BGS 2014 Spring Meeting - Manchester Conference Report
Today’s geriatricians were privileged to be in a position where they were looking after the most vulnerable in society and doing it well. “We should be proud of the fact that we’re no longer second rate doctors in third rate hospitals with fourth rate patients,” Margot Gosney told the BGS’s Spring meeting. “We are now first rate doctors whose care is first rate.”
Geriatricians needed to be imaginative in how they developed services and to use competence, humour and intellect to influence others to join the speciality: there were currently insufficient trainees to meet the ever increasing need. Prof. Gosney’s rallying cry came at the end of her Marjory Warren lecture in which she recalled n
ot just the famous founding members of the BGS but the consultants who had influenced her in her journey from medical student in Liverpool to being director of clinical health services at the University of Reading.
These included Gordon Mills and his holistic approach, Michael Lye who encouraged her in her interest in cancer in older people and Chandi Vellodi who inspired her as a junior doctor to realise women could be married and have children and still be a formidable force. Jeremy Playfer taught her there would be some things she was not good at and that “you sometimes needed to say ‘others are better at this than me’”.
Jed Rowe, who played a major role in highlighting elder abuse, gave her a memorable metaphor. “He used to say that if you had a limited amount of butter and you spread it thin no-one would be able to taste it. It was better to admit you couldn’t do everything and give one half instead, to really make a difference, and tell the other half they would not get any.”
Then there was Gillian Malster, “a formidable role model who was always immaculately dressed in high heels and a fur coat which she wore to domiciliary visits in even the roughest parts of Liverpool. She taught me you can strive for perfection and sometimes that means you don’t always get on with every member of a team, but if you act in a fair spirit you will be fine.”
Influences also included people from outside medicine. Margaret Simey, for example, who was chair of the Merseyside Police Committee at the time of the Toxteth riots and yet who stood up for the rioters, “showed me that sometimes you have to say things that are unpopular”. Liverpudlians themselves made her realise the importance of being a patient’s advocate. “Scousers are friendly but they were quick to tell you if they thought you weren’t looking after a member of their family properly. There were no four page letters to the chief executive, just an offer to slide you up and down the wall.”
After a wry speculation that even star signs might influence the decision to become a geriatrician – a search of 3,384 BGS members’ past and present birth dates had revealed an overwhelming majority to be Capricorns.
One of Prof. Gosney’s influences when she was a junior doctor was Raymond Tallis, now an emeritus professor of geriatric medicine and author, and also a speaker at the Manchester meeting where he argued eloquently for the law to allow physician assisted dying. With Lord Falconer’s Bill due for a second reading in July, he said, the question was not a purely theoretical one.
The proposed legislation would be for terminally ill patients who were suffering unbearably; it was not voluntary euthanasia or assisted suicide for those who were not terminally ill. The key elements were that the condition must be irreversible, the patient must be expected to die within six months, he or she must have the mental capacity to make a fully informed and voluntary decision with a ‘clear and settled’ intention, two doctors must be involved and the declaration and prescription must be 14 days apart or six days apart if the patient was expected to live for less than a month.
The case against, said Prof. Tallis, had been bedevilled by ‘factoids’ and bad arguments including the belief that good palliative care removed the need for assisted dying, that the growth of such care would be stunted if assisted dying became legal and that such a change would mean that the trust between doctors and patients and doctors and society would collapse.
There was no evidence that palliative care would not continue to develop yet some patients remained beyond its help. “It is not a blanket panacea.” Citing the case of a friend who, despite being a doctor herself, the wife and mother of doctors and having access to the best possible care, still went ‘through three or four weeks of unbearable hell before dying of pancreatic cancer, he added, “She died a horrendous death. There are a small number of patients who are beyond its reach.”
As far as trust went, the Netherlands, which allowed assisted dying, had one of the highest levels of trust in Europe: 97 per cent of patients had confidence in their GPs. Similarly in Oregon which had had the procedure for 17 years the proportion of such deaths had remained at 0.2 per cent. “Out of a hundred people who discuss it and have the comfort of knowing it’s possible only two get the prescription and only one actually takes it.” It had not been extended to those who were not dying or those who could not express themselves or to people, especially older people, feeling they had an obligation to die. “The slope has remained stubbornly unslippery.”
