BGS 2016 Spring Meeting conference report
Geriatricians need to invest themselves in end of life care because there is a lot they can contribute.
“We are often involved by default but we are not as proactive as we could be,” Dr. Martin Vernon told the Spring meeting of the BGS. “It’s often not in our mindset and we have to take ourselves on a personal journey about what we can do. We should align our thinking and be working collaboratively with other specialisms like palliative care and in the community. There should be an interface between us all. This is everyone’s business”.
Our expertise meant we could identify people nearing the end of life. Advanced care planning should therefore be part of ageing well, Dr. Vernon, a consultant geriatrician with the Central Manchester Foundation Trust, added. It could avoid unnecessary acute hospital admissions and help people to die in a place and manner of their choosing. Surveys showed that what they wanted included freedom from pain, to be with people they loved, to have good communications and to have access to medical support.
When it was considered that a person might die within the next few days or hours the priorities should be to communicate the possibility clearly and to take decisions and actions in accordance with the person’s needs and wishes. An individual plan of care which included nutrition and hydration, symptom control and psychological, social and spiritual support should be agreed, coordinated and delivered with compassion.
The dying person and those important to them should be involved in decisions about treatment and care to the extent that the dying patient wanted. The needs of families and friends should be actively explored, respected and met as far as possible.
“We need an ongoing narrative with patients. Without good communications between staff and relatives or carers unnecessary misunderstandings and distress can arise. Getting it wrong is disastrous for the individual and for their families who have to pick up the pieces afterwards.”
EoLC - there is no rehearsal
Dr Vernon’s rallying call was echoed by another speaker at this day long special interest group session. “Death is essentially a geriatric event and end of life care should mirror that,” said Prof. Barbara Hanratty, professor of primary care and public health at Newcastle University. “We should not fall into the trap of being too disease focused.”
The often slow decline of older patients meant it could be difficult to recognise the point at which they needed palliative and terminal care but recent developments in measuring frailty, particularly using the electronic index, were proving helpful. Frailty, defined as a distinctive health state related to the ageing process in which multiple body systems gradually lose their built in reserves, was a good indicator that someone might be reaching the last year or so of life.
“Frailty is a state of vulnerability to poor resolution of homeostasis after a stressor event,” she added. “Very frail is obvious but these new tools can help us identify moderate frailty.” Earlier identification could help with care planning. “Frailty can also be exacerbated by isolation. A patient’s social networks may be insufficient to provide informal care, so they need earlier and more support.”
The challenge of end of life care was summed up by Karen Groves, a specialist palliative care consultant for Southport and Ormskirk Hospital NHS Trust. “You have only one opportunity to get it right. There is no rehearsal. Everything you do or don’t do or say or don’t say will be remembered.”
She updated the audience with the new NICE guidance and five priorities for care in a patient’s final days: the aim was to recognise, communicate, involve, support, plan and do. Recognition meant having a competent senior medical assessment with a second opinion if there were doubts, excluding reversible causes for deterioration, including the views of a wider multi-professional team and having a goals of care discussion with the patient.
Communication meant talking with dying people and their families, providing information and checking it had been understood, listening and responding sensitively to issues and concerns and using straightforward language without euphemisms. So one should say ‘dying’ not ‘fading’, ‘ill enough to die’ not ‘poorly’, ‘plan for care’ not ‘pathway’ or ‘tlc’, ‘manage symptoms’ not ‘keep comfortable’. It was often a good idea to write these on cards and give them to staff.
Patient and family involvement and support should include knowing who the senior doctor in charge was and which nurse was responsible for care. Decisions must consider burdens and risks as well as benefits. Where someone lacked capacity their family should be asked of their knowledge of a patient’s wishes in order to inform best interests decision making. Families should be able to spend time with the patient and to assist with care if they and the patient wished
The care plan and its implementation should be holistic and individual with symptom control and help for eating and drinking as long as possible along with personal care to maintain comfort and dignity. Psychological, social and spiritual needs should be met.
The UK had been ranked best in the world for end of life care by The Economist, said Prof. Keri Thomas, national clinical lead at the Gold Standards Framework Centre, but we could still get a lot better. Reactive care meant too many people were dying in hospital when they did not need to. Proactive care on the other hand with earlier recognition, planning and decision making including Do Not Attempt Resuscitation could mean better outcome for patients, families and staff and better and more cost effective use of resources.
