Transcript The Evolution of Geriatric Medicine in the UK: Are there

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
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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..
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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 coordinated 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
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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
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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)
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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
%
Chasm
Innovators
2.5
Characteristics
Venturesome –– Tolerance for uncertainty
Early
adopters
13.5
Opinion leaders – Integrated, – Judicious and Successful
Early
majority
34.0
Deliberate – Interconnected with peers – Just ahead of average
Late
majority
34.0
Sceptical – Driven by economics and social norms – Low tolerance for
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
Challenge of
Ageing 1982. *
Pioneer of stroke
units
Immobility
Confusion
Pressure
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.
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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 comorbidity 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
(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.
III: Key developments 19772007
Key Services pioneered before 1977 and
expanded 1977-2007
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MDT case conference.
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Geriatric day hospital.
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Domiciliary visits requested by
GP
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Community geriatrics.
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Outreach clinics in general
practitioner surgeries.
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Old age psychiatry.
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Ortho-geriatric liaison.
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Stroke rehabilitation units and
services.
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Specialty clinics—for example,
falls, parkinsonism, stroke.
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Rapid assessment clinics.
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 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
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
“star ratings” for
Primary and
Secondary
Care. Quality
and Outcomes
Framework
(QOF) in GP
contract
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
Regulation
of Quality
By
HealthCare
Commission
, complaints
procedure,
National
Patient
Safety
Agency
Total UK health expenditure
Health expenditure (developed nations)
Country
% GDP on health
% Change 19972003 total spend
Spain
UK
New Zealand
Italy
Denmark
Netherlands
France
Germany
United States
7.6
7.7
8.5
8.5
8.8
9.1
9.7
10.9
14.6
36.8%
36.6%
36.5%
27.3%
16.6%
27%
28%
26.4%
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
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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?
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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 subspecialise 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?
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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
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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
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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
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?”
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
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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)
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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 comorbidity
 …
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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
Normal
31%
19%
Confused/Forgetfu
l
60%
65%
Challenging
11%
23%
Depressed/Agitate
d
12%
21%
Continent
53%
20%
Urinary Only
24%
19%
Faecal Only
1%
1%
Both
21%
60%
3. Continence
UK National
Care Home
Census
Bowman et al
Age Ageing
2004
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 EVIDENCEBASE 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 followup 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 coordination
 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