The alternatives to assisted dying were death by starvation or dehydration, an early ‘grim pilgrimage’ to somewhere like Dignitas or amateur assistance with the threat of prosecution.
Public support for the measure now stood at 82 percent overall and at 71 per cent among people with religious convictions. The appearance of universal opposition among medics was false, he claimed. Of doctors who were asked if they would want it for themselves a third said yes, a third opposed the idea and a third did not know.
“Some feel it would be a betrayal of their principles or their professional oath but you are denying a professional duty of care by a refusal to help.” It was appropriate for doctors to have legitimate concerns and there were safeguards and codes of practices including a conscientious objection clause but an illegitimate interest should not be able to override a patient’s needs.
“The case for assisted dying is that it is an act of compassion which reduces suffering. The law would increase the safety of patients and their carers by moving beyond the current lethal and ethical fudge. Doctors would not have to abandon their patients at the time of their greatest need.”
Hello my name is
Death was also the subject of a session just before Prof. Tallis’s lecture, but this one was from a highly personal perspective rather than a professional one. Kate Granger, a 32 year-old specialist registrar in geriatric medicine in Leeds, was diagnosed with a rare sarcoma in July 2011. Since then she has become a blogger, a tweeter, an author, the instigator of the Compassionate Care Awards which bear her name and a committed campaigner for better communication.
In a talk entitled Social media: what’s in it for healthcare professionals? Dr. Granger outlined some of its benefits, particularly those of Twitter where she has nearly 23,000 followers. Connectivity - “I’m now one of the best connected registrars in the country – even Jeremy Hunt follows me” – meant opportunities for continuing professional development and the exchange of ideas. “The awards scheme happened because the seeds for it were sown on Twitter.
“It’s also great for signposts to what you should be reading because so much is accessible just by clicking on a link. I read a lot more now. You can also use it to revise for exams or to give you access to an amazing community of professional support. People point you to where you can get help. Twitter enables you to get into the blogosphere and access to patients’ worlds, to what goes on in their heads rather than just what they tell you.”
Virtual friendships had in some cases translated into real friendships – “I’ve met about 50 people that way now, and some have become quite close” – and although she had been trolled several times the bad had been far overweighed by the good. “I have had abuse and I’ve grown a thicker skin. There’ll always be a negative side but there have only been two or three horrible tweets for every thousand lovely ones.”
The Hello My Name Is project took off after she had a bad experience in one hospital when she found herself on a urology ward with post-operative sepsis. “Until then my experiences had been positive but I was very disappointed with what happened there. People came up and did things to me without ever saying who they were. When I was complaining about it afterwards to my husband, Chris, he said ‘well stop whingeing and do something about it.’”
She began tweeting and the response was overwhelmingly supportive. Now an ever increasing number of health and social care workers introduce themselves to patients in a variety of ways: with verbal introductions, name tags, lanyards, pin badges, screen savers and posters and boards with names and photographs of staff.
A video of the campaign with examples of people saying ‘hello my name is’ and ending with a tribute from Chris to his wife was played to the audience, many of whom were visibly moved.
Dr. Granger who has only a few months to live wants to tweet for as long as possible with the hashtag #deathbedlive. “I want to tweet about the experience, about my fears and anxieties, right until I die. I’d love to trend – so please retweet.”
The meeting opened with an afternoon devoted to psychiatry with Alistair Burns, the national clinical director for dementia for England, setting the scene. “Dementia awareness is at its highest level ever and we need to capitalise on this”, he told his audience. “It is everyone’s business.”
Targets included the need to increase spending on research into the condition; to increase the number of patients in clinical drug trials – the current figure was only around five per cent – and to increase the diagnosis rate. At the moment only half of sufferers are actually diagnosed, the aim was to raise that to two thirds, possibly by adding it to routine health checks, and to give good support afterwards. That was the key, Prof. Burns added, to achieving quality of life and he cited such examples as the four fold growth in memory clinics in recent years, the distribution of 100,000 copies of the Dementia Guide and initiatives such as life story work and the Dementia Friends project.
