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The evolution of Geriatric Medicine in the UK: Are there any lessons for Taiwan?. 12 th January 2008 Dr David Oliver Reading University and Royal Berkshire Hospital Secretary, British Geriatrics Society. Outline. I: How Geriatrics and BGS started in the UK II: Evolution 1947 to 1977

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the evolution of geriatric medicine in the uk are there any lessons for taiwan

The evolution of Geriatric Medicine in the UK: Are there any lessons for Taiwan?

12th January 2008

Dr David Oliver

Reading University and Royal Berkshire Hospital

Secretary, British Geriatrics Society

outline
Outline
  • I: How Geriatrics and BGS started in the UK
  • II: Evolution 1947 to 1977
  • III: Key developments from 1977-2007
  • IV: The state of UK geriatrics and the BGS 2007
  • V: Obstacles & threats to our future
  • VI: Why we need geriatrics and how to convince others?
  • VII: Why the UK doesn’t have all the answers – our services are far from perfect!
  • VIII: Possible lessons for Taiwan
      • From our successes in the UK
      • And our mistakes!
i how geriatrics started in the uk

I: How Geriatrics Started in the UK

And the role of the BGS (founded 1947)

ignatz leo nascher 1863 1944 usa
Ignatz Leo Nascher (1863-1944 USA)
  • Invented term “geriatrics”
  • Two ancient Greek words
  • “Geras” (Old-Age)
  • “Iatricos” (Relating to the physician)
  • “There should be a separate speciality to deal with problems of senility”
  • Although conceived and named in US, geriatrics was first fully practiced in UK..
british geriatrics society compendium www bgs org uk
British Geriatrics Society Compendium www.bgs.org.uk
  • “that branch of internal medicine which deals with the prevention, diagnosis and treatment of diseases specific to old age”.
marjory warren
Marjory Warren
  • Medical director West Middlesex Hospital
  • Responsible for 714 bed poor law workhouse infirmary when it merged with the hospital
  • Patients described as “Incontinent, seizures, dementia, bed ridden, elderly sick, unmoved muscles”
  • “For proper care, they require the full facilities of the general hospital”
  • Created specialised geriatric assessment unit – the first in the UK
  • Systematically assessed neglected, bedridden patients
  • Determined capacity to improve
  • Re-mobilised most. & returned many to own homes
  • Pioneer of discharge planning (a revolutionary idea!!)
  • And Comprehensive Geriatric Assessment
marjory warren8
Marjory Warren
  • Reduced beds from 714 to 240 and increased turnover 300%!
  • Spare beds then used for TB/Chest Medicine
  • Gifted advocate, innovator educator, mentor and teacher
  • Attracted interest from health minister when discharge rate reached 25%”!
  • Published 27 papers in the 1940s and 50s on rehabilitation and assessment of frail older people
  • Most famously…
  • Warren MW. Care of chronic sick. A case for treating chronic sick in blocks in a general hospital. BMJ 1943;ii:822–3. BMJ 1943
  • Warren MW. Care of the chronic aged sick. Lancet 1946;i:841–3.
warren s classification of the chronic aged sick 1946 lancet
.Warren’s classification of the chronic aged sick 1946 Lancet
  • “Chronic up-patients” (that is, out of bed).
  • “Chronic continent bedridden patients.”
  • “Chronic incontinent patients.”
  • “Senile, quietly confused, but not noisy or annoying others.”
  • “Senile dements”—”requiring segregation from other patients.”
md thesis the care of the elderly n h nisbet
MD Thesis, The care of the elderly, N.H.Nisbet

‘Dr Warren’s routine was carefully studied, the method of admission, examination, diagnosis and treatment, the return home or transfer to Home or hostel, the careful follow-up, the close contact maintained with the relatives, the help obtained from almoner, physiotherapists, OTs and chiropodist. The metamorphosis of an utterly hopeless helpless patient into an active, energetic and everlastingly grateful one was observed again and again.’