Of the 500,000 deaths a year around 30 per cent were in hospitals. “About half of these could have been at home,” she said. “This is a big challenge for us. It is a great moment to be a geriatrician: the future of end of life care rests with us.”
Earlier Dr. Jonathan Martin, consultant in palliative care with the Central and North West London NHS Trust, had outlined some of the special end of life concerns for people with dementia including severe disability and behaviour problems. Pain was frequently under recognised, under estimated and under treated and it was vital to use validated assessment tools such as looking at facial expressions and body movements to gauge the problem in patients who could not express themselves.
Dementia and delirium
Dementia was also the subject of parallel morning and afternoon SIG sessions on the opening day of the Liverpool meeting when subjects included the outcomes for frail patients on anti-dementia drugs; optimising cognition and the management of polypharmacy; and cognitive spectrum disorders in the context of hospitals and care homes.
In her presentation on managing co-morbidity Prof. Emma Reynish, professor of dementia research at the University of Stirling, pointed out that patients with cognitive impairment seemed to have a higher burden of frailty and other conditions and illnesses. These could have a detrimental effect on cognitive function and more research was needed to tackle this detrimental effect. “Geriatricians have a pivotal role in this and in future developments,” she suggested
She was followed by Prof. Alasdair MacLullich, professor of geriatric medicine at the University of Edinburgh, who spoke about the management of delirium today and tomorrow. This acute delusional state could be caused by illness, surgery or medication. It could also arise out of pain, brain injury, sensory impairment, poor nutrition and sleep disturbances.
Its onset was often sudden but usually improved when the condition causing it got better though some delirium was much longer lasting. It was extremely distressing not just for the sufferer but for those around them. In its severest form it could cause post traumatic stress, make existing dementia worse or increase the risk of its onset. Persistent delirium could lead to people being institutionalised.
With delirium affecting up to 15 per cent of hospital patients it was vital, added Prof. MacLullich, to increase awareness, improve detection and where possible reduce risk factors. “The humanitarian need is enormous. This should be everyone’s business.” Future developments could include new drugs to target the different components and specialist units for persistence cases.
Delirium was also the subject of a Rising Star presentation by Daniel Davis, senior clinical researcher at the MRC Unit for Lifelong Health and Ageing at University College London, which looked at its population impact on trajectories of cognitive decline. Preventing delirium or reducing its severity and duration could perhaps lower the incidence of dementia with considerable costs savings: dementia costs the country £26bn a year. “Delirium is a gross syndrome which should alarm us, particularly when there can be a very small precipitant,” he said. The hyperactive form with its aggression, wandering and agitation was relatively easy to recognise but the hypo form where the patient was bewildered, sleepy or inattentive, was often missed.
The other Rising Star presentation of assessment of frailty in research and practice was given by Roman Romero-Ortuno, consultant in care of the elderly at Cambridge University Hospitals Trust.
‘Internet of things’
The doctors of the future, of course, will be greatly assisted by technology which is already playing a major role as those listening to a fascinating overview by Kevin Doughty, consultant in technology in healthcare at the University of York, heard on Thursday morning.
Wearable devices in clothing or insoles or as wristbands could now monitor physiological wellbeing including measuring brainwave and heart activity, respiration, pulse, gait, enuresis and blood pressure. They could also give reminders and prompts, improve medication compliance, check safety and assist with navigation and location. A person with dementia, for example, who was prone to wandering could have a personalised ‘safe zone’ set up: if they strayed outside it an alert would be triggered.
If the wearer fell, suffered a seizure or other crisis an alarm would be raised at a telecare hub which could then direct an emergency response. In 80 per cent of cases an admission to hospital could be avoided or reduced: it is estimated that every hour a faller lies on the floor means an extra day in hospital, four or more hours and most patients can never return home. ‘Smart homes’ could also feature detectors on beds, fridges, microwaves and toilets.
“All this means benefits for individuals and reduced anxiety for families and carers.” said Mr. Doughty who added that with the introduction of ever smaller, lighter, user-friendly and affordable devices, the field was increasingly consumer driven. “They can empower the individual to control their environment and self manage. Will they be accepted? Well, older people are not fools. If it’s the difference between living independently with your self esteem or committing yourself to a home where you’d lose all control there’s no contest.”
