Healthier for longer: How healthcare professionals can support older people
Setting the scene: The prevention agenda
Prevention is about helping people stay healthy, happy and independent for as long as possible. This means reducing the chances of problems from arising in the first place and, when they do, supporting people to manage them as effectively as possible. Prevention is as important at seventy years old as it is at age seven.1
Prevention is, and should be, the cornerstone of geriatric medicine. So much of what geriatricians, nurses, GPs and allied health professionals working with older people do is aimed at achieving better health outcomes for their patients, allowing them to stay well, remain independent, stay out of hospital and return home as quickly as possible when they are admitted to hospital.
We all of us have the potential to avoid starting, or stop smoking, moderate our alcohol intake, become more physically active, engage in more cognitively stimulating activities, and adopt a healthier, more balanced diet. All of these changes have the potential to improve brain health.2
A person’s changing needs should not be a barrier to maintaining or improving health and being able to continue to do the things that they value.3
The focus on healthy ageing is not confined to the UK – the World Health Organization (WHO) has declared 2020-2030 as the ‘Decade of Healthy Ageing.’ As populations around the world are ageing, WHO are aiming to ensure that the lives of older people, their families and their communities are improved, regardless of where they live.4
..the extent of the opportunities that arise from increasing longevity will be heavily dependent on one key factor – the health of these older populations. If people are experiencing these extra years in good health and live in a supportive environment, their ability to do the things they value will have few limits. However, if these added years are dominated by rapid declines in physical and mental capacity, the implications for older people and for society as a whole are much more negative. Ensuring the best possible health in older age is therefore crucial if we are to achieve sustainable development.5
- Lifestyle factors (such as physical activity, smoking and alcohol)
- The basics of daily living (such as sleep and eye health); and
- Medical interventions (such as polypharmacy and perioperative care).
Lifestyle changes: It’s never too early and it’s never too late
I believe that if physical activity was a drug it would be classed as a wonder drug, which is why I would encourage everyone to get up and get active.8
When it comes to ensuring good physical and mental health throughout one’s lifetime, medical experts are unanimous on the most effective actions one can take: don’t smoke, consume alcohol in moderation (or not at all), take regular physical activity and maintain a healthy weight.
Get up, get active: Physical activity
Physical activity plays a changing role in the lives of older adults, as for some it becomes more about the maintenance of independence and the management of symptoms of disease, rather than primary disease prevention. There is enough knowledge of the benefits associated with physical activity in older adults to categorically state that they outweigh the risks.13
Exercise can improve physical performance and reduce frailty: exercise in frail older people is indeed effective and relatively safe, and may reverse frailty while sedentary lifestyle is a risk factor.16
The [CMO] guidance states that all adults should aim to be active every day. This should include muscle-strengthening activity – such as exercising with weights, yoga or carrying heavy shopping – on at least 2 days a week. These types of activity are particularly important for people in or approaching older life.This is also the case for balance exercises, which are recommended twice a week for older people at risk of falls. Yet rates of strength and balance activity are particularly low, with just 1 in 4 women (and 1 in 3 men) meeting the recommended guidelines.19
Hospitals are designed for patients sitting in bed. Many lack, for example, dining areas where those who can shuffle about can sit down for a meal. Space between beds is often too tight for walking frames. Helping patients change into their own clothes every day takes staff more time than business as usual.22
Physical activity is defined as any bodily movement produced by skeletal muscles that requires energy expenditure.25
- Moving – standing up from the chair several times a day, moving in bed, brushing teeth, and washing face.
- Moving more often – walking to the dining room each meal time, walking to rooms to collect an item.
- Moving, regularly and frequently – going outside, setting the table for meals, sorting laundry, feeding the birds and doing meaningful and purposeful activity.
