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The selfish answer to the question ‘why do geriatrics?’ might be that one wants to get a good system in place for when one is old oneself.

That was the suggestion of Prof Colin Powell, one of the key speakers at this year’s BGS autumn meeting in Harrogate. And it was a sign of ageing, he said, when patients stopped asking ‘aren’t you a bit young to be a geriatrician?’ To laughter he added: “No-one’s asked me that for 15 years. In fact I was recently with two patients of mine, both in their 80s, and as I left the room I heard one turn to the other and say ‘he’s a nice old gent, isn’t he?’”

More seriously, he stressed the speciality was intellectually challenging and emotionally rewarding. “It’s certainly not all doom and gloom. It can be fun and it can be funny.”

Prof Powell who trained in the UK but later emigrated to Canada where he has since held three chairs - he is currently professor of medicine at the University of Calgary - was giving the Marjory Warren Guest Lecture with the title, ‘Whither Geriatrics?’

So he was looking to the future as well as recalling the first principles of our founder. “We deal with the frail old person and the definition of frailty is lacking general strength and being unusually susceptible to disease and other infirmity. Fifteen per cent of over-65s are frail, 45 per cent of over 80s.

BGS Autumn 2006 - Luminaries

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“We need to face up to frailty, we need to welcome it, to have frail-friendly hospitals and health care systems. A nursing home should be the equivalent of an intensive care unit - a place of real expertise, help and understanding.” A geriatrician, working with a patient’s family and friends as well as other professionals, should be a catalyst to speed a reaction in a certain direction.

As well as ensuring adequate assessment, accurate diagnosis, access to appropriate treatment and aftercare, Prof Powell believes we should now add advocacy to our professional aims; “advocacy for the vulnerable in partnership with the informed.”

Seniors themselves have a role to play in this. “It’s the job of feisty older people to criticise what they don’t like and to tell us what they do. In Canada they’re telling us they want independence, dignity, security, participation and fairness. They know they need a reliable health and safety net, they remember what people say and do, and they vote. There and here, they are our potential political allies. We all need to keep the fire in our bellies and to be in the forefront of the battle against the curse of ageism.”

Best place to grow old
The other guest speaker, Cillian Twomey, consultant physician in geriatric medicine at Cork University and St. Finbar’s Hospital and President of the Irish Gerontological Society, also looked to both the past and the future.

Only a few years ago, he recalled, headlines spoke of a ‘rising tide’ of old people who would be a ‘burden of care’ on younger generations leaving them ‘bankrupt and exhausted’. Today though, his country has an annual event, the Bealtaine festival, to celebrate positive ageing. “We are trying to make Ireland the best place to grow old.”

Geriatrics is growing as a speciality with at least one consultant now in every acute hospital. “We owe a huge debt to the UK because most of us have done postgraduate research here but perhaps this could become a two way thing,” he said and issued an invitation to British trainees to consider spending some time in Eire.

Much of what was happening there is encouraging, he added, showing a picture of a residential home with sea views ‘which could be a hotel’ but there were still problems.

He cited two contrasting situations. Patient A suffers an MI followed by complications leading to renal failure and the discovery of an incidental cancer. At each stage he receives the best treatment – “which is how it should be.” Patient B, however, has a stroke and is admitted to hospital.

“But then he doesn’t oblige the system by either getting better or dying. People are interested for a week or two but then he becomes what is perceived to be a problem.

“Why do we have a health system that spares nothing for patient A and then within a short time brings a totally different mind-set to patient B? It’s immoral and it’s not equitable but it’s increasingly prevalent in Ireland and I suspect here as well.”

There must be no battle between hospitals and communities: collaboration is vital. “There’s no reason why continuing care shouldn’t be in a place similar to where we’d like to live ourselves.”

Geriatricians and euthanasia
The distinguished geriatrican, poet and philosopher Raymond Tallis believes he learnt more about suffering when he spent two weeks at the bedside of his dying father than he did in his years as a clinician. “I think we doctors can often underrate the suffering of patients we see once or twice a week on a ward round.”