wasn t warren really pioneering comprehensive geriatric assessment
Wasn’t Warren really pioneering…..Comprehensive Geriatric Assessment?
  • “a multi-dimensional, interdisciplinary, diagnostic process to determine the medical, psychological and functional capabilities of a frail older person in order to develop a co-ordinated and integrated plan for treatment and long term follow up”
  • Stuck et al Lancet 1994
  • “Applying CGA especially to patients with frailty, functional impairment and multiple long term conditions is what best defines what we do as geriatricians”
  • Rockwood K Age Ageing 2004
n exton smith lancet 1949
N Exton-Smith (Lancet 1949)
  • Advocated “the speciality of Geriatric Medicine for medical management, rehabilitation and long term care of older people.”
  • UCH (1st geriatric unit in London teaching hospital)
  • Worked with Lord Amulree (later civil servant)
  • First English Professor of Geriatric Medicine
  • Worked with Doreen Norton, the first professor of gerontological nursing (Norton Scale)
  • Earlier discharges created beds for other specialities and high profile attracted students and interest from government
  • Founded first memory clinic
  • Pioneered early ripple mattresses
  • Research interests in previously neglected clinical areas
others pioneers e g
Others Pioneers e.g.
  • Joseph Sheldon
    • 11% older people housebound
    • First described community geriatrics
    • Advocated community physio, home adaptations
    • Foot-care, continence etc to maintain independence
  • George Adams.
    • First Professor of Geriatrics in Belfast.
    • First to teach geriatrics to undergraduates
    • Studied Warren’s work and followed her model to “improve the human wreckage and overcrowded wards” in workhouse infirmaries
    • Opened first purpose built geriatric rehab unit
    • Published in stroke and rehabilitation
others e g
Others e.g.
  • Lionel Cosin
  • General surgeon (war casualties)
  • Originator of the geriatric day hospital (Oxford) 1957
  • Pioneer of orthogeriatrics and rehabilitation..
  • Responsibility for 300 “chronic sick” beds.
  • Admitted patients thought to require “permanent care” after hip fracture
  • Operated then started early rehabilitation with the help of a physiotherapist, and many were discharged.
  • Bobby Irvine
  • Worked in Hastings with orthopaedic surgeon (who recognised his own lack of specialist knowledge)
  • Established world famous orthogeriatric unit widely studied as an example
  • Operated on even the frailest patients
  • Mobilised them
  • “The first step in rehabilitation is the first step”
original aims of the bgs 1947
Original Aims of the BGS 1947
  • Meeting of small number of pioneering practitioners convened by Dr Trevor Howell (former GP and now medical director of Chelsea Pensioners Home –i.e. war veterans)
  • “the relief of suffering and distress amongst the aged and infirm by the improvement of standards of medical care for such persons, the holding of meetings and the publication and distribution of the results of research “
early influence of bgs barton and mulley 2003
Early influence of BGS (Barton and Mulley 2003)
  • “This meeting was to begin a revolution in the delivery of elderly care services.
  • These pioneers persuaded the Minister of Health to appoint more geriatricians as part of the hospital consultant expansion of the new NHS.
  • Following Marjory Warren’s example, frail or disabled patients were to be under the care of a geriatrician and comprehensively assessed by an interdisciplinary team.
  • Those who recovered were discharged home
  • Those who were frail but did not require 24 hour nursing care went to long stay annexes.
  • Patients previously thought to be "senile" or disabled were reassessed, and often found to have modifiable organic disease; many could be rehabilitated.
  • As more older patients returned home, there was more space on the wards, which were repainted and upgraded.”
lessons for taiwan
Lessons for Taiwan?…
  • Pioneers and Innovators
  • From variety of clinical backgrounds (just as in Taiwan) – commitment and interest is what counts
  • Challenging assumptions (“that’s the way we’ve always done things)
  • Challenging ageism/therapeutic nihilism
  • Publishing and publicising
  • Developing evidence base
  • Mentorship, teaching, role models
  • Spreading good practice to other units by example and training
lessons for taiwan21
Lessons for Taiwan?
  • Showing the benefits of geriatrics to the whole system
  • Once people see what you can do they can be “won over” and usually want more
  • Getting politicians and civil servants on board
  • Alliances with other professions and organisations (strength in numbers)
  • Put the patients first in your arguments….(not the profession)
the geriatric giants just what warren described 30 years earlier
The “Geriatric Giants” – (just what Warren described 30 years earlier)

