BGS 2016 Autumn Meeting Report
Twenty first century specialist medical care for older people will not be confined within the walls of a hospital: much of it will be delivered in or close to the patient’s home.
This glimpse into the future – with examples of how it is already happening in the present – was the major theme of the first day of the BGS Autumn meeting in Glasgow.
The Hospital At Home Forum – the first ever UK wide one – was run by the Society’s Community Geriatrics Special Interest Group and focused both on the push factors – increasing demand, stretched resources and the unsuitability of many aspects of hospitalisation for frail older people – and the pull ones – innovative technology, clinical effectiveness and patient satisfaction.
“I felt like the queen getting all that attention” one woman had told Dr Graham Ellis, associate medical director for older people’s services in Lanarkshire. Another had said: “it felt like the cavalry coming over the hill.” A third had commented, “just being in your own surroundings makes you feel happier and more confident and able to cope.”
They were all talking about their experiences of their local Hospital At Home system. This had been started five years ago and now covered over half a million people. It dealt with 250 referrals a month, of which three quarters could be managed in their own homes.
Such innovations are urgently needed elsewhere, Dr Ellis told the meeting. “We can’t carry on as we are. There has been a huge growth in demand but our resources have not expanded to match.” Moreover, hospitals could actually be dangerous places for older people. There were increased risks of infection, delirium, drug errors, functional decline and acquired immobility: according to some estimates ten days’ bed rest could equal ten years of ageing.
There could be problems with discharge planning and there was often great strain on carers.
What we want may not be what they want
Increasingly sophisticated equipment for testing and treating, much of it now portable, plus technological developments like video conferencing, electronic records and remote monitoring were offering new opportunities in the field.
It was also important, he added, to consider what patients themselves wanted –“which isn’t necessarily what we want for them.” Dr Ellis had realised this early on in his career when he had visited the home of an old man who regularly presented with respiratory problems and who was regularly told to get rid of his 300 pigeons.
“But when I was invited to go into his back room I saw every inch was covered with trophies and pictures and pigeon memorabilia. He had been a champion racer in his day and he would rather live a shorter life with his pigeons than a longer one without them.”
Opening the session Prof. Sasha Shepperd, professor of health services research at the Nuffield Department of Population Health, had defined the new approach as a geriatrician led acute service which provided a direct alternative to admission to hospital or the opportunity for hospitals to discharge patients early because a high level of care could be offered at home.
Studies so far had suggested encouraging trends in cost savings and reduced admissions and length of stay, but there had been too few to date to be able to draw statistically conclusive evidence and he appealed to his audience to participate in the research his department was currently undertaking.
Some individual schemes, however, have been able to take some measurements. Describing the REACT – Rapid Elderly Assessment Care Team - project in Lothian, consultant geriatrician Dr Scott Ramsay said that over the past three years it had dealt with 1,697 acute patients with an average age of 81 and provided a total of 10,444 care days which might otherwise have been spent in hospital.
Breaking down empires
Although some patients had still to be admitted, most could be given the same investigations and treatment where they lived – in their own homes, in sheltered housing or in a residential or nursing home – as they would have received as an inpatient. “The aim is to shift the balance, focus and location of care but to give the equivalent or even better.”
He told those considering setting up a similar scheme: “You need to recruit a great team and be prepared to blur roles so you can all work together for the benefit of the patient – I change beds and pads, the occupational therapist takes urine samples.
You also need to find a home for your HQ, sort out your shopping list for all your equipment, define your identity and keep electronic records. My message is – just do it and you’ll quickly learn what you can and can’t do.”
Another system in Fife was proving safe and cost effective according to its consultant geriatrician, Dr Angie Wilkinson. Most cases involved acute exacerbations of chronic conditions: the scheme excluded such problems as stroke, cardiac arrest, gastro-intestinal bleeds and head injury with loss of consciousness. “You can pick up clues in someone’s house which you don’t get in a hospital bed. You also get additional information from the family.”
