There are problems with ageing, but one of them should not be ageism. “There’s enough to cope with without that,” Sheena McDonald told the BGS’s Spring Meeting in Edinburgh.
The journalist and presenter who was brought up in a Presbyterian manse said the word simply denoted the church was run by elders. “There’s not a whisper of the perjorative about it.” All too often though, the word elderly was a toxic euphemism leading to hysterical headlines and the turning of funding into a political hot potato.
“One of the challenges is to tackle this notion our society has of us and them.” Research had shown that over three quarters of 65 to 74 year-olds and two thirds of the over 75s did not even think of themselves as old. Yet a survey of younger people showed they thought old age began at 58 – the age, incidentally of the multi-Oscar winning director Kathryn Bigelow.
“Growing old is part of life; it doesn’t demonstrate failure or weakness. In many parts of the world, life expectancy is below 56. If we ask ourselves ‘do we envy them?’ and the answer is no, then we must address the realities of ageing honestly, clearly and cheerfully.”
Ms McDonald, who had personal experience of the reality of health care when she was severely injured after being hit by a car, was giving the keynote address at a BGS meeting innovation. Entitled the Age of Enlightenment, the extra Saturday morning session involved four workshops open to the public as well as the professionals: research with older adults; health services for older people; care and carers’ concerns; and ethical issues in old age.
The format was for each to split into groups of two or three before coming together to decide on priorities, obstacles and recommended courses of action. The facilitator in each group would then present these to the reconvened plenary session for discussion.
Although the 125 members of the public were fewer than had been hoped for, the workshops were productive as well as lively. Certain themes recurred: funding and resources, education and communication, the need to raise awareness, improve access to services, foster cross discipline coordination and, of course, the prevalence of ageism.
There were specifics too. The research with older adults workshop, for example, stressed the need to include more of them in clinical research since any findings would eventually apply to them as well. Care and carers’ concerns highlighted the frequent discrepancy between rhetoric and reality. A participant who had been caring for a husband with dementia said, “Free personal care sounds fine in the leaflet but it’s not always so in experience where there can be constraints.” Another highlighted the difficulties of retaining professional care workers, “when they can earn more stacking shelves in Asda than caring for a member of the human species”.
A third mentioned the need for personalised guidance at the start of a carer’s journey: it had been three years before she had felt sufficiently informed.
Summing up the pioneering session, John Starr, professor of health and ageing at Edinburgh University and chair of the local organising committee, said everyone had been enriched and informed by the debate which had provided thoughts and ideas for the Society to take forward.
‘Nary a con-trail to be seen
The Spring meeting had to cope with a less welcome first – being hit by the air traffic chaos caused by the volcanic ash. As well as preventing a number of overseas delegates from reaching the UK, it also meant that President Graham Mulley was unable to cross the Atlantic, being stuck in Canada after attending a meeting there. President-elect Finbar Martin, whose own arrival was delayed, was belatedly able to step into Prof Mulley’s shoes, even including a poem in his farewell remarks.
Also confined to Canada was one of the speakers, consultant neurologist Serge Gauthier of the McGill Centre for Studies in Ageing in Montreal. Thanks to technology, however, he was able to deliver his talk on managing difficult behaviour in patients with dementia, via a telephone link.
Widgets, gadgets and cyberspace
Technology was, if anything, even more to the fore this year: there seemed few sessions that did not feature some aspect of telemedicine, telecare, new inventions and procedures or dedicated websites.
The theme ran through the opening session on new developments in rehabilitation when speakers described such innovations as eye gaze communication where a camera linked to a computer could register when someone’s gaze was focussed on an item on screen; robotic gait training which held the person in a sling while mimicking normal walking; microprocessor controlled ankle and knee joints; and i-Limbs, realistic looking, state-of-the-art prosthetics where muscle activity elsewhere, in the biceps for example, could be translated via sensors into hand and finger movements. The problem at this stage though, according to Alasdair FitzGerald, consultant in rehabilitation medicine at Astley Ainslie Hospital, Edinburgh, was that such innovations were not just expensive but also complicated to master. They were therefore more suitable to young, highly motivated amputees than the elderly.
