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BGS members were paid a great compliment by an internationally distinguished fellow specialist at this year’s autumn meeting. “You’re better than you know,” Prof Mark Clarfield, chief of geriatrics at Soroka Hospital in Beer-sheva, Israel and adjunct professor at McGill University in Montreal, told them. “If I had to choose between the societies I know best – Britain, Canada, Israel and the U.S. - I’d choose the British any time.”

But Prof Clarfield was not just in Harrogate to praise, but to challenge. His Trevor Howell guest lecture, ‘The perils of prevention in the frail elderly person - a double-edged sword’ was a thought-provoking analysis of the question of when doctors should or should not act.“We know that certain things work to promote health and prevent illness and injury - vaccines, clean water, sterile surgical procedures - but what if it’s the opposite? What if by preventive treatments for elderly people we are simply changing the cause of death? The issue was brought home to him forcefully nearly 30 years ago when, as a GP, he discovered a rectal tumour during a routine examination of an elderly patient. Blood tests, a barium enema and surgery followed, as did almost every post-operative complication.“ He finally climbed out of the hospital bed to drop dead at home. It was three and a half months since my initial examination. That really made me think. In the best case scenario he’d have lived another few years and he’d probably have died of something else before the colon cancer could kill him. But my intervention killed him early.” This was not, stressed Prof Clarfield, a plea to deny anyone timely or appropriate treatment. “ But prevention must always involve weighing the risk/ benefit ratio and that ratio changes unpredictably as people age.” Doctors also had to consider efficacy versus effectiveness. Efficacy was measured in research trials generally on ‘young-ish, healthy-ish’ people. Effectiveness was about how a drug or procedure then performed among the general public –“and there aren’t many such trials”. There were also the dangers of tests producing false positives. An example was PSA tests for prostate cancer in otherwise symptomless men. “This is a disease many people die with, not of. I say it’s like baldness: people die with it because there’s more baldness in older people, but they don’t die of it.” Patting his own pate the professor joked, “God only made a few perfect heads and covered the rest with hair.” Treatments could bring false hopes. “A while ago, women’s groups and the medical establishment were convinced that everyone should be on oestrogen – I was even tempted myself - but we got it wrong and in many cases it did harm.” Similarly, there was little use in an early diagnosis unless there was a cure or effective therapy for the condition. Follow-up tests to screening could be invasive and dangerous and raise anxiety levels. He quoted another doctor who wrote: “conveying risk is like putting a drop of ink in the clear water of a patient’s identity, which can never be quite clear again” and recollected his own father being told he had degenerative disc disease. “ He heard the word ‘degenerative’ and it terrified him. Be really careful what you say. The public cannot understand probabilistic thinking. And because we have limited office time we’re often so busy thinking we should be preventing something in patients, we’re not listening to what really bothers them.” If we weren’t to reach what he dubbed ‘the nightmare vision of Pharmageddon” where medicines produce more ill health than health, and where medical progress does more harm than good, doctors had to look at elderly patients’ life expectancy, at the sensitivity and specificity of a test, its cost effectiveness and its downside. “We have to talk to patients about their preferences and values and not make them crazy and anxious. Good clinical care equals evidence plus judgement.” He ended with another quote: “all screening programmes do harm, some do good as well.”

Like Prof Clarfield, other speakers at the conference used personal experience to give their message extra impact. For example, in the opening session on clinical practice in the modern NHS where one of the recurrent themes was patient safety, Dr Linda Patterson recounted an informal experiment she had carried out at Burnley General Hospital where she is a consultant physician in general and geriatric medicine.“We castigate ourselves when we miss a diagnosis but the majority of errors are not in the diagnostic field but in the implementation. I work in a reasonable unit, we do our best and we work hard and we aren’t bad doctors, but I decided to look at what I saw happening here with my team and my patients over a period of two weeks.” Thirty one incidents were noted, including results not being in the right place, old notes not being available, investigations not done, IV fluids not given, no secretary for three days, and a medication error.“No serious harm came to patients but these incidents caused delays and made for poorer quality of care. If you multiply that by other doctors in other hospitals you get an idea of the scale. We have to recognise that fallibility is part of the human condition and we can’t change that, so we need to look at the systems and work on how we can make them safer by training, for example, or trying to design out problems.”

