BGS Spring 2015 - Nottingham: Conference report
Society’s focus on obesity must not obscure the opposite problem faced by many older people - the danger of malnutrition.
So widespread is the risk – an estimated 1.3 million of people aged over 65 suffer from it – that the entire first day of the BGS’s Spring meeting was devoted to the subject.
Lesley Carter, manager of Age UK’s taskforce partnership, spelled out the scale of the crisis: 93 per cent of the malnourished lived in the community, 22 per cent of people over 60 skipped meals to cut back on food costs and a third of those aged 65 or over were at risk of malnutrition on admission to hospital. “This must be recognised as a priority across all disciplines,” she said.
Strategies included increasing awareness in education and training, developing personalised care and support, finding solutions to social isolation and creating opportunities for self care through information -“ by the age of 75, calorific value is more important than five a day for example”.
Hospitalisation brought its own hazards, Andrew Rochford, consultant gastroenterologist at Barts, told his audience. Patients often had lower reserves at the outset. “They then might come in for a relatively minor procedure but they’re put on nil by mouth for a gastroscopy and then again for radiology and before you know it they’ve gone five or six days without eating anything.”
Patients needed to be risk assessed and managed accordingly. He recommended the MUST, the Malnutrition Universal Screening Tool as consistent, reliable and quick and easy to use. If the score was low the patient simply needed routine care, if medium, observation and if high, referral to a dietician.
A striking illustration on his powerpoint presentation highlighted how the most basic needs could be overlooked. The question asked had been ‘what can I as a doctor do for you the patient right now to improve your stay here in hospital?’ and the size of the letters giving the answers was in direct proportion to their frequency. The largest lettering by far was the answer ‘a glass of water’. “Maybe on ward rounds we should routinely pour one for everyone,” he added.
With nurses under ever increasing workloads it was not always possible for them to assist patients at mealtimes and he envisaged a time when families might be needed to plug that gap.
A way of plugging that gap which has already been tried in Southampton is the Mealtime Assistance Study, a two year project where 29 volunteers, trained by a dietician and a speech therapist, helped with a variety of tasks for over 3900 patients with a mean age of 87. These included cleaning patients’ hands and their tables, preparing food trays and opening packaging, encouraging eating, cutting up food, guiding food from plate to mouth where necessary and completing food and fluid intake charts.
Nursing staff who had been initially hesitant, fearing an increased risk of choking or aspiration came to welcome the volunteers’ input, said Fiona Rossiter, clinical research fellow at University Hospitals in the city. Although food intake did not increase, the quality of patients’ mealtime experience improved and they valued the regular presence of someone with whom they could build a relationship.
Up to 75 per cent of patients lose weight in hospital with a significant association between malnutrition and increased length of stay, slower rehabilitation and increased rates of infection, ulcers, re-admissions and death. Malnutrition was estimated to cost the NHS £8bn a year.
Volunteers can similarly work with geriatricians in other ways to prevent malnutrition according to Karl Demian, director of strategy and development at the Royal Voluntary Service. “When you’re commissioning services you can recognise the value of what the sector can offer and you can expand the concept of social prescribing, like suggesting someone joins a lunch club for example.”
The RVS, he added, had a huge pool of volunteers and resources aimed at helping 100,000 people over 75 to live independently. Eating properly was a key component so the organisation ran meals on wheels and wheels to meals for communal eating events. Supported eating for those living alone had proved unpopular because no-one wanted someone watching them eat; what worked better was taking an old group of friends to a curry house or the pub.
The RVS involved older people in designing their support systems; a lot of the traditional services addressed practical needs but also encouraged passivity and dependence. A lot of people complained of being patronised and not being sufficiently involved or valued. Many volunteers these days were older themselves: around a third were over 75. “It’s a way of staying motivated, happy and engaged. We have 600 lunch clubs and the best are those where client and volunteer can’t be told apart.”