He also outlined the Sliding Doors concept where a small change could lead to two very different outcomes. In the first, 79 year-old Mr Smith becomes distressed and agitated one Saturday night, is seen by the oncall GP, admitted to hospital, diagnosed with delirium from a urinary tract infection, sedated and later discharged to a care home. In the second scenario, Mr Smith’s memory loss has been identified two years earlier. He has been supported by a dementia advisor and his wife has been involved so that on that night, when she notices he is not himself, he is visited by a GP who knows him and prescribes antibiotics. Mr Smith recovers without the need for hospital admission.
Although the condition was the most feared among the over 55s there was some good news that it might be decreasing. Meanwhile we needed more integrated health and social care and to break down barriers between primary and secondary care providers.
Jim George, consultant in medicine for the elderly at Cumberland Hospital, then spoke about the difficulties of managing dementia in the general hospital. “Hospitals are designed for younger mobile people but their customers are older people.” Three fifths might have mental health problems.
Acute admissions of such patients, especially the over 85s, were increasing and the failure to recognise cognitive impairment and the general unsuitability of the environment to older confused patients could lead to over-sedation, infection, adverse drug reactions, falls and delirium. The longer the stay, the greater the risk became: those with dementia had a seven times higher mortality rate. It was vital therefore to establish safety domains including better staff training, an improved environment and a geriatrician-led comprehensive assessment including cognition tests at the front door of the hospital.
The hurly burly, time sensitive nature of acute units also led to poor detection of delirium in older patients, John Young, national clinical director for integration and the frail elderly for England, told the meeting. “They think the patient is sleepy or incoherent but they then often don’t follow that up.” Studies suggested only 28 per cent was detected so we needed to do better; the target was to improve detection rates by a third.
“We need to look for disturbances in attention, excessive sleepiness, incoherent speech or disorganised thinking. Look for repetitive abnormal movements of the hands either waving them or picking at things. These gestures were in fact first identified by Hippocrates. There are simple bedside tests. Ask them to recite the months of the year backwards. If they make a mistake by June that’s indicative of some impairment. And if you shake hands with a person with delirium they will look away.
“Changes often happen over a short period of time and you need to notice change from the baseline state of the person. You should give priority to information from carers: they can be much better at recognising delirium than professionals.”
Consultant psychiatrist Ross Overshott gave a neat definition of psychosis as a disconnection to reality. “The delusions must be out of keeping with the patient’s educational, cultural and social background. For example, in our society it would be socially acceptable to believe that Jesus was the Son of God; it would not be socially acceptable to believe you are Jesus.”
Around 23 per cent of older people experienced psychotic symptoms at some point. They were unlikely though to be caused by schizophrenia which tended to occur in earlier life. Similarly, bipolar problems tended to appear before old age. It was more likely to be a result of Alzheimers and other forms of dementia, disorders like Parkinson’s Disease, adverse drug reactions and delirium.
Psychosis could also take the form of hallucinations, which could be auditory and gustatory as well as visual, and thought disorders which could centre on paranoia, control, love and jealousy, even infestation, and were often characterised by chaotic speech including ‘word salad’ and the loss of the goal of a sentence. Patients should be approached with empathy but not patronised. “Test the intensity of the feeling. Validate the emotion but don’t collude in the delusion.”
His pharmaceutical advice would be to treat carefully with anti-psychotic drugs, be mindful of co-morbidities and aim ultimately for discontinuation. Some patients were not prescribed anything. “They seemed happy so why run the risk of drug side effects; we just chatted.”
Sometimes a picture can be worth a thousand words as Tamara Griffiths, consultant dermatologist at the University of Manchester, demonstrated in a session on the photoageing of skin. The picture was of a 69 year-old truck driver in America with at first only the right hand side of his face visible. The face looked normal, even relatively youthful but then Dr. Griffiths revealed the other half. After a working life’s exposure to the sun through the truck’s open side window, the skin now had coarse wrinkles, laxity, pigmentation and redness. It was a dramatic illustration of the ageing effects of UV radiation which reduces the skin’s collagen and consequently its strength and elasticity.