Adapted from Isaacs B* The Challenge of Ageing 1982. * Pioneer of stroke units

Immobility

Confusion

Pressure

sores

Geriatric Giants

Falls

Vision

Hearing

Depression

Incontinence

the 1960s and 1970s expansion
The 1960s and 1970s: expansion
  • Improvements in medical care of patients managed on geriatric units.
  • Rapid increase geriatrician appointments.
  • 4 geriatricians in 1947. 335 by 1977
  • Academic departments established.
  • First UK Professor 1965 Glasgow. (William Ferguson-Anderson)
but not all good still opposition
But not all good. Still opposition..
  • Many general physicians questioned need for separate specialty
  • Considered inferior specialty for third rate doctors who could not “make the grade” elsewhere.
  • Negative, disdainful attitudes from doctors in training
  • Medical students generally not inspired by the image of geriatrics.
key themes of this expansion phase barton and mulley 2003
Key themes of this expansion phase (Barton and Mulley 2003)
  • Awareness of atypical/ non-specific presentation of acute illness in old age.
  • Whole person approach to older people with co-morbidity and complex disability.
  • MDT team working and CGA
  • Central importance of rehab.
  • Recognition of caregivers’ stress; respite care.
  • The teaching of geriatric medicine to medical undergraduates.
slide27
3 models of practice by the 1970s (fuller discussion of pros and cons in BGS compendium at www.bgs.org.uk)
  • (1) Traditional or needs based, where geriatricians take selected referrals from other consultants, with a view to rehabilitation, or, if appropriate, placement in long term care.
  • (2) Age defined care (regardless of patients’ needs) based on an arbitrary age cut off (usually 75 years and over). (e.g. Bagnall et al)
  • (3) Geriatric services fully integrated with general medicine. (e.g. Grimley Evans et al)
  • Advantages and disadvantages to each…
slide28
Recommendations of Royal College Physicians (1977) working party on medical care of the elderly(Note how little things have changed 30 years on!)
  • General medical and geriatric facilities to be integrated.
  • Posts for general physicians with an interest in geriatrics
  • Multidisciplinary approach to elderly care.
  • Undergrad/postgrad training in elderly care for every doctor.
  • Elderly medicine to become component of MRCP syllabus.
  • Increased involvement of general practitioners in the medicine of old age.
  • Local authority residential care review.
  • Review of elderly mental health services.
key services pioneered before 1977 and expanded 1977 2007
MDT case conference.

Geriatric day hospital.

Domiciliary visits requested by GP

Community geriatrics.

Outreach clinics in general practitioner surgeries.

Old age psychiatry.

Ortho-geriatric liaison.

Stroke rehabilitation units and services.

Specialty clinics—for example, falls, parkinsonism, stroke.

Rapid assessment clinics.

But

Geriatrics more and more hospital based

Only 14% consultants with dedicated community or long stay care involvement

And increasingly involved in acute general internal medicine

Stroke becoming a separate speciality with more acute focus

Key Services pioneered before 1977 and expanded 1977-2007
slide31
Current NHS structure58.5 M Pop£ 70 billion expenditure (£8 b drugs, £6 b IT)1 M employees. 35,000 GPs. 34,000 hospital consultants, 350,000 nurses

Performance targets and “star ratings” for Primary and Secondary Care. Quality and Outcomes Framework (QOF) in GP contract

Regulation of Quality By HealthCare Commission, complaints procedure, National Patient Safety Agency

Local Social Services. Provide assessment, home care and long term residential/nursing care (means tested). Funding through local tax (20%) and national government. Elected local political leaders. Regulation by National Commission for Social Care and Inspection (CSCI)

