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Leading geriatrician, philosopher and poet, Ray Tallis is fond of telling his medical students: “All old people are different, which is why they’re interesting. All young people are the same, which is why they’re boring.”

The saying invariably leads to laughter as it did when he repeated it during a symposium on epilepsy at the BGS’ Spring Meeting last month but it nonetheless sums up the enduring appeal of our speciality: its sheer complexity and variety.

Those qualities were certainly in evidence during the three day event where topics ranged from major ethical issues to how to improve the length of someone’s gait by sticking a piece of plastic tape on the floor.

The latter, in fact, came during the first session of the programme on movement disorders when Ann Ashburn, professor of rehabilitation at Southampton General Hospital, was speaking about the effectiveness of physiotherapy, particularly the use of visual and auditory clues, for people with Parkinson’s Disease. The session had opened with Romi Saha, consultant neurologist at Royal Sussex County Hospital, Brighton, on what to do “when the drugs don’t work”. Remedies ranged from the mega – £25,000 worth of deep brain surgery – to the micro: PD medication needs to reach the duodenum to be effective so might be better taken on an empty stomach or with small meals.

The relationship between low weight and a propensity towards dyskinesia was discussed by consultant physician Jagdish Sharma of Kings Mill Hospital, Mansfield, who stressed the need to aim for the lowest effective dose of levadopa per kg of body weight. Dr Sharma illustrated his talk with videos of thin patients suffering extreme dyskinesia as well as a slideof Laurel and Hardy to illustrate body types.

More interesting visuals came from Catriona Good, consultant neurologist at Brighton and Sussex University Hospitals, who used outlines of humming birds, morning glory flowers and even a hot cross bun to aid the recognition of various pathologies in brain scans and from Khaled Amar with his films of sleeping patients with restless legs syndrome. “Some can have a hundred movements an hour with micro awakenings which lead to reduced sleep and efficiency”.

The Parkinson’s theme continued into the sponsored evening symposium where members heard of a new treatment whereby a gel form of levodopa carbidopa can be delivered directly into the intestine by a small pump worn by the patient.

Opening our doors
Brighton saw one of the first steps along the path to giving our meetings a regular multi-disciplinary input with a session devoted to nurse consultants specialising in care of the elderly. There are around 65 such senior nurses in the UK now, who have been meeting for six years. In late 2005, the BGS opened its doors to the group, as a first serious step towards making the Society truly multi-disciplinary. The group held its first AGM last year.

Their aim, as their chair Clare Abley from Newcastle explained, is to raise the profile of the nurse’s role in delivering expert care, to be a forum for sharing innovation and developments, to identify priorities for short and long-term research and to foster whole-person centred care.

It was a lively and informative session which included details of specific projects such as the nurse-led intermediate care services in Derbyshire as well as ongoing concerns over dignity and privacy for elderly people. During her talk on the need for ‘zero tolerance of lack of respect’ Sally Mansfield, nurse consultant at Leeds Teaching Hospitals Trust, asked members to spend a minute thinking about what would be their greatest worry in this area if they themselves were elderly residents in care homes and then another minute working out possible solutions.

Two female members who said they had recently given birth revealed their fears about not being given enough time or a secure enough environment in which to bathe or shower. Prof Graham Mulley said that he feared being “horribly constipated and nobody noticing. I want someone to ask me about it out of earshot of everyone else, to give me access to lots of fruit and vegetables and the chance to go for a walk if I’m physically able to do so.”

The session also highlighted a troubling attitude among nurses towards care of the elderly. A Dutch survey of 113 student nurses and 90 nurses in their mid-30s found limited, even poor, knowledge and attitudes that were at best netural and at times negative. Only 1.3 per cent said they actually preferred working with older patients. “Care is seen as too basic, the complexity of the job is not recognised,” said Marieke Schuurmans, associate professor of care of older persons at Hogeschool Utrecht. “Changing these attitudes is a great challenge but it has to be done.” Demographic changes would mean that even if they had not chosen the speciality, most nurses were sooner or later going to find themelves nursing the elderly.

Fighting sepsis
The conference’s reputation for attracting experts who can make their field both accessible and fascinating was further reinforced by its two guest lecturers. Jon Cohen, professor of infectious diseases and dean of Brighton and Sussex Medical School, painted a dramatic picture of the fight against sepsis.