One of the main problems, she said, had been changing attitudes and getting both hospitals and the community to understand the new concept, a sentiment echoed by other speakers.
“We have to let go of the paternalistic culture in health and social care and find new ways of working,” said Dr Bruce Willoughby, a GP and clinical lead for the Harrogate and District New Care Model.
“Some GPs saw us as a threat, they thought we’d be increasing their workload at a time when they’re already overstretched so we rolled it all out slowly in a pilot study to show them there were no adverse effects.”
Another GP, Dr Chris Preece from Boroughbridge, added, “It is difficult to change people when they’re all walled off in their own empires. So you need good communication and information sharing. You need to keep all your stakeholders up to date. And you need to be clear on your core values and aims, and work out what’s actually needed, not just what’s currently in fashion. We reviewed all roles and tasks and asked, could a job be done by someone else, the voluntary sector for example.”
Other challenges included recruiting staff prepared to work beyond the traditional professional boundaries, and ensuring staff safety. In the Guy’s and St. Thomas’s scheme practitioners always went in pairs for a first visit. Another difficulty in London was dealing with traffic and finding parking spaces.
Otherwise, said consultant geriatrician, Dr Rebekah Schiff, ‘bringing the ward to the patient’ for acute or semi acute care in their own home had already enabled the Trust to close one hospital ward.
“It takes time to embed the concept into practice because a lot of health professionals are risk averse and prefer to keep patients in hospital. And that’s where some patients want to be. Other patients like it so much they self-refer.”
An example of how technological developments can enable community care advances was given by Rachel Binks, nurse consultant for Digital and Acute Care in Airedale.
Their clinician-led service offers face to face advice via video to residents and staff in care homes. It now covers 500 homes around the UK with 18,000 residents. Its aim is to avoid unnecessary trips to A&E, distressing in themselves but often exacerbated by long waiting times.
A tele-consultation involves looking at a patient with a high definition camera so you can see if they are clammy, sweaty or if their face is collapsing from a stroke, or count their respiration rate just as if you were at their bedside or sitting beside them on the settee.
“We aren’t just a call centre following pathways like 111. We have a pro-forma but we’re staffed by senior nurses. Our aim is to enhance services, not be a substitute for them. They can call us back as many times as they want and we also call them back to see if the patient has taken the pain relief, for example, or the necessary fluids. We can also act as a triage process for GPs.”
The hub offers its Gold Line service for end of life care and the session concluded with a moving video of a husband telling how much its support had meant in his wife’s final days.
The meeting had its own technological innovation which allowed members of the audience to submit questions electronically during a talk which the speaker could then address afterwards, along with the usual method of questions from the floor.
How difficult is it to carry shopping?
The conference also saw the launch of a new Special Interest Group for Sarcopenia and Frailty, described by the first speaker, Prof Avan Sayer, director of the Newcastle Biomedical research Centre, as a ‘core business’ for geriatricians.
Sarcopenia, literally ‘poverty of flesh’, is the loss of skeletal muscle mass, function and strength with age. It may be indicated by slow gait and poor grip strength and responses to such questions as, ‘how much difficulty do you have carrying shopping, walking across a room or climbing stairs?’
Frailty is a multi-system impairment associated with increased vulnerability to stressors and a consequence of cumulative decline in physiological systems over a lifetime.
It can be measured by the frailty index which lists 36 conditions or situations; the more that apply to a patient, the higher the frailty score.
Dr Helen Roberts, associate professor in geriatric medicine at the University of Southampton, pointed out that Shakespeare recognised sarcopenia in the sixth age of man with his ‘shrunk shank’, but that in practice it was not always easy to spot. “You can be obese and still be at risk. People can look better than they are.”
There is a growing interest in the lifelong approach: some research suggests childhood influences, even birth weight, can play a part in the development of sarcopenia and frailty in later life and it was important to preserve the peak muscle strength reached in adult life for as long as possible.