More promising for the older age group were environmental modifications which could monitor such factors as individuals’ blood pressure, heart rate or movements within their own homes and trigger an alarm if necessary. “There are ethical concerns here though as to whether we’re leaving people vulnerable or isolated because it’s cheaper or whether we’re setting up a Big Brother environment,” added Dr FitzGerald.
The topic was raised again in the primary care gathering when Louise Robinson, professor of primary care and ageing at Newcastle University, described the £12m ‘ambient kitchen’ project where a normal looking kitchen would in fact be a digital hub aimed at facilitating independent living for people with dementia. The idea would be to replace the verbal prompts given at each stage by a carer to someone making, say, a cup of tea with audio and visual prompts. “If we can’t provide traditional support we have to look at innovative ways of support.” Ageing, she stressed, was everyone’s business. Fifteen per cent of the present population are 65 and over. By 2050 that could be as much as 35 per cent.
Another way in which technology could cut costs was outlined by Tracey Howe, director of the research consortium HealthQWest at Glasgow Caledonian University. Musculo-skeletal problems, particularly low back pain, take up 30 per cent of GP consultations and cost the country billions in lost working days. The current system is for patients to go on orthopaedic waiting lists even though 70 per cent of them will never require surgery. “Meanwhile there is no active management of the problem so there’s a spiral of decline, stress and further cost.”
The proposed new pathway would harness technology to enable some self-referrals through NHS Direct. An integrated team of occupational and physiotherapists would signpost patients to the right services at the right time. Surgeons would then see a higher proportion of those who actually needed their help.
Telemedicine and Strokes
In one of the stroke sessions Mary Joan Macleod, senior lecturer in clinical pharmacology at Aberdeen University, described the setting up of a telemedicine service for brain attacks in the Grampian region. Someone who suffered a stroke in Elgin on the perimeter of the region could be up to 90 minutes away from the specialist in Aberdeen meaning their chances of being appropriately thrombolysed were increasingly slim. Under the new system they were scanned in Elgin and a video of the scan transmitted to Aberdeen for review and advice. Since its inception in 2008 it had dealt with 28 patients of whom 13 were thrombolysed. Similar systems which cost £10,000 for the video unit plus £1,500 a year running costs are now being set up in Stornaway and Orkney.
Technology’s double edge
Although technology might be able to solve problems in the future, it is sometimes technology which causes them in the present. Roman Romero-Ortuno presented research from St. James’ Hospital and Trinity College Dublin which showed that the usual six seconds allowed by the ‘green man’ light at crossings was insufficient time for the majority of older pedestrians to cross the roads in that city. There is a general regression in walking speed with age: an average 1.3 metres a second declines to 1.1 for a 70 year-old, 0.9 for an 80 year-old and 0.7 for an 89 year-old.
“We found the time insufficient when we measured it in a laboratory. In real life there would be other factors to slow someone down such as poor visibility, wet surfaces, crowds and having to carry bags. It is essential that town planners and traffic management bodies are aware of this to prevent accidents or social isolation because people are too afraid to go out.”
His presentation ended with a touching little animation of an old woman struggling to cross a junction while cars swerved around her and drivers hooted but it was not, he said, just an issue for older people. “It is about accessibility in general, how we provide for disabled people, pregnant women and children.”
Understanding the Unintelligible
Delegates who attended the medical ethics session probably learned a new word: hermeneutics. It comes from the Greek Hermeios, the priest who interpreted the Delphic Oracle, and means the art of understanding the unintelligible. It used to refer to the interpretation of sacred texts but according to Kenneth Boyd, professor of medical ethics at the College of Medicine and Veterinary Medicine at Edinburgh University, it can be relevant to doctors’ work.
Here it would involve the doctor acknowledging his or her own intellectual and cultural horizons as well as trying to see things from someone else’s perspective. It involved wisdom, dialogue, listening and empathy in order to discover what was right for a particular patient at a particular time “I like to think of this as our gaining wisdom from our patients. Sometimes the gap is unbridgeable, with some mental illness perhaps, but generally I hope we can arrive at a richer understanding that is both nuanced and efficacious.”
