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Over the past 50 years, there has been a remarkable evolution in the assessment and management of sick and disabled old people in the UK.

Initially, the first wave of geriatricians focused on dependent long stay patients. By applying clinical skills, developing inter-disciplinary teams, assessing patients holistically and comprehensively, improving the environment, providing equipment and improving education, geriatricians were able to optimise function and well-being. People were rightly astonished at the achievements in the pioneering elderly care departments.

The realisation that many of these patients were not suffering from “old age” but had iatrogenic diseases (e.g. contractures, pressure sores) or conditions that were wrongly thought of as “social problems” (e.g. immobility, incontinence, falls) led to the wish to assess ill old people early in the course of their illness. It took many years to progress to elderly care units in district general hospitals. Geriatricians, often working single-handedly in lack-lustre departments some distance from the main hospital, had previously had inadequate staffing levels and few diagnostic resources. Recruitment was difficult, standards of care were patchy and morale was low. The attitude of other consultants towards those who worked in elderly care was often derogatory.

The move to having elderly care wards in the main hospitals was hard won but brought enormous benefits to old patients, staff and the specialty. Sick old people, who often present in silent, atypical or non-specific ways, or who had multiple co-morbidity, were properly assessed early in the course of their illness. They had the benefit of full diagnostic facilities. Rehabilitation could begin on day one, with prevention of de-conditioning, early mobilisation, goal-setting and use of therapists and aids and appliances. Doctors in other branches of medicine rotated through elderly care departments. Attitudes towards old people and those who cared for them improved. Recruitment steadily increased: today, geriatricians form the second biggest hospital specialty and are the biggest group in the Royal College of Physicians.

There had always been an interest in caring for old people in non-hospital settings. Geriatricians did many domiciliary visits, which had the potential to prevent inappropriate admissions as well as giving the opportunity for mutual education between consultant and GP. Most units had day hospitals, enabling earlier discharges and allowing some patients to be rehabilitated without having to be admitted to a hospital bed. In Birmingham, Rowe initiated a rapid access clinic – this reduced the need for home visits and enabled more people to be seen on a single assessment. It was popular with patients, hospital staff and GPs.

In recent years, the landscape has altered further. Specialisation within geriatrics has helped improve the standards of care for patients with specific conditions. Stroke units, falls clinics, continence promotion clinics, movement disorder clinics, orthopaedic geriatric wards, delirium units, memory clinics are a few examples. Latterly, more geriatricians have developed an interest and expertise in community geriatrics. Geriatricians have always been willing to change if patient care improved in consequence. Examples of proven effectiveness of geriatricians working in with others include, early falls assessment, A&E schemes for admission avoidance of falls patients, community hospitals, home care by hospital outreach teams and some early supported discharge schemes. In many ways, there has never been a better time to be old and ill or disabled.

Not all the changes have necessarily benefited old people. Many geriatricians have taken on a disproportionate responsibility for all-age acute medical take, sometimes to the detriment of old people with complex needs and rehabilitation problems. The year-on-year reduction in hospital bed numbers has meant that some patients are discharged before they are fit; others are transferred to long term care without the benefit of a truly comprehensive geriatric assessment or without the opportunity to receive optimum rehabilitation. Patients are often moved from ward to ward in hospitals – this increases the risk of delirium and nosocomial infection. The added closure of beds because of outbreaks of infection adds to these pressures. There is often under-provision of beds in the winter, when there is usually a big increase of admissions of elderly people with chest infections, stroke and heart disease. It also means that staff do not always know the patients as well as they might – this can make for inappropriate or badly planned discharges, with the risk of early re-admission. The reduction in rehabilitation staff in many acute units means that rehabilitation is not always started early or is not as good as it might be. The closure of large numbers of geriatric rehabilitation beds may have deprived patients of the opportunity to achieve their potential. Many day hospitals have closed (admittedly, studies of their efficiency and effectiveness have not shown positive results). There has been a decline in the number of domiciliary visits.

A number of assertions and practices are questionable and should not be accepted uncritically.

Many elderly admissions to hospital could be avoided
Geriatricians who work on acute assessment see relatively few patients who do not benefit from timely assessment by a skilled team who have access to diagnostic and therapeutic facilities. On the other hand, the experience of intermediate care teams is that selected people can be well cared for without the need to go into hospital – for example, selected falls patients, those with uncomplicated chest or urinary infections, patients with DVTs, cellulitis. The current pressures and incentives to keep old people out of hospital simply because they are old are unacceptable. They are intrinsically ageist and may deny the ill person of the opportunity of CGA. There is a concern among geriatricians that more sick people are now being diverted from acute geriatric assessment units and may not being properly diagnosed or are being managed sub-optimally at home or elsewhere. It would be better to assess these patients quickly in a well resourced centre and then arrange for efficient transfer to the most suitable management once the crisis had been resolved.

Old people prefer treatment nearer to home
Easy access by public transport and convenient parking at a unit where the patient will receive the best care is far more important than simple geographical considerations.

Old people should be discharged as quickly as possible
Most old people in hospital do want to return home as soon as possible. Huge strides have been made over the years in reducing lengths of stay in geriatric wards (which was hundreds of days a few decades ago). Sending people home when the acute medical problem has been stabilised but before their other concerns have been addressed is a questionable approach and can lead to re-admission. Good discharges should be carefully planned with detailed communications between the hospital and community teams.

