the sense that we are grounded in something bigger than ourselves, that our lives are not wholly random, they have depth and fulfilment, we are made for something. There is also the sense that life may make moral demands of us even if that involves suffering and that all our lives are linked to each other.
“Health care professionals often shy away from matters of religion and spirituality yet they are an integral part of a person and what makes them tick. They often want to talk about their beliefs when decisions have to be made so we should at least do them the courtesy of trying to understand their world and be sympathetic. Otherwise it can add to their sense of alienation. It might even make for better outcomes.”
Ethics and law are, of course, crucial in euthanasia decisions as a visiting Dutch doctor emphasised in a special hour and a half long session on the situation in the Netherlands.
The definition of euthanasia, said Prof. Hans van Delden, professor of medical ethics at Utrecht University, was death caused by a drug administered by a physician to end a patient’s life at the patient’s explicit request. Physician assisted suicide was where death was caused by a drug prescribed by a physician but administered by the patient him or herself with the explicit intention of hastening death.
The Euthanasia Act of 2002 stated that a physician may perform it if he or she was convinced the patient had made a voluntary and well considered request, was suffering unbearably with no prospect of improvement, was well informed of the situation and prognosis, and there was a joint conclusion with a second independent doctor that there was no reasonable solution to relieve suffering.
The law, which was based on both autonomy and compassion, originally arose out of cases where judges, in line with public opinion, wanted to find ways of not punishing doctors. The emphasis therefore was medical with a strong reliance on doctors’ conviction that there was no prospect of improvement.
Over the years, however, attitudes had changed. Society now tended to focus more on autonomy with less acceptance of the evaluation of suffering by a physician. “The idea is ‘who is that doctor to judge if I’m suffering enough? I’ve always been independent but now someone else is deciding my moment of death’”.
The difficulty for doctors, added Prof. Van Delden, was when a person did not have a serious medical condition. “For example, some older people just don’t want to go into a nursing home but it’s impossible for me to say on objective medical grounds that they’d be better off dead.”
Doctors could refuse to carry out euthanasia or assisted suicide but patients could now go to an end-of-life clinic which would be more amenable to their request. Many physicians who were front runners in the movement were now questioning the development. “If you want to kill yourself that’s your decision but why should I be the one to do it?”
Geriatrics; the past and the future
The afternoon concluded with an address on the past and future of ethics in geriatrics by Prof. Desmond O’Neill, consultant geriatrician at Tallaght Hospital, Dublin, who called for a celebration of ‘the wonder and marvels of ageing’ and the need to embed it in the arts and humanities. Exciting things, he pointed out, were happening in cultural gerontology which aimed to transcend old paradigms and bring a fuller, richer account of later years.
“Ageing is always described in terms of loss but we have to be very cautious about how we engage with these negativities. Even people with dementia can still have a good quality of life. My mother has a degree of it but we can still have a lot of pleasure together.
“Ageing, which is the most important experiential source of knowledge and what it is to live a finite life, is neglected by the same culture that needs its wisdom. Ageism means we are discriminating against our future selves.”
Other topics during the day included an update on the Deprivation of Liberty regulations, the development of ReSPECT, a Recommended Summary Plan for Emergency Care and Treatment in which patients could address issues like resuscitation, treatment options and their own priorities with more complexity than in some other advance care planning options and real life examples of DNAR, Do Not Attempt Resuscitation decisions.
In the latter, audience members were asked to vote electronically on various options, another example of how technological BGS meetings have become. The Newcastle event was paperless: programmes were downloaded and feedback delivered online, CPD registration was done by scanning one’s pass and questions to speakers could be posed via an app during an address.
Advances in technology and their implications for patients, particularly older ones, were outlined in a whistle-stop tour of the latest developments in telehealth by Dr. Kevin Doughty, consultant in technology at York University.
Comparing each stage to a wave and beginning at the start of the 21st century, Dr. Doughty took the audience through community alarm systems, telecare alarm services, vital signs and activity monitoring, mobile and wearable devices and apps to home video services. This was the present day: the sixth and seventh waves expected over the next decade were personal care technologies and the internet of things and social robotics, digital assistants and artificial intelligence.
Over the years, technology had become smaller, faster, cleverer and cheaper, which meant it could be used to support health, wellbeing, self-care and independence and increasingly, to avoid the need for long term care.
Examples included exoskeletons to help people with mobility problems, mind-controlled prosthetics, monitoring systems which sensed specific actions or the lack of them, apps which improved medication adherence, devices which could turn mobile phones into ECGs, ‘doctor-in-your-pocket’ tools which could take pulses, temperatures, measure heart rates and body chemistry. Some could be set up to diagnose common conditions.
Tele-conferencing could link patients with GPs, consultants, specialists and therapists without the need for travel; audio-visual systems could connect older people to distant friends and families to alleviate loneliness; tele-concierges could monitor security and screen visitors to increase safety; older people could participate in exercise classes and other activities from their own home; virtual reality headsets could offer entertainment or reminiscence experiences that could overcome the limitations of mobility and finance.