He was followed by Robin Downie, emeritus professor of moral philosophy at Glasgow University who, without using notes or a power point presentation, gave a stimulating critique of the concepts of choice and consent at the end of life.
He distinguished between the traditional notion of choice which was consistent with a medical situation and summed up by the acronym FAIR: Freedom, Alternatives, Information and Responsibilities and the relatively recent consumer idea of choice or CHARM: competition, (regulations to protect from) Harm, Advertising, Responsibility and Money – if you pay for something you can have it.
“This works well in the free market but does it work well in health care? It’s happened to a great extent in the NHS but I doubt consumer choice is beneficial to the elderly.” Sometimes relatives petitioned for inappropriate chemotherapy for a family member or an elderly person said they wanted to die at home when in fact they could be harmed by not having round the clock nursing care.
“The whole idea of consent has been turned upside down. Now the patient is saying ‘I want’ and the doctor is consenting. Can you still be a professional if you’re simply doing what the patient wants? The whole idea of being a professional is that you’re acting in their best interests. If you’re now just an agent of their wants and demands you’re in the same position as a shop assistant. We’re so afraid of the accusation of paternalism. The phrase ‘doctor knows best’ would be said with a sneer. But you should know best.”
Incontinence
One of the geriatric giants, incontinence, was tackled at a lively masterclass during which Ann Capewell, consultant in medicine for older people at St Helens and Knowsley Hospitals, Adrian Wagg, professor of healthy ageing at Alberta University, Canada and Susan Orme, consultant geriatrician at Barnsley NHS Foundation Hospital Trust, gave practical advice on managing the problem as well as data on its incidence and causes.
Issues included the use of catheters, medication, the expectations of carers and families, ‘toilet mapping’ for patients put in new surroundings, the need to check for skin infections, vaginal atrophy and manual dexterity as it related to self care. On a darker note Dr Orme said professionals must be alert to the possibility that incontinence was an indicator of abuse.
Never too late to exercise
Another giant was the subject of a session on falls and balance disorders and ways of preventing them. “Doctors often think a patient is too old or too frail for exercise and that it’s not worth it”, said Jane Thomas, clinical specialist physiotherapist at NHS Fife, “But it is. You’re never too old. One study of a 12 week intensity strength training programme for nursing home residents over 90 doubled their leg strength. The situation is reversible and changeable. The lower the baseline, the greater the health benefits.”
Showing cross section slides contrasting the leg muscles of a sedentary 70 year-old and an active one, she added that not only did exercise reduce the incidence of falls it reduced the site of a fracture if someone did fall. The unfit broke a hip, the fit, who put out their hands to save themselves, broke a wrist. “Exercise increases quality of life and social activities, improves bone density and reduces fear. If you’re afraid of falling you become inactive and therefore more likely to fall.”
Intensive balance training was the most helpful technique. It was not enough simply to encourage people to walk: if they were unfit they would be at greater risk. Tai chi was useful in preventing a first fall as was general activity. Exercise could be done at home, chair-based if the subject was particularly frail, but it needed to be done twice a week for six months, and so could be a challenge. People needed motivation, positive goals and possibly a buddy system to help.
Fiona Neil, research associate at Glasgow Caledonian University School of Health, brought home the impact of visual impairment by showing on screen a scene changed to how it would look for sufferers from macular degeneration, cataracts and retinopathy and by quoting patients on the restrictions on their lives such conditions had caused. Increased awareness was vital, she added, not just because of the statistics – 33 per cent of the over 65’s fall once a year; 80 per cent of the one million visually impaired people in Britain are over 65 – but because at the moment “those in the vision field are not exploring falls; those in the falls field are not exploring vision.”
