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The importance of geriatrics to the future of mankind was spelled out at this year’s spring meeting, by leading academic and educator, Lord Sutherland of Houndwood.

He had attended recent ministerial discussions on the government’s budget for research councils. “We were told the three major issues facing us were climate change, the provision of clean water and ageing and demography,” said the Provost of Gresham College in London who gave the guest lecture on the final morning of the conference, “That’s the size of the issue and the company it keeps.”

Currently in the UK for every three people of working age, one is pre-work or retired; within three or four decades the proportion will be two non–working to every three working members of society. In some G7 countries, such as Japan, the situation would be even worse.

“China has famously had a one child policy for a long time, which has been good for limiting the population, but what is it going to do, as these single children are faced with so many older people? These differences are beginning to make themselves felt in a country which has a quarter of the world’s population.”

Ageing was changing our culture and our civilization. “Unless we take it on seriously we’ll be in terrible difficulties. It’s good news in so many ways. As a 65 plus year-old man I think it’s marvellous, but we have to think about the implications for the economy and our way of doing things.”

The retirement age, for example, had to be reconsidered. One approach might be for people to take more time off when they had young families, on the understanding that they would then be active until the age of 70. Housing was another issue. “At the moment we have flats, semis and detached houses, and the residential homes for when you encounter problems, but that won’t do for the future”. We needed to think differently and look at beacon schemes like the £21m Rowntree ‘care village’ project. Telecare was another avenue, he added, citing the example of a woman in Kent who’d been admitted to hospital 26 times in a year because of niggles about her health. Since a telecare programme had been introduced these had dropped to two a year. Still in the field of technological innovation, South Korea planned to give everyone a ‘houseworking robot’ by 2010.

“The speed at which things are happening is incredible but we need a new vision of how society operates. We need to think of the talent and capacity of people now living into their 70s and 80s and how they can contribute to society. To do that though, you’ve got to meet their transport, housing and other needs. You’ve got to integrate health and social care.”

It was therefore essential to debate how money was spent. “They say they can’t afford finance for personal care but the cost is minimal compared to the total that goes into care of older people in the community. At the moment attendance allowances, housing and disability benefits are all portioned out in bits. We need to think coherently about these vast amounts of money.

“You as geriatricians must contribute to this new vision. You have the expertise because of the profession you’ve chosen. You need to use your influence to make people in power think imaginatively and long term.”

Doing health remotely
The potential of telecare and e-health to future geriatrics was cited by other speakers: indeed every BGS conference these days seems to bring news of exciting new developments both here at home and from half way across the world. Richard Wootton, director of the Scottish Centre for Telehealth in Aberdeen, for example, described a scheme for online assessment and reporting which had been developed in Queensland.

The system had been set up as a way of tackling both the shortage of geriatricians in the area and the vast distances involved. Superimposing a map of Great Britain onto this section of Australia to show the scale of the area, Dr Wootton pointed out that 20 of the 38 health districts had no access to a geriatrician. “There aren’t enough to go round and the huge distances mean bringing patients to doctors or doctors to patients on a regular basis is very difficult. The third alternative is to manage at a distance.”

The system set up at Toowoomba Hospital therefore, began with a standardised screening for all elderly patients on admission, done by a specially trained nurse. The data was fed into a computer and presented on a web base in a clinician-friendly formula to be reviewed by a geriatrician in Brisbane, who could then add comments. There were also weekly care conferences by video link and virtual ward rounds where specialist and patient could speak to one another through TV monitors. “None of the patients seemed to have any reservations about this. For anyone who was hearing impaired we could simply turn up the volume.”

The system’s effectiveness had been tested by asking geriatricians to diagnose dementia in 230 paired cases. One set was assessed by video link, the other by face to face consultation. Results were the same for both methods. Though further studies were under way, anecdotal evidence to date from over 1,200 assessments showed reduced length of stay and readmission rates. This is e-geriatrics of the 21st century in Australia.”

In another session devoted to the Telecare and Telehealth Special Interest Group, members heard from Chris Nugent, reader in computer science at Ulster University, how cognitive prosthetics can improve the level of independence in those with early dementia. The top four needs were help with memory, daily activities, communications and feelings of safety.

Devices already in use or in development included item locators, video and phone prompts and webcams linked to carers. “So you can have messages saying ‘put your lunch in the microwave, take your medication or make sure the door is locked’,” he said. “People always say they would rather stay at home even if they’re at risk. The idea now is to tailor the support to the effects caused by the impairment so that they can experience greater autonomy and feelings of empowerment and thus an enhanced quality of life.”