The development of proactive calling from health professionals plus video consultations, virtual speech, occupational and physiotherapy, risk management and ongoing checks had implications for long term care. There were also important advances for specific diseases and conditions. Parkinsons Disease patients, for instance, could have their tremors measured and then offset by gyroscopic procedures. Pressure sores could be avoided by equipment that turned patients regularly. Exoskeletons could restore mobility.
In the future headsets could improve hearing or visual impairment or simply provide virtual reality entertainment to combat isolation or loneliness. Virtual reality was already being used to tackle paranoia by encouraging sufferers to enter computer generated recreations of situations which they feared and then reduce those fears by learning they were safe.
The next stage, he added, would be the vast growth of the ‘internet of things’, the connectivity between physical objects that allowed them to collect and exchange data. There were currently five billion connected devices; by 2020 there would be an estimated 50 billion.
The most successful use of technology came when you started with a problem and then found its innovative solution rather than trying to find a use for a new piece of kit, said Dr. Frank Miskelly, consultant physician at Imperial College, London. “In one dermatology clinic, for example, there was a nine month wait to see the consultant. But a certain percentage of patients needed an urgent appointment because there was a query over skin cancer. So what they did was train technicians to photograph the lesions. The consultant could then go through them quickly and decide who should be seen immediately and who could wait.”
‘Store and forward’ techniques where technicians or paramedics could carry out examinations and tests and then transmit the results to a distant expert for advice was particularly useful in battlefields, oil rigs, expeditions, cruise ships and prisons.
Telemedicine was also increasingly used at a distance for radiology and robotic surgery. Telehealth and telecare were being used more and more for remote monitoring of and care for chronic disease, a growing concern in an ageing population: patients with chronic disease used 60 per cent of hospital day beds; two thirds of medical emergencies had chronic disease or exacerbations of it. Possible drawbacks included variable image quality, the amount of equipment which might be needed and the lack of personal and physical contact.
The take home message from the next speaker was that electronic health records were coming and would be beneficial for geriatrics - they were searchable, accessible and assistive - but change could be stressful. Describing the switchover at St Mary’s Hospital in London, consultant geriatrician Colin Mitchell said the lessons learned included the vital need for early and ongoing clinical engagement even if that involved difficult discussions. “Understanding IT should become a curriculum competence,” he said.
De-motivating people who do very little
Appropriately for a workshop on exercise for rehabilitation, the session began with a 400 metre walk in the spring sunshine around the conference venue led by Prof. John Buckley, professor of applied exercise science at the University of Chester, and with one walker wearing a pulsoximeter to measure his heart rate at regular intervals.
Earlier Prof. Buckley had turned down one volunteer as being too fit. “You don’t represent 80 per cent of the population. The problem we have is fit people trying to get the rest of the population active but they haven’t got a clue about the psychology of people who do very little and often the effect is actually demotivating. And rehab is ultimately about behaviour changes.”
Active living and exercise were great medicine, he added, but there were several factors affecting older people including co-morbidity, a natural loss of both aerobic capacity and economy of movement. It also took longer for oxygen to reach the muscles: someone over 75 for instance might struggle with activity for the first six minutes compared to the first two minutes in a younger person.
It was important, he stressed, not to be fooled by an increase in the distance walked in six minutes after six weeks of rehab which might be achieved by better motivation, familiarity with the route, increased confidence and relief that nothing dreadful was going to be caused by breathlessness or aches and pains.
“I’m not knocking these psycho-social benefits but if the heart beat cost is still the same the patient is not actually fitter and there’s no morbidity or mortality gain.. You’re only fitter when the same amount of work is done by fewer heart beats - when you get more bang for your buck or spend less money to get the same amount.”
Strength training coupled with aerobic exercise had proved more effective than aerobic exercise alone, added Prof. Buckley who also praised being active around the home, playing wii or doing ballroom dancing to offset the ‘being bored to tears’ element of a lot of exercise. “We must also ask what the patient’s rehab goals are, not ours. And those may be just the ability to move from the house to the garden or pick up a grandchild.”
Skin problems are a common feature of ageing – an estimated 70 per cent of older people suffer from them, according to Dr. Hamish Hunter, consultant dermatologist at the University of Manchester who illustrated his address with vivid pictures of various conditions. These included rashes caused by polypharmacy, different types of eczema, dryness, bacterial, viral and fungal infections, psoriasis characterised by thick crusty patches covered by silvery scales and cellulitis where one leg was hot, painful and tender and the patient ran a high temperature and felt very unwell.