Throughout the day the meeting heard of the various barriers to good nutrition including acute illness, low mood, poor appetite and a decline in or loss of taste and smell. Problems with mobility or weakness made shopping and cooking difficult and eating often became a lonely consumption of calories rather than a social event or shared experience. Cognitive impairment was a major factor as Margot Gosney, professor of elderly care medicine at Reading University, explained. “There are very few fat elderly patients with dementia. They get thinner and thinner and fade away in front of your eyes. This is very distressing for families though patients themselves may be unaware of it.”
Older people generally, but especially those with dementia, got less pleasure from food and there were fewer triggers to eat. Nutritional supplements could bring their own problems: patients often complained of a metallic taste or a drying mouth.
Strategies could include getting patients to eat little and often – five small meals a day rather than three big ones; offering snack rounds or afternoon tea; getting families to bring in a delicious dessert as a reward for eating a main course; prescribing a small sherry as an appetite booster; not leaving too long a gap between meals so that patients did not get past hunger; being prepared to swop foods in the middle of a meal. “If someone eats half a plate of fish and chips and you take the rest away and give them a roast dinner they’ll eat half of that. It’s something to do with boredom”, added Prof Gosney. “And never use sandwiches. No-one likes them. Not even junior doctors will eat them.”
Prof Gosney and her team had been working with chef Heston Blumenthal to enhance the ‘umami’ or meaty fifth taste content of dishes like shepherd’s pie by adding flavourings like soy or miso sauces. Such dishes were proving more popular with older patients. “Use familiar terms. A lamb tagine means nothing to an older person, a lamb stew does. Basically do anything you can to increase calorie intake. Give them a Mars bar if they want that.
“We have got to get through to people that food is probably the most important medicine in hospital. A patient might leave 95 per cent of what they’re given. We wouldn’t find that level of waste acceptable with medication but we do it all the time with food.”
The parallel sessions on Wednesday were similarly devoted to another widespread geriatric concern, dementia: with older people occupying two thirds of NHS beds and 60 per cent having a mental disorder – depression 29 per cent, dementia 31 per cent and delirium 20 per cent, there is a pressing need for progress in the field. Sessions included ones on hospital screening for cognitive impairment, the role of education and training in changing practice and models of care in the community.
Demystifying confusion and delirium
Dr Claire Copeland, consultant physician in care of the elderly at University Hospital Crosshouse and Ayr, devoted her address to demystifying the confusion about delirium - an acute medical disorder manifesting itself behaviourally as a psychiatric illness. Symptoms included disturbance of consciousness and a reduced clarity of awareness of the environment, a reduced ability to focus, sustain or shift attention, changes to cognition or the development of perceptual disturbance, not better accounted for by pre-existing or evolving dementia.
It developed over a short period of time usually hours to days and tended to fluctuate over the course of the day. It was common for it to be superimposed on dementia but the latter was gradual and irreversible. Delirium could occur as a direct physiological consequence of a general medical condition, an intoxicating substance, medication or other causes.
The pathogenesis was probably neuro-inflammatory causing an acute brain dysfunction, a direct insult to the brain by something like a stroke or infection or an overreaction or exaggerated response to a mild insult. “There is the notion of the ‘vulnerable brain’ which is tipped over the edge by something - age, frailty, severe illness sensory impairment, polypharmacy, infection, even constipation. I’ve cleared out patients’ bowels and they’ve woken up brand new. Sometimes there doesn’t seem to be any obvious cause. I had one lady who had terrible delirium for weeks after a flu jab. It probably wasn’t that but we couldn’t see anything else.”
Delirium was bad, Dr Copeland added, because it had an impact on cognitive status, could worsen or even lead to the development of dementia and was associated with increased length of stay, a higher rate of institutionalisation and increased mortality. It could also lead to post traumatic stress type symptoms. “Hallucinations are incredibly distressing and patients are terrified of them happening again.”
