BGS 2017 Autumn Conference Report
Geriatricians should start introducing themselves to fifty-somethings to help them age well and to combat the widespread negative image of older people. That was the message from Baroness Sally Greengross who told the BGS’s Autumn Meeting, “There’s a huge reluctance to be old, instead of relishing it, being proud and active and as involved as possible.”
The 82 year-old president and chief executive of the International Longevity Centre-UK added, “I’m very lucky in that I’m very old and still able to work. I want everyone to be in that position and I want geriatricians to be part of that.”
Old age now could be anything from 50 to 100 or more. “We should see 50 as beginning the second half of life – perhaps we should be called second-halfers. At that age we should have a health check, a money check, a planning check with our families about what we can do with and for them and, a work check. Do we want to work full time, for instance, or flexibly?”
Such checks could help make the later years the most enjoyable part of life. “We need your help in achieving this. The BGS can make it happen.”
There were also increasing economic and social needs for an active and healthy older population, as Baroness Greengross spelled out in her guest lecture. The ‘new normal’ of longer lives was leading to longer retirements but governments might not be able to pay pensions for extended periods.
“Working longer is an answer to both personal economic stability in older age and to reducing the state pensions bill.”
Many industries already relied on older workers and there was a growing trend for retirees – one in four – to return to work within five years of retiring. But it was not only a case of getting paid employment in our 70s and possibly beyond, older people also needed to be well enough to enjoy the arts, use new technology and be volunteers. “No-one could manage an election in this country, for example, without all those older people pushing envelopes through doors.”
Not so long ago, Baronness Greengross recalled, when old people became ill they simply died. Now they survived with long term conditions and many co-morbidities. But these in turn meant huge pressures on the NHS where 70 per cent of the budget was spent on the management of chronic disease and on social care with its £100bn a year cost.
There were other stark statistics. The over 65s represented 23 per cent of all accident and emergency attendances but they accounted for 46 per cent of all admissions from those departments. People aged 75 and over were staying an average 9.1 days per admission, compared to five for all ages. And between 2010/11 and 2014/15 the number of outpatient appointments for people aged 60 plus increased from 28.1m a year to 36.1 million.
Residential care fees today averaged £33,000 a year compared to £27,400 five years ago but pensions had not risen accordingly. “There’s a huge impossible gap,” she added, hence the need to achieve and sustain good health for as long as possible.
Baroness Greengross cited various examples from around the country, of projects and measures aimed at attaining this. These could range from simple measures - such as Hull’s decision to give out relatively cheap devices and adaptations such as higher toilet seats or hand rails immediately, without waiting for bureaucratic clearance so that occupational therapists were freed to attend to those who needed more complex help - to the sophisticated, such as the imminent opening of first A and E unit for older people at Norwich University Hospital.
Another example of good practice was in Southampton where the creation of a consultant geriatrician’s post to support the community rehabilitation team had led to a 14 per cent reduction in delays of transfers of care, a six per cent reduction in injurious falls and a seven per cent reduction in admissions for over 65s.
A similar multi-speciality community provider in Hampshire called Better Local Care comprised a partnership of GPs, NHS providers and commissioners, Hampshire County Council and a number of local community, voluntary and charity organisations.
Other important factors in healthy ageing included an increasing focus on education, advice and guidance for the prevention of illness, encouraging older people to take exercise, supporting them to manage their own health, helping them to stay safe at home, effective use of outpatients clinics for managing long term conditions and good communication across the primary and secondary care interface.
Housing and social networks had a big role. She was a big fan of retirement living with care but such places needed more space for staff and treatments and the people who were trying to create them were in competition with commercial builders who wanted to pack in maximum housing density.
“Perhaps the role of the geriatricians is to look at these areas and where necessary be involved in politics. A lot has changed but there’s a still a lot to do and we want you to be central in making this work.”
Geriatrics in beyond the United Kingdom
One of the suggestions Baroness Greengross made during her address was that we should look at what other countries were doing, which was appropriate as her fellow guest speaker was Dr Roger Wong, clinical professor in geriatric medicine at the University of British Columbia, whose Trevor Howell Guest Lecture was entitled, Improving Acute Care for Older People – Lessons from Canada.
He described several of their systems: the geriatric assessment unit GAU, the geriatric evaluation and management unit, GEMU, the acute geriatric unit AGU, acute care for elders ACE and the senior friendly hospital. GAU and GEMU offered mid to late acute phase or post acute phase care with a broad spectrum of diagnostic and treatment services except for high acuity options. ACE and AGU gave direct emergency room admission with a full spectrum of diagnostic and treatment services including high acuity options. There was also MACE, a round the clock mobile service for patients already known to geriatrics clinics in a hospital to ensure continuity of speciality care on admission.