Frailer older adults are those who are identified as being frail or have very low physical or cognitive function, perhaps because of chronic disease such as arthritis, dementia or advanced old age itself. Any increase in the volume and frequency of light activities, and any reduction in sedentary behaviour, is a place to start and contributes towards health. For this group, more strenuous activities are less likely to be feasible. A programme of activities could focus instead on reducing sedentary behaviour and engaging in regular sit-to-stand exercise and short walks, stair climbing, embedding strength and balance activities into everyday life tasks, and increasing the duration of walking, rather than concentrating on intensity.13
Simple physical activity has been found to have a beneficial impact in older adults with depression and is associated with a 20-30% reduction in risk of depressive illness.15
Case study: Southampton Mobility Volunteer (SoMoVe™) study
The SoMoVe™ study looked into whether assistance with early mobilisation could be provided by volunteers, thus ensuring that patients are supported to be mobile and freeing up the time of healthcare staff, particularly nursing staff. Findings from this study indicate that this intervention was well received by patients, appreciated by staff members and showed signs of improvement in physical activity levels. However, the researchers identified that the busy clinical environment and lack of awareness of the intervention among staff were barriers.24
"I think it’s a matter of keeping the body mobile which is the important thing. I’ve been in hospital now six times with pneumonia and fortunately, and luckily for me, I’m physically fit I can get out of bed every day. Yeah, so to get somebody mobile I think is half the way to getting them better."
"Would I have done it if he had not have come in? I might not have done. It is having the volunteers; they encourage you to have a go. I think the more chances patients are given for activity I think they will all get well quicker. No doubt about it. I feel good now, and I want [to] get home. So yeah. I think mobility is a very important thing for everybody."
"I consider them as part of the team. They’re an asset to the team. Anyone who comes in and provides that extra bit of service, it’s a good thing... Like I said, talking about time before, we should have time, but we haven’t, and that’s the role they’ve been playing, which is a very vital support to us."
Not too late to quit: Smoking
The cigarette is the deadliest artefact in the history of human civilisation.27
Stopping smoking in your seventies is still one of the best things you can do to improve your health, your attractiveness and your wellbeing in your eighties and nineties.31
There is strong evidence that smoking increases the risk of developing dementia. Current smokers, when compared to people who have never smoked, are more likely to develop Alzheimer’s disease and may also be more likely to develop other types of dementia. However ex-smokers have been found to have a similar risk of all types of dementia to people who have never smoked.2
This is an encouraging finding for dementia prevention, suggesting, as with other adverse impacts of smoking, that the increased risk of dementia can be avoided by quitting smoking.32
Alcohol in later life
Alcohol is the third leading risk factor for death and disability after smoking and high blood pressure. Alcohol is a legal, socially acceptable drug which is seen as an integral part of Scottish life; used to celebrate, commiserate and socialise. It’s also a toxic substance that can create dependence and causes serious health and social problems. Drinking too much, too often, increases the risk of cancer and liver disease, being involved in an accident, being a victim or perpetrator of crime, experiencing family breakdown, and losing employment.33
The ageing population means that, far from diminishing, the problems of alcohol misuse in older people are set to rise, especially when combined with the drinking patterns that younger adults of today are adopting, and which they are likely to continue into their older years.35
Excessive alcohol consumption over a lengthy period can lead to brain damage, and may increase your risk of developing dementia. However, drinking alcohol in moderation has not been conclusively linked to an increased dementia risk, nor has it been shown to offer significant protection against developing dementia. As such, people who do not currently drink alcohol should not be encouraged to start as a way to reduce dementia risk. Conversely, those who drink alcohol within the recommended guidelines are not advised to stop on the grounds of reducing the risk of dementia, although cutting back on alcohol may bring other health benefits.37
Whatever a ‘safe’ ‘recommended’ limit, ‘sensible’, ‘low’ risk or at an ‘acceptable’ risk of consumption is, this will differ from individual to individual. The UK alcohol guidelines of 14 units a week for both men and women may still be too generous for older people. Vigilance is needed due to the possibility of interactions with prescribed and over-the- counter medications, as well as comorbid disorders including suicidal risk. Physiological changes related to ageing may make alcohol consumption much more risky than in younger adults. There are those who would argue that for some, particularly older, individuals with physical and mental health comorbid disorders, there are no ‘safe limits’ for alcohol consumption.39
Getting the basics right
Addressing the basics: The voluntary sector
The ongoing workforce crisis across health and social care means doctors, nurses and allied health professionals often do not have the time to focus on non-health issues. The NHS and social care must look to alternative models of provision, such as using volunteers and services provided by local and national charities, to ensure that older people are empowered to live independently and age well. In this report, we have touched upon a few examples of services provided by charities or where the NHS has worked in partnership with volunteers. We have however barely scratched the surface – many local and national charities provide services to support people to stay healthier for longer and healthcare professionals should look to these organisations to provide support.