The condition could be hyper or hypo active or a mixture of both. The hypoactive type was often worse – patients were ‘no bother’ so they were left alone. It was vital for nursing staff to know what was normal for an individual so they could recognise change and that they listen to what families and carers said about someone not being their usual self.
Drug treatments could be divided into the ‘do something now’ type or those which ‘take the edge off’. There was also a ‘delirium toolkit’ showing how to help patients by playing music, talking to them, offering drinks and helping to orientate them.
Understanding aggression to defuse aggression
Dementia was also a theme in the following morning’s sessions on aggression which began with Dr Liz Sampson, clinical senior lecturer at University Colllege London, looking at its causes as the key to managing it. Firstly though, she said, one had to differentiate between aggression proper – anger or antipathy resulting in violent behaviour and a readiness to attack or confront – and other actions. “Arguing, shouting, rattling the ward door or shaking a fist when someone approaches you with a catheter might just be ways of trying to make yourself understood or asking for help.”
Causes could be biological, psychological or environmental or a ‘collision of all three, an unholy trinity’. Biological causes could be the loss of brain cells or neurochemical changes. Alzheimers tended to affect the fronto-temporal part of the brain which controlled higher function behaviour. Neurochemical changes might lead to a decrease in serotonergic activity and from that a rise in anger and depression, deficits in cholinergic transmission could make a patient disinhibited. “It helps to take a step back and understand that this person is brain damaged,” she said.
Other possible factors were delirium, constipation, misperceptions due to visual problems such as cataracts and pain which was often underdiagnosed in those with dementia who could no longer express their pain. Similarly, discomfort could be a reason: someone sitting awkwardly or being too hot or too cold.
Psychological causes included depression, fear, boredom and embarrassment – “shame is one of the deepest human fears and we do anything to save face.” Toxic environments would be too much noise and light, sleep deprivation, disorientation and lack of exercise. “These are actually the ‘enhanced interrogation techniques’ used in Guantanamo Bay but they could apply to many hospital settings.”
Behaviours were driven by unmet needs so it was important to ask what the patient was trying to communicate. Early intervention was a great help. “My plea is for you to ask us to see people early. Too often we’re only called when something has got really bad.”
The last speaker, Prof Graeme Yorston of the Centre for Ageing and Mental Health at Staffordshire University, spoke about violence in old age. “There is a continuum of seriousness but violence is different from aggression which is mainly reactive. Violence implies a more severe result, it’s a physical act with the intention to harm or kill and it may include sexual violence.
Although the number of older homicide offenders was relatively small – between ten and 20 a year – the methods could be as savage as anything perpetrated by younger adults. “You are never too old to be dangerous.” Weapons he had encountered included a mallet, a flat iron, garden shears and a saw. Methods included punching, strangling, suffocating, drowning and using a blunt instrument.
He recalled one tragic case of a middle class family man who’d been a WWII pilot and ‘something of a hero’. “He’d been a pleasant, warm, hard working man with no criminal record or any hint of what could happen but he was suffering from vascular dementia. He’d shown minor aggression and sexually inappropriate behaviour in hospital and then in the nursing home. He did some kicking of shins and raising his walking stick and he tried to push someone downstairs.
“These incidents were not dealt with and he then came to believe that one of the other residents was a German spy and when, one night, she walked into his room he bludgeoned her to death with his walking stick.”
It was important to watch for the danger signs caused by fronto-temporal degeneration in the brain: changes in personality such as someone becoming an extrovert after being an introvert, the loss of the ability to empathise with others, aggression, disinhibition, joking at the wrong moments, sexual inappropriateness. “Behaviour may arise out of desperation or it may be manipulative or attention seeking. You need to try and get a decent history of someone’s functioning before the offence.”
Risk assessment was always difficult because it was hard to know whether someone would get more or less violent. You must though, assess the risk to age matched peers. Violence which wouldn’t be effective against someone younger can have catastrophic results in an older frail person.”