key developments general
Key developments (general)
  • Structural re-organisations of the NHS focus on efficiency, performance and reducing inequality
  • Increase in spending to 8.8% GDP by 2006
  • Introduction of “internal market” and “purchaser-provider split” between primary and secondary care
  • Primary care now receives 70% of resource and commissions services from hospitals
  • NHS Plan with performance targets for hospitals (efficiency, access, waiting times etc)
  • Quality and Outcomes Framework (QOF) for GP contract with incentives to hit targets for screening, prevention, long term conditions
  • Growing involvement of private sector in building hospitals and providing elective treatment
  • Shortening and re-structuring of postgraduate medical training
  • Overhaul of medical research funding and performance assessment
evolution of policy since 1990
Evolution of Policy Since 1990
  • For Older People, key themes have been:
    • Transfer of responsibility (1990 Community Care Act) to local government for social care and closure of NHS Long-stay beds
    • Shifting balance back towards primary care
    • Reducing “inappropriate hospital bed use”
    • Better management of long term conditions
    • Social Vs Medical Care (and funding)
    • Quality and inspection
    • More integrated working between primary and secondary care and social services
    • Resource allocation/rationing
    • (Policies and guidelines for older people/mental health tend to have come with few resources)
nsf for older people 2001 clear targets but no real money or penalties
NSF for Older People 2001 (Clear targets but no real money or penalties)
  • 1:Rooting out age discrimination
  • 2:Promoting person-centred care (including a single assessment process for care records)
  • 3:Intermediate care
  • 4:General hospital care
  • 5:Stroke services
  • 6:Falls and Bone Health services
  • 7:Mental health in older people
  • 8:Promoting health and active life in old age
progress against initial nsf
Progress against initial NSF
  • Increase in provision of complex social care at home
  • More stroke units
  • More falls clinics and services
  • More Intermediate Care places
  • Less overt age discrimination
  • “Spin off” benefits for older people from other targets
  • But services still not “fit for purpose” or “age-proof”
  • Breaches of Dignity and deep-seated negative attitudes to older people still common
  • Skills, training and knowledge lacking
  • General hospital care just as problematic
  • Very few people actually receiving appropriate falls and OP treatment
  • Many people still not getting to stroke units
  • Single assessment process rarely implemented
a new ambition 10 programmes under 3 themes
“ A new ambition” 10 programmes under 3 themes
  • Dignity In Care
    • Dignity in care
    • Dignity at the end of life
  • Joined Up Care
    • Stroke Services
    • Falls and Bone Health
    • Mental Health in Old Age
    • Complex Needs
    • Urgent Care
    • Care Records
  • Healthy Ageing
    • Healthy Ageing
    • Independence, Well Being and Choice
more than an ambition
More than an ambition?
  • No dedicated money
  • No “must do” targets
  • Many competing priorities in the “hierarchy”
  • Little in the GP contract to incentivise them
  • Still ageist attitudes in the system
  • Focus on short term gains, not long term planning
  • “Box-ticking” approach rather than real change?
lessons for taiwan42
Lessons for Taiwan?
  • As the speciality grows you can begin to sub-specialise and expand range of services and outreach into other settings
  • You must expect negative perceptions and attacks and work hard to improve the “image” of geriatrics and “sell” it to potential recruits and to colleagues in other specialities
  • You need to think about the model of service delivery (needs, age, integrated etc) and how it fits with existing local services/facilities
  • Be careful about being sucked into general internal medicine so much that you neglect the frail and the long-term
lessons for taiwan43
Lessons for Taiwan
  • Pointless to have service frameworks and targets with no money, no incentives, non infrastructure
  • Other incentives in the system (some “perverse”) may fight against what you are trying to achieve – you need to battle this
  • No good having “Rolls Royce” services if only a small percentage of people receive them
  • Prevention and primary care matter
  • “Softer” gains around attitudes and care are harder to achieve but vital to the patients’ experience
bgs for full range of our activities please join or use www bgs org uk
BGS…(for full range of our activities please join or use www.bgs.org.uk)
  • Geriatric Medicine is now the second biggest hospital-based speciality in the UK
  • BGS membership 2007
  • 2,500
  • 589 trainees,
  • 1,200 consultants
  • 310 overseas
  • 150 allied professionals
roles of bgs
Roles of BGS
  • Bi-ennial scientific meetings (600 delegates)
  • Age and Ageing (700 submissions per annum)
  • Sections (e.g. falls&bone, stroke, continence, prescribing)
  • Education and training
  • Continuing Professional Development
  • Academic and Research (including grants and fellowships)
  • Policy – produces compendium of good practice
  • National Audits
  • Advice/input to government and medical colleges!
  • Campaigning, influencing and highlighting issues
  • www.bgs.org.uk
how healthy is geriatrics in the uk now
How healthy is geriatrics in the UK now?
  • Strength in numbers?
  • Growing evidence-base for what we do
  • Ageing population
  • Frailty, long term conditions are crucial
  • Other physicians don’t all want complex, frail older patients
  • Current GP performance framework does not incentivise them to look after these patients
  • Getting care of older people right will surely help every part of the system
  • So the future looks good surely?
v the obstacles in our way

V: The obstacles in our way

Threats, challenges or opportunities?