He also dealt with leg ulcers, venous, which could be large and shallow, and arterial which often turned gangrenous, benign neoplasms and cancer. The key factors to look for with malignant melanoma, the most serious cancer, were asymmetry, irregular border, multiple colours, a diameter larger than 6mm and elevation from the surrounding skin.
Skin problems arose through intrinsic ageing related to genes and extrinsic related to the environment particularly exposure to ultra violet light, air pollution and smoking. The skin lost its elasticity, became thinner and its barrier functions declined. Treatments were wide ranging and included antibiotics, steroids, compression and light therapy but prevention could often be helped by simple measures. Soap should be avoided and substitute cleansing creams and lotions used instead. The skin should be kept well moisturised and extremes of cold and heat avoided.
Another session where pictures were used very effectively was that on visual impairment when Dr. Carmel Noonan, consultant ophthalmologist and neuro-ophthalmologist at Aintree University Hospital used specially adapted photographs to give a sense of what a patient might see. So someone with age related macular degeneration, for example, would be unable to see faces or objects in their direct line of vision. Cataracts would make vision blurred, hemianopsia would remove half the field of vision. Prosopagnosia meant faces could not be recognised. In akinetopsia smoothly moving objects appeared stationery.
Visual impairment is widespread, with over two million people in the UK living with some degree of sight loss. With the majority being older people – one in five over 75s have a problem, one in two over 90 - the number is predicted to increase by a further 250,000 by 2020.
“Reduced vision can have serious consequences,” added Dr. Noonan. “It increases the risk of falls, it stops people working and driving. It increases isolation and depression. It prevents you reading, web browsing, texting or using a smart phone which are all part of the modern age.”
There were, however, modern advances such as injections for the wet variety of macular degeneration as well as cataract surgery and treatments for glaucoma. There were also helpful apps which could give directions, answer questions or read something aloud.
Care and Compassion is not widespread
A non-medical view of health and social care was given by journalist Michael White of The Guardian who opened his guest lecture by telling his audience “I’m 70 years old so I have an interest in your future success. I now have friends going into hospital all the time and I realise what a raffle it is. Care and compassion are not as widespread as they should be although I’ve never had a bad experience, nor has my family.”
The pressure on our health care came from rising demand and expectations at a time when money was tight, although, he pointed out, no system anywhere whatever they spent or however they organised it, had got the situation entirely cracked.
We had to look on the bright side – everyone was living longer, even the poor – but there were some hard decisions to be made. “We have three major players: the medical profession, the taxpayer and the government and the customers. We need more honesty and a willingness to talk about things. The NHS is essentially a socialist concept which is still loved in Tunbridge Wells. But it is rather conservative and monolithic and resistant to change.”
Diversity of provision was needed including from the private and voluntary sectors. The government must also square up to vested interests especially those in the food and drink industries.
“There is a routine failure to be frank with the electorate about hard choices” he added. “ There is, for example, a sound argument for specialist hospitals or reducing the number of hospitals and transferring care elsewhere, not just to save money but because there is a respectable case for it. Most politicians though, feel that an MP is not going to be re-elected if he or she proposes or supports that. Doctors also run for cover when difficult decisions have to be made. Newspapers are guilty too. On one page they’ll say tax is too high, on the next why don’t you give us this?”
There was never a customer who did not want to pay less for a better product but we expected the NHS to patch us up when we ate, drank and smoked too much. “We see here an inverse health care law. Those who need most attention and who prove to be the most expensive get less attention and devote less attention to themselves. We are not honest with each other and ourselves.”
Referring to the loss of blue collar jobs to technical innovation and the ruin of the business model of newspapers by the internet, he told the doctors, “You may be the last workers to be put out of work by technology.”
What is medicine for?
It was back to the medical perspective for the meeting’s other guest lecture when Dr Rowan Harwood, consultant geriatrician with Nottingham University Hospitals NHS Trust posed the question: What is medicine for?
A lot of the improvements in health were due more to better nutrition, sanitation and clean water. The reduction in heart disease, for example, was only half attributable to medicine; the other half had come through life style changes.