The principles for the systems were patient centred care, frequent medical review, prepared senior friendly environments, early exercise for rehabilitation and enhanced discharge planning. These could improve patient outcomes, were efficient, could be cost saving or cost neutral and could identify opportunities for improved care but their success required an adequate workforce capacity. Professionals on the team included social workers, dieticians, pharmacists and spiritual care workers as well as doctors, nurses and therapists.
Acute care environments for older people needed adequate and natural lighting, non-glossy flooring, wide hallways and room entrances, wall clocks and calendars, handrails, space for the storage of things like walking aids, easy way finding, the right position and font size of signage, ambient noise management and mobile and wifi technology.
Hospitals of the future, he believed, would integrate care with education and research and provide space to promote wellness. There would be widespread use of technology with wearable devices such as GPS trackers in footwear for patients with dementia who wandered or airbags inside belts which activated automatically if an old person fell.
The first session of the conference had also featured examples of care from abroad, this time from the Netherlands with the opening speaker Prof. Jos Schols, professor of old age medicine at Maastricht University, describing the role of elderly care physicians.
Nursing home care was carried out by multidisciplinary teams employed by the nursing homes themselves. Teams consisted of doctors and nurses, physio-, occupational, recreational and speech therapists, dieticians, psychologists, social and pastoral workers who could be supported by such specialists as hospital geriatricians, neurologists and psychiatrists.
The advantages of a home having its own in-house team included better continuity of care, more frequent and lengthier medical, psychological and paramedical consultations and more proactive and preventive interventions.
“GPs and others from community health services often have inadequate time, affinity or experience to give residents the continuous attention they need. Also, by using their own personnel, nursing homes can achieve logistical and organisational advantages contrary to the situation where the home is visited by many different consulting professionals.
“Professionals employed by the nursing home itself, or working within a closed staff model, seem to be more committed and knowledgeable about long term care practice and more continuously available.”
Moreover nursing home medicine in the Netherlands was now called elderly care medicine, thus recognising it as a distinguished speciality with specific training and experience and giving such physicians an identity and position between the family physician and the hospital geriatrician.
However, although the country was proud of its nursing home traditions, since 2015 there had been moves to reduce the numbers in residential care and postpone the institutionalisation of the frail and disabled people. Ageing in place was EU policy and fitted the preferences of most frail older people. Already, the number of residential or nursing home beds had decreased from 163,000 to 96,000.
The new approach meant elderly care physicians giving more complementary support for community based care. Collaborative models might include advising GPs or working in GP practices one or more days a month, doing home consultations or working with hospital geriatricians or old age psychiatrists. By such means the relevant aspects and benefits of the intramural multidisciplinary team approach could be incorporated into community health care services.
The second speaker, Prof Wilco Achterberg, professor of institutional care and elderly care medicine at Leiden University, said that the Netherlands now had 1,500 nursing home medicine specialists who had undergone a three year training programme.
When the speciality began in the late Eighties, it often attracted ‘burnt out’ doctors who thought it would be an easy option. “We worked hard to find a new generation with the motivation to make a career in this field. Now we have energetic problem solvers who really want to improve quality of life for older people.”
As part of the move towards ageing in place there were also training programmes for family doctors and a course for all medical specialisms. “It aims to change attitudes among those who always want to cure and prolong life at any cost. Some like the course, some don’t get it at all though, and still think operating and giving medicine is the only thing.”
Another innovation had been for academics to liaise with nursing homes to ensure research was relevant.
Tale of two nations
The third talk in the Tale of Two Nations session, itself part of a full day devoted to care homes, was given by BGS President Dr Eileen Burns, consultant geriatrician at Leeds General Infirmary, who recalled that when she first became a consultant she and her colleagues had to fight to get older people into hospital. Ageism was common: 25 per cent of coronary care units, for example, had restrictions on the over 65s; 40 per cent were denied thrombolysis.
The problem now, however, was that there was a high risk of older people not being able to get out of hospital. “This is often because the services they’d need are not available.
The lack of services might have caused the reason for the admission in the first place and then the care needs are increased even more as a result of the stay in hospital,” she said.
“Staying in hospital is bad. If discharge to intermediate care is delayed by only two days a patient can never regain what has been lost. Patients are at risk of deconditioning with loss of mobility, weight loss, increasing frailty and worsening cognition. Ten days of bed rest can mean 12 per cent loss of muscle strength at hip and knee and 14 per cent loss of aerobic capacity. People with dementia are especially at risk of adverse outcomes in hospital.”
A body of evidence was now emerging to support the development of models of care for frail older people in the community. These included support systems for care homes, comprehensive geriatric assessments while a patient was in an acute hospital, remote monitoring of people with long term conditions, improved GP access to specialist expertise, hospital at home projects and the introduction of better tools to measure frailty. “GPs’ new contracts require them to identify frail patients and to offer falls assessment and a medication review,” she added. “This is a tremendous step forward.”