A key element currently being worked on are portable versions of assistive technology, particularly using mobile phones. “Otherwise the fear is that you put so much technology into the home that people become afraid to leave it.”

The session also heard from Frank Miskelly, consultant physician at Charing Cross Hospital in London, about the use of electronic bed and chair monitors in falls prevention. Here, pressure pads under chairs during the day and mattresses at night worked by alerting nurses or carers when the seat or bed was vacated, either by sounding an alarm (with different tones for different patients if that was helpful), or by flashing a light at a nurses’ station to avoid disturbing others. “People say we’re planning to use this kit and take away carers but I want to stress that the idea is to keep carers and add this additional safety factor”

Although the system couldn’t always prevent falls it could stop wandering and prevent anyone lying on the floor for long periods. “It can reduce the need for physical and chemical restraints and can reassure staff and relatives.”

Earlier in the afternoon David Craig, senior lecturer at Queen’s University in Belfast, had outlined some of the technologies available to monitor tremor and difficulty in movement in patients with Parkinson’s Disease. Such data could then be related to when someone was on or off their medication. Another device was the invention of the ‘smart cane’ which helps users maintain their gait by emitting a red laser line in front of them.

As technology progresses - especially if a device has commercial potential - it should become cheaper and more readily available. Low tech measures, however, can still be extremely effective as the first session of the meeting learned from American fitness expert Miriam Nelson, director of the John Hancock Centre for Physical Activity and Nutrition at Tufts University in Boston.

A little pain for a lot of gain
Giving the guest lecture on physical activity training for older people, Dr Nelson outlined some of the benefits of aerobic exercise including reduced risk of coronary heart disease, depression, osteoporosis, diabetes and hypertension. Muscle strength and metabolic rates could be boosted and bone health and balance improved. Studies suggested that the best effects came from moderately intensive exercise for 30 minutes five days a week or from vigorous exercise for 20 minutes three times a week. “This is relative intensity – what older people themselves see as intensive, not some super fit ideal.”

Strength training twice a week had helped one group of women aged between 50 and 70 gain muscle mass and bone. In another project 72 per cent of exercisers had been able to reduce their medications. Conversely the less fit people are, the faster they get to the disability threshold.

Though the benefits of exercise were clear, actually getting older people to do it was more complex, dependent on emotional, mental and societal factors, even, as Dr Nelson acknowledged in response to a question from the floor, on whether the doctors recommending it undertook exercise themselves.

Showing slides from a group in Alaska, she described the success of America’s community based programmes currently running in 33 states and led by 1,600 specially trained health professionals. “They’re done in convenient, familiar surroundings in comfortable atmospheres. They don’t have the cost or intimidation factors of gyms or other fitness centres which can be very daunting to a 75 year-old woman.”

Exercising in old age can mean breaking the habits of a lifetime for some women. In the US only six to eleven year-old girls do any meaningful physical activity. “It’s abysmal but the UK is not much better.” Frailty, she stressed, was not in itself a contra-indication. “Some conditions are not appropriate but generally, inactivity is more risky at any age than inactivity.”

Her call to action was followed by a review by Tracey Howe, director of HealthQWest at Glasgow Caledonian University, of 34 studies involving nearly 3,000 participants which showed that exercise, including walking, had led to a significant improvement in balance ability, particularly in gait, coordination and muscle strength.

Bony Issues
Bones, bone health and its related issue of falls and fractures featured high on this meeting’s programme with no less than three sessions covering in some measure to preventing falls. Good attendance of the excellent Servier sponsored session at first sparrow’s cough on Thursday morning attested to the magnitude of the problem of falls and fractures in geriatric practice.

Prof David March of the Institute of Clinical Orthopaedics and Musculoskeletal Science in Stanmore argued for treating falls and fractures as a chronic condition, requiring a comprehensive model to manage fracture and fracture risk, as we have with cardiovascular disease. “Fracture leads to Fracture,” he said, flashing up a slide of the osteoporotic ‘career’ showing the progression from Colles’ to vertebral fracture and finally, to the dreaded hip fracture - a process spanning a 40 year period - a clear indication of falls and factures constituting a “chronic condition”.

Dr Angela Campbell, consultant physician in medicine for the elderly at Victoria Infirmary, Glasgow, followed with a presentation on the evidence base for various treatments available in treating osteoporosis and preventing hip fractures. Among treatments available, Dr Campbell pointed to the Boonen et al 2005 study which indicated that little evidence currently exists to support the efficacy of bisphosphonates in reducing the risk of non-vertebral factures in women aged 80 and older. Strontium Ranelate, on the other hand, is shown to reduce non-vertebral fracture risk in patients aged over 80 years. The NICE HTA consultation document (2008) recommends this as a second line agent behind generic Alendronate, she said, but only on the basis of cost. Dr Campbell argued that the evidence base indicates Strontium Ranelate as a first line treatment, particularly in the very elderly.