Culture and attitudes
The speaker who followed her, Dr Tanzeem Raza also put a personal note into his lecture on cultural pitfalls in delivering education and patient care by contrasing some aspects of the two countries he knew best: Pakistan where he was born and brought up, and the UK where he now works as consultant physician and director of medical education at Royal Bournemouth Hospital. The latter role, he said, had made him realise that doctors from different backgrounds often struggled more. A group’s culture – its way of life which includes behaviours, beliefs, values and symbols - affects its attitudes to disease and treatment. He cited the instance of a trainee from Pakistan who had kept failing exams that involved patients. When they observed him they saw he was too assertive and authoritarian because “that’s what he thought a doctor should be.” In contrast to the highly individual, student-centred approach in the West, education in the East was teacher-centred, highly structured, allowed no discussion and failure was a humiliation borne by the whole family. “There is no right way to be human; thinking that your own way is right, is where problems arise,” he added. “Tomorrow’s doctors need to be prepared to be culturally sensitive in their consulations and management methods.”

Revalidation
Another session had kicked off with the stark fact that the NHS kills 40,000 patients a year and that mistakes cost a staggering £2bn. The question of patient safety marches hand in hand with new developments. As one speaker succinctly put it: medicine used to be simple, ineffective and relatively safe; now it is complex, effective and potentially dangerous. Moreover each incident often has three victims: the patient, the family and the medical professional.This theme of patients needing to be protected and doctors kept up to scratch continued during the second half of the first afternoon with the session on revalidation. Robert Slack, consultant ENT surgeon at the Royal United Hospital, Bath and GMC member, gave an insider’s view of the Council which existed, he reminded members, not just to promote safety but to foster the professionalism of doctors and to be independent, fair and effective. He also gave a brief outline of the aims of the current White Paper on relicensure and recertification. He was followed by Dr Ian Starke, consultant physician in acute and geriatric medicine at University Hospital, Lewisham and the CPD and revalidation lead for the Royal College of Physicians (London), who gave the College’s perspective on the issues. The discussion afterwards raised widespread concerns about both the principles and practicalities of the concept.

Donald Rumsfeld and the BGS
Conferences can sometimes make for strange bedfellows. The name of Donald Rumsfeld, for example, is perhaps not the first name that might spring to anyone’s lips during a BGS meeting but Marjory Warren guest lecturer Prof John Potter took the former US Secretary of State’s famous phrase about known knowns and known unknowns and applied it to blood pressure and stroke.After an extensive review of current research the professor of ageing and stroke medicine at the University of East Anglia concluded that what we do know is that anti-hypertensive medication is of benefit in reducing both kinds of stroke although we are less sure about whether this is the case in the over-80s. The unknowns are whether high blood pressure is associated with cognitive impairment, dementia and Alzheimer’s Disease and whether reducing it is of benefit in these conditions.

