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The definition of ageing is being shaken up and re-defined for the 21st century, according to Chris Phillipson, one of Britain’s leading gerontologists.

The changes are both exciting and challenging for anyone working in the field and have enormous implications for both policy and practice, he told his audience at this year’s BGS autumn meeting. “For some, growing old gives freedom and extended choice. For others it’s the opposite: millions continue to experience ageing as a time of exclusion and loss of the resources necessary for a meaningful life.”

Giving the Trevor Howell guest lecture, Chris Phillipson, professor of applied and social gerontology at Keele University, outlined some of the dramatic developments that have happened over the past 50 years. Multi-generational households which were once the norm are now the exception: then only ten per cent of old people lived alone; today only 16 per cent live in households with two or more generations. The exceptions were ethnic groups: only one in five older Asians, for example, lived on their own.

“Living alone is increasing across all groups and may become the norm for the future,” he added. “It may reflect having a choice about who one lives with but it may also place many extra demands on services and increase mental illness among some groups. It has clear implications for social care.”

Of those who were married, nine out of ten lived only with their spouse – “couples now supporting each other is one of the most significant trends” – and divorce and remarriage further complicated the picture.

With the fragmentation of the family, a key issue among service providers might be to recognise the importance of other relationships such as long standing friendships and to support those. “We might get more examples of kin behaving like friends and friends behaving like kin.” Ties of friendship often sustained older people and deprivation of the means to maintain them could mean profound loss, comparable to losing a family member.

Some research findings have been positive. “The good news is that, contrary to predictions, commitment across the generations appears to be being maintained.” Half of all adults still lived within 30 minutes of their childhood area or within 30 minutes of a parent or child. Over half, even at 75 plus, met up with their children once a week with a still higher percentage meeting once a month. Sixty one per cent of grand-parents saw their grandchildren at least once a week, another 17 per cent at least once a month.

A third of grandparents spent an average of 21 hours a week looking after their grandchildren and more than a quarter over 26 hours a week. “A lot of older people now are donors rather than recipients of help. This is a compelling feature.”

The other side of the ageing coin, however, as revealed by a study of 600 elderly people in deprived areas in Liverpool, Manchester and East London, has some grim features: poverty, severe loneliness, social exclusion, fear of crime, no family ties, negative feelings about their neighbourhood and inability to participate in civic activities. Overall, 70 per cent experienced some form of exclusion. Urban environments, though rich in many ways for older people, could accentuate some problems: it was crucial for regeneration policy to take them into account.

Globalisation had also made us aware of concepts of old age beyond our Western ones. “Sixty to 65 is ours because that’s when we draw our retirement pensions but pensions aren’t even a consideration for three quarters of the world’s 90 million over 65s,” he added. And though our life expectancy might be rising, in Russia and sub-Saharan Africa it was plummeting.

Issues of inequality at home and abroad provided ongoing questions for gerontological research and he called for sociological inputs into geriatric medicine. “We need our disciplines to come together if we are going to be truly effective.”

Factoids and policy zombies
These were the themes of the Marjory Warren guest lecture by Steve Iliffe, professor of primary care for older people at University College London and a former GP with 30 years experience in a diverse inner-city practice. The former were assumptions repeatedly reported until they were considered true, the latter, intellectually dead ideas which could not be put to rest.

So factoids, for instance, dealt in apocalyptic demography: Illness increases with age so an ageing population creates a burden of disease and escalating costs with which we will not be able to cope. “It’s true that illness increases with age but people are ageing more slowly now and illness and age are disconnecting,” said Prof Iliffe. “Most gains in life expectancy are occurring without disability.”

An example of a policy zombie was the pressure for widespread population screening. “The evidence is very weak that if you screen older people there are benefits. There is a case for highly targeted needs assessment followed by active management: this may improve survival and function. But screening everyone over 70 for cognitive function is ineffective.”

Other myths surround health economics: there is widespread belief, for example, that there simply will not be enough money to support an older population. In fact studies both here and in America had shown that that was not the case. In a robust economy the NHS could consume up to 30 per cent of the GNP without serious repercussions.

The legacy of many of these myths and misunderstandings was to be preoccupied with disease to the detriment of social consequences, he added. Primary care was fragmented, the system favoured younger people, it was often industrialised with patients continually passed on to someone else, illness orientation over-rode patient-centred care – there was lots of hypertension management, for example, but little for falls or incontinence - and complex problems were often marginalised. Although many of Marjory Warren’s original objectives had now been met, he suspected “she would still be incandescent about some aspects of care of the elderly.”