Prof Tallis, who was speaking against the motion, ‘Geriatricians must oppose the legalisation of euthanasia in the UK’, said he had initially disagreed with the recommendations of the Joffe report but had changed his mind after being convinced that the proposed bill contained all the necessary safeguards.

Helen Watt, director of the Linacre Centre for Healthcare Ethics in London, speaking for the motion, however, remained unconvinced. In countries like Holland, she argued, assisted dying had already been extended to those who had not given their consent, such as those with dementia.

Even when patients had requested it the cause may have been treatable depression or a desire not to be a burden either on their families or society. “Once the idea that a life is unworthy has taken hold you’re on a slippery slope”, she said.

Earlier the audience had heard barrister and former consultant physician Margaret Branthwaite outline the current legal position but also call for changes in the law. “I find it offensive that we call ourselves a compassionate society and yet people have to go overseas to organisations like Dignitas.”

Although the number seeking euthanasia would be relatively small – an estimated 600 out of 600,000 annual deaths – the issue is obviously one that will directly affect geriatricians and one about which they feel strongly. In an often emotionally charged debate speakers from the floor spoke not just of their ethical concerns but sometimes of their personal experiences.

And despite their being in effect two platform speakers arguing for euthanasia, an informal vote at the end showed a 50/50 split among members.

Clinical Effectiveness
Clinical and cost effectiveness, audit and evaluation are the buzz words of the moment so it was very useful for members to have a whole afternoon symposium dedicated to the subject. For although organisations like the National Institute for Health and Clinical Excellence are constantly in the news – and affect all our lives – we may not be familiar with their detailed workings.

To date NICE has carried out around 100 appraisals on pharmaceuticals (three quarters of its work), devices, diagnostic techniques and procedures including surgery. Around a quarter of its projects are cancer related. As well as research evidence it also takes patient experience into account, an approach which makes it unique among such bodies world-wide.

Prof David Barnett, chair of the appraisals committee, summed up the aim. “The definition of clinical effectiveness is how well something works in comparison with what we already use and how much more life or quality of life do we get for the extra money. In other words is it worth paying for?”

Cost effectiveness also looked at other outgoings associated with a particular treatment such as administration and social and economic consequences: would it mean the recipient no longer had to claim benefits, for instance? Would it help a carer?

He dispelled the idea that NICE set a cost effective threshold. Their recommendations were based solely on the benefit to the patient. It was then up to government to decide whether a treatment was affordable. “With something like statins, for example, the cost effectiveness to the individual patient is very clear but it would cost millions to prescribe to all who would benefit.”

Neither did they make judgements based on gender, behaviour or social class, and age was only relevant when it made a difference to outcome. “At the same time individual choice doesn’t trump clinical or cost effectiveness. A patient can’t say, ‘I want this drug so I must have it’.”

John Pounsford of NICE’s advisory committee for topic selection then ran through the selection procedure, ending with an appeal to BGS members to come up with suggestions, before Michael Pearson, professor of health outcomes at Liverpool, spoke about national auditing and the cultural changes that made society want to measure what the medical profession was doing.

The advent of personal computing, he said, had turned people away from the idea that doctors, once appointed, should be left to get on with it. “For the first time individuals could collect, analyse and evaluate their own data.” Auditing, he added, had already saved lives by identifying needs or by showing that simple things were not being done. “It can make care delivery safer and make us watch what we’re doing.”

The session ended with a rallying call to the BGS from Jonathan Potter, consultant in geriatric medicine at Kent and Canterbury Hospital and director of the Royal College of Physicians’ clinical effectiveness and evaluation unit, who told the meeting: “If we want the best care, we have to be influencing the national agenda”.

Small interventions - big benefits
One of the rewards of geriatrics is that often small interventions can have big beneficial effects. Cataracts, for example, affect mobility, independence and quality of life yet are relatively simple to deal with. The condition, opacification of the lens, is extremely common and becomes more so with age: it’s found in over two thirds of octogenerians, for example.