Other extrinsic ageing factors included smoking, the environment, pollution, too much sugar and chronic stress. These were additional to the ordinary intrinsic process of the ageing of skin which was chronological and influenced by genes. The thinning of the epidermis and the growing irregularity of the stratum corneum reduced the effectiveness of the skin’s barrier function in older people and made them more susceptible to poor wound healing, reduced nutrient transfer, eczema, pruritis and dryness: “which is why we should push emollients in older people.”
The skin’s appearance may be a predictor of life expectancy. Studies of offspring of a nonagenarian parent who also had a sibling who lived into their nineties found they had a lower perceived age than a control group. The male group had a mean age of 61 but a perceived age of only 51; in the control group both the real age and the perceived age were the same at 61. The female group who were actually 60.9 years old were seen as being 52.7; the control group who were 61 were thought to be 62.4. “Long lived families had less skin wrinkling in sun protected sites. Skin ageing may help us to understand other internal ageing processes.”
Can frail older people be happy?
Dr. Griffiths was opening the Thursday morning session on The Clinical Implications of Ageing which also covered genetic underpinning of frailty and socioeconomic and gender inequalities in trajectories of frailty. The session closed with the intriguing question ‘Can frail elderly people be happy?’ Bram Vanhoutte and Cathy Marsh from the Institute for Social Research looked at the differences between the Epicurean and the Aristotlean schools of thought.
The former, hedonic philosophy, was about minimising suffering and maximising pleasure. The latter, eudaimonic, was concerned with developing oneself and realising one’s potential. As frailty increased, happiness tended to go down among both types but social background and personality still played a major role. Although geriatricians tended to focus more on the physical, successful ageing was also psychosocial. Sometimes there was the phenomenon of some older people becoming happier than they had been maybe ten years earlier. “They learn to live with it and adapt. The attitude is ‘well, I’m in a wheelchair but I’m still here’ ”.
Tackling hearing impairment
A heartening aspect of any BGS conference is learning about new developments such as the success of cochlear implants in older people. Kevin Green, consultant otolaryngologist at Manchester Royal Infirmary, told his audience that there was no upper age limit for the procedure and cited the case of 99 year-old Mollie who had had an implant after decades of deafness.
There have been 350,000 such operations worldwide since the late 1980s with a thousand a year currently being done in the UK for children and adults. They worked by stimulating remaining nerves to convert sound energy to electrical energy. NICE recommended them for people with severe to profound hearing loss which would apply to 60 percent of those over the age of 70. He believed, however, that NICE’s definition - a 50 per cent loss at 60 decibels - was too stringent. “You get problems before that,” he said. As a result the procedure was very under-used: Only five per cent of those over 18 who would benefit actually got an implant. Yet they were safe and effective although the signal received was not like normal hearing and rehabilitation could take months, even years. There was no difference in the outcome between older and younger patients. Over half could even use the phone which was a significant measure of success as the person was not relying on lip reading in any way.
The big issue for older patients, added Mr Green, was their suitability for surgery which could be assessed with a CT or MRI scan. Some patients were reluctant to undergo surgery or believed hearing loss had to be accepted as an inevitable part of ageing..
The stigma of hearing loss was one of the themes of the previous lecture given by Kevin Munro, professor of audiology at the University of Manchester, who called for a cultural shift in attitudes. “It might be the way in which we distribute hearing aids through GPs and hospitals that makes them seem a sign of frailty, a sense that ‘we’re now shuffling towards the finishing line’. We don’t feel that we get glasses or sort out our teeth or feet. Perhaps the fact that celebrities and young people now have things hanging from their ears may help to break down barriers. Ideally what we want is for a hearing aid to suggest that you now have ‘super hearing’ rather than it being a sign of weakness. We need to stress the importance of ‘communication fitness’ ”.
Since hearing loss greatly affects quality of life Prof. Munro also suggested that people might be screened for impairment at an earlier age in order to benefit from improved modern technology, including self adjusting aids and directional microphones. “The earlier you start, the earlier you can train yourself and get used to it and the greater the benefits.”
Dizziness and balance disorders
Another benefit of meetings is when members get access to some hands-on help from experts in a different field. International dizziness expert Joana Lawson, a consultant at the Royal Victoria Infirmary in Newcastle, had several takers when she offered to demonstrate some of her examination techniques in the coffee break after her talk.