We were already moving, explained Dr. Doughty, from virtual to augmented reality where these processes were available on ordinary looking spectacles rather than wraparound headsets which made them easier to wear and obviated any sense of being stigmatised. He showed an illustration of how a person with cognitive impairment could look through such glasses on to a kitchen work surface and read labels and instructions about how to make tea and toast.
The internet of things referred to the ability of physical objects, embedded with electronics, software, sensors and network connectivity, to collect and exchange data. “There are about five billion connected devices at the moment and the number is predicted to exceed 50 billion by 2020,” Dr. Doughty told the meeting. “It will involve everyone and everything – retail, government, health, transport, community, entertainment and industry.”
A smart kitchen, for example, might offer personalised menu suggestions based on activity levels and bio data with recipes from online celebrity chefs using ingredients from the fridge and automatically ordering refills. A smart bathroom mirror might prompt medication, monitor pallor and blemishes and offer advice on sunscreen and hydration related to the day’s weather.
The seventh wave would see the arrival of social robotics who would understand human language, learn through observation and determine what actions to take to fulfil a request or solve a problem. “In the future robots could replace doctors. As we increasingly digitise health information, artificial intelligence will gain a deeper understanding of medicine than humans can.”
Another speaker Dr. Malcolm Fisk, senior research fellow at De Montfort University in Leicester, stressed the importance of not seeing older people as technologically averse or incompetent. There were some barriers including lack of skills, satisfaction with the status quo, dexterity and sensory impairments and a reliance on other family members to use the internet on their behalf.
“This is balanced though by technology enthusiasts, by the new tranche of older people in work, by better designs and accessibility and people seeing proven benefits. There are challenges to manufacturers to make technologies more user friendly for the older user and we want to hear older people’s voices on this subject.”
At the other end of the technology scale a session on oral health heard how a 30p toothbrush might be a life saver – pathogens which build up on plaque can be aspirated and cause pneumonia. Yet there is widespread ignorance even among health professionals about the importance of oral health, an omission which the Mouth Care Matters campaign aims to redress.
“Every patient has a mouth,” Prof Sara Hurley chief dental officer in England, told the audience. “This is about a lot more than just teeth – it’s eating, drinking, talking. My mission is to make sure the NHS integrates it into every care pathway. Oral and general health are inextricably linked.” As well as pneumonia there were also connections with diabetes, malnutrition, osteoporosis and dementia.
Her own elderly father’s experience was illustrative of the problem. During a two day stay in hospital no-one offered to bring him his toothbrush. He felt unclean, became depressed, developed a mouth ulcer and fell behind with his physiotherapy. “For the lack of that small task there was a physical, emotional and financial cost.”
Dr Mili Doshi, consultant special care dentist with the Surrey and Sussex Health Care Trust which has been implementing a Mouth Care Matters programme, described some of the problems faced by older people in hospital and care homes including dry mouths, tooth decay, ulceration, mouth cancer, oral thrush, broken teeth, broken or lost dentures. The very old often had no teeth – their generation were often given false teeth as a coming of age present – whereas the baby boomers were known to dentists as the ‘heavy metal generation’ because they had so many fillings, crowns and bridges which could be very difficult to look after in later years.
Her talk and those of her colleagues were illustrated with shocking photos of patients’ appalling oral care. “If we had dirt like that anywhere else on the body we’d do something about it but because the mouth can shut we don’t check.
We strive for sterility elsewhere but we allow mould and fungi to grow on toothbrushes and dentures or we let bits of medication stick on teeth. And patients often don’t like to ask staff for help, they think they’re too busy.
But simple things worked: good training and simple but effective tools: pen torches, labelled denture boxes, non-foaming toothpaste, soothing gel, small headed brushes – “we sometimes give a brush more suited to cleaning a horse’s teeth than those of an old lady who can barely open her mouth.” Dr. Doshi’s bugbear was pink foam swabs – “ineffective and dangerous, the foam can come loose”.
Good mouth care was cost effective. Just replacing the 700 dentures lost in hospitals cost the NHS nearly £400,000 last year.
As well as routine oral care it was essential for there to be a pathway to dental input. “Sometimes a dentist just removing a loose tooth or smoothing a sharp one which is lacerating the mouth makes someone able to eat and drink again.”
The ‘geriatric giant’ of incontinence was the subject of both a three speaker session and a sponsored symposium. Both stressed its prevalence and its impact on quality of life. Nocturia, the subject of the symposium sponsored by Ferring Pharmaceuticals, was defined as the interruption of sleep two or more times in a night by the need to urinate.
Such chronic sleep deprivation could lead to mood disturbance, cognitive and memory impairment, difficulties with the activities of daily living, falls and fractures and an increase in cardiovascular risk. Poor sleep affected pain perception and the immune response. It was hard both on sufferers and their spouses and families. After dementia, incontinence was the second most common cause of admission to care homes.
Causes could include an over active bladder, storage disorders, bladder pain, kidney problems, uro-genital atrophy and sleep disorders such as apnoea. It could also be due to serious underlying problems like renal or congestive heart failure.
