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September 2017

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Highlights 

 

New horizons in multimorbidity and frailty

Speakers' Corner: The frailty industry: too much to soon

If frailty is viewed by some as a 'commissioning Trojan Horse' this should be admitted

Why I'm fine with 'Frailty'

Should we be prescribing or stopping statins in people over eighty years?

 

Geriatrics for Medical Students

Jack Whitney says: For five weeks I was on my care of the elderly attachment at Royal Sussex County in Brighton, and enjoyed it immensely. Many patients had complex conditions, so there was much to learn on how to treat them holistically. Most patients were happy to have me involved in their care, and all had interesting stories to tell. Being a medical student meant I had the time to listen to them. As an inspiring placement came to an end, here were three ‘golden rules’ which emerged during my time here.

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A new approach to assessing nutrition and hydration capacity in patients with dementia

Patients living with dementia often present to hospital with signs that they do not eat or drink enough. The challenge is to identify those patients who have a reversible underlying cause and may therefore benefit from a trial of non-oral feeding. This is an evidence poor area with a lot of legislation.

Inserting nasogastric (NG) tubes in patients where failure of oral intake is due to disease progression is not known to improve outcome1,2 and as such, could be considered harmful. However, where reversible illness exists, a patient may benefit from a trial of NG feeding3,4,5, and excluding a patient from this intervention on the basis of a diagnosis of dementia could constitute neglect.

MEHT Approach
The team at Mid Essex Hospitals NHS Trust (MEHT) developed a flowchart to ensure that these decisions are approached in a consistent, multidisciplinary and holistic way. The collaborative effort involved input from geriatricians, our dementia specialist team, speech and language therapists and dieticians. The flowchart also acts as a decision aide to prompt clinicians to consider Mental Capacity Act (MCA) and Deprivation of Liberty Safeguarding (DOLS) assessments for patients who lack capacity, using a standardised approach which is compliant with current legislation.

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Editorial

Marjory Warren would be pleased to see that geriatric medicine has gone from strength to strength since she established the principles. We are now the largest medical specialty in the UK and places on our training scheme are highly sought after.

Rather than resting on our laurels, geriatricians are open to evolving where necessary to ensure we provide excellent quality, holistic care. The concept of frailty has assumed a leading role recently, driving much research effort and now probably characterises the specialty more than any other aspect. I think most of us believe that is a positive development and that frailty provides a useful focus for service development. But is frailty definitely taking us in the right direction?

We try to encourage healthy debate here in the newsletter so in order to allow our beliefs to be challenged we have launched a new column called “Speaker’s Corner”. This issue sees BGS Vice President for Research Prof Steve Parry ask “The Frailty Industry: too much too soon?”

The piece triggered a huge response when published on the blog in recent weeks, becoming our most commented on blog ever. Despite eliciting many diverse opinions the discussion remained good natured! We even received two full blogs in response to Steve’s observations and we also include those here. If you have an idea for a speaker’s corner focus, please get in touch on !

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President’s column

It’s hard to believe that my period of office as BGS President is almost half way through, but that realisation made me think that this might be a good point to reflect on the role.

As many of you will be aware, the BGS has a small number of appointed posts and a number of elected positions which are filled by members. We also have a small employed staff team who are based in Marjory Warren House in London, led of course by our chief executive, the indomitable Mr Colin Nee.

The president is an elected role and any member may stand, requiring a proposer and seconder. The president is elected two years before they take office and serves as “president elect” for that time. There are some duties which fall to that role, and many additional requests, demands and opportunities which also come the way of the office bearer.

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Cambridge care home’s outreach programme to prevent falls among the older community

Staff at Home Close residential care home in Fulbourn near Cambridge are helping residents and local community members to stay physically strong in an effort to stop them coming to harm through falls.

The home, based on Cow Lane in the village, hosts ‘Falls Prevention’ classes every Thursday morning, which are open to members of the community as well as the people who live at the home.

Every year, more than one in three people over 65 suffer a fall that can cause serious injury, and even death (Age UK, Stop Falling: Start Saving Lives and Money), so the Home Close team were keen to find a way to help local older people and their residents avoid these types of accidents.