threat 1 systems reform
Threat 1:Systems reform
  • DH want old people out of hospital and in “community”
  • (But to what alternative services?)
  • But UK geriatrics has become largely hospital-based
  • So now we must persuade primary care organisations to buy our services or take over the running of some “intermediate care”
  • Many aren’t interested – despite the evidence-base for CGA etc
  • There is little in the GP performance framework about geriatrics
  • But a perception from some GPs that geriatrics is “easy” and its “what GPs do anyway” .It doesn’t need specialist training or a separate speciality
threats 2 funding and incentives
Threats 2: Funding and incentives
  • Service frameworks around older people not funded
  • Main performance targets for hospitals do not focus on acute/subacute frail complex older patients
  • More around waiting lists and waiting times
  • Payment systems mean that hospitals make money from elective surgery and lose money from acute unscheduled care
  • So older people in beds are generally a “problem” for the system rather than being seen as the main customers!
threats 3 negative attitudes and ignorance
Threats 3:Negative attitudes and ignorance
  • Negative societal and media attitudes to older people
  • Most students, doctors and nurses still say they don’t want to work with old people (though that will be their job!)
  • Negative attitudes to doctors/nurses who work with older people
  • Medical values still favour “high-tech” treatment, curative, individualistic and basic science over…
  • …low tech, long term incurable conditions, health services research and multidisciplinarity
  • Working with dementia, incontinence, falls or frailty isn’t “sexy”
  • Little private practice income in geriatrics
  • Patients with legitimate and treatable medical illness still labelled as having “social admissions” or “acopia” or “bed blocking”
  • Older people themselves often do not wish to be on specialist wards for older people and may not see themselves as old.
  • Many professionals still don’t see the need for a separate speciality
slide53
Roger DobsonDoctors rank myocardial infarction as most "prestigious" disease and fibromyalgia as leastBMJ, Sep 2007; 335: 632 ; doi:1
  • diseases and specialties associated with technologically sophisticated, immediate and invasive procedures in vital organs located in the upper parts of the body are given high prestige scores
  • Respondents were asked to rank 38 diseases as well as 23 specialties on a scale of one to nine. The authors say that the prestige scores for diseases and for specialties were remarkably consistent across the three samples.
  • Myocardial infarction, leukaemia, spleen rupture, brain tumour, and testicular cancer - highest scores by all three groups.
  • "The existence of a prestige rank order of medical specialties has been known for a long time,"
  • They add that disease is a "nexus around which many medical activities are organised, such as categorising patients, planning and allocating work, setting priorities at all levels, pricing services, and teaching and developing medical knowledge.
  • "A widespread, and at the same time tacit, prestige ordering of diseases may influence many understandings and decisions in the medical community and beyond, possibly without the awareness of the decision makers."

especially where the typical patient is young or middle-aged."

In the study, the authors, from the University of Oslo and the University of Science and Technology, Oslo, sent questionnaires to 305 senior doctors, 500 general practitioners, and 490 final

slide54
Meyrowitz J (1985) No Sense of Place: The impact of electronicmedia on social behavior. New York; Oxford: Oxford University Press.
  • ‘Old people today are generally not appreciated as experienced "elders" or possessors of special wisdom.........Old people are respected to the extent that they can behave like young people, that is, to the extent that they remain capable of working, enjoying sex, exercising and taking care of themselves’.
negative perceptions
Derek Chan Taipei 2006

“How do we convince all our colleagues in Taiwan of the need for geriatrics and help them understand what we do?”

My mother (again and again!)

“David. I don’t understand why there needs to be a separate speciality for older people. Why couldn’t you be a proper doctor?”

Negative perceptions
dr felix silverstone quoted in gawande a new yorker 2007
Dr Felix Silverstone, (Quoted in Gawande A New Yorker 2007)
  • “Mainstream doctors are turned off by geriatrics,because they do not have the faculties to cope with the Old Crock. The Old Crock is deaf. The Old Crock has poor vision. The Old Crock’s memory is impaired. With the Old Crock, you have to slow down because he asks you to repeat what you are saying. And the Old Crock doesn’t just have a chief complaint—the Old Crock has fifteen chief complaints. How in the world are you going to cope with all of them? You’re overwhelmed. Besides, he’s had a number of these things for fifty years or so. You’re not going to cure something he’s had for fifty years. He has high blood pressure. He has diabetes. He has arthritis. There’s nothing glamorous about taking care of any of those things.”...
threat 4 education training and academia
Threat 4: Education, Training and Academia
  • BGS survey suggested that in 50% of medical schools, little or no geriatrics being taught
  • Funding structure and performance framework for research makes it hard for academic departments of geriatrics to survive
  • Several professorial units closed or professors not replaced
  • Which weakens position within medical schools
  • Still insufficient geriatric medicine content in postgraduate curriculae
  • And NSF Standard for “all health professionals to receive appropriate training and have appropriate skills” has not happened
the best arguments and the ones to use in taiwan in answer to derek chan s question
The best arguments (and the ones to use in Taiwan – in answer to Derek Chan’s Question)
  • Older people are the main customers of health and social care
  • Demographic change means this will continue
  • So older patients with frailty, multiple long-term conditions and disability, needing CGA multidisciplinary input will continue to be central to health care (not marginal)
  • There is plenty of evidence for interventions
  • If we apply them, both patients and the whole system will benefit so win/win (quality, access, capacity, cost)
  • These might be the right arguments BUT…we have to be more outspoken and unreasonable in making this case
gawande a neurosurgeon the way we age now new yorker april 2007
Gawande ( a neurosurgeon). “The way we age now”. New Yorker April 2007
  • “There is, however, a skill to it, a developed body of professional expertise.”
  • “ Until I visited my hospital’s geriatrics clinic and saw the work that geriatricians do, I did not fully grasp the nature of that expertise”
  • “The job of any doctor…. is to support quality of life, by which he meant two things: as much freedom from the ravages of disease as possible, and the retention of enough function for active engagement”
  • Most doctors treat disease, and figure that the rest will take care of itself. And if it doesn’t—if a patient is becoming infirm and heading toward a nursing home—well, that isn’t really a medical problem, is it?”
  • “To a geriatrician, though, it is a medical problem. People can’t stop the aging of their bodies and minds, but there are ways to make it more manageable, and to avert at least some of the worst effects....”
challenge of long term illness uk
Challenge of long-term illness (UK)
  • 80% GP consultations
  • 80% hospital days
  • 70% admissions
  • 70% health spending
  • 95% spending on 65+ population
  • 10% of inpatients account for 55% bed days and 5% account for 40% of bed days
  • Evercare Pilots, Case Management and Community Matrons…
argument 3 geriatric giants e g
Argument 3: GERIATRIC GIANTS e.g.
  • Falls: 30% of over 65s per annum will fall. Falls are 7th commonest reason for hospital admission and commonest reason for emergency attendance in over 60s
  • Fractures: 1 in 2 women and 1 in 12 men or 200,000 p.a UK.
  • Incontinence: 24% of >65s, 40-60% in institutions
  • Dementia: (e.g. 40% of long term care. 20% emergency admissions >65)
  • Delirium: 11-40% prevalence in hospital >65s (often unrecognised)
  • Stroke: 150,000 per annum. 85% 65, usuall multiple co-morbidity
argument 4 frailty
Argument 4: Frailty

