Geriatrics is not just the largest specialty in general medicine - there are currently 1,200 consultant geriatricians in the UK - and the fastest growing, it is also, according to a recent survey led by Dr Sally Briggs, the happiest.

Certainly the 400 plus BGS members who came to the autumn meeting in Harrogate (our return visit to this fine Yorkshire spa town) had plenty to be happy about. As President Jeremy Playfer said: “Ours is a very lively specialty covering many areas. Some specialties have a silo mentality, ‘long and narrow’, but ours has lots of overlapping borders and this conference has reflected that. It has been a wonderful time for exchanging ideas and there has been a great vitality about the discussions. As well as all the opportunities for continuing professional development, it has also been a great chance to catch up with old friends and make new ones. Geriatricians are very mutually supportive”.

As usual, delegates were spoilt for choice among the parallel sessions offered by the scientific programme. It was gratifying to meet up with overseas colleagues from Ireland and the Netherlands, and from as far afield as Iceland, America, New Zealand and Australia. The BGS wishes to encourage more abstract submissions from other countries with a view to providing some interesting “cross pollination”.
 
While the meeting had no less than three reporters trying to cover the hive of activity at this event, we cannot do justice to everybody’s contribution. We hope however, that the following will give a flavour of another excellent event.
 
Trevor Howell Guest Lecture
Doctors who have problems finding enough volunteers for their pet research projects could find Francis Galton a useful role model. In 1899 he persuaded nearly 10,000 visitors to a health exhibition in South Kensington to pay 3d (three old pence) for the privilege of testing their ‘powers of reaction time’. Although Galton was to be commended on his ingenuity it still took subsequent researchers three years of slaving over slide rules in the late 1920s to interpret the data.

This story was just one of many in a fascinating look at the history of falls prevention research given by one of the conference’s keynote speakers, Stephen Lord. Prof Lord, an associate professor at the Prince of Wales Medical Research Institute in Sydney Australia, has been identifying risk factors for falls and evaluating prevention strategies for over 20 years. In the Trevor Howell Guest Lecture, intriguingly entitled ‘Horse hairs, smoke paper, pulleys, slide rules and museums’ he paid tribute to some of his predecessors in the field. As well as Galton’s museum and his heirs’ slide rules, a horse hair stylus was used to measure sensitivity to touch and pulleys and smoke paper (where the subject had a lighted candle on his head and the paper showed up the smoke traces) were two ways of measuring sway. There were similarly inventive devices for assessing visual acuity, hand grip, muscle strength and proprioception, all of which have been known to play a part in predisposing someone to fall since the early 19th century.

The talk, illustrated with wonderful old diagrams and photographs, was a quirky way of looking at a subject of vital importance: a third of older people in Western societies fall. “Falls costs the Australian health service twice as much as road accidents”, he said, a fact having echoes in the UK. For each statistic there is a human as well as an economic cost in pain, fear, loss of confidence and frequently independence.

Prof Lord brought his history of research up to the present day before outlining what he sees as the way forward: greater linkage between assessing the risk factors and intervention. In some cases the risks may be several and require multi-disciplinary approaches. In others they may be relatively straightforward: expediting cataract surgery, for example, or providing strength and balance training through disciplines like Tai Chi. Prof Lord is much intrigued by the fact that old people in South East Asia and Japan have a fall rate half that of the West and may have much to teach us.
 
Benign “Big Brother” 
Geriatrics might deal with the care of the elderly, but there is nothing frail or declining about the specialty itself. On the contrary it is frequently at the cutting edge of  medical, surgical and, increasingly, technological innovation.

An intriguing glimpse into the future was provided by Nicholas Robinson of NHS Direct who asked his audience to imagine ‘smart houses’ which could keep an eye on an older person’s wellbeing. “So it would know if someone wasn’t opening their fridge enough or was moving more slowly,” he said. Devices that check blood pressure or pulse are also becoming more wearable and easier to use. “The challenge now is how to use all this information.”

An instance of how it is already in use was provided at the same ‘telecare’ session by Sally Herne, who runs a home monitoring system in the East End of London. Under this scheme patients with long term conditions are linked to a nursing station from a user-friendly home computer. “It can ask them how they are each day, it can remind them to take their medication, it can show them the effects of their behaviour such as missing meals. It can also be programmed to trigger an alert if there’s a problem.”

Another example of technology being harnessed to serve the elderly was given by Robert Kane, director of Minnesota University’s Centre on Ageing and a man described as ‘one of the great geriatricians of the world.’ In his address ‘How can we improve long term care?’ he outlined an American project where residential care aides were asked to input simple but regular observations on, for example, patients with congestive heart failure. Deviations outside certain parameters would flag up the need for intervention.

Not only did the system help the patients, it also made the carers, many of whom were semi-literate or did not have English as a first language, feel much more involved and hence more likely to stay in the job. In the discussion that followed Prof Kane gave a robust defence to the suggestion this was just another version of form filling. “It’s always difficult to recruit people to do this work and we often end up exploiting an immigrant class or family members. We need to make it as meaningful and satisfying as possible.”