For older people already enduring the condition there were various approaches including resistance training and nutritional supplements. Intervention was important, stressed Dr. Roberts, because sarcopenia and frailty were associated with a range of adverse outcomes.
“You can reach a point where an older person can’t actually stand up, which impacts on their independence.”
Dr Miles Witham, clinical reader in ageing and health at the University of Dundee, listed some of the possibilities being explored in what has become a fast moving field in both practice and research. These included, with their attendant advantages and disadvantages, Vitamin D, ACE inhibitors, testosterone, leucine, multi-component nutrition and myostatin inhibitors.
“What does work is resistance training. There’s good evidence for this. What is less known is how we can actually make this work in clinical practice.”
Horrible and bad for you
Another major subject highlighted at Glasgow was delirium, summed up by Dr Elizabeth Teale as ‘horrible and bad for you.’ Symptoms included visual hallucinations, misinterpretation of sensory experiences, fear, anxiety, delusions, disorientation, time distortion and a reduced ability to direct, focus, sustain or shift attention.
The most common subtype, the hypoactive, which affected around 39 per cent of patients, was also the most difficult to diagnose. Sufferers might be withdrawn, sleepy, difficult to rouse, have poor oral intake, slurred or incoherent speech and abnormal hand movements such as plucking at the air or at bedding. Patients might have poor eye contact, seem vague and be easily distracted. A good test of inattention was to ask them to say the months of the year backwards. They should also be asked if they were frightened by anyone or anything, or concerned about what was going on.
The hyperactive subtype was less common at 21 per cent, but easier to spot with its symptoms of agitation, wandering and behavioural disturbances. Other patients fluctuated between the subtypes and some showed no motor symptoms at all.
Delirium, added Dr Teale, clinical senior lecturer in geriatric medicine at Bradford Teaching Hospitals, was the most common complication of hospitalisation in older people affecting around one in five patients. Triggers included medication, pre-existing dementia, dehydration, pain, acute illness, infection, noise and other environmental factors. Sometimes something as simple as moving wards in the middle of the night could provoke an attack.
Treating the underlying causes and paying close attention to such basics as bowel movements, sleep disturbances, nutrition and hydration – even just checking that hearing aids worked and spectacles were clean - could prevent or significantly shorten perhaps a third of all episodes.
Doing so was crucial, she stressed, because delirium could persist after discharge and could have longer term implications including acceleration of cognitive decline, incident dementia, institutionalisation and mortality.
Around half of all patients could recall their experiences and some suffered flashbacks.
“Those with more severe delirium or underlying cognitive impairment are less likely to recall but that doesn’t mean their distress was any less at the time,” she added.
We’re not superfluous yet
Comprehensive geriatric assessments are now a standard part of our speciality’s armoury but they have had to be fought for over the years, as a guest lecturer from America reminded the meeting. Prof Laurence Rubenstein, chairman of the Donald W Reynold Department of Geriatric Medicine at the University of Oklahoma, outlined three stages in their development.
The first between 1935 and 1975 saw the early concepts and models - and the subsequent setting up of the BGS – which arose out of the work of Marjory Warren and her colleagues, particularly in UK workhouses.
The second stage from 1975 to 1995 involved refinement and testing: controlled trials and meta-analyses, conferences in Britain and overseas, the introduction of home visit teams, Geriatric Evaluation and Management units and Acute Care of the Elderly units
The third stage from then until the present day was about integrating CGAs into mainstream care as well as further multi-site trials and analyses, and creating uniform databases.
He reminded his audience of what a comprehensive geriatric assessment actually meant: it was a multi-dimensional interdisciplinary diagnostic process to identify and then plan for the care needs of frail older people. Its purpose was to get better diagnostic accuracy, optimise medical treatment, improve outcomes, function and quality of life, optimise living locations, minimise unnecessary service use and arrange effective care management.
