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The BGS must be more vocal in combating stereotypes and must act as an advocate for those it serves, declared Graham Mulley in his opening address to the BGS 2009 Autumn Meeting in Harrogate.

“Our work has been understated and underrated,” he said. “There is a new emphasis this year on highlighting the visibility of our Society and the key aspects of positive ageing care.”

Our focus this year, he went on to say, is to amplify the Society’s messages to new MPs expected to enter Parliament after next year’s general election.

Prof Mulley said that trainees, some of whom are already members of standing committees, “are our future” and the BGS continues to encourage them to take up quality research.

A further emphasis, hitherto a little neglected by UK geriatric medicine, is prevention - a notion rightly high on the Department of Health agenda. “‘It’s never too late’ could be one of our straplines.”

Multi-disciplinary partnerships
Geriatricians are working more closely with colleagues in other medical disciplines and forging stronger links with some of the Royal Colleges, said Prof Mulley.

He highlighted the Society’s work with many organisations and charities, including Help the Aged, Age Concern, the Stroke Association and Friends of the Elderly. “We are one of 58 medical specialist societies and in isolation our advances are limited,” he said.

It was a theme reflected in a sponsored symposium at which Dr Steve Parry, senior lecturer at the Institute of Ageing and Health at Newcastle University and chair of the BGS cardio-vascular section, asked: “How much of a cardiologist should a geriatrician be?”

“There is a lot we can learn from each other. Multi-disciplinary teamwork is now routine for cardiologists but incorporating the principles of geriatric medical care should be more easily facilitated.”

But while there is a high incidence of cardio-vascular disease in older people, there are not enough cardiologists in the UK, Steve said. “Chicago alone has more than the entire UK.”

The recommended number in the UK is 35-40 per million of population, which equates to around 2,250 - the actual number is between 750-800. Nor does the UK have an equivalent of the USA’s Society for Geriatric Cardiology.

Although there is no direct evidence that geriatricians are better than others at managing older patients with heart disease, there are examples of good practice.

Steve believes the BGS should look at better models of co-operative care, with both specialities needing to know when to refer patients to each other.

“Geriatrics” - boon or bane?
Geriatrics: a medical term with a long history and heritage used world-wide or an out-dated, derogatory and offensive word which has come to represent prejudices. The on-going debate on whether the BGS should change its name continued in a scientific presentation based on research by Dr Laura Murphy.

She looked at how often the term ‘geriatrics’ occurred in titles used by physicians and hospital departments and how many times it appeared in BMJ advertisements for jobs in the speciality.

Dr Murphy, who conducted the research during her Core Medical Training (CMT) in Leeds, found that the most commonly used word in all categories was ‘elderly’, with ‘medicine of the elderly’, ‘care of elderly’ and ‘geriatric medicine’ all among the descriptions. Although ‘geriatrician’ was often used in communication between health professionals, it was not a common term in job or department titles.

She found that of 331 posts in ‘geriatrics’ advertised in the BMJ, only 38 per cent used that specific term.

Anecdotally, when Dr Murphy telephoned hospital departments to check their titles, some secretaries made it clear that “patients don’t like the term ‘geriatric’.”

Audience responses included the comment from Prof Steve Jackson from the Department of Health Care of the Elderly at King’s College, London, that the most important piece of data would be the opinion of patients. “I have not met one who likes it,” he added.

Prof Mohan Datta-Chaudhuri, whose title is consultant in medicine for older people at Stockport NHS Foundation Trust, said research in his area through Age Concern showed that of 600 people asked, 599 did not like the term ‘geriatrics.’

But only one alternative was suggested in the debate – Senior Medicine.

Outside the conference hall, Graham Mulley, whose title is Professor of Elderly Medicine at St James’s University Hospital, admitted that, “if you ask four different medics, you’ll receive five different opinions!”

He felt it would be difficult to find a new name which reflected the different groups of elderly people who fall within the specialty remit. “There is almost an apartheid between the groups,” he said. “There is a huge difference between a healthy 70-year-old and a 90-year-old with multiple conditions. I have some 70-year-olds who are not happy to be called ‘elderly’.”

A poster in the Harrogate International Centre illustrated Prof Mulley’s point. In November this year (2009), Bill Wyman’s Rhythm (sic) Kings will be strutting their stuff on stage - one month after the former Rolling Stone’s 73rd birthday!

So, the debate goes on and will no doubt continue from time to time. Bill Hazard (former president of the American Geriatrics Society) said – ‘I am a geriatrician and proud of it.’ In the short term, we will continue to be “geriatricians” as changing brands is an expensive business. Perhaps the idea of putting on footnote on our letterheads, explaining the venerable origins of the word, “geriatrics” would be a sensible first step! Comments from the geriatricans’ gallery are always welcome.

Inside an old person’s head
In his guest lecture Prof Ingmar Skoog of the University of Gothenberg, whose main research interest is dementia and other mental disorders in the elderly, reassured his audience that “everything in old age is not depressing.”