Shelagh Palmer, research and development coordinator visibility, Glasgow, recommended falls risk screening at home by occupational therapists who could improve lighting, remove hazards, even just remind people to keep their spectacles clean. Routine eye tests needed to be promoted - the risk of falling increased in direct proportion to the time elapsed since the last test. Patients needed their own awareness increased – some did not appreciate the extent of their problem.
Fiona Shaw, consultant geriatrician for rehabilitation and intermediate care service in Newcastle, spoke about the best falls risk interventions for the cognitively impaired including medication modification. Some drugs whose side effects contributed to falls could sometimes be stopped once an acute episode was over or a condition stabilised.
Closer to conquering shingles
One of the rewards for being a regular at BGS meetings is seeing scientific research achieve clinical reality. This was now the case with the prevention of herpes zoster and post herpetic neuralgia by vaccination. The symposium, sponsored by Sanofi Pasteur MSD, heard first from Donald Palmer, senior lecturer in immunology at Imperial College London who explained the relatively new term of immunosenescence, the age associated deterioration of immune function and the attendant problems of susceptibility to cancer, auto immune diseases like arthritis and a poorer response to vaccination. The flu vaccine, for example, gave only 30 to 50 per cent protection in the elderly as opposed to 65 to 80 per cent in younger groups. “All is not lost though. We are developing new strategies to counter this including an increase in the antigenic dose and alternative routes for vaccines.”
He was followed by David Carrington, a consultant medical virologist with the Health Protection Laboratory in Bristol who gave an overview of the problem. The herpes virus is prevalent in nine out of ten of the population meaning that one in four will suffer shingles by the age of 80 when the virus encountered in childhood chickenpox is reactivated in later life, usually with extremely painful results. Not only is there pain in the acute period but one in five can be affected by the aching, stabbing, burning and shooting sensations of PHN for months, even years, leading to sleep disorders, fatigue, depression and isolation.
The good news was given by Robert Johnson, emeritus consultant in pain medicine at Bristol University who told the audience that studies in the U.S. had shown vaccination reduced herpes zoster by around 50 per cent, PHN by 66 per cent and the burden of illness by 61 per cent. The vaccine has been cleared by the Joint Committee on Vaccination and Immunisation and is now awaiting production and pricing agreement.
Other symposia featured two on Parkinson’s disease sponsored by Teva Pharmaceuticals and Lundbeck and GlaxoSmithKline and one on dementia sponsored by Eisai/Pfizer.
As the ‘Athens of the North’ the city attracts and develops world class experts and one of them was a guest lecturer at the meeting. Neil Douglas is professor of respiratory and sleep medicine at Edinburgh University and an international authority on the subject: his Sleep Centre is the largest in the U.K.
Driving drunk vs driving tired
His particular interest is in sleep apnoea, a disorder where patients suffer ten second breathing pauses at least 15 times an hour and sometimes up to a thousand a night. Around 90 per cent of the 50 new referrals his clinic sees a week are for this condition which can cause daytime sleepiness, impaired concentration, nocturia, nocturnal choking and depression.
It’s caused by a small throat, a narrowing of the airway due to obesity or a shorter jaw. Incidence increases with age – one in five cases are in the over 60s – due to a variety of factors: the jaw gets shorter in the elderly especially those without teeth; there is an increase in fat deposit on the upper airways; muscles weaken and tongue strength falls.
Prof Douglas’s clinic only sees patients with an Epworth sleepiness scale 11 or more or nocturia or an inability to concentrate. Treatments involve weight loss, no alcohol and mandibular splints which hold the jaw forward. CPAP, continuous positive airway pressure delivered through a mask worn by the sleeping patient, can be very effective.
It is vital to treat the condition not just for the sufferer’s benefit but for society. “If it’s left untreated there can be a three to six fold increase in road accidents,” added Prof Douglas who cited a test where the errors of apnoea patients were plotted against a control group.
“The control group were then asked to get drunk and both groups were measured again. The untreated sleep apnoea sufferers drove less well when sober than the control group drove when drunk. We never overlook the drunken driver, we must never overlook the sleepy one. That driver might be following you down the motorway.”