At the cutting edge
One of the attractions of BGS meetings is the opportunity to hear new thinking on familiar subjects. During the What’s Happening in Academic Geriatric Departments in the UK, for example, the first speaker challenged a widely accepted belief about delirium. “The received wisdom in text books is that although it’s unpleasant it’s not remembered afterwards,” said John Young, head of the Academic Unit of Elderly Care and Rehabilitation Research at Leeds University and Bradford Hospitals. “This is a fallacy. Forty three out of 50 patients in a study who recovered had clear recall of a negative and unpleasant experience.” He put a quote from Ian McEwan’s Atonement on the powerpoint screen which described the feeling of being ‘in the grip of illogical certainties’ and wondered whether the author had had such an experience himself in order to be able to describe it so accurately. A third of delirium was preventable, he declared, but although current studies into blood proteins may help diagnosis in the future, at the moment one had to rely on ‘good old-fashioned bedside medicine’. Earlier he had described the very different symptoms of two patients: one an agitated and twitchy older woman, the second a sleepy, polite elderly man not interested in eating or drinking and inattentive. Both were suffering delirium but the man’s was harder to spot. Protocols being worked out in the USA may be useful here, he added. Colleagues interested in collaborative research into delirium are invited to contact him. In the same session, Prof Margot Gosney, professor of elderly care medicine at the University of Reading, focussed on cancer in older people, particularly colon cancer. “This is a neglected area despite the fact that it affects five per cent of the population and it’s a tragedy that the over- 70s have to request screening because the national programme stops at 69.” Running through investigations and treatments as well as the importance of diet, Prof Gosney was another speaker to use personal experience to emphasise a point. Her own father’s colon cancer, she said, had been picked up by a diligent GP and he was now disease-free. Prof David Stott, professor of geriatric medicine at Glasgow University then gave a succinct summary of the extensive field of cardiovascular prevention and the session ended with an update by Prof Alan Sinclair, the BGS’s director of Continuing Professional Development, who appealed for members to contact him with ideas. CPD should, he said, be a broader concept than just the acquisition of knowledge.

Mild Parkinsonism
Sponsored symposia are a regular event at the meetings and this year there were four: on fractures, diabetes, the management of vertebral compression fractures and the NICE guidelines for Parkinson’s Disease. In another session devoted to PD, both Dr Graeme Macphee, consultant and senior lecturer from the department of medicine for the elderly at Southern General Hospital in Glasgow and Ray Chaudhuri, consultant neurologist from King’s College and University Hospital, Lewisham, covered the difficulty of diagnosing the condition generally and in older people in particular because there is no one specific biomarker and there are frequently other confounding co-morbities. The presence of mild or subtle parkinsonian signs (MPS) is an emerging concept. These signs which include gait disorder, bradykinesia rigidity, tremor and mild parkinsonism become increasingly common with advancing age but significantly exceed the prevelance of PD in age matched populations. MPS may have diverse causes such as age associated basal ganglia pathology, drugs, cerebrovascular disease, and other non PD neurodegenerations such as Alzheimer pathology as well as cases of early PD. A brief review of emerging biomarkers including imaging with techniques such as SPECT scanning, transcranial ultrasound and olfactory testing was rehearsed by Dr Macphee. The take home message however was that the diagnosis of PD remains clinically based on UK Brain Bank criteria although it was emphasised that specialists often use a complex construct of pattern recognition beyond formal diagnostic criteria. Ancillary testing such as DAT scanning may be useful in selected cases but for optimal diagnostic accuracy, early assessment and ongoing review by a specialist will yield best results. Prof Ray Chaudhuri then gave a fascinating review of new management in PD focusing particularly on the challenges of detection and management of non motor symptoms (NMS) such as depression, sleep disorders, urinary symptoms and autonomic problems. These are important since they correlate significantly with good quality of life more than simple motor disability. The use of the NMS Quest screening tool for early detection and optimal clinical management was demonstrated and Prof Chaudhuri reviewed the evidence for earlier drug treatment intervention from the PD Life and TEMPO studies. He also reviewed new drugs such as the transdermal patch of Rotigotine and the intraduodenal infusion of duodopa which may be useful in complex disease.

There was no breakfast symposium this time, on Friday morning which allowed a little more of a lie-in for delegates who had been feasting and dancing the previous evening at the conference dinner. At the dinner there had been a brief report from Peter Crome on the Society’s recent activities and the news that membership was now 2,500. Instead of an after dinner speaker, entertainment came in the form of the Mr Swing band who performed music and songs from the Thirties, Forties and Fifties. Judging by the numbers who took to the dance floor many BGS members have become fans of Strictly Come Dancing.