The measurable dimensions of a patient’s physical health should involve taking a traditional history, giving a physical exam, examining relevant lab data, listing the problems, using disease specific severity indictors and implementing prevention practices such as exercise or vaccination.
There were scales, like the Activities of Daily Living scale, which could also be used to measure function, mobility and quality of life, and scales to measure cognition and psychological health. Other factors to be considered included social networks and support systems, economic adequacy and environmental safety.
Geriatric assessment should be targeted according to risk: dependent or higher risk older people should have tailored CGAs and follow up programmes; over 75s at medium risk should have preventative home visits; over 65s at low risks should have general appraisals. But all CGAs had to be part of a bigger picture.
Over the years CGAs had contributed significantly to better outcomes for older people, improving physical function, cognition and morale, reducing unnecessary medication and hospitalisation, avoiding premature admission to nursing or care homes and reducing costs.
“But big questions remain. What are the most effective models; which outcomes can we now most improve; what are the key elements of a programme; who benefits the most; how can it be best integrated into the care system?”
He compared health care systems in the US and the UK. The advantages of the former were good resources, high technology, active research, choice of provider, provider flexibility, relatively high provider income. The disadvantages were that it was too expensive, could be too high tech, there was often duplication and inefficiency, there were gaps in coverage, it was not well planned and it was unequal.
“Geriatrics now has a major place in your health care system but in the US it is still confined to major health centres. And we haven’t yet achieved critical mass. There aren’t enough geriatricians to go round. We are very envious of your system.”
“When I started 35 years ago the goal was to teach every young doctor so much about the subject that in the end we wouldn’t be needed as a separate speciality. But we’re not superfluous yet.”
The other guest lecturer at Glasgow was Sir Muir Gray, director of Better Value Healthcare and professor of knowledge management at Oxford University. In a talk entitled, ‘how to stay young and get younger’ , Sir Muir, who has just written a health and lifestyle book called Sod Seventy, told the audience, “There are only two phases of life: growth and development and decline. The turning point between them is what we need to postpone. That generally tends to be in your late thirties though you could say for a lot of people, it’s all downhill from when you get your first job because the most dangerous activity is sitting.
I always want to ask Bear Grylls to commute to work every day and then see how healthy he is after six months.”
“The key issue is loss of fitness marked by decrease in ability. The gap between the best possible rate of decline and the actual rate of decline tends to open up as you get older but actually without a great deal of effort most people can move themselves back to where they were ten years before so the fittest 50 year-old can be like the average 40 year old.”
Disease accelerated the rate of decline and some disease was caused by environmental factors rather than lifestyle.
He himself often suffered from breathlessness because he was born before the Clean Air Act and had measles as a child. The impact of illness though, could be reduced by developing positive attitudes as well as improving strength, stamina and suppleness.
Geriatricians had a role to play in prevention as well as cure, in fighting to ensure resources were allocated to all those in need while also striving to cut waste and increase efficiency.
“We need to develop a culture of stewardship to ensure the NHS is still here in ten or twenty years. We need some big debates. You can give the leadership. You can make the difference.”
Shrinking brain inside a fixed cranium
Other subjects at the meeting included sessions on stroke, polypharmacy and prescribing, molecular biology, orthogeriatrics, peri-operative care, thyroid disease and head injury. In the latter, Dr Roddy O’Kane, consultant neurosurgeon at the Institute of Neurological Sciences in Glasgow, explained that head injury presentation could include mental deterioration, headache, drowsiness, coma, seizure, collapse, visual disturbance, gait disturbance and limb weakness.
There could be chronic subdural haematoma or other causes. A trauma like a bang on the head could, in itself, be negligible but the older brain did not repair itself as efficiently as the younger brain. “Older people have less neuronal reserve and less plasticity. In old age we have a shrinking brain inside the fixed space of a cranium so there is more room for it to shake.”