Older people behind bars
Offenders unfit to plead would be contained in a secure hospital but others might go to prison, a subject addressed on Friday morning in the Hard to Reach Communities session. The number of older prisoners is increasing: in 2002 for example the over 60s accounted for two per cent of the population, today it is four. The rise was due to more incarcerations, longer sentences and convictions for historic sex abuse, Dr Anne-Marie Stewart, a Nottingham GP who also works in HMP Whatton, told her audience.
The prison houses 860 male sex offenders and has one of the oldest populations in the country. Prisoners were in effect, she said, ten years older than their community contemporaries. They may have previously chaotic lifestyles – addictions, homelessness and poor diet – and the stress of prison life accelerated the ageing process.
The group were often seen as giving no problems because they were old and quiet but 35 per cent had cardiovascular illness, 24 per cent musculoskeletal conditions and 15 per cent respiratory ones. Half smoked, a third were obese and there were much higher rates of diabetes and hypertension than in her local practice. Eight out of ten older prisoners had anything between one and seven co-morbidities. There was also a high incidence of mental illness: 42 per cent of those over 60 would have at least one psychiatric problem. Prisoners often refused further tests or procedures because they knew they would have to be shackled for any hospital visits.
Improvements had already been made at Whatton with the provision of a dementia suite and an end-of-life palliative care suite where families could also stay. There was also a system of ‘wing buddies’ to assist and report health problems. In the future she would like to see special disability units with inhouse specialists plus an increased use of telemedicine to avoid hospital appointments and help with confidentiality.
The first guest speaker at the conference was David Lock, a barrister with Landmark Chambers in London, who looked at when the state could or should intervene to protect the health and interests of a vulnerable older person who had capacity.
The concepts of capacity and vulnerability raised some fascinating questions such as the right to self neglect, to have poor personal hygiene, to hoard or to live in unhealthy surroundings. “When did the state acquire the legal right to require anyone with capacity to wash at regular intervals or not collect old newspapers?”
Should everyone with capacity be treated equally, he asked, or was there a halfway house for those who had capacity but were vulnerable. “There is a grey area between capacity and incapacity. It is a spectrum. People should be able to take an unwise decision but what about those who are too easily open to exploitation as lots of geriatric patients are.”
Geriatricians, he suggested, might sometimes see circumstances where they thought improper pressure or coercion was being applied or where someone had acquired a measure of influence or ascendency over an old person and was taking unfair advantage. “Adults have complex relationships. It’s a delicate balance between protection of the vulnerable and their autonomy.”
Cases where undue influence had been used to obtain property, possessions or money from older people might be settled in the Chancery Division, originally set up to express the monarch’s concern for the vulnerable through judges but now essentially a court of fairness. The law set limits on the extent to which one person could persuade another to act to their benefit. “If the transaction is secured by unacceptable means, the law does not permit the transaction to stand.”
Although Chancery was traditionally a private court in that only the wronged individual could seek redress, access to it had recently been extended. Local authorities also now had a statutory duty to make inquiries if they had reasonable cause to suspect an adult needs care and support and is at risk of or experiencing abuse, including financial abuse, or neglect and, as a result of their needs, are unable to protect themselves. Local authorities must make whatever enquiries it thinks necessary to decide if any action should be taken and if so by whom.
Mr Lock’s lecture followed the ethics and law session which opened with a talk on responsibility and liability by Ben Troke, a lawyer with Browne Jacobson in Nottingham, which acts for 50 NHS bodies. Ever increasing expectations bred a sense of entitlement and though this was far more progressive than the old paternalism it did have ramifications in the context of an ageing population. There were more ambitious interventions available now but in complex situations more things could go wrong.
Although people believed we lived in a compensation culture, the reality was that there were between 12,000 and 14,000 clinical compensation claims a year while the actual number of adverse incidents was 850,000, of which half were avoidable and a third were serious.