Medicine could be said to be cure, comfort and care: the art of restoring and preserving health in a soundness of body and mind. “The disease centred and disease focussed view is very limited though. We also need to deal with a person’s emotions, feelings and values.”
He cited the case of a man who was being treated for incontinence until it was discovered that the problem was caused by his taking laxatives. This had not been discovered, however, until there had been a detailed conversation. “The medical model is not wrong. It’s just inadequate. We need to take account of what’s important to people and also to look at how organisations work and their culture.”
Preventive medicine was important as were rehabilitation and respite care. Patient and carer satisfaction were similarly significant even when there was no effect on mortality. Medicine should also embrace the family. “This can be more difficult with older patients where one in ten have no friends or family. In view of this you need to ensure you look after your medical staff and support them psychologically.” The good news about this broad view of medicine was that better care could be done today. “Geriatricians are in the vanguard of this and must remain so”.
Where are we going to live for the next twenty years?
A previous session at looked at public health in older people with the first speaker Prof. John Ashton, president of the UK Faculty of Public Health, urging his audience to become involved in housing issues as they affected older people. “This is a plea to say, let’s start thinking about town and country planning and joining up the clinical agenda with the social and housing one. You are rooted in the biology of old age and the sociological side but there’s less thinking about the environmental side
Often patients were stuck in hospital because their homes were unsuitable or there was no provision or support for independent living. “Every hospital board should have a housing provider on it,” he said.
In Tokyo it had been found that older people who lived a five or ten minute walk from green space lived longer. Sweden had sheltered and independent living units in the heart of the community. Yet in the UK successful people tended to finish up in a detached house in the suburbs with no public transport. When they had to give up their car they were isolated.
“We need to ask ourselves, once the kids are gone, where we are going to live for the next 20 or 30 years so that we then won’t have to move if we have a stroke or develop dementia. If the housing is right, people with dementia can live another year or two in the community, which means thousands of bed years saved.”
Prof. Ashton was followed by Prof. John Britton, professor of epidemiology at the University of Nottingham, who looked at the effects and treatment of smoking in older people. Smokers, he said, lived on average ten years less but stopping smoking, even at the age of 70 or 80, dramatically reduced the risks. Help with quitting should be routinely offered to the 1.1m smokers admitted to hospital every year: often they were more highly motivated at this point. Those who could not give up should be encouraged to switch to electronic cigarettes to reduce harm.
The last speaker in this session was Dr. Tony Rao, a consultant old age psychiatrist with the South London and Maudsley NHS Foundation Trust, who looked at the problems caused by excessive alcohol consumption. Alcohol related deaths for men increased by 40 per cent between 1991 and 2009 with 54 to 74 being the most vulnerable age. “We are also now seeing more mental health problems related to alcohol than cases of cirrhosis.” More problems could be expected as the baby boomer drinkers got older.
A Friday morning session on oncogeriatrics looked at some of the problems specific to older people with cancer. Andrew Jazaerli, senior policy officer with Macmillan, said their survey had found that this age group were often given less information on possible side effects or advice about benefits and finances even though they were less likely to have support systems than younger patients. There could also be inequalities of treatment. The picture was further complicated by co-morbidities.
People who had been fully informed and consulted on their needs and preferences were much happier with the care received and found the experience positive and empowering.
The encouraging news was that survival rates were improving. “By 2030 many cancers may well be long term conditions which we manage. The challenge used to be to stop people dying of cancer; the challenge now is to support people living with the disease.”
The way forward should be the engagement of elderly care physicians as an active part of cancer care teams.
The following speaker Prof. Jackie Bridges, professor in older people’s care at the University of Southampton, looked at how we could ensure shared decision making. Elderly patients often felt hospitals engendered feelings of worthlessness and lack of autonomy. What they wanted were reciprocal relationships with staff, to feel legitimate as a patient and significant as a human being.
It was therefore vital to find ways of involving them. “We all want better, faster, cheaper but cancer time targets can be a constraining factor as older people's needs are more complex. Often there isn't the time to gather the information but it is up to us clinicians to mediate between these gaps.
More than 600 people attended including nurses, students and allied health professionals as well as doctors. Among them were visitors from New Zealand, Malaysia, Germany and Singapore, all of whom had a chance to socialise at a drinks reception on Wednesday evening and a gala dinner with entertainment on the Thursday.