The Evolution of Geriatric Medicine in the UK Are there any lessons by yaohongm

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									 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

 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
 And the role of the BGS (founded
               1947)
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

 “that branch of internal medicine which
  deals with the prevention, diagnosis and
  treatment of diseases specific to old age”.
Marjory Warren – “the mother of
       British Geriatrics”
                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 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
 “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
‘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?
 “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
Some other early pioneers…
       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
             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.
   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


 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)
    “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 from this pioneering phase
  Adoption of change in systems (After Gladwell
              M The Tipping Point)
                Tip


              KOLs



Enthusiasts


   Category     %                                       Characteristics
            Chasm
 Innovators     2.5         Venturesome –– Tolerance for uncertainty
 Early               13.5   Opinion leaders – Integrated, – Judicious and Successful
 adopters
 Early               34.0   Deliberate – Interconnected with peers – Just ahead of average
 majority
 Late                34.0   Sceptical – Driven by economics and social norms – Low tolerance for
 majority                   uncertainty
 Laggards            16.0   Traditional – isolated – Suspicious –
         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 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)
II: How geriatrics evolved in
 the UK from 1947 to 1977
     The “Geriatric Giants” – (just what
         Warren described 30 years earlier)
Adapted from
Isaacs B* The                       Immobility
Challenge of           Confusion
Ageing 1982. *
Pioneer of stroke                                Pressure
units                                             sores
                    Falls
                            Geriatric Giants

                                                 Vision
                                                 Hearing
                    Depression
                                 Incontinence
 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..
 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)
 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.
 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…
   Recommendations of Royal College Physicians
 (1977) working party on medical care of the elderly
                  things have changed 30 years on!)
 (Note how little and geriatric facilities to be integrated.
 General medical

 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.
III: Key developments 1977-
            2007
     Key Services pioneered before 1977 and
              expanded 1977-2007
   MDT case conference.

   Geriatric day hospital.
                                       But
   Domiciliary visits requested by    Geriatrics more and more
    GP
                                        hospital based
   Community geriatrics.              Only 14% consultants with
   Outreach clinics in general         dedicated community or
    practitioner surgeries.             long stay care involvement
   Old age psychiatry.                And increasingly involved
                                        in acute general internal
   Ortho-geriatric liaison.            medicine
   Stroke rehabilitation units and    Stroke becoming a
    services.                           separate speciality with
   Specialty clinics—for example,      more acute focus
    falls, parkinsonism, stroke.

   Rapid assessment clinics.
                         Current NHS structure
                              58.5 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
                                                             Regulation
“star ratings” for
                                                             of Quality
Primary and
                                                             By
Secondary
                                                             HealthCare
Care. Quality
                                                             Commission
and Outcomes
                                                             , complaints
Framework
                                                             procedure,
(QOF) in GP
                                                             National
contract
                                                             Patient
                                                             Safety
     Local Social Services. Provide assessment, home         Agency
     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
Total UK health expenditure
  Health expenditure (developed nations)
Country         % GDP on health   % Change 1997-
                                  2003 total spend
Spain           7.6               36.8%
UK              7.7               36.6%
New Zealand     8.5               36.5%
Italy           8.5               27.3%
Denmark         8.8               16.6%
Netherlands     9.1               27%
France          9.7               28%
Germany         10.9              26.4%
United States   14.6              40.1%
       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
 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
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
   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
 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?

   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 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 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
IV: UK geriatrics and the BGS
           in 2007
       Where are we now?
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
 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?
 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?
Not so simple….
V: The obstacles in our way

     Threats, challenges or
         opportunities?
       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
 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
 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.
                    Roger Dobson
Doctors rank myocardial infarction as most "prestigious"
           disease and fibromyalgia as least
                       BMJ, 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."
   Meyrowitz J (1985) No Sense of Place: The
             impact of electronic
  media 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         My mother (again and
  2006                       again!)
 “How do we convince       “David. I don’t
  all our colleagues in      understand why there
  Taiwan of the need for     needs to be a separate
  geriatrics and help        speciality for older
  them understand what       people. Why couldn’t
  we do?”                    you be a proper
                             doctor?”
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
 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
VI: Convincing colleagues,
 commissioners (and older
people) that we are needed
  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
   “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....”
Argument 1: DEMOGRAPHICS: 1901:
          57,000 >65 years
          2001: 8.1 Million
Source: D Wanless Report 2006
   Argument 2: LONG TERM
CONDITIONS (people now live with
            them)

  AGE      0        1                >2

  18-44   75%      18%               7%

  45-64   45%      30%               25%

  > 65    20%      28%               52%




                         NHIS 2000
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.
 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
“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
Fried 1999
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
High users of hospitals have overlap
of physical and social vulnerabilities
1. Mobility         Residential   Nursing
Ambulant            40%           18%
With Assistance     43%           28%
Totally Dependent 16%             53%
2. Mental State                             UK National
Normal              31%           19%       Care Home
Confused/Forgetfu   60%           65%       Census
l
                                            Bowman et al
Challenging         11%           23%
                                            Age Ageing
Depressed/Agitate   12%           21%
d                                           2004
3. Continence
Continent           53%           20%
Urinary Only        24%           19%
Faecal Only         1%            1%
Both                21%           60%
             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”
 Argument 5: Growing EVIDENCE-
  BASE for effective interventions
 For example…
 Comprehensive geriatric assessment for older hospital
                           patients
      systematic review and meta-analysis G Ellis, P
        Langhorne British Medical Bulletin 2005 71(1)
 In-patient comprehensive geriatric assessment (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
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)
 “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.

 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
 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
 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
 Harari D et al The older persons' assessment and liaison
   team ‘OPAL’: evaluation of comprehensive geriatric
          assessment in acute medical inpatients
                    Age 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’).
     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
 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?)
 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.
   We still have a long way to go.
        Some examples…
   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)
 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)
 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)
 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.”
 VIII: So can you learn
anything from us at all?
     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
The Taiwanese Exton Smith,
   Warren and Irvine??
       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
 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
 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

 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
 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
Xie Xie Nimen

								
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