“If you live long enough you’ll probably get one,” said consultant ophthalmologist, Stuart Roxburgh introducing a talk on the subject and a video of an operation which he said he hoped was not putting his first-session-of-the-morning audience off their breakfast.

Although attempts at treatments date back to a thousand years BC, it wasn’t until half way through the 18th century that doctors began pioneering surgical techniques. Advances have moved rapidly even since Dr Roxburgh trained. Then it involved a general anaesthetic and a week in hospital. Today the procedure can be done swiftly under local anaesthetic with a very high success rate.

Surgery is desperately need in the Third World: cataracts are the most common cause of blindness accounting for around 40 per cent of the 37 million cases worldwide.

Falls and fractures
Fractures due to falls are similarly a commonplace problem – they take up two million bed days a year - which could be addressed by often inexpensive and simple measures. Early cataract surgery, in fact, helps prevent them as do strength and balance training and sorting out potential home hazards.

It is, however, according to Jonathan Treml, consultant geriatrician at University Hospital, Birmingham, and Opinder Sahota, consultant physician at the Queen’s Medical Centre in Nottingham, vital to do some joined up thinking on the subject.

In a breakfast symposium they argued that fracture clinics should screen for a history of falls and bone mass density while patients presenting with osteoporosis should be given falls prevention advice.

Studies were showing positive benefits from a combination of Vitamin D and calcium. The latest thinking is that this might have an effect on skeletal muscle function leading to better posture and balance.

Ageing in Prisons
A need for expert geriatric input into a new area was suggested by findings from the Memory Assessment and Research Centre at Southampton University who have been studying chronic disease in elderly life-sentence prisoners.

In a three year project looking at 181 subjects with a mean age of 64, who had been jailed for murder or serious sexual crimes, the team found that their biological age was on average ten years older than their chronological age. In almost every health category they scored worse than their counterparts in the outside world.

Although their problems had been imported into prison rather than developing there, they did have implications for the NHS which took the previously independent prison service health care into its remit in April.

With a prison population in England and Wales of 80,000 and rising, there were now long term implications for the NHS. Geriatricians, the researchers argued, should become involved in the assessment and management of this complex group.

Cerebral ageing
The mental health of old people was the subject of an update session with Robert Baldwin, consultant in old age psychiatry at Manchester Mental Health and Social Care Trust and James Lindesay, professor of psychiatry for the elderly at Leicester General Hospital.

“What’s special about late life depression,” said Dr Baldwin, “is that it goes alongside co-morbidity and it worsens the prognosis for many medical outcomes. It can lead to brain damage and brain atrophy

“It’s a risk factor for non-suicide mortality and a risk factor for dementias. It may have a neurobiological basis such as Parkinsons or stroke but being socially disadvantaged can also trigger it. So can medication.”

New treatments for later life depression ranged from the sophisticated such as transcranial magnetic stimulation to the cheap and simple such as exercise. A lot of advances were in the organisation of care, particularly collaborative systems between specialities.

For example, research was suggesting a link between depression and vascular disease: one study showed the risk of plaque formation increased two fold with a life time history of depression. “It’s two way traffic: you’re more likely to be depressed if you have vascular disease but you’re more likely to have vascular disease if you’re depressed. We need to treat both.”

Old age psychiatrists therefore need to know some geriatric medicine but geriatricians should also become skilled in the management of depression.

Highlights from other sessions
Delegates were treated to a Mancunian double act from Dr Bernard Prendergast and Mr Ben Bridgewater, who argued that with careful patient selection, age was not a barrier to performing valve replacement or repair. The take home message was to keep talking to your local cardiologists.

Dr Deepa Sumukadas from Dundee presented data showing that ACE inhibitors improve walking distance and quality of life in older people even without heart failure - a reassuring finding given the number of our patients taking these medications.

Lung cancer is undertreated in older people, and the assessment of performance status is rarely done, despite this being a key indicator of who is likely to tolerate and benefit from intervention. Dr Robert Milroy from Glasgow outlined current approaches to treatment of lung cancer, and suggested that the inclusion of a geriatrician in the lung cancer multidisciplinary team might help to improve care for older lung cancer patients.

