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The ideal geriatrician is someone who ‘knows something about everything and everything about something’, said Prof Graham Mulley as he opened his first conference since becoming president of the BGS.

He was recalling the definition as he contrasted the state of today’s society with how it was a previous time it had held its Spring meeting in Bournemouth 40 years ago.

Then there were only 100 delegates and all men. By contrast today’s 460 male and female attendees came from a speciality much risen in stature and now “infused with enthusiasm, goodwill and talent. Geriatrics is in good heart in Britain. There has never been a better time to be old and disabled.”

Reviewing advances both at and away from the conference, Prof Mulley cited continuous improvement in presentations and posters; the impressive resources of the website and Age and Ageing; the number of grants, awards and prizes now stimulating scientific endeavour and the influence on the Royal College of Physicians to make age-related themes the subject of major symposia.

But there was still much to be done. We needed to raise our still low visibility: a problem to be addressed by the appointment of Mrs Iona-Jane Harris, the Society’s first press, PR and parliamentary officer. The Society would also be seeking ‘rising stars and leaders of tomorrow’ for media training. “We need to be more vocal in championing the values we hold dear,” he added. “We’re not very assertive. We need to shout about injustices and inequalities,we need to be promoting dignity and combating the negativity of the pervasive current social model.”

Links with patient groups and charities needed to be strengthened and the skills of patients and their families harnessed. We needed to be more politically savvy, to nuture the talents of young members of the profession and to beef up the academic side: although there were now 53 chairs in geriatrics or related disciplines, many of them were still honorary.

Challenges for the future included the tensions between generalist and specialist geriatricians and between hospital and community. “The move to care outside hospital is now inexorable and we need to make sure geriatricians are more and more in the community.”

An unexpected cloud was the downturn in the economy. “Although we might not be entering a financial ice age as the prophets of doom claim, it is bound to have an effect on staff levels, bed numbers and services. We need to think seriously about health economics and any thoughts anyone has I’d be glad to hear them.”

From beyond our shores
One measure of how far BGS conferences have come is the degree of international input nowadays: guests speakers from halfway across the world, a dozen different nationalities in the audience and a whole session on dementia given over to a joint meeting of the BGS, the European Union Geriatric Medicine Society and the Clinical Section of the European Region of the International Association of Gerontology and Geriatrics.

Dementia, of course, knows no boundaries: there are an estimated 9.4 million sufferers in Europe. But as Emma Reynish, who helped set up and co-ordinate an Alzheimer’s Disease consortium based at Toulouse University, explained there can be wide variations in definitions and approaches. The UK distinguished between different types of dementia but that was not necessarily the case elsewhere: France for example used Alzheimer’s as a generic term.

Through Emma’s work with the ICTUS study in Toulouse, we learnt that important predictors of early presentation of Alzheimer’s dementia include being a male, taking anti-psychotics, and agitation – confirming what we all know, that being a stroppy male gets one’s attention!

Dr Reynish, who is now a consultant geriatrician at Victoria Hospital in Kirkcaldy, quoted President Sarkozy’s words on its Euro1.66 billion programme: “The mark of honour of a civilisation is that it offers help and protection to those who with the passing of time have become imprisoned in their own lives”

Dr M Baxter from the Royal Bournemouth highlighted how various psychomotor tests might help with predicting which patients with dementia might struggle with inhalers, but Adrian Wagg in typical geriatricianly style, reminded us that the best way of finding out if anyone can use an inhaler is to try them with an inhaler!

Nadina Lincoln from Nottingham presented work on psychomotor tests which might be useful in identifying unsafe drivers with cognitive impairment – one can only wonder how those without cognitive impairment might fare!

Finally, Dr van Munster from Holland presented some early work on understanding the genetic basis of delirium – and cleverly highlighted the importance of this work in identifying causal pathways. More to come in the future for sure.

The human story behind research
We saw a rare glimpse of the human story behind the bureaucracy of funding and awarding BGS fellowships. Three recipients of BGS grants/ fellowships gave us an insight into how the grant had changed their lives and the direction of their careers. One clear theme that emerged from all three presentations was their appreciation of having the independence to manage their time and the variety of tasks inherent in the research process.