Looking to the future, Prof Iliffe – ‘I’m a fan of NHS reform’ – outlined some of the possible paths including use of independent care organisations in some circumstances, integrated directorates, polyclinics, hub and spoke models of primary care, an upgrade in commissioning and a pyramidal structure of public health, primary care and geriatric medicine.

Day hospitals
The challenges facing geriatrics was a recurrent theme throughout the Birmingham meeting. It started with the first session which even included it in the title: ‘challenging issues in intermediate care’. One of the tasks here, according to Jan Beynon, consultant geriatrician at Portsmouth Hospitals, was to champion the cause of the day hospital. “Probably most GPs and hospital doctors are unaware of the services and facilities provided by them. They’ve often got a bad or outdated reputation. Perhaps we need a new name such as assessment and treatment centres.”

In his review of day hospitals from their origins in Oxford in the late ‘50s through their subsequent expansion to over 400 at their peak, to the present day and beyond, Dr Beynon looked at their aims and achievements. Their aims were to be a bridge between a stay in hospital and a return to the community. The emphasis was on rehabilitation and assisting independence. On the achievements side, patients liked them and carers found them helpful. It was unclear, however, how cost effective they were. Some reviews suggested they shortened inpatient treatment and delayed or reduced readmissions; other studies were less conclusive.

He believed though, that the day hospital still had a vital role to play - “we must be the interface between primary and secondary care and be part of a continuum to facilitate independent living” - and that it was important for the next decade for the Society to champion the service to the moneymen. “Commissioners’ base line is preventing hospital admissions and they want evidence of cost effectiveness as well as clinical effectiveness. We must offer value for money.”

He was followed by Finbarr Martin, consultant physician at Guys’s and St. Thomas’s Hospitals in London who issued another rallying call, this time for better integration between specialist and community care and in raising public expectations about help for the secondary prevention of falls and fractures. “You need top down pressure to promote change”. Professional and political levers could be applied to spread successful models such as strength and balance training and increased opportunities for physical activity.

Intellectual disability
The session closed with yet a third challenge – the need to look for new ways of caring for older adults with learning disabilities. John Starr, professor of health and ageing at Edinburgh University recalled how only 20 years ago, when he was a senior house officer in Birmingham, such people were still shut away in institutions. Then, as in earlier years, they also died relatively young. In 1900 life expectancy was nine, by 1983 it was still only 25 but by 2007 it had risen to 59.

There were now an estimated one million Britons with mild intellectual disability (having an IQ of between 50 and 69) and around 150,000 with moderate to severe disability. A major problem was the fact that age related diseases such as osteoporosis and dementia were very common and tended to occur earlier. “So you get multiple pathologies both physical and mental,” he said. Extra training for geriatricians was needed – “this is a clinically demanding area” - as well as ways of finding out what intellectually disabled adults themselves wanted.

Intellectual disability in older people was in fact the subject of a special interest group session, a measure perhaps of its increasing relevance in our field and the need to work out new strategies. Sally-Ann Cooper, professor of learning disabilities at Glasgow University, said it was important to see the problem in context: such adults were generally unmarried and without children; they may lack other family or social networks and they had probably never worked. They may have once lived in institutions and then been re-settled into the community but their support packages were often unable to cope with changes in their mental or physical health which meant they often ended up in nursing homes.

Intellectual disability brought forward the risk of dementia by 15 years – by 30 years for adults with Down’s Syndrome – and other types of mental illness, including depression, were common. Their physical health was also worse than that of the general population. Although they had much lower rates of smoking and drinking, they still suffered worse rates of heart and respiratory problems as well as conditions such as cataracts, impacted ear wax, arthritis, reflux disorders and hearing impairment. They tended to have poor nutrition and a higher incidence of injuries, accidents and falls.

Although life expectancy was increasing, older adults still only accounted for around ten per cent of the intellectually disabled, so services remained geared to younger people, concentrating on skills development and behaviour modification. What was needed now was to look at these problems, to share information and to work jointly across the professions.

The need to change approaches as intellectually disabled adults aged was stressed by Sarah Black, consultant old age psychiatrist at Wonford House Hospital in Exeter. “If you’re caring for someone who has developed dementia you’re looking at ways of minimising difficulties. If that person has a life long disability you might have to switch from encouraging them to do things for themselves to getting them used to having things done for them and allowing themselves to be helped.”