PEG
Although there was no crack of dawn start on the Friday, members who felt in any way unsteady would have had to steel their nerves for the first item on the Friday programme. This was a video of the insertion of a percutaneous endoscopic gastronomy into a patient’s stomach by Dr Sean Weaver, consultant physican and gastroenterologist at the Royal Bournemouth Hospital, who admitted as he carried out the tricky manoeuvre, “This part is my sweatiest moment”. A PEG is a procedure of last resort: it has a 40 per cent mortality rate in the first seven days and is often largely ineffective but it does sometimes save a patient from starving to death. “Nothing makes me happier than removing one,” said Dr Weaver who in a clinical update on nutrition had reminded his audience of the need to be viligant about the risks. A shocking 40 per cent of hospital patients are malnourished, eight per cent severely, and many lose more weight during their stay. His message was that doctors must use MUST the Malnutrition Universal Screen Tool: patients who scored one were at medium risk and should be monitored; patients who scored two or more were at high risk and should see a nutritionist as soon as possible. In the same session Dr Sally Briggs, specialist registrar in geriatric medicine at Northwest Deanery in Manchester gave an elegant summary of the legal and ethical considerations in artificial feeding, running through the recent court case Burke v. the GMC, the distinction between medical treatment and basic care, the philosophies of Bentham and Kant and the concept of virtue ethics – what would the good doctor do in a particular situation? As well as some of the practicalities of artifical feeding such as the need to set objectives and review the situation after an agreed period, Dr Briggs also stressed the need for more discussion, not just between patients, their families and the medical profession, but in the wider public arena. “This issue is too fundamental to leave to doctors alone. It’s important that these decisions should be subject to moral scrutiny. Nowadays we can almost always get articial food and water into someone but does this show respect for life? Are the benefits outweighed by the burdens? These are not decisions to be made at the end of a patient’s bed on a ward round. Perhaps fittingly, at the end of a session on the importance of nutrition, Dr Briggs went off to feed her new baby who was probably the youngest person ever to come to a BGS conference.

Other clinical updates included sessions on haematology, falls, home care medicine, incontience and dementia. In the latter, neurosurgeon Laurence Watkins from the National Hospital for Neurology and Neurosurgery described the use of shunts to treat normal pressure hydrocephalus, the symptoms of which include gait disturbance, cognitive decline, urinary incontinence, impaired wakefulness, a tendency to fall backwards and postural disturbances. One year on from the operation 76 per cent had better gait, 48 better memory and 58 per cent relief of urinary symptoms. On the whole, he said, doctors should err in favour of the procedure.

Care on the farm
In home care medicine, Professor Tischa van der Cammen presented an entertaining comparison of elder demographics and community care systems between the UK and the Netherlands. With a population of only 16.2 million, 14% of which are aged over 65 years, most older people in the Netherlands stay at home while a large proportion of those who are institutionalised return home later, with the average stay in residential care being just under four years. This may be because means testing does not include family wealth or the patient’s home, so if they get better they have somewhere to go back to. Geriatric care is done mainly in an acute setting and the speciality is far smaller than in the UK, with only 152 consultant geriatricians and 53 trainees (against the over 1,000 consultants and nearly 600 trainees in the UK). Supporting the older institutionalised population is the far bigger specialty of nursing home physicians who undergo a two year training programme emphasising general prevention and problems like pressure sores. In an exotic new development, Care on the Farm, Dutch farmers faced with a declining industry are now creating day care centres where patients, largely from ex-farming backgrounds themselves, help with the animals, the gardens and in preparing home grown products. The benefits to patients with dementia have been dramatic: drug use was reduced substantially and behavioural problems dropped to virtually zero. There are now 40 care farms in the Netherlands.This was followed by platform presentations of two papers. Shelagh O’Riordan from East Kent Hospitals presented the alarming finding that over 80% of residential residents within their large scale study presented with some form of chronic kidney disease with its attendant implications for osteoporosis. Her team’s findings suggest that the standard recommendation of 800 iu/day of Vitamin D may not be enough and that activated Vitamin D may be required. Dr A M Yohannes presented evidence of a high correlation between depression and length of stay in intermediate care. He recommended that structured group exercise programmes and depression management (cognitive and behavioural therapy) should be considered to combat this.