“Frailty is a failure to integrate responses in the face of stress. This is why diseases manifest themselves as the “geriatric giants”….functions …such as staying upright, maintaining balance and walking are more likely to fail, resulting in falls, immobility or delirium”

Rockwood Age Ageing 2004

i.e. Poor Functional Reserve

frailty syndrome epidemiology
Frailty Syndrome Epidemiology
  • 3 or more of 5 criteria
  • 6.7% of community residing elderly
  • 3 year incidence —7%
  • Increases with age: 3%-65; 26% -85-89

Fried L, et al J Gerontol Med Sci 2001: 560: M146-M156

example hip fracture
Example: Hip Fracture
  • 90,000 hip fractures per annum
  • 50% injury admissions and 66% of bed days from injury in the NHS
  • Median Age 81 years
  • Falls, ostepporosis, multiple co-morbidity, cognition, nutrition, confusion, intercurrent illness, polypharmacy
  • Following hip fracture high mortality, morbidity, dependence
  • Are Systems designed around needs?
  • Are orthopaedic surgeons the right people to care for them?
  • Could outcomes be improved?
  • What system would we design in an “ideal world”
slide76
Comprehensive geriatric assessment for older hospital patients systematic review and meta-analysis G Ellis, P Langhorne British Medical Bulletin 2005 71(1)
  • In-patient comprehensivegeriatricassessment (CGA) may reduce short-term mortality, increase the chances of living at home at 1 year and improve physical and cognitive function.
  • 20 RCTs (10 427 participants) of in-patient CGA.
  • Newer data confirm the benefit of in-patient CGA, increasing the chance of patients living at home in the long term.
  • For every 100 patients undergoing CGA, 3 more will be alive and in their own homes compared with usual care [95% confidence interval (CI) 1–6]. Most of the benefit was seen for ward-based management units
  • CGA does not reduce long-term mortality.
  • This evidence should inform future service developments.
langhorne p et al 1993 do stroke units save lives systematic review
Langhorne P et al 1993. Do stroke units save lives? Systematic Review

10 RCTs.

1586 stroke patients were included; 766 were allocated to a stroke unit and 820 to general wards.