Because of the increased risk of dementia among such people and the difficulties in diagnosing it, one possibility for the future might be to assess someone at 30 to establish a base line and then screen them at 40. Joint protocols for learning disabilities and old age psychiatry were definitely needed: by 2020 the number of intellectually disabled adults over 65 will have doubled.

Earlier in the session Shoumitro Deb, clinical professor of neuropsychiatry and intellectual disability at Birmingham University, had sounded a note of caution. “Lots of other things can mimic dementia, especially in a person with Down’s syndrome. A change in their environment, even just moving house, can make them unhappy and withdrawn. So you have to modify the ordinary neuropsychological tests or, even better, use observer rated scales.”

Academic geriatric medicine in good heart
Academic geriatric departments are in ‘remarkably good heart’ in the UK, Graham Mulley, professor of elderly medicine at St James’s University Hospital, Leeds and now BGS president, told members attending the ‘at the frontiers’ session on some of the latest research in the field. There are now 46 geriatricians who hold a chair, either in geriatric medicine or a related speciality.

Respiratory and a hidden geriatric giant
The session heard from Steve Allen, consultant geriatrician at the Royal Bournemouth Hospital on the difficulties of treating airways disease in old age. The elderly needed big changes in their respiration before they reported a problem and therefore there was later use of rescue therapy. The effectiveness of inhalers and spirometry could also be affected by cognition and physical conditions. His department therefore was working with design engineers to make new equipment to measure airflow resistance and he showed images of the prototype.

He was followed by Roger Francis, professor of geriatric medicine at Newcastle University who spoke on musculoskeletal disease in older people and the need to be mindful that although fractures and osteoporosis predominated in women they also occurred in men and it had been found that giving men oestrogen helped increase bone density.

Avan Aihie Sayer, MRC clinical scientist and honorary professor of geriatric medicine at Southampton University, called for sarcopenia, the loss of muscle mass and strength with age, to be recognised as another geriatric giant. Usually it was mass which was measured but at Southampton they were pioneering the use of muscle strength as a measure, particularly grip strength. This was linked to a range of conditions including obesity, osteoporosis and type 2 diabetes and could be a powerful predictor of future mortality.

Post office closures - the hidden cost
Although intellectually rigorous science is a major part of BGS meetings, serious points can also sometimes also be made through personal recollections. One such occurred at the end of the session ‘improving patients’ outcomes in community care’. In answer to a question from the floor Gillian Parker, director of the social policy research unit at York University, who had earlier spoken on the need to find out what really matters to service users, said that the post office used by her 80 something year-old father had closed over a year ago. “It also meant the closure of the newsagents which was part of it. So for the first time in his life he had no newspaper and nowhere to walk to get it. In those 12 months I have seen a deterioration in his walking.”

The session also heard from Stuart Parker, professor of health care for older people at Barnsley Hospital, who illustrated today’s changing expectations of old age with a wonderful picture of three older ladies wearing sunglasses, flamboyant hats and riding in a convertible. An ageing population could bring a “tsunami of wisdom and experience from which we could gain great benefits as a society”. There was a need though, to move from acute care models to management of chronic disease and long term conditions.

The final speaker brought a Dutch perspective. Marcel Olde Rikkert, who holds a chair in geriatric medicine at the Radboud Medical Centre in Nijmegen in the Netherlands, outlined several assessments of older people which had been carried out there. The issue was complex but the best outcomes seemed to be where assessments were selectively targeted rather than being routine.

Only one chance to get it right
End of life issues are of immense concern not just to doctors but to the general public as well. As John Ellershaw, director of the Marie Curie Palliative Care Institute in Liverpool, pointed out barely a week goes by without a story or debate in the media. Those who actually cared for the dying though, had only one opportunity to get it right. The Liverpool Care Pathway had been set up to promote best practice, to find a way of transferring hospice skills to hospital settings where most people still die. In the 12 years since the programme was introduced, it had been adopted in 118 hospitals around the UK. A show of hands in response to his asking how many BGS members were familiar with it was overwhelming.

Originally designed for cancer patients it was now extended to those dying from other diseases. But it was not a quick fix, he warned. Institutions wanting to adopt the LCP’s ten step plan, which runs from diagnosis of dying through care to after care, needed six months preparation and 12 months implementation. “It is about education and training but it is also about changing practice and changing culture.” It was also important to audit the programme in order to sustain it.

How theory translated into practice was shown by a letter Prof Ellershaw had from a man who wrote to say that his mother had died with peace and dignity in a room within a busy ward and that he had been able to say his goodbyes properly.