He gave a brief overview of both surgical and medical approaches. The brain had huge metabolic demands and an injured one would take what it needed to prevent secondary problems at the expense of every other organ. Focusing on the cerebral meant an assault on the lungs, heart, kidneys.
“We are treating more but we are getting better at doing so, partly through better anaesthesia, rehab and geriatrics. It’s a rapidly evolving science with increasing choices of interventions and drugs. As geriatricians you should never hesitate to call us if you are concerned about a patient. We can help each other.”
He was followed by a colleague at the Institute, consultant clinical neurophysiologist Dr Veronica Leach who spoke about the use of EEG in epilepsy, seizures and attack disorders, states of altered consciousness like coma and delirium and in the diagnosis of specific neurological disorders in the elderly.
Electroencephalography, which records cortical activity usually for about 20 to 30 minutes, could be a very useful test in the correct context but all recordings should be interpreted with detailed and accurate clinical information and patient history.
There must not be over reliance on the test which was not always helpful and could sometimes be counterproductive.
As in previous years the meeting drew visitors from overseas including a group of trainees from Canada who, with a group of their UK peers, shared their experiences of persuading other young doctors to go into geriatrics. An ageing population in both countries meant the need was growing but there was still a shortfall.
Those who were put off the speciality had cited the on-call duties of medical registrars, not wanting to deal with patients with cognitive impairment or chronic illness and a feeling of therapeutic nihilism, a belief that nothing could be done. Some thought the speciality lacked prestige and had more to do with social issues.
Those who were attracted liked the intellectual challenge of dealing with complexity, the focus on the whole patient and the chance to work in an interdisciplinary team.
To promote interest in the UK, Geriatrics for Juniors conferences had been launched in 2013 to bring together like-minded individuals. “If you find others who share your enthusiasm, that’s empowering,” said Peter Brock, an ST5 geriatrics and general medicine with the Northumbria NHS Foundation Trust and one of the founders of the scheme.
Speakers were chosen to project a positive image, give practical advice, counter negative ideas and deal with issues fundamental to juniors. The year the scheme began 14 per cent of geriatric registrar posts were unfilled; in 2016 the figure had dropped to 6.9 per cent. “This is amazing, a huge change”, he added, “and the quality of applicants is very high. There are a lot of rising stars.”
Dr Marisa Wan, a consultant geriatrician at Mount Saint Joseph Hospital in Vancouver, described the efforts of the National Geriatrics Interest Group which now involved medical students, to promote the speciality. These included publications, lectures, skills programmes, community outreach and mentoring. There was also a project involving retired police officers, judges and members of the armed forces to advocate for health literacy and promote a positive image of older people.
The rest of the feast
In the falls session, Prof Dawn Skelton, professor of ageing and health at Glasgow Caledonian began her talk by asking her audience if they had fallen for whatever reason during the past 12 months.
When the majority rose to their feet she told them, “Falls are part of life. Why should all falls be bad? We can stop falls by not moving at all. But what effect does this have on mental health, isolation, loneliness and depression?”
Older people who were fearful often avoided activity to reduce their exposure to hazards, a response that some professionals used as well, she added. But risk aversion could also have serious physical consequences. Sedentary behaviour in the over 60s was associated with higher plasma glucose, higher BMI, higher cholesterol and reduced bone density. Sitting still in a hot room could raise blood pressure, increase postural hypotension and reduce stamina; in a cold room it could result in less muscle strength, slower walking speed and lower sit to stand velocity.
“In hospital it’s normal not to move so people are coming out frailer than when they went in. Or patients might do rehab for a bit and then sit for the rest of the day. Are we allowing deconditioning of patients to reach epidemic proportions? We must talk about moving more, maybe getting patients to stand for a minute every hour, for example, and geriatricians have a role to play in this.”
“We must send out a consistent message to older people: sit less, move more and we must encourage all professions to regularly mobilise patients. It’s important to encourage an active lifestyle beyond rehab so we must help patients aim towards self-directed exercise and effective doses of highly challenging strength and balance exercise to reduce frailty and falls. We need to work strategically with the fitness and exercise industry to ensure training frameworks meet our standards of effectiveness and safety.”