“Severe sepsis and mortality increase with age: at 50 to 60 the graph really takes off,” he said. Switzerland has the lowest death rate in Europe, Portugal the highest – “probably related to the availability of intensive care units” - with the UK and Ireland towards the top of the middle cluster. “Overall mortality is around 30 per cent, despite ICU care and antibiotics. This is a bad disease.”

The favourite target for sepsis, a systemic inflammatory response to infection by a microorganism, is the lung (47 per cent of cases) followed by the abdomen (15 percent) and the urine (ten per cent). What makes tackling it particularly difficult is that in acute cases there is no time to wait for laboratory tests to identify the pathogen responsible.

“You have to make an empiric judgement about treatment. If you guess right the patient is much more likely to survive but if you get it wrong you can get it very wrong.”

We are also, he added, not very good at recognising the condition in the first place. “It’s easy in advanced cases when the blood pressure is in the boots but we’re very bad at picking it up in the early stages.”

Understanding of sepsis has changed over recent years. It used to be thought that the storm of over-reaction by the body to the pathogen was essentially an uncontrolled immune response until it was established that its incidence also occurred in patients who were immuno suppressed by old age or chronic illness. The good news, however, is that increased understanding is leading to new developments in treatment. These include activated protein C, low dose steroids, intensive insulin therapy, statins, Eritovan and immuno nutrition.

“Though we need to retain sepsis as a clinical term we should try to abandon the idea of finding a single drug and focus instead on specific infectious diseases. As with cancer there is not going to be one answer. We should go for an incremental approach rather than the big bang.”

Stroke management - what’s new?
The other guest lecturer was Hugh Markus, professor of neurology at St. George’s University of London who spoke on new ideas for stroke management. Strokes cost the UK £7bn a year in mortality and morbidity. But although patients take up a lot of nurses’ and therapists’ time they take up much less of doctors’, particularly compared to some other countries which deal with the problem more proactively. Many European countries, for instance, admit all transient ischaemic attack patients because the risk of TIAs being followed by a stroke is much greater than was previously thought. The key to the efficacy of treatments such as carotid endarterectomy is speed: benefits tail off if they are done after a few weeks.

Similarly, thrombolysis for acute ischaemic strokes tends to be more effective the sooner it is given. Prompt treatment also lessens the risk of transforming infarcts into haemorrhages. New developments currently being trialled include fast tool screening by paramedics, augmenting thrombolysis with ultra sound and alternative mechanical procedures for dealing with a clot. Advances in brain imaging are increasingly able to identify salvageable tissue.

“Improving acute care would mean a better outcome, long term cost savings and a reduced risk of recurrence.We also need to educate people to realise when they’re having a stroke so they can phone an ambulance. Getting patients to present earlier is a major challenge but the cardiologists have done it.”

Blacks, whites and greys in between
It was not just physical conditions that the meeting covered of course. In the capacity and consent session, for example, Premila Fade, consultant in medicine for the elderly at Poole Hospital, gave an elegant account of the history of the philosophical and legal concepts of autonomy and the radical rethinks of recent years.

“In the past the legal system was very deferential to doctors: if you could find a body of medical opinion to support you, you were OK. So in 1974 it was not negligent not to tell a patient about the risk of spinal surgery because other doctors routinely did not.”

That has now changed following a case in which it was ruled that a eye surgeon was negligent in not telling a woman he was about to operate on that there was a minute risk of 1 in 14,000 attached to the procedure. Information must now be given according to what a ‘reasonable’ patient would want to know. It must be “‘significant, specific and include details of alternative treatments.”

In terms of someone’s capacity, an unwise or seemingly irrational decision is not evidence of incapacity. “A key part of autonomy is the right to make our own mistakes. This is not a black and white area but very grey and case specific. There was a patient in Broadmoor who developed gangrene but refused amptutation. He said he would rather die with two legs than live with one. Although he had had schizophrenic and delusional episodes in the past, the court ruled that he had the capacity to make this decision which was logical to him.”