While Emma Fletcher, Research Fellow at Sunderland Royal Hospital and recipient of the Kuck Fellowship could express appreciation for the support and leadership provided by her mentors, Anna Hatton, physiotherapist and recipient of a BGS/Dunhill Medical Trust Fellowship works in splendid isolation at the University of Teesside. The latter spent a year unemployed after graduation, which put paid to her intention to go into clinical work. She found herself working as a research assistant which, together with securing the Fellowship, has set her on a path to what she hopes will be a permanent career in research.

Simon Conroy, senior lecturer at the University of Leicester, formerly one of Professor John ("Gladders") Gladman's Nottingham "wunderkinder", and recipient of the BGS/RIA Dhole fellowship, presented a witty analysis of the life lessons to be taken from doing academic research and he too expressed a heartfelt appreciation for the leadership he had received from, among others, "Gladders".

"It's amazing to think that what we're doing can change medical practice in the future.", said Emma and indeed it is amazing, but the most poignant aspect of these personal stories was the knowledge that the BGS has played a part in the development of such confidence and passion for their careers, in these three young people.

Boo the villain
As well as the traditional format of speaker presentations followed by questions from the floor, Bournemouth also saw the expansion of other formats aimed at increasing delegate participation: debates, workshops, a masterclass and a ‘trial by jury’.

This conference saw a first when the BGS audience momentarily abandoned its habitual air of gentility and “hissed” as Dawn Garrett, Consultant nurse in Intermediate Care, Bournemouth and Poole Community Health Services, made the case for nurse led re-enablement services at home. "Who should lead?", she asked, pointing to a cariacature of a white coated doctor, "Him? Who consults for 10 minutes and goes away? Her?" (pointing to a blue uniformed therapist), "with her goal orientated programme which isn't holistic? Or her" (pointing to a picture of a nurse) "available 24 hours a day, 7 days a week?" As one of the trio batting in a debate for their service to lead renablement services at home (Richard Day for doctors and Nicola Bryan for therapists), Dawn was obviously aiming to provoke a strong reaction from her mainly doctor audience, and she succeeded! During question time, Dr Peter Murdoch expressed good natured shock at the divisiveness among the professions south of the Scottish border, but all ended with amicable consensus around Richard Day's view that leadership came from the person who in response to a patient's question: "I have a problem. Can you help?", could galvanise the intermediate care team to say "Yes, we can!"

Entrenched attitudes
Entrenched attitudes showed in the debate: ‘Complementary medicine should be used more widely in the NHS’. Speaking in favour, Dr Peter Fisher, clinical director and director of research at the Royal London Homoeopathic Hospital, outlined the latest research into the effectiveness of acupuncture for back and neck pain, St. John’s wort for depression, fish oil for joint pain in rheumatoid arthritis, echinacea for reducing the incidence and duration of colds and the benefits of chiropractic manipulation.

Modern technology was now illuminating the processes by which these measures might work. “Acupuncturists used to be thought of as mad Maoists but new MRI scans show changes in brain during its use.

“Reliable, quality assured information is now available for health professionals. There are safe and effective treatments for common conditions and they should be more widely used, especially where there is a lack of other treatments. Patients want them and if they’re properly integrated they can be cost effective. Just because we didn’t learn them at medical school shouldn’t deter us.”

Arguing against was Dr Dennis Johnston, consultant in geriatric medicine and professor of clinical pharmacology at Queen’s University, Belfast, who spoke of the ‘gullibility factor’. “Everyone is biased and people tend to observe what they expect.” There could be a placebo effect – “and remember, sometimes things get better on their own.”

The objections to complementary medicine included: absence of definable outcomes, too many disclaimers, universal diagnosis, exaggerated claims and the suggestion that conventional medicine was conspiring against it.

It was also unacceptable to say that they could not hurt. There could be the direct problems of toxicity or reactions with other drugs or the indirect ones of causing a diagnosis to be missed or a treatment delayed or stopped. Despite his spirited arguments, the almost unanimous “for” vote among a small, self-selected audience at the start of the debate for the motion, remained so at its end.