Often older people themselves thought it was an inevitable part of ageing but in fact much could be done nowadays. It was essential, however, Dr Susie Orme, consultant in the elderly at Barnsley Hospital, stressed, to make it a part of comprehensive geriatric assessments and to ask the right questions of patients.
Small doses of the desmopressin Noqdirna had been found to increase reabsorption of water, concentrate urine and reduce its production, increasing the duration of uninterrupted sleep and improving sleep quality. Noqdirna was generally well tolerated but sodium monitoring was recommended in the over 65s, before treatment, once between four and eight days and again after a month.
Solutions for urinary incontinence in the older female were outlined at a session on the last day by Sharon Eustice, a nurse consultant with the bladder and bowel specialist service in Cornwall. Treatment should start with pelvic floor muscle training and bladder retraining before moving to pharmacology and surgery. Topical oestrogen could help with atrophy and Vitamin D might also have potential. Weight loss and exercise could help if patients were obese.
Incontinence was not just a physical problem, she added. “There is embarrassment and a sense of shame and taboo. There is loneliness - people avoid going places and doing things – and it can affect relationships.
“We need to raise awareness and get away from our pad culture – if you’re over 65 and wet you’re just asked which pad do you want? But they should only be used when every other treatment has failed.”
The second sponsored symposium from Daiichi Sankyo looked at new approaches with direct oral anticoagulants in the treatment of non valvular atrial fibrillation. The second guest speaker Prof. Rose Ann Kenny, professor of medical gerontology at Trinity College, Dublin, spoke about new insights into cardiovascular ageing.
Other subjects covering at the meeting included haematology, emergency medicine, oncology, frailty, falls and syncope, comprehensive geriatric assessments, work among older HIV patients in Tanzania and multimorbidity. In the latter, Dr. John Hindle, consultant geriatrician and senior lecturer at Bangor University, defined it as two or more long term physical or mental health illnesses as well as ongoing conditions like learning disabilities, complexes such as frailty and chronic pain, sensory impairment and alcohol and substance misuse.
It was not, however, just a question of counting diseases, he said.“One study of over 85 year-olds found they had good levels of self-rated health and functional ability despite significant levels of disease and impairment.”
Moreover some conditions had greater impact on quality of life and daily function. There were also complex interactions between diseases. Multimorbidity guidelines should therefore be for people not diseases. There should be care plans tailored to the individual, empowering them in clinical decision making, focussing on overall quality of life rather than disease specific endpoints, exploring treatment burdens and establishing values, future goals and priorities. “This is a tremendous opportunity for geriatricians to drive multimorbidity research and we need to take a lead here”, he added.
The need to speed up the translational pathway from research to implementation was stressed by Dr. Andrew Clegg, senior lecturer and consultant geriatrician at Leeds University and Bradford Teaching Hospitals, in his talk on recent advances in frailty. “If you’re 65 your life expectancy is another 20 years but it also takes 20 years for findings to progress to clinical practice. We should push the pace.”
Living better, longer
A Thursday afternoon session, with all three speakers from Newcastle University, was entitled, Living Better for Longer and looked how best to tackle dementia which currently affects 850,000 men and women in the U.K. with an economic impact of £23.6bn a year.
Since drug candidates for treating Alzheimer’s Disease have a failure rate of 99.6 per cent and current treatments can only offer some symptom relief, risk reduction and prevention are the only ways to decrease numbers. The good news though, said Dr Blossom Stephan, senior lecturer in risk prevention, was that numbers did seem to be going down. There were now 214,000 fewer sufferers in this country than population ageing alone would have predicted.
The disease was complex and resulted from a combination of factors: genetic, environmental and lifestyle. Protection appeared to be afforded by social engagement, exercise, a balanced diet, higher levels of physical and mental activity and education. The cognitive reserve hypothesis suggested that those with higher educational attainment appeared to be able to compensate for disease related loss in the brain. This might be done by an increase in the number of synapses and neurons or the synapses might be more efficient or alternative circuitry might be operating.
Risks included genetics, smoking, obesity, diabetes, hypertension, high cholesterol, depression and head injury. “Improving behaviours could make a substantial reduction in numbers, maybe up to 15 per cent worldwide by 2050,” he added.
Dr Stephan was followed by Prof Carol Jagger, AXA professor of the epidemiology of ageing, who said that there had been a real reduction in the number of years spent with cognitive impairment, mild, moderate and severe, but the picture was very different for disability. Most of the years gained were spent with disability even though most of that was mild.
The third speaker was Prof. Mike Trenell, professor of metabolism and lifestyle medicine, who spoke of the importance of not being sedentary. This had been highlighted as early as 1953 when bus drivers who sit all day were found to be twice as likely to have a heart attack as conductors who were constantly up and down stairs.
Getting older people to move more and sit less was less daunting for them than urging exercise. “Not fit to slightly more fit is only a little way but it has a good effect.”
Fitness was particularly important now that more and more older people were having elective surgery. “If you’re over 75 and unfit the mortality rate can be one in four.” It also meant more time in hospital with an average extra £6,500 in care costs per patient.
The social side of the conference which attracted nearly 500 attendees featured a drinks reception, a dinner in the Hilton with a Sinatra-style singer and chance to join a guided walking tour of the city.