Geriatric care is easy and can be practiced by people with relatively little training
It is easy to practice elderly medicine badly. Old people deserve the best. About 40% of GPs have had no formal training in elderly medicine (there is a role here for the re-vamped Diploma in Geriatric Medicine). Nurses in intermediate care often feel out of their depth and are worried that they may be missing something, especially when reviewing patients who have fallen (these are the commonest group of people seen by intermediate care teams). It is not always easy on first contact with the GP or ambulance service to determine which patients might benefit from the panoply of hospital investigations and interventions. Direct involvement of geriatricians with community teams can help ensure that important diagnoses are not missed and that patients are not deprived of the possibility of treatment, rehabilitation and secondary prevention.

Possible future styles of care for old people
Given the inexorable move to fewer hospitals with fewer beds and an increasing focus on high-technology interventions in these places, together with increasing management of more people in the home or other non-hospital settings, how can we ensure that old people get safe and effective high quality medical care?

1. Specialist centres
Old people with myocardial infarction benefit from thrombolysis and angioplasty and should be admitted promptly to coronary care units. There is evidence of benefit of thrombolysis in people under 80 with ischaemic stroke and urgent admission is vital. Other old people who might benefit from specialist care include those with acute limb ischaemia, sub-dural haematoma, respiratory failure, spinal cord compression, and certain cancers.

It would be wise to have a sufficient number of geriatric beds on site so that those who are not suitable for these treatments or who are found to have other geriatric or medical problems can be transferred promptly to a unit with expertise in elderly care.

Just as orthopaedic care of older people has benefited from the close involvement of geriatricians, so might general surgery, vascular surgery and other high-tech disciplines.

2. Comprehensive Geriatric Assessment
This may not necessarily have to be done in hospital. There are other possible options – day hospitals, care homes, community hospitals, rapid access clinics, GP surgeries, independent treatment centres, and perhaps selected nursing homes. There are important questions about diagnostic facilities and staffing levels and availability. Traveling to such units may mean that fewer patients can be seen in a session than in a traditional ward. Studies of safety and effectiveness are needed. It is uncertain that providing these new models of care would be any cheaper than the present system.

The move away from hospitals has major implications for undergraduate and post graduate teaching and training. Initial experience of undergraduate community firms is encouraging, with opportunities for inter-disciplinary education and increasing awareness of the role of other members of the team.

3. Improving hospital facilities
Much could be done to improve the experience of those old people who need to spend some time in hospital:-

• Rapid movement through A&E to a dedicated elderly care unit, with close links to intermediate care teams, where rapid comprehensive assessment could take place.
• A sympathetic environment for people with delirium, with closer working between geriatricians and old age psychiatrists
• More single rooms for patients with transmissible infections
• Improving staffing levels so that old people are properly fed (there is a a role here for dietary assistants), fully assessed (gait, continence, cognition) and given optimum and timely rehabilitation
• Rapid access to CT head scanning for those with suspected stroke
• Education and awareness training to improve dignity of care and avoid inappropriate interventions and investigations

4. More geriatricians working outside hospitals
In those places where there are community geriatricians, community teams welcome inclusion of committed and experienced clinicians. The work can involve rounds in care homes (to review both permanent residents and intermediate care patients), home assessments at the request of community colleagues and GPs, working with stroke early supported discharge teams, being integral members of community case discussions, providing education and stimulating research. Closer links should be established with community matrons, nurse consultants and other specialist nurses.

Experience from the USA suggests that many ill people can be managed in non-hospital settings – IV or subcutaneous fluids, IV antibiotics, analgesia, anticoagulation, palliative care. There are implications here for training, audit and staffing levels.

The development of academic community geriatric units would be important in raising the status of this sub-specialty, as well as fostering much-needed research on effectiveness.

5. Enhancing the role of Care homes and community hospitals
Many Care homes have felt “locked-out” of the mainstream NHS services. There are important opportunities to enhance and extend the care provided to old people in these facilities. Some could become centres of excellence (e.g. in dementia care, stroke, movement disorders, rehabilitation). The concept of teaching nursing homes should be seriously considered, with opportunities for academic appointments.

Closer involvement of geriatricians with long stay residents may reduce the number of inappropriate hospital admissions of these people to hospital. Advice can be given on ethical and practical aspects of tube-feeding and resuscitation.

Community hospitals are popular with patients, relatives and staff and there is evidence of benefit when a geriatrician visits regularly. Infection rates may be lower, family support may be better and recruitment of staff may be easier

6. Red flags, pathways and guidelines
The use of these by GPs, community nurses and therapists would potentially improve the safety of old people who are being considered for community care. Evidence-based teaching to community colleagues on “diagnoses not to be missed“ would be an important step forward. Perhaps the RCP could consider national or regional inter-disciplinary meetings to inform people how to ensure that important reversible, modifiable or preventable conditions are not missed.

Final thoughts
There is considerable unease among geriatricians that the move away from the hospital model may result in a return to the bad old days when old people were deprived of full and timely assessment and appropriate treatment. The introduction of untried initiatives - some of which have been found subsequently to be ineffective (Evercare nurses have been an expensive failure) – has not helped. Nor has the lack of engagement of geriatricians in the formulation of policy. However, the hospital model has its limitations and there are many opportunities for new ways of working. The emphasis should be on identifying the best forms of care for old people and their families and basing these decisions on good evidence.

Graham Mulley