Deprivation of liberty
The Friday morning workshops were another departure from the usual format, requiring more delegate involvement. In the mental capacity one members were divided into groups, each with an expert facilitator, and given a scenario based on a real case history. The aim was to examine the concerns raised and suggest possible courses of action.

Before that, they were given an outline of some of the issues surrounding deprivation of liberty. Prem Fade, consultant in geriatric medicine at Poole Hospital, explained that essentially there was no exact definition that could be measured by a checklist: it depended on the circumstances surrounding each individual case such as the intensity and degree of confinement, whether it was cumulative in nature and the feelings of patients themselves and their families. So in one appeal, for example, a man’s family had objected to him being kept in a care home but the court had agreed to it as the man himself was happy to be there.

Deprivation of liberty might also be lawful if it was in a patient’s best interests to prevent him harming himself or others but it had to be proportionate and no more restrictive than it needed to be. “It’s not what you do but how you do it,” said Dr Fade. Locked doors did not always signify deprivation of liberty if that meant patients could wander freely in a safe environment.

Deprivation of liberty had to be authorised by a supervisory body and meet several criteria. In urgent cases, however, staff could make the decision themselves. “It’s important to stress to front line staff that where something needs to be done within the hour in the patient’s best interests then they must not get hung up on the issues. Authorisation can wait until the next day.” She cited various cases and their solutions. One was a patient with alcohol related dementia living in a care home who wanted to go to the pub and get drunk. The staff felt that should not be allowed but his daughter felt that the refusal was depriving him of his liberty. The decision was that the care home be required to provide an escort to take him to the pub three times a week for limited quantities of alcohol. Another example was a woman who was highly mobile in her wheelchair but so confused she was a danger to herself and others. The solution was to give her the freedom of the wheelchair when it could be supervised. Similarly complex dilemmas were then the subject of stimulating and enlightening group discussions.

Trial by jury
This was the other format, requiring delegate participation. It addressed the consequences of atrial fibrillation with various ‘charges’ being brought, including the need for significant improvement in its management and the underestimation by physicians of its impact on quality of life. Witnesses were called and cross-examined before a verdict was reached. This and the masterclass were two of several sponsored symposia at the event which also featured stands and displays from 21 pharmaceutical and other exhibitors.

Although the programme was, of course, primarily concerned with old age, it did feature one important ‘new baby’ - the Quality Care Commission.

Our second guest lecturer was Prof Allan McLean, associate dean at the University of Notre Dame in Sydney and director of clinical services at Werribee Mercy Hospital in Melbourne. Prof McLean,who is also a consultant in geriatric medicine, spoke about some aspects of Australia’s policy on ageing including strategies to promote older people in the workforce, particularly women, and to target the prevention of the common diseases which prevent people working in later life.

“It’s estimated that if 64 year-olds could be retained for only one more year there would be a ten per cent increase in the GDP. So we should start by being nice to them and paying them properly.”

Prof McLean then devoted the second half of his lecture to discuss in detail his work on age related changes to liver mechanisms.

There are 57 different medical and surgical specialities in Britain today and as geriatricians need to ‘know something about everything’ the conferences can provide valuable insight into those areas where their subject overlaps with another.

In the session entitled The Older Surgical Patient – A Guide for the Referring Physician, Andrew Severn, consultant anaesthetist at the University Hospitals of Morecambe Bay, spoke of the need for geriatric input before surgery was carried out. “We can all recognise the extremes of frailty, for example. We need you to tell us the borderline cases.”

He was followed by another consultant anaesthetist, Irwin Foo, of the Western General Hospital in Edinburgh, who looked at preoperative risk prediction in older patients. The mortality rate increased with the degree of invasiveness so it was vital to assess physiological ageing and see how much function was reduced. It was often necessary to follow questionnaires with ‘a reality check’. “Ask a patient who says they don’t have breathing difficulties to climb a flight of stairs, for example, to see if they really don’t. One of mine once collapsed. Patients who’ve waited a long time for an operation may gloss over difficulties for fear of it being postponed.”. New computerised risk assessments based on 12 physiological parameters could put patients into low, medium or high risk categories and help with post-operative placement.