The odds ratio (stroke unit vs general wards) for mortality within the first 4 months (median follow-up 3 months) after the stroke was 0.72 (95% CI 0.56-0.92), consistent with a reduction in mortality of 28% (2p < 0.01). This reduction persisted (odds ratio 0.79, 95% CI 0.63-0.99, 2p < 0.05) when calculated for mortality during the first 12 months.

young and inouye bmj 2007 delirium
Young and Inouye BMJ 2007 (Delirium)
  • “studies investigating such interventions in medical patients and those who have had hip fracture have reported significant reductions (of about a third) in incidence of delirium and/or reduced severity and duration of delirium”
falls e g
Falls e.g.
  • Individually targeted, falls 31%
    • Postural hypotension
    • Sedative medications
    • Use of ≥4 medications
    • Transfer skills, grab bars
    • Environmental hazards
    • Gait training, assistive device
    • Balance exercises, exercises against resistance
  • Cost saving in higher risk group (4 of 8 risk factors)

Tinetti ME et al. N Engl J Med 1994;331:821-7

falls
Falls
  • Referred from A & E
  • Clinic based assessment and referral:
    • Postural hypotension
    • Visual acuity
    • Balance
    • Cognition
    • Depression
    • Carotid sinus studies
    • Medication
  • Home safety assessment and advice
  • Falls 61%, cost neutral

Close J et al. Lancet 1999;353:93-7

argument 6 getting treatment right doesn t just benefit patients but whole health system
Argument 6: Getting treatment right doesn’t just benefit patients but whole health system
  • If we can get people to listen to the arguments and respect the evidence
  • Remember the data from Marjory Warren 1946 (714 beds down to 204)?
  • Replicated by Adams in Belfast
  • Or from Dr Bagnall in Leeds 1976 (40% reduction in length of stay for older patients on needs based unit)
  • The benefits for the whole system are just as relevant 60 years on
  • E.g. recent “real-life” examples from St Thomas’ hospital
slide82
Harari D et al The older persons' assessment and liaison team ‘OPAL’: evaluation of comprehensive geriatric assessment in acute medical inpatientsAge Ageing July 2007
  • Setting: urban teaching hospital.
  • Subjects: acute medical inpatients aged 70+ years.
  • Intervention: multidisciplinary CGA screening of all acute medical admissions aged 70+ years leading to (a) rapid transfer to geriatric wards or (b) case-management on general medical wards by Older Persons Assessment and Liaison team (OPAL).
  • Results:pre-OPAL, 0% fallers versus 92% post-OPAL were specifically assessed
  • . Over twice as many patients were transferred to geriatric wards, with mean days from admission to transfer falling from 10 to 3.
  • Mean LOS fell by 4 days post-OPAL.
  • Only the OPAL intervention was associated with LOS (P = 0.023) in multiple linear regression including case-mix variables (e.g. age, function, ‘geriatric giants’).
slide83
Harari D et al Proactive care of older people undergoing surgery (‘POPS’): Designing, embedding, evaluating and funding a comprehensive geriatric assessment service for older elective surgical patients Age Ageing 2007
  • Intervention: multidisciplinary preoperative CGA service with post-operative follow-through (proactive care of older people undergoing surgery [‘POPS’]).
  • Results: Comparison of 2 cohorts of elective orthopaedic patients (pre-POPS vs POPS, N = 54) showed
  • POPS group had fewer post-operative medical complications including pneumonia (20% vs 4% [p = 0.008]) and delirium (19% vs 6% [p = 0.036]),
  • significant improvements in areas reflecting multidisciplinary practice including pressure sores (19% vs 4% [p = 0.028]), poor pain control (30% vs 2% [p<0.001]), delayed mobilisation (28% vs 9% [p = 0.012]) and inappropriate catheter use (20% vs 7% [p = 0.046]).
  • Length of stay was reduced by 4.5 days. There were fewer delayed discharges relating to medical complications (37% vs 13%) or waits for OT assessment or equipment (20% vs 4%).
these are all the right arguments but we have to make sure they are heard and acted upon
These are all the right arguments but we have to make sure they are heard and acted upon
  • Less nice and more unreasonable?
  • Geriatricians tend to have high service values and concern for a neglected group of patients
  • But not always very outspoken
  • We know what the benefits are of geriatrics
  • We know that older people do have special needs
  • And that there is a logical basis and need for our speciality
  • We can define what we do well by how badly we see others doing it.
  • “all progress is achieved by the actions of the unreasonable man” (George Bernard Shaw)
  • [Does this translate to Taiwanese culture?]
and we still need to convince older people themselves how can i make you love me
And we still need to convince older people themselves! (How can I make you love me?)
  • They may not see themselves as frail
  • Or old
  • And may be reluctant to see specialists in elderly care
  • Or be admitted to elderly care wards
  • We have to “sell” it to them in the right way
  • (i.e. more rehabilitation, experts in the conditions they are suffering from, better chance of getting home and staying there etc)
vii why the uk doesn t have all the answers

VII: Why the UK doesn’t have all the answers.