BGS meetings also consider topics related to the law and ethics and an example of this was the talk on the Court of Protection and Best Interests given by Jane Buswell, an independent consultant nurse and best interests assessor. Her role, she explained, was to provide independent reports for the Court which dealt with health and welfare cases for children and adults lacking capacity.
Issues might include resuscitation, serious medical treatments, restrictive practices and restraint, where someone lived and what care they needed.
The Official Solicitor representing the individual would ask a BIA for their opinion of that individual’s care needs and how these could be met and the advantages, and disadvantages of residing in a care home or their own home.
They would also be asked whether they had specific recommendations about any arrangements and what they thought were the wishes and feelings of the person concerned.
Recent cases had seen interesting rulings from judges. The most well-known was that of the woman who refused medical treatment after taking an overdose because she did not want to live if she could no longer enjoy her ‘bling’ lifestyle.
Her decision might be unwise, even fatal, and one that other members of society might consider unreasonable, illogical or even immoral, but it was not in itself, the judge decided, evidence of lack of capacity, provided she was able to weigh the relevant information. Even where someone did lack capacity their belief and values must not be undervalued, according to a judge in another case.
Ms Buswell had trained to be a BIA, she said, because she wanted to be the voice of the older person and help stop arguments between doctors and social services. She had produced seven reports to date, the findings of which had all been accepted by the judges.
Being a nurse had helped with this ‘serious and fascinating’ job because she already had a knowledge of medical conditions and specialist language, an understanding of the pressures on clinical staff and also of the impact of complex, life limiting health problems on patients’ mental and emotional states.
It was often important though, to question the paternalistic, risk averse culture of the NHS. “Sometimes capacity only becomes an issue on discharge when the patient disagrees with the team.”
As a BIA she felt she had perhaps had more impact on people’s lives than in all her years as a nurse.
“You can be an advocate for the vulnerable and you can challenge poor practice and discriminatory attitudes.”
She advocated five principles: “assume initially that everyone has capacity; talk to the patient and their family; accept that an unwise decision does not necessarily mean someone lacks capacity; always act in their best interests; and when there has to be intervention make sure it is the least restrictive.”
Don’t prescribe before doing the basics
There were three sponsored symposia: one by Bial on the role of COMT inhibitors in Parkinson’s Disease, another by Internis Pharmaceuticals on the problem of adherence with alendronate tablets and a third by Astellas Pharma on the treatment of over active bladder in older people.
In the latter, Dr Susie Orme, consultant geriatrician at Barnsley Hospital, spoke of the link between incontinence and falls, urinary tract infections, falls, fractures, pressure ulcers and depression. Frequency and urgency meant older people were often fearful to leave their homes.
“It really impacts on someone’s quality of life. There are big care costs to society – the pad budget is enormous - but there is no need for nihilism, we now have treatments.”
Outlining the use of Mirabegron in patients who might be at risk of an anticholinergic overload with its possible effects on cognition, Andrew Sinclair, consultant urologist at Stepping Hill Hospital in Stockport, told the symposium that it was important to use other approaches first.
These included lifestyle advice – stopping smoking, losing weight and reducing caffeine intake - bladder retraining and pelvic floor physiotherapy. “There’s no point in giving drugs if you haven’t done the basics.
The meeting was dedicated to the memory of Dr Kate Granger, the young geriatrician who started the ‘hello my name is’ staff and patient communications social media campaign, after being diagnosed with cancer and who died earlier this year at the age of 34.
There were 701 attendees including nurses and other health professionals as well as doctors. There were 108 abstracts, 88 posters and a social agenda: a drinks evening with the Lord Provost and representatives from Glasgow City Council on the Wednesday evening and a dinner the following night at the Grand Central Hotel, followed by a lively ceilidh with the Reel Time band.