Dr Cooper presented the dilemma faced by GPs who are encouraged to prescribe Alendronic acid for those at risk of fracture, because it is cheap. Patients on Alendronic acid then often subsequently present with dyspepsia, being one of the contra-indications of Alendronic acid, for which PPIs are then prescribed, which in turn increases the risk of fracture.

Prof Tash Masud, Consultant Physician at Nottingham University Hospitals NHST, demonstrated the “FRAX” (the WHO Fracture Risk Assessment Tool) which may be used to estimate the risk of fracture even though the user may not have the patient’s BMD. The FRAX may be found at www.shef.ac.uk/FRAX/

Disability Paradox
At the opening of a session on evidence based rehabilitation, Shah Ebrahim, professor of public health and policy at the London School of Hygiene and Tropical Medicine, had described a fascinating study in Bristol which had traced 1,000 people from a pre-war nutrition and household income study and then timed them on a six minute walk. Those from a poorer household then, took longer to cover the distance now, suggesting that factors in infancy may have effects in later life.

Prof Ebrahim also referred to the ‘disability paradox’ where quite severely disabled people still maintained they had a good quality of life. The phenomenon was found in nearly a quarter of elderly affected people. The implication for rehabilitation was that it had to focus on social and psychological factors as well as physiological ones.

He was followed by John Young, professor of elderly care medicine at Bradford Teaching Hospitals Foundation Trust, on the need for properly integrated care for early discharge hip fracture patients and by Lynn Legg, CSO research training fellow at Glasgow Royal Infirmary, who gave a condensed history of the contribution of occupational therapy or ‘purposeful activity to achieve functional outcomes for health and healing’. It had first been noticed by Galen in the second century who said “employment is nature’s best medicine and essential to human happiness.”

A bit of spit
Sometimes improvements in health can bring new problems as Petrina Sweeney, senior lecturer in adult special care dentistry at the University of Glasgow, described in her talk on dental health in the older patient. “Thirty or 40 years ago, most old people had dentures, now 50 per cent have some of their own teeth. That’s great in one way but it’s also a problem as 90 per cent have caries. In fact the incidence of caries in those over 65 is higher than among 14 year-olds in non-fluoridated areas.”

Oral care often became very difficult in old age due to loss of dexterity through arthritis or other conditions. Dry mouth was often a problem – over 600 drugs have it as a possible side effect. “Saliva is such an important thing. It’s 98 per cent water but it’s incredibly complex. There are 10 to the power of 8 micro organisms per millilitre. We know of 350 species which we can cultivate and there are probably the same number again. It’s when the balance is shifted that you get problems. Saliva’s just a bit of spit if you have it, a nightmare if you don’t.”

Other conditions included gum disease, bacterial and fungal infections, herpes, cracks at the corners of the mouth and soreness caused by ill fitting or dirty dentures. One poor man had packed his with bread to make them fit and couldn’t remember when they had last been cleaned.

The slide of his mouth was just one of a series illustrating the effects of poor dental care. “You’re probably thinking I’ve chosen these to shock you but I’ve got 100s of others like them,” added Dr Sweeney. “The trouble is there aren’t enough dentists and hygienists to go round and we have to rely on other carers and in a lot of places like residential homes not enough is being done. Also, the mouth’s quite a private place so people don’t like to talk about it. But it’s so important – we eat and speak and socialise with it and we need to do that without pain or discomfort or embarrassment. If an older person’s mouth is sore or sticky or so smelly they can’t have their loved ones near or their grandchildren on their knee then we’ve failed them.”

Dignity - it’s so basic
Another impassioned plea for the need to remember the basics came from Jackie Morris, consultant geriatrician and chair of the BGS Behind Closed Doors campaign. In her address on dignity and respect in the care of the older adult she ran through a long list of examples of poor practice.

These included mixed wards with little privacy; ignoring patients’ requests to go to the toilet; telling them to wait or use an incontinence pad; insisting on the use of commodes or bed pans when they could use a toilet: “going behind curtains might hide you from sight but what about sounds and smells”; carelessness with poor hygiene: “one study showed that of 100 patients only one had their hands washed after going to the toilet”; scolding or humiliating incontinent patients; entering closed curtains without asking; leaving patients on bedpans for unnecessary lengths of time: “one of my juniors actually saw someone being fed while on a commode with the curtains open”; leaving them in soiled bedlinen; giving bed baths rather than showers: “this is a power inbalance - why are we still giving bed baths in the 21st century? You’ve got to be pretty sick not to be able to use a shower.”