Mind and body
Similarly, in the last session of the meeting, a symposium on rehabilitation Raymond Tallis, emeritus professor of geriatric medicine at Manchester University (and recent Desert Island Discos guest), outlined our notions of mind and body from the Cartesian concept of dualism – the ‘ghost in the machine’ – to our current understanding of the endless interplay between the physiological and the psychological. Today we appreciate that psychiatric illnesses such a schizophrenia and depression have biological and neurochemical components and that physical conditions can be affected by emotional components such as stress.

Mental states can therefore affect physical recovery as the following speaker Marie Johnston, professor of health psychology at Aberdeen University explained. Motivation, for example, is greater when patients have a sense of self efficacy, the confidence that they can perform a behaviour and and achieve an outcome. Rehab experts are now fine tuning techniques to boost confidence and maintain a positive, persevering mood.

In the previous session Andreas Hiersche, Macmillan consultant in palliative care for the South Downs Health NHS Trust, had tackled one of the most difficult areas in geriatrics – end of life issues. Talking about the question of food and water in the terminal stages of an illness he outlined some of the big questions. Not eating and drinking could be part of the natural process of dying – and even a conscious choice for some patients - but how uncomfortable is it to die without nutrition and hydration? Are lethargy and blurred consciousness part of that same natural progression or are they a result of dehydration? Is a dry mouth the same as thirst? How do you balance the risks and burdens of artificial feeding against the need for symptom relief?

“Malnutrion is always a risk for the elderly and we have an obligation to ensure that those who can eat have something to eat but where death is imminent the position changes. It can though, be extremely difficult to estimate how long a patient will live: different diseases have different time scales.”

The problems were compounded by the public reluctance to get involved in any discussion of dying. His conclusion was that there could be no blanket policy but a symptom focussed approach would offer the best source of comfort and good care.

Dr Hiersche was followed by Douglas Chamberlain, visiting professor of cardiology at Brighton University, who spoke on cardiac resuscitation in the elderly.

Although such factors as comorbidity and inflexible chest walls made skeletal and other trauma more likely – “cautious compressions save bones but not lives” – there was no evidence of an increase in cerebral impairment in patients who survived. “If the heart recovers so might the brain at all ages. Resuscitation is not futile especially if there is a shockable rhythm.”

0 = dead; 100 = great
At the same time people needed to be aware that the rate of success was not the same as that portrayed optimistically in television dramas. Patients also ought to be encouraged to discuss the concept of ‘do not attempt resuscitation’ directives. “Their views ought to be properly recorded and reviewed regularly.” To warm applause he added: “Us elderly have the right to die with dignity but also the right to the best medical care and it’s hard to get the balance right.”

A speaker from the floor who had trained under the eminent cardiologist provoked laughter when she recalled his ONF ‘diagnosis’ or Overall Nick Factor – “where nought is dead and 100 is great.”

Changing misconceptions
Correcting misconceptions or shedding new light on seemingly familiar conditions can be one of the most valuable aspects of the meetings. Presenting a paper on the consequences of an increasingly overweight elderly population, Dr Iain Lang from the Peninsula Medical School in Exeter, pointed out that although we are constantly reading about fat children the greatest weight increases are among 55 to 74 year-olds. Obesity at the age of 50 doubles or triples the risk of mortality. In the older age group, 65 – 70 year-old, however, the risk of mortality is not increased though the risk of disability is. “So they don’t die but they need extra health care with all the associated costs. This could be a double whammy.”

Though obesity brings problems it may also have some benefits as was mentioned during the Friday breakfast symposium on osteoporosis (well attended despite the revelry of the previous evening). Along with postural instability, frailty, slow responses and environmental factors, ‘lack of padding’ was a factor in fall related fractures. The session also heard from Steven Boonen, professor and consultant in geriatric medicine at Leuven University, Belgium, on the effective role played by strontium ranelate in women over 80.

Another frequent misconception is that a first epileptic fit is uncommon in the elderly. On the contrary, Raymond Tallis pointed out in a well-attended breakfast symposium on the subject, the biggest group of first timers - up to 50 per cent of epilepsy sufferers - are the over 60s.

“A seizure is an unpleasant experience which can have physical consequences like a fracture and can also have psycho-social consequences. Like a fall, a seizure can be a watershed in someone’s life, making them lose confidence and become afraid to go out.”