We still have a long way to go. Some examples…

health care commission report caring for dignity 2006
Health Care Commission Report “Caring for Dignity” 2006
  • Negative attitudes towards older people persist
  • Insufficient education and training for staff
  • Routine breaches of dignity e.g.
    • Respect for personhood
    • Communication
    • Confidentiality
    • Privacy
    • Toileting/Continence
    • Nutrition
    • End of life care
stroke from national stroke strategy 2007
Stroke (from national stroke strategy 2007)
  • The chance of dying after a stroke has remained constant at around 24% while the risk of dying after a heart attack has fallen by about 1.5% per annum
  • Around 40,000 people per year have suspected TIA or minor stroke but currently only 35 per cent are seen and investigated in a neurovascular clinic within seven days.
  • Only 12 per cent of hospitals have protocols in place for the rapid referral of those with suspected stroke and less than 50 per cent of hospitals with acute stroke units have access to brain scanning within three hours of admission to hospital.
  • 91% of hospitals now have a stroke unit
  • Although two-thirds of stroke patients are managed on stroke units at some time during their hospital stay, only about 10 per cent of patients are likely to be admitted directly to an acute stroke unit.33
  • 62% of patients were admitted to a stroke unit at some point in their stay, compared to 46% in 2004. 54% spent over half their stay in a stroke unit (40% in 2004).
falls and bone health from rcp audit
Falls and Bone Health (from RCP Audit)
  • 74% hospitals now have part of a service
  • Only 20% Directors Public Health H reports include falls and only 8% fracture rates
  • Only 50% falls services have referral to Osteoporosis Pservices
  • <50% acute trusts had links between casualty and falls services around hip # and fallers
  • Even if admitted <50% have links to OP and falls”
  • Only 1.7 new patients per week/100,000 receive falls or OP assessment
  • Only 40%% all patients with fragility fractures receive any OP assessment or advice or falls assessment
  • Even for people admitted with hip fracture only 50% receive falls assessment or bone health intervention
continence from rcp audit
Continence (from RCP audit)
  • The audit has demonstrated that:
  • • “Where a continence problem is identified, an assessment or management of that problem is not guaranteed.”
  • • “Whilst most of the structures required to provide continence services exist, ,provision of integrated services is variable and incomplete.”
  • “Documentation of continence management is inadequate.”
  • “Management consists predominantly of containment rather than treatment of the problem.”
we certainly don t have all the solutions
We certainly don’t have all the solutions
  • And your health system…
  • Culture and patient expectations
  • System incentives
  • Primary care and social services are different
  • But…
  • You do have a rapidly ageing population
  • You do have state funded health care with means tested social care
  • You have recognised the health challenges of the ageing population
  • You are beginning to train geriatricians of the future
perhaps you can learn
Perhaps you can learn…
  • As much from our mistakes
  • As our successes
  • Lessons for geriatricians
  • Allied professionals
  • Other clinicians in the system
  • Government and Health Service Management
lessons from the uk i
Lessons from the UK I
  • You need champions, campaigners and early opinion leaders.
  • We need to be outspoken, challenging and campaign sometimes. (Geriatricians are usually “too nice” by nature and easily undermined by more powerful “high-tech” specialties)
  • Ally yourself with other interested bodies, charities, and professional groups – strength in numbers
  • Get the ear of government ministers and show them how you can solve some of their problems in the system
lessons from the uk 2
Lessons from the UK 2
  • Expect colleagues in other specialities (and even patients) to be hostile or not convinced. Don’t let it worry you. We know we are right! You just need to sell the benefits
  • Keep emphasising that older frailer people will be the main users of health and social care – not a minority
  • And that getting their care right will benefit the whole system
  • You can be the solution to problems (and to other doctors who don’t really want to look after these patients)
  • Keep emphasising the strong evidence base for much of what we do
  • Grow the evidence base through your own research
  • And keep good enough data to demonstrate the impact of your service
  • When people see what you can do they usually want more of your service
lessons from the uk 3
Lessons from the UK 3
  • Geriatrics is a major part of healthcare so it needs to be a major part of undergraduate and postgraduate training for all adult specialists – you cannot treat everyone
  • You need to be a strong presence in the medical schools
  • So avoid research funding and performance frameworks which prioritise basic science over clinical and health services research
lessons from the uk 4
Lessons from the UK 4
  • You need to think about the model of care for service delivery which makes most sense locally
  • Primary care needs to focus more on the needs of older people
  • Generalists have advantages over super-specialisation for complex patients with multiple illness – patients don’t enjoy being “passed around” specialists with no overall co-ordination
  • But we have to convince patients themselves
  • Finally, there is no point having targets or plans to improve services without the right financial investment and performance frameworks
  • Perverse incentives in the system can make the care of older people worse not better
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