Dr Avan Aihie-Sayer and colleagues from Southampton presented intriguing data on the association between the metabolic syndrome and sarcopenia as measured by grip strength. The rising tide of obesity suggests that dissecting this association will be of great importance if we are to maintain cardiovascular health and physical function in older people.

Dr Sinead O’Mahony from Cardiff reviewed the evidence on exclusion of older people from study protocols – a continuing problem in all fields, especially cardiovascular medicine and cancer. Despite some progress over the last decade, the mean age of trial participants in leading journals is still in the mid 50’s. A discussion followed, centred around a draft Charter for Prescribing in Older People. A draft of this Charter will be placed on the BGS website – please have a look and comment on it.

Constipation and faecal incontinence are core issues for all geriatricians – yet they are still not always well handled. Dr Jonathan Potter introduced the ‘Behind Closed Doors’ campaign for privacy and dignity in toileting. Digital rectal examination, rational prescribing, dealing with comorbid disease and regular toileting remain key features of the diagnosis and management of this important and still neglected problem.

Dr Bancroft from Keele University presented results of a five year follow up of stroke patients and noted that urinary incontinence remains a problem for up to 50% of patients, although the impact on quality of life is unclear.

Pulmonary embolism remains a difficult diagnosis, according to Prof Paul Collis of Newcastle University. The advent of D-dimer testing has led to widespread misuse of the test – it should only be used after assessing the pre-test probability of PE, and in most cases, further imaging is needed. Dr Tony Fennerty gave an excellent historical overview of the treatment of Pulmonary embolism from pre-war times to the present.

Topics covered by the posters on display ranged from education and training through health service practice and epidemiology to detailed analysis of current practice and pointers to future approaches.

Converting bullshit into plane tickets
Raymond Tallis, emeritus professor of geriatric medicine at Manchester University, who earlier in the day had participated in the euthanasia debate switched roles later to be the speaker at the Thursday evening conference dinner.

As well as such pithy remarks as ‘a professorship is a remarkable device for turning bullshit into plane tickets’ and a lively version of Henry V on his mobile phone before Agincourt, the man who is one of only two doctors in Prospect’s list of the top 100 intellectuals in Britain went on to make his own battle cry.

We needed, he said, to reassert the authority of the medical profession against Secretaries of State for Health who hated doctors. On a wider level there were assaults on freedoms that needed to be resisted.

Winds of change
The Harrogate meeting marked the end of Jeremy Playfer’s presidency. Paying tribute, the new president, Peter Crome said that he would be a hard act to follow. His achievements had included reorganising and strengthening links with the Royal College of Physicians, working with other professional and voluntary organisations and industry and expanding research.

“Jeremy is open, honest, friendly, self-effacing, always ready to acknowledge other people’s contributions and an enormous encourager of others, especially trainees. He is passionate about his profession and his speciality.”

Jeremy’s wife Liz was called to the platform to join her husband in receiving the Society’s farewell gift.

The winds of change could be blowing through BGS meetings. Numbers attending the autumn meetings have fallen over the past couple of years due partly, to the difficulties in getting time off and funding for continuing professional education and the increased bureaucracy which has made research projects more difficult to get off the ground.

In a session on the final morning, John Gladman, professor in the medicine of older people at Nottingham University, gave out a questionnaire asking for both gripes and suggestions. He wanted, he said, to make the event more interactive so that members could get the maximum benefit.

“Feedback is useful for speakers and reflecting on the conference can be a learning experience for you.”

Ideas for future meetings include public votes on poster and platform presentations, guest lectures cut from an hour to 45 minutes to allow for debate, availability of key slides for later use, splitting into smaller groups to explore clinical skills and the possible use of key pad technology for instant responses. Prof Gladman would welcome further suggestions.

Liz Gill, Freelance Journalist and
Miles Witham, Dundee