The civil court is restitutionary and compensatory not punitive. Awards were about restoring to claimants what they would have been entitled to if things had not gone wrong. An old person with no earnings potential and no long life ahead would probably not be entitled to very much whereas a brain damaged baby who neededed round-the-clock care would get millions.
“The law is not just a stick to beat you with, it’s also a shield for doctors, “ he added. “You have no liability if you reasonably think the patient lacks capacity and you do something you believe is in their best interests. Risk aversion means people often play safe but positive risk taking can be the right thing to do. The courts could be a place to share responsibility. Don’t be paralysed by liticaphobia”.
The forgotten giant
The other guest speaker dealt not with the theoretical but with one of the very practical needs of our speciality – incontinence. Giving the Majory Warren lecture Prof Adrian Wagg, director of geriatric medicine at the University of Alberta in Canada, spelled out the extent of the problem. “It leads to physical limitations, to the cessation of activities, the loss of sexual contact, the avoidance of intimacy. It can mean a reduction in social interaction or travel or everything having to be planned around toilet accessibility.
“It means absence from work and decreased productivity, leads to depression, a loss of self esteem, the fear of being a burden, a sense of lacking control, of smelling of urine, to sleep disturbance and anxiety. It contributes to ulcers, falls and fractures, and infection. It puts demand on care givers, it increases the likelihood of admission to a home with all the associated costs.”
It was not an inevitable condition of old age and it did bother people. There were also implications for the coming time when society wanted people to keep on working. There was, he stressed, no place for therapeutic nihilism. “Geriatricians are ideally placed to manage urinary incontinence and its associated conditions in older people. There is accumulating data favouring active management.”
There was a range of treatments and approaches including prompted voiding, exercise, weight reduction, the appropriate use of catheters, minimally invasive surgery for some cases and a range of pharmaceutical options. He listed the pros and cons of different drugs but in each case the mantra would always be ‘start low, go slow’. Sometimes the aim had to be modest – “good enough for bingo or good enough to get out to the shops.”
Simple interventions and big gains
Although geriatrics deals with complex problems sometimes a simple intervention can have a significant effect as the session on pain heard from Dr Andrew Severn, a consultant anaesthetist at Lancaster University who recalled the case of an 82 year-old snooker player who was no longer able to play because of neck pain. A single needle intervention into his cervical spine enabled him to win a trophy which he presented to Dr Severn as a gesture of thanks.
“It wasn’t just being able to play, it was about socialising again, about walking three miles a day. Pain management can be about transforming lives and enhancing the quality of those last years. We should share ideas and insights so please talk to your pain management team.”
Early palliative intervention
There was also a plea from Prof Miriam Johnson, professor of palliative Medicine at Hull University for geriatricians to consider her speciality at an early stage for patients with heart failure. The old model of treating until you could treat no more and then handing a patient over to palliative care had long gone for cancer patients. Heart failure patients, however, still often had difficulties accessing palliative care despite the fact that they also suffered pain as well as fatigue, breathlessness, insomnia, anxiety and depression. “The time to involve us is when there are persistent complex symptoms and other support is needed both for the patient and their families. The care should be pro-active, specific and problem not prognosis based. The aim is to help people live as actively as possible until their death.”
The 550 attendees, including visitors from Australia, New Zealand, Canada, South Korea, Hong Kong and the United Arab Emirates could also choose from sessions on education and training, management, interface geriatrics and meet the professors as well as an early morning update on the Care Quality Commission’s review of integrated care for older people.
The meeting which was held in the conference centre on Nottingham University’s cherry blossom filled campus also had nine platform presentations of research papers plus nearly 90 poster presentations and two sponsored symposia: one by Astellas Pharma on incontinence and the other by Vifor Pharma on anaemia. For those who wanted to socialise there was a drinks reception on the first evening and a dinner and dance in the Arkwright Rooms at Nottingham Trent University.