Poor practice around food included assuming the elderly always wanted to have breakfast in bed or leaving meals out of reach.

“Equalities and human rights are being infringed everyday in hospitals,” she said. “We see frail older people losing them as soon as they go in. The lack of dignity in personal care needs and neglect is Victorian in some places.” Older people take up two thirds of hospital beds and failure to recognise their needs made the NHS inefficient and ineffective.

Best practice should site toilets adjacent to patient areas, make them easily accessible and clearly signposted with doors that closed. The flush mechanism and the paper should also be easy to reach. Hoists must protect modesty. Staff should respond politely and promptly and pro-active toileting should be offered with patients’ personal preferences and choices taken into account. “If you really need curtains, they should be closed with a notice on them telling someone to knock and doctors, who are often the worst offenders here, should be prompted on this.

“Patients of all ages and disabilities should be able to use the toilet in private. As soon as you enable people to get control of their most basic functions the sooner they’re able to move and improve.”

MRSA
Consultant medical microbiologist Stephanie Dancer from Lanarkshire was also a speaker with a powerful crusading message: the need to control MRSA in hospitals. “The burden is falling on the elderly. The official figures are the tip of the iceberg because some infections are not in the blood so they never get counted. But they get into an ulcer which then never heals or they wreck a hip replacement. They’re also extremely painful.”

In the pre-antibiotic Thirties staphylococcal infections killed 80 per cent of their victims. After the introduction of penicillin that figure dropped to 25 per cent but had begun to creep back up only ten years later. “Luckily we had methicillin but it shows how fragile our hold is.”

Her answer to those who say the current outbreaks mark the end of the era of antibiotics was “not quite – we do have other agents in the pipeline” - but it was still vital to have better control.

Dr Dancer then ran through the various strategies. She believed isolation worked but was rarely done properly – doors were left open for instance, gowns and gloves not worn. Similarly topical clearance was done inefficiently in many cases with, for example, fingernails forgotten. Screening every patient was time consuming and costly and few places had enough laboratories or infrastructure to cope.

One of the problems was that cleanliness was hard to measure. “You get people walking around with clipboards and all this deep clean stuff about walls and floors but these organisms are invisible. And we don’t get infections from walls and floors, we get it from hand touch sites. Most organisms are on medical equipment which is the responsibility of nurses anyway, not cleaners.”

There was a correlation between infection and crowded wards and understaffing but none between infection and whether doctors went tieless or wore short sleeved shirts. “Hand washing is the single most important thing but overall compliance is poor. One study showed a take-up rate of only 22 per cent. It happens because medical staff are busy and our culture has led them to be reliant on antibiotics. It’s been said that because the number of people killed by MRSA now exceeds the number of people killed on the roads there should be cameras by washbasins.”

Consumer issues
Patient satisfaction is obviously of great importance to any doctor who cares about the experiences of those in his or her care as well as to the NHS in general. But measuring that satisfaction is not as straightforward as it might seem, as Vikki Enwhistle, professor of value in health care at the Universities of Dundee and St Andrews, explained in the session on consumer issues.

“Satisfaction rates are often very high, especially among older people. But that can sometimes tell you more about patient characteristics than about the quality of the services. People often say things were OK despite poor experiences. They do this possibly because they ignore a few negatives if the overall experience was good. They might also make allowances for certain conditions or think they weren’t entitled to something. They may use “satisfied” to express only moderate contentment or they may fear negative answers will be disclosed and make them vulnerable if they’re still dependent on the service. They may be influenced by gratitude and loyalty and concern not to make things difficult for the staff. There may also be a self protection mechanism of orientation to the positive – the ‘it wasn’t too bad’ mentality.”

Alternatives to satisfaction surveys included approaches which asked whether something was important on a scale of “very” to “not”, or asked about performance, about what actually happened. “These other types tend to be less positively skewed and less likely to obscure poor experience though there can still be some ambiguity about interpretation”, she added. Her other tips included choosing surveys that were fit for purpose, paying attention to domain coverage, asking about things that mattered, using cognition tests to check answers, using independent collectors and not someone involved in the care, and ensuring and reassuring about anonymity.