Dizziness, she had said earlier, was one of those conditions which was of very high importance to patients but often less so to doctors who often approached it like a ‘jumbled wardrobe’ instead of with a logical, efficient and cost effective method. One of the first priorities was to get a patient to describe the condition accurately. “It can be difficult to describe but try to get them to avoid the zz words like fuzzy or whoozy and to talk instead, about ‘tipping’, for example, or ‘spinning’.”
Vertigo and other balance problems arose when there were malfunctions in the peripheral or central vestibular systems. Dr Lawson illustrated her talk with videos showing how abnormal eye movements in patients could give clues to what was happening.
Lisa Robinson a physiotherapist at the same hospital talked about how avoidance techniques adopted by older people often caused further problems, such as neck stiffness and postural changes. Physiotherapy could help with strength training and improving balance. “Older people should be working at the limits of their abilities. We need to challenge them.”
The session concluded with the presentation of an abstract by Arun Kumar of the Division of Primary Care at the University of Nottingham, showing how exercise could reduce the fear of falling in older people living in the community. Fear of falling was sometimes worse than actual falling as it led to avoidance activities, loss of confidence and poorer mental health.
A meta-analysis showed that structured and repetitive exercise could reduce both the fear and the actual rate of falling at least during the period in which it was undertaken. Further research was needed to see whether the effects were maintained after the exercise programme end
Care home medicine
Care home medicine was the next frontier of geriatrics and we needed to tackle it before it got away from us, Martin Vernon told his audience in the final session of the Spring meeting. “The key point is that everyone here needs to go into a care home if only for one hour a week. There is no substitute for face to face contact. These are complex environments with governance and safety issues and we are often guests there. But it is rewarding.”
There were now 20,000 registered nursing and residential homes in the UK, mostly in the independent sector. Less home care and fewer day centres meant occupancy numbers were increasing. From 2006 to 2013 the number of those in residential care rose from 135,000 to 154,000 an increase of 21 per cent and those in nursing care from 65,000 to 79,000, an increase of 22 per cent. There was a wide variation in standards with safety concerns in maybe as many as one in five homes.
“My personal view is that inspection doesn’t change anything, it just observes what’s going wrong,” added Dr. Vernon a consultant geriatrician at University Hospitals South Manchester. Their area had been running a service to liaise with homes, community teams and GPs to draw together all interested parties in planning care, reviewing medication and involving families. It had already meant fewer hospital admissions, less time spent in hospital and more older people dying in the home which is what they had wanted. User satisfaction was high.
Eileen Burns, clinical director of specialist acute hospital care for older people at Leeds Teaching Hospitals, argued that we could now be at the ‘end of the disease era’ in that older patients often had so many symptoms that the primary diagnosis did not matter to the same extent. Instead we needed a pro-active care home service to reduce the burden of disability, improve the management of long term disease and where possible reduce acute deterioration in health.
“What’s wrong with staying in hospitals as geriatricians and waiting for patients to come to us?” she asked. “The pros are that any facilities and tests that are needed are easily accessible and we are in our comfort zone. The cons are that hospitals are expensive, not patient centred and older people don’t want to be there. For them being in hospital has unwanted effects like injury, weight loss and pressure sores. And patients at the end of life should only be admitted to hospital when they need the comfort aids which they cannot get in a home.”
Other sessions included ones on movement disorders, stroke, falls, inflammatory bowel disease, thyroid disease and incontinence. There were workshops on e-learning and curriculum mapping and four sponsored symposia: by BMS/Pfizer on anti coagulation and stroke prevention in patients with non-valvulaer atrial fibrillation; by Teva UK/ Lundbeck on treatment decisions in Parkinson’s Disease; by Napp on pain in the elderly and by Takeda on falls and bone health.
Members also had the chance to socialise over drinks and canapés in the Fossils Gallery of Manchester Museum and over dinner followed by dancing in the splendid surroundings of the Town Hall.
The autumn meeting will be held in Brighton from 15 - 17 October. Registration is open and abstracts are invited until 5 p.m. on 1 June.