Where have all the old men gone?
Of course new technology is only one route to improving later life. Sometimes the answer lies in more traditional methods. In the very first session of the conference, for instance, ‘Models of primary care for older people’, Prof Chris Drinkwater of Northumbria University spoke of the success of local physical activity programmes such as swimming and walking clubs and the mountaineering expeditions led by a retired policeman. Money spent early in the ageing process, he argued, reaped rewards later. One of the big challenges, however, was to get more men involved: women were still always in the majority.

He also called for an ‘at risk’ register, similar to that for children, for elderly people with a number of problems and for better co-ordination between primary and specialist care. “Basically geriatricians in hospital need to get out more into the community.,”
 
Marjory Warren Lecture
Adverse drug reactions are a common cause of hospital admissions and can be responsible for up to four per cent of bed occupancy. Yet seven out of ten such reactions are probably avoidable. According to a recent study of nearly 19,000 patients, nine per cent could definitely have been avoided, sixty-three per cent, probably.

This stark warning was given by Steve Jackson, professor of clinical gerontology at Guy’s, King’s and St Thomas’s School of Medicine, in his Marjory Warren lecture on the clinical pharmacology of ageing. It was therefore vital for doctors to be aware of the interaction between the physiology of an older body and the drugs prescribed for it. Key changes might include impaired renal or hepatic functions, reduced blood flow and enzyme activity and weakened homeostasis. The increased proportion of fat in the body and the decreased proportion of water have implications for lipid soluble or water soluble drugs. The changes could be further compounded by conditions like cardiac failure or small bowel disease. “Sometimes the sensitivity to drugs is increased with age, sometimes decreased.” It was vital therefore to anticipate problems, to keep a prescription check list, to stick to the evidence, to use the lowest effective dose and to maintain clear communications with GPs. Patients should be involved in the decision making and the burden of tablet taking should be recognised and the difficulties of compliance anticipated. With one disturbing photograph, Prof Jackson summed up how doctors may overlook the sheer practical difficulties of an older person’s life. Unable to remove the top of a child-proof bottle, the old woman had been driven to gnaw through it to reach her medication.
 
Sleep Symposium
Jeremy Playfer played Michael Parkinson to guests Jim Horne, director of Loughborough University’s sleep research centre and Ian Smith, director of thoracic services at Papworth Hospital, in a chat show format symposium on ‘Excessive sleepiness in later life.’ The informal structure led to a wide ranging discussion of the state in which we spend a third of our lives and some fascinating facts about the nature of sleep itself and the various disorders that can first occur or worsen in old age.

According to the experts every older patient should be asked two questions: “Do you have trouble falling asleep or staying asleep? And Are you sleepy in the daytime.” Their answers plus appropriate follow-up questions could help uncover physical and mental health problems quickly. Delegates were also given copies of the Epworth Sleepiness Scale and the Fatigue Severity Scale to help them distinguish between the two states. 

Tinnitus and Deafness
The highslight of this session was the excellent presentation on how modern technology can help older people achieve better hearing through technological advance. Ian Johnstone, Consultant ENT Surgeon with special interest in cochlea implants surgery delivered a take home message that “most people, including older people with deafness should be able to benefit from modern hearing aids through the NHS.

Dr B Ceranic quoted that fifteen per cent of the adult population suffered from tinnitus, the majority of sufferers having organic ear disease, with a small percentage being accounted for with neurological conditions. It is important to recognise that stress, psychological disorders/depression can also produce tinnitus.

Exercise – a new consideration
Dr Molloy from Aberdeen presented a surprise finding on the merits and de-merits of exercise, with his unusual focus on the care giver. He concluded that exercise intervention for heart failure may increase strain on the care giver. Future studies should consider the involvement of informal care givers and the impact of an exercise programme, both on the patient as well as the care giver.

Respiratory Medicine
The session was dedicated to occupational lung disease, presented by Prof S Burge, Midlands Occupational Lung Service. Epithelioma, lung cancer and silicosis and occupational asthma are some examples that were highlighted. Separation of occupational lung disease from concomitant pulmonary pathology in older people can be quite difficult, except in specific situations such as IGE in occupational asthma.

Prof Wells from Royal Brompton Hospital and Imperial College discussed interstitial lung disease with special emphasis on chronic fibrosing alveolitis. HRCT and biopsy is needed in establishing diagnosis. However, CT intervention in older patients can be more difficult. The behaviour of the disease is more important than radiopathological changes and mortality is higher in older people.

Parkinson’s Disease
In an unsually interactive session, Dr Doug MacMahon presented the draft NICE Guidelines for the management of Parkinson’s Disease and canvassed opinion from the audience. This anticipated that NICE Guidance may be delayed although it was expected that the final guidance would be produced by Spring 2006. The audience was invited to access the draft guidance through www.nice.org.uk.