Eating and drinking
In 2011/12, malnutrition was estimated to cost £19.6bn in health and social care services in England alone, representing approximately 15% of overall health expenditure. It is likely to have risen considerably in the years since then. On average, it costs £7,408 per year to care for a malnourished patient, compared to £2,155 for a well-nourished patient.43
Research has found that there is a general reduction in thirst sensation with age, meaning that many people are unaware that they may need to drink more fluids. Medication can prevent absorption of water into the body or in the case of diuretics act to remove excess water compounding the problem. For those with dementia, one of the symptoms of cognitive impairment is a reduction in an individuals’ ability to recognise that they are thirsty; putting this group at a significantly higher risk of dehydration. Related to this is that those older people who are dependent on others for their care, whether living in a care home or independently, rely entirely on others to remembers to offer and provide access to fluids regularly.45
Not much change occurs after your adult teeth have arrived. The teeth do not produce new cells, but nor are they affected much by the process of ageing because there is little metabolism or cell division taking place. It is amazing that we still have teeth at the age of 70; it is like having a china dinner service for sixty years. And the teeth, like a dinner service, come in for some pretty rough handling.31
Those with dementia can experience changes in behaviour. The loss of interest and ability to complete everyday tasks such as tooth brushing can cause rapid development of dental decay (caries) and gum (periodontal) disease. Many people may have heavily treated teeth (fillings, crowns, bridges and implants), which need increasing care with age. People with mild to late stage dementia may develop reflexes that make tooth brushing difficult, such as closing their lips, clenching their teeth, biting and moving their head.50
Addressing the basics: The role of social prescribing
GPs and other healthcare professionals can refer people to non-medical services through a programme called ‘social prescribing.’ Social prescribing is coordinated by ‘link workers’ who will work with people to identify their needs and connect them to local groups and other support services. The NHS Long Term Plan emphasises the importance of social prescribing and states that by 2023/24, over 900,000 in England people will have been referred to social prescribing schemes.7
Social prescribing is often referred to as a remedy for loneliness and social isolation. However, it is important to remember that social prescribing can also be used to help people to find practical support for things that may be worrying them. An Age UK report refers to case studies of people for whom social prescribing helped them with finding a reliable tradesperson, help with the garden or financial advice.57 There is potential for social prescribing to be utilised to great effect in helping older people to cope with daily living and to live independently.
Ears, feet and sleep
Many inpatients are wearing footwear with insufficient structure to promote optimal stability or gait. There are discrepancies between perceptions and practice. Providing safe footwear for use in hospital is potentially a low technology resource-efficient way to promote patient safety in older patients.52
Many medicines come with the risk of harmful side-effects, or adverse drug reactions. In older people the most common include nausea, dizziness, loss of appetite, low mood, weight loss, muscle weakness and delirium. Over a six month period, over three quarters of people over the age of 70 will have an adverse drug reaction. This can seriously impact on older people’s quality of life and ability to live well. The more medicines they take, the more likely they are to experience harmful side-effects in the first place, as well as being more likely to experience many of them at the same time.57
The cumulative side-effects of multiple medications, such as dizziness, muscle weakness and balance problems all make a major contribution to this risk. Nearly 1,000 older people a day are admitted to hospital because of falls, and their chance of falling again if they are over 65 goes up by 14% for every extra medicine they take over the first four.57
Case study: POPS at Guy’s and St Thomas’ London
Established in 2003, the proactive care of older people undergoing surgery (POPS) team at Guy’s and St Thomas’ is the first of its kind in the UK. The POPS team looks after older, complex patients undergoing emergency or elective surgery and is recognised locally and nationally for quality, innovation and clinical effectiveness. The team assess patients pre-operatively with the aim of reducing postoperative problems and ensuring a safe and effective discharge from hospital. The team can also give patients advice on aids and strategies to help with independence and speak to social services on behalf of patients.61 This model has been replicated in other services across the country.