Workforce challenges though, remained significant with not enough geriatricians, community nurses or GPs, as did the financial pressures. “The vast majority of NHS spend is still on hospitals. There’s a need for some pump priming.”
No more policies, thank you
In the following section on commissioning high quality health care, Dr William Roberts, care model lead for NHS England, spelled out the dilemma facing today’s providers. “People are living with conditions of complexity which we have never seen before in history.” We did not need more policies though – there were already 45 active policies - nor necessarily massive new investment at a time of financial pressures. “We need a way of working better with what’s already there,” he said.
Enhanced care in six ‘vanguard’ homes had already shown the importance of a person centred approach, good leadership and collaborative working between all interested parties.
“Everyone wants the silver bullet solution but often the best approach is lots of small things in a coordinated way. You can get very quick benefits, almost overnight results sometimes, which helps with staff satisfaction and staff retention. There are people now who are desperate to do good work and there are often pockets of brilliance but we need to spread and share this learning.”
Sharon Blackburn, policy and communications director for the National Care Forum, then asked members of the audience to put up their hands if they had taken any medication that morning, were living with a long term condition or caring for someone. When lots of hands went up she told them - “and we’re still living in the community.”
It was the same for older people. “Our language often betrays our attitudes: we talk about people ‘ending up’ in a home. But in fact a person has just changed their address, they have same rights to access health and care as you and I.”
The client base was changing. “These are tech savvy baby boomers and they expect professionals to work in their best interests. They have a sense of entitlement and are more aware of their consumer rights. Nowadays we don’t have people who just accept what the doctor or the nurses say: they are often as informed as they can possibly be and they will be challenging you and me.”
Exercise, the best medicine
Another speaker who asked for audience participation was Prof Dawn Skelton, professor of ageing and health at Glasgow Caledonian University, who asked members to fold their arms and stand up. She then asked them to stand up using only one leg which, of course, proved much more difficult. “But that’s how an older person who’s put on a bit of weight or who’s maybe lost half their strength, might feel.”
She also asked them to balance on one leg. Anyone who could not do it for a minimum of 30 seconds needed balance training; Prof Skelton herself can now do it for ten minutes.
The tasks were an attention grabbing way into her talk on the opportunities and challenges for physical activity interventions for older people living with frailty, defined as a loss of physiological reserve as a result of time, disease and dis-use.
It was important firstly, she said, to distinguish between physical activity which was any bodily movement that expended energy and exercise which was characterised by planned and purposeful training of the components of physical fitness, was planned, structured and repetitive. It aimed to achieve skills and outcomes.
“Exercise is one of the most frequently prescribed therapies for both health and disease so you should treat it as a drug. As with any medicine the important factors are dosage, of both volume and intensity, frequency of administration, i.e. the number of sessions per week, type, contra-indications and side effects. You should start with a minimum effective dose and titrate upwards.”
The good news was that it was never too late to exercise. A 12 week strength training programme in nursing home residents aged 90 and above had doubled their leg strength. A group of over 75 year-olds had rejuvenated 20 years of lost strength in 12 weeks of seated strength exercise. A high intensity functional exercise project for care home residents with dementia, also for 12 weeks, improved strength, balance and activities of daily living. Other studies had shown exercise had increased muscle mass and strength for sarcopenia patients and a reduction in falls after a highly challenging balance training project of more than three hours a week for another cohort.
The minimum requirement for any exercise to be effective was 50 hours or more but support and encouragement were also essential. Successful strategies included goal setting, self monitoring, overcoming lapses and relapses, educating participants and highlighting achievements. “Often we don’t push older people hard enough but they don't have many years ahead so you need to get results quickly.”
It was important too, to encourage an active lifestyle beyond rehabilitation and condition specific programmes and to discourage sedentary behaviour: the over 65s typically sat for ten and a half hours a day while care home residents spent 80 per cent of their day sitting. Being sedentary could lead to musculo-skeletal pain, higher plasma glucose, higher BMI and waist-hip ratio, higher cholesterol, reduced muscle strength and reduced bone density, all of which could affect quality of life and social engagement.
“All contacts with older people need to reinforce the sit less, move more message,” added Prof. Skelton.”I tell patients if you avoid activities that make you feel wobbly you will get more wobbly. It’s use it or lose it. We need to stop wrapping older people in cotton wool but we need to explain to them why we’re doing something. So emphasise the benefits. You can maintain your independence, play with your grandchildren, live life to the full. Strong muscles fight infection, protect your joints and bones, protect your brains and your memory and help you stay warm – so you might even save on your electricity bill.”