Haematology
In haematology Dr Alistair Smith, a consultant haematologist and senior lecturer from Southampton University Hospitals and national clinical lead in haematology in Cancer Services Improvement Partnership, gave an overview of haematological malignancies. Though such patients are often younger, the majority of Dr Smith’s own patients are older and in many cases the treatment of the malignancy represent the management of a long term condition. Although research suggests that age remains an adverse prognostic factor, the hope is that haemato-oncologists will start making more detailed assessments of older patients and unpick the co-morbidities behind age which may then allow targeted therapy in conjunction with CGA. The platform presentations included fascinating new work on balloon kyphoplasty which offers hope for vertebral osteoporotic collapse and new data on a small but potentially significant link between birth weight and sarcopenia in later life. Special Interest Groups are a growing feature of BGS conferences and Thursday afternoon saw a session devoted to the Primary and Continuing Care SIG. Prof David Challis, professor of community care research and director of the personal social services research unit at Manchester University, opened with a talk on recent developments in assessing older people’s needs in the community and in care homes. Among his key points were the need to standardise assessments, to make them more holistic and person centred, to bring health and social services personnel together and to increase the involvement of specialist clinicians.

He was followed by five brief presentations on new models of medical input to nursing home patients. Speakers included Dr Ian Donald, consultant in general and old age medicine at Gloucestershire Royal Hospital, who outlined Partnerships for Older People Projects which aims to increase opportunities for the elderly to participate in developing services; Dr Eileen Burns, consultant geriatrician with Leeds Teaching Hospitals Trust and Leeds PCT, who spoke about their local pro-active care home management where greater involvement by a community geriatrician and a specialist nurse had led to a drop in hospital admissions; and Durham GP, Dr Elizabeth Kendrick described how a training programme on falls for care home staff meant that ambulances needed to be called out less often. At the end of the session its chair the BGS’s Prof John Gladman emphasised that because this was a pioneering area the Society needed to work to write up these experiences so that other colleages could learn from them.

Please vote now
Harrogate saw the first use of interactive technology at a meeting. Using hand held key pads members were able to respond to questions set by the speakers. The innovation which was widely welcomed meant that the audience could test their knowledge, express their views and input their experiences. Speakers could gather data and feedback and also find out at the end of their address whether it had changed anything.

What doc to wear
There were some fascinating entries among the posters with the usual wide range of subjects. One that particularly caught the eye since it was illustrated by a researcher wearing different garb including suit, jeans and scrubs, was one on how a doctor’s dress affects patients’ perceptions. A case maybe, of What Doc To Wear…

Among the platform presentations was a fascinating item from a team in Cork in Ireland on their development of two new paper protocols to work out whether patients were needing the medication they get - STOPP (Screening Tool of Older Person’s potentially inappropriate Prescriptions) - and getting the medication they need - START (Screening Tool to Alert Doctors to Right appropriate Treatment). When they applied the tools (based on literature reviews by 18 experts in geriatric pharmacotherapy) to 715 over-65’s they found 35 per cent were taking at least one inappropriate drug and and 43 per cent were not receving ones that could have helped. The final session of the conference was a wide ranging symposium on the subject of strokes with topics ranging from the investigation and management of TIA, an update on cardio embolic stroke management, the risks and benefits of thrombolysis and improving outcome among stroke patients.

Glasgow 2008
The Spring 2008 meeting will be held on April 23 to 25 at the Scottish Exhibition and Conference Centre on the banks of Clyde in Glasgow. As well as the professional attractions of hearing speakers like Lord Sutherland on the subject of free personal care and Prof Miriam Nelson from the American College of Sports Medicine on guidelines for exercise in old age, delegates may also be tempted by the idea of the conference dinner at the Kelvingrove Art Gallery and Museum which recently knocked Edinburgh Castle off the top tourist spot after a £27m facelift.

Liz Gill, Freelance Journalist
with help from
Simon Conroy

BGS Newsletter, December 2007
Issue 14 ISSN 1748-6343 14