Diagnosis was not always easy but the key issue was to distinguish genuine epileptic seizures from syncope caused by underlying heart problems. “This must be pursued vigorously. Very few people die of fits but people do die of undiagnosed cardiac arrythmias.”

His talk was followed by a discussion on how to set up an epilepsy in the elderly clinic and the role of the specialist nurse, led by Jan Bagshaw who has that position at Hope Hospital in Manchester.

Advances in technology and refinements of procedures mean that conditions that were untreatable a few years ago can today have very good outcomes. That was the message from Michael Eckstein, consultant ophthalmologist as the Sussex Eye Hospital. Remarkable results could now be achieved, for example, in the ‘wet’ or vascular type of macular degeneration; cataracts were done as day care surgery under local anaesthetic and diabetic retinopathy was usually caught early by digital photoscreening.

White noise and ambience
This was the Society’s first visit to Brighton, a place first made fashionable by the Prince Regent in the 1700s and then popular by the Victorians with their new railway, extravagant piers and fondness for seabathing. Since then the city has combined a rather racy reputation – it was classically the destination for a naughty weekend – with the artistic, creative and sybaritic. Its 400,000 inhabitants for instance have more bars and restaurants per capita than anywhere else in Britain – attractions probably sampled by many members after the intellectual rigours of the day.
More than 600 attended the conference – the most since the move out of London three years ago – and feedback suggested that most did in fact like to be beside the seaside. Some felt the centre itself – home to many a party political conference and rock gig – was rather hard to find one’s way round initially and that perhaps the interior felt a little ‘tired’ (it is due for a major revamp). Set against that was the appeal of the location itself and its convenience, good rail links and proximity to Gatwick making it easily accessible for visitors from Scotland and Ireland and particularly from overseas.

Other sessions included:

Dementia Update
Dennis Chan, consultant neurologist in Brighton gave a systematic analysis of the topic – “Neurodegeneration: Can we prevent it?”. He concluded that due to evolving knowledge and research probably we will be able to prevent it, at some point in the future.

Ken Miles, professor of imaging at the Brighton and Sussex Medical School, gave a detailed presentation which included a review of imaging techniques available and their roles. He referred to the NICE guidance on imaging and also discussed the potential cost/ benefit implications of making a correct diagnosis of the dementia subtype, versus the cost of treating a patient diagnosed using clinical assessment alone.

Diabetes and Endocrine Update
Dr John Quinn, consultant in diabetes and endocrinology in Brighton discussed the concept of insulin resistance, the clinical issues and broader social and public health implications.He explained how the reduced biological response to insulin results from a complex intracellular pathophysiological process and highlighted the implications of the metabolic syndrome with regards not only to insulin resistance but also including hypertension and changes in blood cholesterol. Measurement of waist circumference is key in the diagnosis of metabolic syndrome, and treatment options must be based primarily around life style advice as well as possible therapeutic options.

Dr Steve Holt, consultant nephrologists at the Royal Sussex County Hospital, explored why renal function worsens with age and whether this is a physiological or pathological process. He concluded that renal dysfunction is common however it remains unclear whether this is due to the kidney ageing or the result of co-morbidities. Key factors are undoubtedly hypertension, diabetes, vascular stiffness, angiotension II and nitric oxide. It was postulated that salt intake may also be important due to data from Kuna Amerinds of Panama.

Dr Anna Crown, consultant endocrinologist at the Royal Sussex County Hospital in Brighton, discussed the factors involved in the awareness of hormone therapy amongst our ageing population. Dr Crown explained that hormone treatment is a balance of risk and benefit which has been highlighted by the HRT evidence which evolved over time. Studies of hormonal therapy are variable in the elderly with inconsistent results and a lack of important outcomes. The take home message from this presentation was that this is a complex subject in which applying therapies indicated for patients with pituitary dysfunction to an elderly population with a view to “maintaining youth” is probably not recommended.

Hospital acquired infections
Alison Holmes, director of infection prevention and control at the Hammersmith Hospital, London, described the tremendous importance of optimising preventive and management strategies for hospital acquired infections, particularly referring to clostridia difficile associated diarrhoea (CDAD). She highlighted some potential improvement strategies and was optimistic that clinicians could use the current media attention and political agenda as a leverage tool to drive change.