Jugdeep Dhesi, consultant in geriatric medicine at Guy’s and St. Thomas’s Hospital, gave an update on POPS: Pro-active Care of Older People undergoing Surgery. The system included comprehensive geriatric assessment and the involvement of physio- and occupational therapists, and social workers as well the surgeon and anaesthetist. Over 600 patients a year were now being seen under the scheme which had reduced deferrals and cancellations, post-operative complications and length of stay in hospital. It was hoped other centres would adopt the model.

Computers, everywhere computers
Although there was no designated session on telemedicine at this conference, the role of computers inevitably appeared elsewhere. In a clinical update on orthogeriatrics, for example, Prof Cyrus Cooper, professor of rheumatology at Southampton University, referred to the use of a computer programme to assess the probability over ten years of a patient suffering a hip or other major osteo-fracture. The programme was useful, he said, in deciding on intervention thresholds. High risk individuals would be given immediate treatment, usually with alendronate, whereas mid- range ones could then have their bone density measured and be reassessed accordingly.

There were also clinical updates on cardiology and gastroenterology. In the latter, Trevor Smith, consultant gastroenterologist at the Royal Bournemouth Hospital, covered the diagnosis and treatment of oesophageal disorders and James Barrett, consultant in geriatric and stroke medicine at Arrowe Park Hospital in The Wirral, discussed the investigation and management of constipation in the elderly.

With a touch of humour - the ideal ‘Goldilocks stool’, for instance, would be not too hard and not too soft but ‘just right’- Prof Barrett stressed the need to investigate and deal with a problem that can adversely affect a patient’s quality of life and sometimes even be life threatening. And he was forthright about rectal manual examination. “Doctors don’t like doing it but sometimes it just has to be done and you need to lead by example.”

Constipation was in fact the subject of the first breakfast sponsored symposium when Adrian Wagg, senior lecturer and consultant in geriatric medicine at University College Hospital, London, spoke on the scale of the problem and its consequences. Its incidence was 20 per cent among the elderly in the community and 50 per cent in care homes. Causes included a wide range of medical conditions and drug side effects as well as age related changes like a loss of rectal sensation and a decline in the call to stool. “It has a very negative impact on quality of life. The distress can be so high that I’ve known patients actually welcome diarrhoea as a side effect of radiation.” Extreme cases could lead to sepsis, breathing difficulties, even death. Yet despite its prevalence and dangers there was evidence that the problem was often poorly managed.

Andrew Davies, consultant in palliative medicine at the Royal Marsden Hospital in London, said opioid induced constipation was a major problem for his cancer patients, occurring in up to 70 per cent. It could be caused by lower level analgesics as well as morphine and complications could include haemorrhoids, anal fissures, intestinal obstructions and perforations. Everyone on opioids should be put on prophylactic laxatives, he believed.

On a more cerebral level there was a Meet the Professors session. Prof Chakravarthi Rajkumar, professor of geriatrics and stroke medicine at Brighton and Sussex Medical School, outlined his department’s work on cardiovascular disease, the effects of the Mediterranean diet – they had done a study comparing old people in Brighton and Verona – and pro-biotics. And he called for geriatricians to be active in their hunt for research funding– “there’s lots of money out there.”

In a talk entitled ‘Beyond the black box’ Prof John Gladman, professor of medicine of older people at Nottingham University, spoke of the benefits of backing up randomised controlled trials with qualitative research to illuminate missing areas. “So you ask not just what the outcomes were but how they were achieved. You get a richer picture.”

A little play ‘midst all the work
The meeting was, of course, not all work and no play. With lovely weather and a conference centre just yards from the beach there were opportunities for delegates to enjoy being by the seaside. On the Thursday evening, the Royal Bath Hotel, once the haunt of Oscar Wilde, was the setting for the dinner. The after dinner speaker was former RAF pilot and air traffic controller David Gunson. As President Mulley reminded delegates in his introduction: “you don’t stop laughing because you grow old; you grow old because you stop laughing.”

Liz Gill
Freelance journalist, with a little help from
Simon Conroy, Senior Lecturer, Leicester,
Katy Ladbrook and Recia Atkins

BGS Newsletter, May 2009
Issue 21 ISSN 1748-6343 21