Hope for shingles sufferers
A recurring topic at recent BGS conferences has been the advance of tele-care and other high tech innovations relative to the elderly. The Birmingham meeting, however, brought details of a new development in a field which has already saved millions of lives of all ages – vaccination. The development is a vaccine for herpes zoster or shingles which has been licensed for use in the UK and should be available once sufficient supplies have been produced. According to Robert Johnson, senior research fellow and emeritus consultant in pain medicine at Bristol University, a US study of 38,500 immunocompetent over-65s showed that it reduced the incidence of the condition by around 50 per cent and in those who still got shingles it reduced the burden of illness by 61 per cent and prevented pain by 67 per cent.

The vaccine is certainly much needed. As David Carrington, consultant medical virologist at the Health Protection Agency Regional Laboratory in Bristol, pointed out we have a one in four chance of getting shingles at some point during our lives. There are 200,000 cases a year in the UK. While the ophthalmic or thoracic rash is present, pain is the rule rather than the exception and 43 per cent of patients continue to have postherpetic neuralgia ranging from mild to severe - four out of ten people said it was the worst they had ever experienced.

The illness, which occurs when the chickenpox virus, dormant since childhood, reactivates, is particularly relevant to geriatric medicine: incidence is low until the age of 50 and then there is a sudden rise, probably due to reduced immune efficiency.

Flu jabs and more
The symposium also heard from George Kassianos, immunisation spokesperson for the RCGP, and Jean-Pierre Michel, academic director of the EU Geriatric Medicine Society, on the advisability of offering the flu jab to 50 year-olds and the importance of maximising the take-up rates of pneumonia vaccination: pneumococcal infection complications such as meningitis and bacteraemia had high mortality rates.

The vaccination meeting was one of several sponsored symposia. Others covered hip fracture, Parkinson’s Disease, chronic pain and fractures.

One of the interesting aspects of all BGS meetings is hearing from experts in other disciplines and Birmingham was no exception. One research presentation session, for example, featured a sociologist, a physiotherapist and a nurse. Siobhan Reilly from Manchester University looked at how active case management for people with long term conditions of which there are 17. 5 million in Britain could have an impact on emergency admissions and associated length of stay. A study of community matrons and specialist nurses taking such an approach to 250,000 patients in the Manchester area reduced admissions by 22 per cent and length of stay by 26 per cent.

She was followed by Emma Stack from Southampton University who explored the ‘context effect’ of Parkinson’s Disease where patients appear able to perform better in laboratory and clinic settings than they can at home. Measuring 80 patients at home and in the laboratory, however, found no significant differences. Measurements obtained in labs therefore could still be valid.

Jenny Billings of Kent University then presented the findings of her qualitative study of privacy and dignity in continence care. Her interviewees’ often moving testimonies described the professional approaches they found helpful – respectfulness, smiles, a ‘don’t worry’ attitude, discretion and social chit chat – and those they did not – slow response time and ‘being pulled about’.

Informing members about facilities they might not always be aware of is another useful aspect of Society meetings. An example of this came in the talk ‘fitness to drive in neurological diseases’ by Owen David, consultant in general, geriatrics and stroke medicine at the Royal Bournemouth and Christchurch Hospitals, who described the work of the 17 mobility centres in the UK.

Users could be referred by their GP, the DVLA or an insurance company for information, advice and assessment and where appropriate the modification of their vehicle.

Other sessions at the meeting in the city’s International Convention Centre included updates on education, respiration, stroke, falls, alcohol, syncope and drugs and prescribing. More than 500 members attended including representatives from Denmark, the Netherlands, New Zealand, Ireland, Canada, Iceland, Australia, Italy, Switzerland, Abu Dhabi and Israel.

Birmingham makeover
Those who had been expecting a concrete jungle where traffic was king – once the popular image of Birmingham – would have been pleasantly surprised. The city centre is now largely pedestrianised with pleasant squares, fountains, grand Victorian civic buildings and smart shops. There was even a German Christmas market in full swing to walk through to reach the society’s dinner in the splendid Council House. In these august surroundings guests enjoyed salmon trout, chicken with asparagus and Madeira sauce and brandy snap baskets to the accompaniment of a jazz quartet.

Liz Gill, freelance journalist
Additional reporting by Jessica Beavan
and Simon Conroy

BGS Newsletter, Dec 2008
Issue 19 ISSN 1748-6343 19