Glasgow - the ‘dear green place’
Over 500 members attended the meeting from all parts of the UK and all corners of the world including Australia, Canada and America as well as Europe and the Far East. As well as their professional interest in the programme many were no doubt drawn by the attractions of the City of Glasgow or the ‘dear green place’ to give it its ancient name.

Once in decline after the closure of industries such as shipbuilding, the old ‘Second City of the Empire’ has been given a new lease of life in various regeneration and renewal programmes. The conference was, in fact, housed in one such manifestation, the new Scottish Exhibition and Conference Centre on the banks of the Clyde and right next to the now famous ‘armadillo’ concert venue.

The theme was continued in the society’s dinner which was held at the newly refurbished Kelvingrove Art Gallery and Museum. Guests wandered through the beautiful galleries to survey a wonderful collection of art and artefacts to the accompaniment of a string quartet before sitting down to goat’s cheese and pepper roulade, Ayrshire lamb and seasonal vegetables and passion fruit tart. Chardonnay and cabernet sauvignon were followed for many by a ‘wee dram’ to accompany the laughter caused by after dinner speaker Dr John Paul Leach, local neurologist and stand up comedian.

Other sessions
A clinical update on the management of COPD in the older patient was delivered by Neil Thomson, professor of respiratory medicine at Glasgow University. The disease is currently the sixth most common cause of death in the UK and predicted, as the population ages to become the third by 2020. After outlining diagnostic techniques and treatment Prof Thomson argued the case for all patients to be considered for pulmonary rehabilitation, with assessment for long term O2 therapy during periods of clinical stability.

At another clinical update, this time on cerebro-vascular disease and stroke, the audience heard about the practical aspects of neuroimaging for older stroke patients from Andrew Farrell, consultant neuroradiologist at the Western General Hospital in Edinburgh. The important thing, he said, was to rule out haemorrhage. CT scans could do this quickly, easily – they took 20 seconds – and cheaply. MR scans which took at least ten minutes and were unsuitable if patients could not lie still or were confused, were best for late presenting strokes.

He was followed by Martin Dennis, professor of stroke medicine at Edinburgh University, who discussed the pros and cons of various ways of predicting outcome after strokes and Helen Rodgers, reader in stroke medicine at Newcastle University,
who spoke of the need for effective integrated care packages for early discharge patients. A third of stroke patients could be considered for such a system.

There were also sessions on heart failure, falls prevention and bone health, age related cognitive decline, renal disease in older patients and gastroenterology and clinical nutrition. The latter session focused on managing constipation, a common and distressing condition for many elderly people, via a range of approaches including diet, the role of probiotic drinks, the need for attention to mobility and oral care and when to use laxatives. The dynamics of defecating were accompanied by an illustration of the “bulge and brace” position.

After talks by Sian Jones, senior dietician at the Royal Gwent Hospital in Newport and Judith Ford, bowel specialist nurse at Nevill Hall Hospital in Abergavenny, there were updates on the latest pharmacological treatments and surgical procedures from consultant physician Nadim Haboubi and consultant colorectal surgeon Ray Delicata, both also from Nevill Hall.

Guest lecturer Stuart Cobbe, professor of medical cardiology at Glasgow University, spoke on the management of common tachyarrhythmias in the elderly with emphasis on atrial fibrillation and ventricular arrhythmias.

Atrial fibrillation is an important cause of morbidity and mortality in the elderly as it is both common and associated with a 75% five year mortality in the over 70 year old age group. Direct complications are thromboembolism as well as the less commonly recognised tachycardia related cardiomyopathy. The objectives of management remain thromboprophylaxis and rate or rhythm control.

Prof Cobbe also discussed the increasing evidence for the use of implantable cardioverter-defibrillators and cardiac resynchronisation therapy for both primary and secondary prevention of malignant ventricular arrhythmias in patients with left ventricular systolic dysfunction.

The final afternoon saw the critical appraisal/research methods symposium which is part of a new development exploring aspects of research methods and their importance for clinical practice. The session opened with David Stott, professor of geriatric medicine at Glasgow Royal Infirmary on the need for such appraisal even of articles in high ranking journals. Peter Sandercock, professor of medical neurology at Edinburgh University discussed the current information explosion and the impossibility of keeping up. Gwyn Seymour, professor of geriatric medicine at Aberdeen University, spoke about assessing quality of life, illustrating his presentation with entertaining examples from popular tv.

Liz Gill, freelance journalist
Additional reporting by BGS members Donna Clark, Peter Langhorne, Colin McCarthy, Alan McKenzie and Pamela Seenan

BGS Newsletter, May 2008
Issue 16 ISSN 1748-6343 16