He also explored other sleep disorders including cataplexy and narcolepsy. Though their onset was usually earlier in life he had seen one new patient in her late 60s who had sought help only after her doctor husband had died. “He had always told her to pull herself together. Her life had been miserable when it needn’t have been.”
The elderly and late middle-aged were more likely to experience sleep behavioural disturbances as these were often associated with neurological diseases. One case involved a 68 year-old man who had suffered frightening dreams for 15 years, waking screaming at least twice a week and hitting out at his wife. An American study had looked at 41 potentially lethal cases of sleeping patients opening windows, diving out of bed or grabbing their partner in a headlock. Insomnia was the most common sleep problem for older people with 60 per cent reporting problems. Most sleep conditions were amenable to treatment through medication or lifestyle adjustments.
Critical friend
The other guest speaker was from Edinburgh’s rival city: David Cargill, professor of geriatric medicine at Glasgow University who gave the Marjory Warren lecture. Entitled ‘Confessions of an academic geriatrician’, Prof Cargill looked at the present state of the subject in the UK from the position of a ‘critical friend’. “One of the challenges is the tension between the generalist nature of our speciality and at the same time the need for clinical research to be intensely focussed.”
Academic medicine was struggling to recruit and retain personnel: ten per cent of posts were currently unfilled. Disincentives included hard work, prolonged training, competition for resources and the fact that research nowadays was much more complicated: projects took twice as long and cost twice as much as they used to.
There was, however, a lot to be positive about. The field was still attractive to those with intellectual curiosity who sought opportunities for leadership and teaching and who wanted to provide new evidence which could change clinical practice. “One of the fantastic things is that there is a whole load of potential areas to be explored. The variety makes it an exciting subject.” He concluded with advice for those applying for research projects and challenged more geriatricians to move on from generalised observational studies. Twenty five out of the 88 abstracts at the BGS’s autumn meeting had been simple descriptions of clinical practice. “This is not an ideal balance”.
More advice for researchers was given at the session on how to get your paper published in the BGS’s Age and Ageing Journal by editorial manager Katy Ladbrook and Chakravarthi Rajkumar, chair in geriatrics and stroke medicine at Brighton and Sussex Medical School. Those who wished to please an editorial team should select the relevant category, comply with instructions to authors, use the requested reference style, suggest reviewers, ensure there was sufficient detail in the results to justify the conclusion, mention any limitations, accompany it with a brief letter to the editor, acknowledge funding and declare interests. “Be prepared for rejections which are more likely the more junior you are. And never give up.”
Bits ‘n bobs
Other topics covered at the meeting included diabetes, drugs and prescribing, long term disease management, pre-operative assessment, heart failure management, angina, BGS supported research, clinical leadership in postgraduate education and geriatric medicine in developing countries. In the latter Richard Walker, consultant physician at North Tyneside General Hospital, who had conducted a study into stroke fatality rates in Tanzania, issued a rallying cry to the BGS. As the oldest and one of the largest geriatric societies in the world it could play a vital part by helping to train specialists in developing countries perhaps with scholarships in the UK.
As well the professional side of the meeting there was the usual opportunity to network and socialise. Members who went to the dinner in the splendid surroundings of the Signet Library at the heart of the Royal Mile enjoyed scotch broth, lamb and passion fruit cheesecake followed by a lively ceilidh with The Occasionals band.
Prize Winners
Congratulations to the following prize winners:
Ferguson Anderson - Best Scientific Presentation Poster: Dr C L Liu - Research Poster entitled: Predict Frailty Progression with Cardiovascular and Pulmonary Diseases in Older Institutionalised Men
Elizabeth Brown - Best Platform Presentation: Dr R Romero-Ortuno - Platform Presentation entitled: Do older pedestrians have enough time to cross roads in Dublin? A critique of the Traffic Management Guidelines based on clinical research findings
John Brocklehurst - Best Clinical Effectiveness Poster - Dr D Ahearn - Best Clinical Effectiveness Poster entitled: Introduction of an electronic discharge summary improves transfer of care information post-stroke
Liz Gill
Freelance Journalist