- Care at every contact
You have a unique role in the lives of your patients and every touchpoint of care is a potential opportunity to help people to engage in their own health and work with you to improve it.
- Cover the basics
Be aware of the basics of compassionate, practical care, remembering older people’s need to be able to see, hear, eat, drink and sleep well even if other more complex health issues are being addressed.
- Consider the whole person
Healthcare issues may not be the only or even the most pressing concern for a patient. Ask what matters to them and how they can be supported.
- Communicate clearly
Tell older people what is going on and how they can help with improving their health, and feed back when you see it happening.
- Collaborate with others
Work with colleagues, nursing and therapy teams, families and the older person themselves to give the best chance of recovery and independence.
Longer lives are one of society’s greatest achievements. We should take pride in the developments in public health and medical treatment that mean we are living longer. With over half of adults expected to be 50 or over by 2035, we must seize the opportunity to enable more people in later life to be happy, healthy and active, and to use their skills, knowledge and experience to benefit the wider community.3
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- Alzheimer’s Disease International (2014)World Alzheimer Report 2014: Dementia and Risk Reduction - An analysis of protective and modifiable factors. Available at: www.alz.co.uk/research/WorldAlzheimerReport2014.pdf (accessed 4 October 2019)
- Public Health England and Centre for Ageing Better (2019) A consensus on healthy ageing. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploa... (accessed 16 October 2019
- World Health Organization, undated. Decade of Healthy Ageing 2020-2030. Available at: /www.who.int/ageing/decade-of-healthy-ageing (accessed 17 October 2019)
- World Health Organization (2017) Global strategy and action plan on ageing and health. Available at: www.who.int/ageing/WHO-GSAP-2017.pdf?ua=1 (accessed 17 October 2019)
- Buck D, Baylis A, Dougall D, Robertson R (2018) A vision for population health: Towards a healthier future. Available at: www.kingsfund.org.uk/sites/default/files/2018-11/A%20vision%20for%20popu... (accessed 30 August 2019)
- NHS England (2019). NHS Long Term Plan. Available at: www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-ve... (accessed 17 October 2019)
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- Alzheimer’s Society (undated). How to reduce your risk of dementia. Available at: www.alzheimers.org.uk/about-dementia/risk-factors-and-prevention/how-red... (accessed 24 September 2019)
- Livingston G, Sommerlad A, Orgeta V, et al. (2017) Dementia prevention, intervention, and care Lancet;390:2673-734
- British Geriatrics Society and Royal College of Psychiatrists (2018) Depression among older people living in care homes: Collaborative approaches to treatment. Available at: www.bgs.org.uk/sites/default/files/content/attachment/2018-09-12/Depress... (accessed 29 October 2019)
- National Institute for Health and Care Excellence(2009). Depression in adults: recognition and management. Available at: www.nice.org.uk/guidance/cg90/resources/depression-in-adults-recognition... (accessed 29 October 2019)
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- National Institute for Health and Care Excellence (2013). Falls in older people: assessing risk and prevention. Available at: www.nice.org.uk/guidance/cg161/resources/falls-in-older-people-assessing... (accessed 4 October 2019)
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- Healthcare Improvement Scotland (2019). SIGN 157 – Risk reduction and management of delirium. Available at: www.sign.ac.uk/assets/sign157.pdf (accessed 16 September 2019)
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