The classes, led by a local physiotherapist and exercise leader, guide attendees through a series of exercises that help provide strength and conditioning to reduce the chance of their falling.

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Should we be prescribing or stopping statins in people over eighty years?

Statin use is controversial, especially for very old people. Do older patients benefit from starting or continuing statin treatment to prevent cardiovascular disease (CVD)? Should very old people discontinue statin treatment that they may have begun when younger? We have limited evidence to answer these questions because most randomised controlled trials have focused on people aged younger than 80 years old.

The safety of statin treatment is also an important consideration. Side effects from statins may include muscle pains and muscle weakness, which might contribute to reduced quality of life and loss of function making this quite an issue in managing CVD risk in older people.

In our recent study from King’s College London, published in Age and Ageing, we investigated current practice by analysing rates of starting statin prescription and rates of discontinuation in people aged 80 years and over. We analysed electronic health records data for a cohort of 212,566 participants aged ≥80 years registered with UK general practices. The sample was drawn from the UK Clinical Practice Research Datalink. We classified frailty using Andrew Clegg’s e-Frailty Index.

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New horizons in multimorbidity and frailty

There is increasing political and clinical interest in the concepts of multimorbidity and frailty. For those of us working with older people in primary and secondary care we feel that we intuitively understand these concepts. After all, we have been working towards improvement in caring for people with multimorbidity and frailty for many decades, and in some ways, doing so was the original raison d’être of the specialty of Geriatric Medicine.

However, although I have been working as a geriatrician for over thirty years, armed with my intuition, it is only in recent times that I have begun to truly understand the complexities of these issues. In recent years the concept of multimorbidity, and particularly frailty, have been injected with scientific understanding and explanation.

We have come to understand the great impact that these issues have on health and social care, and the pressures that they bring to bear. The complexity of multimorbidity in the context of frailty, dementia and polypharmacy particularly bears a substantial healthcare burden. If, like me, you struggle to understand the full picture of the relationship between frailty and multimorbidity, it is worth reading the article on New Horizons on Multimorbidity in Older Adults1. This overview helps explain the link between the concepts of multimobility and frailty and their relevance to the healthcare of older people.

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Up-skilling professional groups to support the needs of the older adult population

In 2016 the Nurse and Allied Health Professional Council or the British Geriatrics Society was asked to engage with the Society’s Education and Training Committee (ETC) with a view to expanding the Committee’s role to improve education in older people’s health care among Nurses and Allied Health Professionals. It has been a pleasure to be the first such representative into the Committee.

I arrive to the group with a background in working with Health Education England (and predecessor organisations) in development programmes for aspiring Consultant and Advanced Practitioners in the fields of Mental Health, Learning Disabilities and, most recently, in Frailty. It is with interest and enthusiasm that nurses and AHPs note the growing UK appetite to enhance skill set in order to better serve the older population and to thus to also extend clinical career options.

In terms of the development of roles pertaining to older people, the ETC are currently focusing on two key areas with a view to offer expertise, encourage focus on older people and to influence parity across the UK.

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Consultant Practitioner Trainee Programme

In 1999 the then Prime Minister Tony Blair, announced the introduction of the Nurse Consultant role. These posts were announced with the dual purpose of enhancing the quality of nursing care and providing new career opportunities for experienced and expert nurses, midwives and health visitors who wished to remain in clinical practice. The role centred on the four domains of advanced practice, including clinical practice, leadership, education and service development. At that time there were no formal educational programmes to support the role or its development.

In 2004 Health Education Wessex and Thames Valley established a Nurse Consultant Development Programme for Emergency Care. Following its success the programme was opened up to other specialties: midwifery, neurology, mental health and learning disabilities. It was also open to professions other than nursing. In 2014, the political drive to increase clinical leadership within the “Older Persons” agenda necessitated the introduction of the Consultant Practitioner Trainee (CPT) programme specialising in frailty.