Pain Management
The delegates heard that the American Geriatrics Society has published a 2nd edition of Management of Pain in the Elderly and there is a plan for similar guidelines to be produced by the British Geriatrics Society.

Prof Hanson, President of Danish Geriatrics Society presented a topic of Pain in the Elderly: New Challenges and New Possibilities. Transdermal approach seems to be gaining interest as an alternative option for pain control since NSAID’s and Cox II became disappearing options in the pain management. Professor Hanson stressed that the combination of Tramadol and SSRI should be avoided as this can lead to Serotonin Syndrome.

Asymptomatic Carotid Sinus Hypersentivity is more common in the community than previously realised. This topic was presented by Dr Kerr. Dr Lakhani from Leicester highlighted through his presentation the rule of transcranial doppler assisted carotid sinus massage in the diagnosis of carotid sinus hypersensitivity.

Dr A Rash, SpR from Sheffield, presented the result of randomised control trial of Warfarin and Aspirin for the prevention of Stroke in octogenarian patients with chronic atrial fibrillation. Adjusted dose of Warfarin was significantly better tolerated with fewer side effects compared to Aspirin 300mgs.

Dr Highet, Consultant Dermatologist provided an excellent update on Pomphigoid and its management. High dose steroid still remains the mainstay of treatment for severe disease.

Osteoporosis
Dr Fraser Anderson, from Southampton, outlined the role of calcium and vitamin D in the prevention of Osteoporosis and fractures. It is now well established that Vitamin D supplementation is of benefit in secondary prevention of fractures.

Prof R Eastell, whose specialist area is bone metabolism, from the University of Sheffield, outlined the new drug treatment for Osteoporosis including Ibandronate, Strontium Ranelate and Teriparatite. Ibandronate is the latest of this Bisphosphonates, given to a dose of 150mgs once a month.

Prof Selby from Manchester Royal Infirmary highlighted the role of vertebroplasty and Kyphoplasty in painful vertebral body fracture. Vertebroplasty and Kyphoplasty have been approved by NICE as long as the centre practising this method has access to spinal surgery. It is only for pain refractory to usual treatment. Dr Selby stressed that appropriate case selection is important, infection such as discitis, osteomyelitis must be excluded by MR Scanning.

Posters and Exhibitors
As usual, the siting of the poster display, exhibitors’ stands and food and drink facilities in the same area made for a lively mix. One novelty for anyone feeling the need to unwind the brain for a few minutes, was the chance to try ‘driving’ a Formula One car in the Grand Prix simulator, provided by a blood pressure lowering medication supplier.
 
Response from the two dozen company stands was very positive. Comments included:
“Geriatrics is always one of the busiest departments in any hospital so here we get chance to spend a much better amount of time with the doctors.”
“Members are always very keen to keep abreast of new developments”.
“It’s the chance to put the record straight if prescribers have any concerns.”
“Geriatricians are jacks-of-all-trades so it’s always interesting to talk to them about their multi-faceted approach. For instance, we produce medication for urological problems which a geriatrician might diagnose after someone has first fallen because they were getting up in the middle of the night to go the bathroom.”
“It’s very useful to get feedback from the people who actually prescribe our products.”
 
And the prize goes to…. 
The Norman Exton-Smith prize for best poster was awarded to Dr A Kerr from Southampton University Hospitals for ‘Does admission grip strength predict length of stay in hospitalised older patients?’
 
The Elizabeth Woodford-Williams Prize for best platform presentation went to Dr A Rash for ‘A randomised controlled trial of warfarin and aspirin for stroke prevention in octogenarians with atrial fibrillation.’
 
Dinner
The conference dinner took place in the grand surroundings of the Majestic Hotel. Mellowed by good food washed down with chenin blanc and merlot, the diners were a receptive audience for after-dinner speaker Peter McDonald.

As well as being a consultant general surgeon at Northwick Park and St. Mark’s Hospital in Harrow, Dr McDonald is also a writer and performer and author of the Oxford Dictionary of Medical Quotations. His wry look at the profession provoked much laughter as well as revealing some interesting facts. The highest doctor’s fee in history, for example, seems to have been a Dr Felix’s operation on Louis XlV’s fistula for which he was rewarded with half of Provence. He’d had to practice on four paupers first though.
 
2006 Spring Meeting
The BGS’s Spring meeting 2006 will take place at the Sage in Gateshead, from Wednesday April 5 to Saturday April 8. Presenting an amusing trailer for the event, organiser Janice O’Connell gave members a few handy local phrases including ‘Eeeh man ahmn gannen te the booza’. She was sure, however, that the conference would be too interesting for anyone to want to slip away to the pub. Distinguished guest speakers include Prof Rudi Westendrop from the Netherlands on genes and ageing and Prof Lew Lipsitz from Boston on blood pressure. Social highlights will include dinner at the Hilton and a reception at the Baltic art gallery.

Liz Gill
Freelance Journalist
Prof M Datta-Chaudhuri
Stockport