Prof Skelton, who had been presented with the Majory Warren lifetime achievement award at the start of the conference was the keynote speaker following a workshop addressing common problems in movement and posture.
Seventy and going strong
The meeting at ExCel in London which marked the 70th anniversary of the BGS was the biggest ever with nearly a thousand attendees including visitors from 24 countries and many sessions were fully booked.
It featured a number of firsts, the most eye-catching of which was The Fringe (see box opposite).
The initiatives demonstrated during The Fringe could be a way of counteracting the widespread depression and loneliness experienced by older people, as highlighted in a session devoted to the problem. There were ten million people over 65 in England and in every thousand, 250 would have a mental illness of which 135 would have depression, said Prof Sube Banerjee, professor of dementia at Brighton and Sussex Medical School.
The problem of loneliness and depression
Such mental disorders in older people reduced quality of life, increased the use of health and social care facilities and were associated with a range of adverse outcomes especially if occurring with physical disorders. Depression in dementia was particularly problematic: the former may have been there for five or ten years before the diagnosis of the latter. “In some individuals, depression may be a subtle sign of neuro-degeneration,” he added. “But being sad and depressed is also a reasonable reaction to the damage to the brain from Alzheimer’s or other forms of dementia.”
Not everything which looked like depression necessarily was, and there were also several causes of the disorder so it was important to distinguish them to know which might benefit from anti-depressants and which from therapies.
Eighty five per cent of older people with depression received no help from the NHS, the next speaker Prof Alistair Burns, National Clinical Director for dementia at the University of Manchester, told the meeting. And when they did they were six times as likely as younger people to be on medication. They should instead, he urged, have more access to psychological therapies because in fact older people often recovered more quickly than the younger generation.
Loneliness - a good definition of which, he said, was the difference between the contacts you had and the contacts you wanted - was a major problem for older people. Eight and a half per cent of older people said they felt lonely often or always, 1.76 per cent had not had a conversation with friends or family for a month and nearly a third said television was their main form of company.
“Loneliness can increase the risk of premature death by a quarter; it can be as harmful as smoking 15 cigarettes a day.”
Sometimes, however, there is a simple and charming solution as demonstrated by the Henpower scheme which provides chickens as anti-depressants. The scheme was launched after carers discovered that a man with dementia who was constantly shouting women’s names was in fact shouting the names of his chickens. Provided with six and the support to care for them, he was transformed.
Chronic pain in older people was the subject of the meeting’s last afternoon. The problem affects 62 per cent of those over 75. Many of the diseases which cause it, such as diabetes and arthritis, increase with age and many of its risk factors such as reduced physical activity, co-morbidities and reduced social networks are associated with ageing.
An example was presented, of how innovative technological solutions might help. The Chatbot project was an ‘interactive clinical expert’, available via PC, tablet or mobile, which enabled people over 65 to self manage their condition by engaging in a conversation with the device, which then led to suggestions based on algorithms for medication or exercise based treatment. The data could also be fed back in real time to healthcare professionals.
Other sessions included ones on frailty and sarcopenia, movement disorders, gastro-intestinal disorders, cardiac disease, teaching and training including e-learning, drugs and prescribing, respiratory problems and foot disorders. The latter delivered by Mark Davies, consultant orthopaedic surgeon at the London Foot and Ankle Centre, featured the most dramatic visuals of the meeting, some of which were shocking enough to make the audience gasp.
The photos illustrated the many problems older feet are prone to, including corns and calluses, fractures, osteoarthritis, metatarsalgia, problems with ligaments, joints and tendons and the diseases and conditions affecting toenails. “These can be extremely painful - never underestimate the misery they can cause”.
Although foot disorders were widespread among older people, much could be done by chiropody, physiotherapy, orthotics and ultimately surgery. “Making the right decisions is essential to help maintain mobility and independence as their reserve tanks are on low,” he said. “My personal approach is that whatever the affliction there is an optimum treatment. Good podiatry is essential for most older people. Modern surgery has a lot to offer older people and they should not be denied the opportunity to discuss this option. The elderly are human beings with more wisdom and life experience than anyone else. As doctors it is a privilege to look after and help these people”.
There were 142 posters and four sponsored symposia: one on nocturia and three on Parkinson’s disease – one on the use of Safinamide sponsored by Profile Pharma, another on improving care and referral for patients with advanced PD sponsored by Abbvie and a third on COMT inhibition sponsored by Bial.
Social activities including early morning runs, a guided walking tour of the area, a drinks reception on the first evening and on the Thursday evening, in a break with tradition, not a gala dinner but a more informal get-together with a finger buffet of locally sourced food and an evening of talks, music and dancing including live jazz, another performance by the flash choir and a silent disco.