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The Wessex Frailty Fellowship Programme

The Wessex Frailty Fellowship Programme was instituted by Health Education Wessex to offer opportunities for senior clinicians working with older people with frailty, to improve their knowledge and understanding of the syndrome; to learn from colleagues from a range of healthcare settings and to undertake a project to improve delivery of care in their workplace.

Wessex Frailty Fellows meet monthly for education sessions led by their peers, consultant practitioner trainees and clinical experts and to participate in action learning sets to address challenges and refine aspects of their quality improvement projects. Fellowship days, coordinated and facilitated by Dr Gwyn Grout, are fun and informal.

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Complex Care for Older People

The University of Southampton now offers an MSc Complex Care for Older People, for professionals working with older people with complex needs.

As a university with an excellent reputation for continuing professional development opportunities in health and social care, we are aware that opportunities for professionals to access university-based education to develop their specialist skills and knowledge in older people’s care and leadership are limited. Care for older people, and people with dementia is a vital part of this Faculty’s research and education, and so we are well placed to offer a programme that draws on our world-leading research and ideas. Our MSc Complex Care in Older People is designed to equip health and social care staff working in a range of settings to meet the complex needs of older people from culturally diverse backgrounds. We run a programme that individuals can tailor to their own needs and those of their organisation. This flexible programme runs for between 12 and 18 months of full time study, or between two and five years part time. Individuals can access the modules as stand-alone modules, and/or depending on the number and type of modules they successfully complete, can exit with a postgraduate certificate, a postgraduate diploma or MSc in complex care for older people.

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It’s all about having klout!

One of the strategic aims at the BGS is to increase the profile of the Society in the UK, and internationally. BGS’s presence on social media plays a key role in achieving this objective.

To help measure our presence we use an online tool called Klout which quantifies and ranks our ‘social media authority’. Just as Google’s search engine attempts to rank the relevance of every web page, Klout ranks the influence of every person, and organisation, online. Its algorithms comb through publicly accessible social media data which means if you have a public account with Twitter you also have a Klout score, unless you actively opt out via Klout’s website.

Scores are calculated using a number of variables including number of followers, frequency of updates, the Klout scores of your followers, and the number of likes, retweets, and shares that your updates receive.

Other facts about Klout that may be taken into account include:

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Why the BGS fringe?

The idea for the BGS Fringe comes from an emotion: Frustration, and a cause: Resistance.

Frustration first. I realise this might be heresy but the national conference frustrates me. Geriatricians are the funniest, quirkiest and most humble of doctors. Many of us chose geriatrics because we want to work with geriatricians. Of all the hospital specialists, we pride ourselves on being the most holistic, we try to see our patients as human beings, within their network of family and carers. “Aha!” the geriatrician will say on a ward round, “I know Mrs Jones, she loves Elvis and has a watch with a cat on it” (I actually said that last week).

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Developing Geriatric Medicine in Myanmar

Myanmar, previously known as Burma, is a developing country situated in South East Asia. Like the rest of the developed (and developing) world, the population is ageing and this is increasingly evident in Myanmar. In 2014, approximate 4,122,000 Myanmar residents were aged 65+ and constituted about 8.5 per cent of the total population of the country. It was also estimated that about 6 percent of these senior citizens lived on their own. The older population is getting larger year by year. There are about 25,000 care home residents in Yangon, the largest city of the country. In these circumstances, it is vital to provide the comprehensive medical care and services to our older people.

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The Churchill Memorial Fellowship

Do you enjoy travel? Meeting new people? Sharing ideas? Could a Churchill Memorial Fellowship be for you? Or have you already been a Fellow?

The Churchill Memorial Fellowship Trust is a charitable body that funds British citizens to travel abroad to investigate inspiring practice in other countries and then bring that knowledge back to the UK for the benefit of British citizens. Peter Mayer and Doug MacMahon, both now retired geriatricians, share their experiences.

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Sodium docusate: the Emperor’s new laxative?

Constipation is a common problem in hospitalised people and, like many common conditions, its treatment is not supported by a strong evidence base. A range of different therapeutic options are available and some of these predate the modern requirement for systematic testing prior to widespread use. One such option is sodium docusate.

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