Dr Martin Llewelyn, senior lecturer and consultant in infectious diseases at the Brighton and Sussex Medical School, spoke about necrotising soft-tissue infection (NSTI), urging clinicians to be aware of the infection when formulating a differential diagnosis on a patient with an area of presumed uncomplicated skin infection or deep vein thrombosis. He stressed that particular attention must be paid to symptoms (severe pain and risk factors including diabetes and alcoholism), signs (bullae, bruising, hypotension and pyrexia) and investigations (such as white cell count, C - reactive protein, serum creatinine) to aid early recognition during the lag phase, and stimulate urgent surgical and intensive care consultant review.

Acute coronary syndrome in the elderly and cardiac interventions
Stephen Holmberg focused on the use of drug eluding stents, which has shown promising results in the management of coronay heart disease. He presented research data comparing this with other forms of treatment. It seems a very good option for symptomatic angina with fewer complications when compared to coronary artery by pass surgery.

David Hildick-Smith gave an excellent presentation on the different cardiac interventions in the elderly. The three main areas covered in his talk were management of valve disease, structural heart disease and the use of pacemakers internal defibrillators.
Valve problems are common in the elderly but treatment options are limited because risks often outweigh the benefits, however newer treatment like percutaneous valvuloplasty will prove to be more useful with fewer chances of complications. There is however, less evidence for interventions in structural disease like patent foramen ovale and further trials are required.

There is no upper limit to the use of pacemakers in the treatment of bradycardias, its use for resynchronisation therapy in heart failure is still rarely used in over eighties.

The use of internal defibrillators has improved survival but their use in the elderly is still restricted due to various factors and the appropriateness of the procedure in this age group is debatable.

Heart failure and the Palliative Care Team
Jan McFadyen, nurse consultant in palliative care described the approach, which improves the quality of life of patients and families facing problems with life threatening illnesses like heart failure. Early identification and assessment of physical, psychological and spiritual problems is vital. She talked about the main role of palliative care team including the support of relatives, end of life initiative and advanced care planning. She concluded by outlining future challenges such as payment by results and PCT commissioning strategies.

Clinical update - Arthritdes
Ken Davies, professor of rheumatology in Brighton Medical School spoke eloquently about the diagnosis and management of the different types of arthritis in the elderly. He described the different presentations of arthritis in the elderly and how to distinguish between them with the use of different laboratory tests and imaging. He emphasised that a methodical history taking is important in order to come to a diagnosis. He discussed the pharmacological treatments including the use of immunosuppression.

Falls and Bones
Dr A Johansen showed that there is considerable evidence to suggest that delay in hip surgery is detrimental. In this audit done in University Hospital of Wales, Dr Johansen and his colleagues found that a significant number of delays were caused for anaesthetic reasons. He looked at the different groups of patients identifying the high-risk groups and the implications of delayed surgery in these. He suggested that the problem could be minimised by changing our practice.

Diabetes
Dr Simon Croxson, who has a special interest in diabetes in later life, talked about the management of late onset diabetes, focusing mainly on insulin therapy.
He discussed some useful points for general physicians such as, when to start insulin in the elderly; the positive and negative points of insulin therapy; which insulin to use and what to do when switching from oral therapy to insulin.

He described the various types of insulin available, highlighting the pros and cons of novo mix insulin, glargine insulin and the newer levemir isulin. He also talked about the various devices used to inject isulin and the practicality of using them. He concluded his talk by enlightening us about the exciting new therapies such as glucagons like peptides, exanetide and inhaled insulin.

Vascular Surgery Update
Aortic aneurysm rupture is associated with high mortality in the elderly. In his talk Mr Waquar Yusuf discussed how we could potentially reduce the risks of this happening. He described it as a common condition, which could be easily picked up by the use of ultrasound scanning and the cost implications were half that of screening for breast cancer. He spoke about the current guidelines, which is to screen men from their 65th birthday and discussed the treatment options and when and whom to treat.

Open surgery is associated with high mortality and morbidity is being replaced by endovascular surgery, which seems a much better option. He presented the evidence from two important trials EVAR 1 and EVAR 2, which has had a major impact on our practice. His conclusion was that in carefully selected patients the outcome of intervention was promising but more resources were required.

Liz Gill, Freelance Journalist
Nabarun Sengupta
Charlotte Willis