He outlined the results of many long-term detailed studies into groups of older people, the most recent of which - into 70-year-olds born in 1930 and 85-year-olds born in 1923/24 – are just beginning.

The Professor in Psychiatry at the Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University, said that today’s 70 and 75-year-olds are completely different from those in the earlier Gothenberg studies which began in 1971.

“People are better educated, have better physical health and perform better in psychometric tests.”

Although dementia is common in old age, not all mental disorders in the old are dementia. Depression is more common than dementia at the age of 65 and around half the people with Alzheimer’s Disease are not demented.

Prof Skoog said that feeling life was not worth living was more important as a factor in dying than many other conditions.

In one study only four per cent of 85-year-olds with no mental disorder said they felt that life was not worth living.

“One man told me he was curious to watch his grandchildren grow up,” he said. “It is important to have a holistic view of all your patients.”

Talking about sex
“Sexuality in later life”, the State of the Art lecture by consultant Claudine Domoney, Chair of the Institute of Psychosexual Medicine, was timely – it came one week after the launch of Manchester City Council’s Guide to Good Sexual Health for the Over 50s whose £5,000 cost attracted controversial media coverage.

The consultant obstetrician and gynaecologist at London’s Chelsea and Westminster Hospital said her message was intended to reach health professionals including physicians, surgeons, GPs, nurses, therapists and medical students, who in turn could help patients.

“It is important for men and women to feel they can discuss sexual issues with their health professionals,” she said. “It may be that we are not ready to talk about sex. We are often frightened to ask in case we open a can of worms, raise patient expectations and then do not have a ‘specialist’ to whom we can refer.”

But she believes that simple questions – “are you in a sexual relationship?” and “do you have a partner?” – can open the door for patients to discuss their problems and that clinicians can be as good as sex therapists in offering advice.

“What we can do is be kind, comfortable, understanding and concerned.”

She also outlined the normal effects of ageing on the sex lives of men and women, the sexual dysfunctions affecting both sexes and what advice, aids and treatments were available.

Fixing ‘indeterminate care’
Many of us feel that intermediate care, sometimes known as ‘indeterminate care’, has not lived up to expectations. But geriatricians need to step up and accept some of the responsibility, as we have stood on the sidelines and seen frail older people’s care being transferred from acute hospitals into the community setting, but have not fully engaged in designing and delivering intermediate care. Some catch up is taking place, but not in a systematic way. John Young, Professor and Head of the Academic Unit of Elderly Care and Rehabilitation, Bradford Institute for Health Research, perfectly encapsulated the current state of play, highlighting the paucity of data on outcomes relating to intermediate care, the new ‘cinderella’ service which, from the Department of Health perspective is somewhat out of sight and out of mind. The evidence clearly shows that medical (i.e. geriatric) input leads to better outcomes, yet too few intermediate care services have geriatric input, and general practice input is limited.

But our ‘knights in shining armour’ (aka John Young, Duncan Forsyth, Consultant Geriatrician, Addenbrooke’s Hospital and Tom Hutchinson, SpR at Bradford) are coming to the rescue. A baseline audit has been carried out, looking at the systems in place in intermediate care, the types of user (mainly frail older people) and some outcomes (e.g. transfers to acute care, length of stay, complications). The (albeit self-selected) audience were in full support of rolling out the audit nationally, to make use of governance as a way of driving up quality. At last!

Catch them early
A study showing that grip strength is an important predictor of poor mobility, by Phil Stevens, a student of the School of Medicine at the University of Southampton, deserves mention. Apart from being a well conducted study, it was particularly well presented and was all the more impressive because Phil is a medical student, carrying out an intercalated BSc project - and a very good example of how important it is that geriatricians engage with medical colleagues at an early stage, so that we might influence their attitudes towards geriatrics, and the role that research can play in sparking enthusiasm.

Frailty
Related to Phil’s presentation were two studies on frailty; the first used two large cohort studies of older people to try and identify a definition of frailty that predicts mortality (Dr S Kamaruzzaman from the London School of Hygiene and Tropical Medicine), the second assessing the use of the Rockwood frailty index to assess the impact of smoking on frailty (Dr Ruth Hubbard, from Dalhousie University, Halifax, Canada). Both studies are of interest as they tackle the important area of frailty, often the core remit of geriatricians, but both highlighted how little we really understand about frailty, even to the extent of agreeing a definition!

Prescribing
Dr P Gallagher from Cork University in Ireland presented his excellent work on the STOPP/START tool, an evidence based set of criteria used to identify inappropriate prescribing, but also omissions (e.g. bisphosphonates). Perhaps not so useful for geriatricians, who should be carrying out drug reviews in this fashion anyway, but the tool is potentially a very important intervention for non-geriatricians. It is valid, reliable and does seem to impact on inappropriate prescribing.

All in the taste
Improving the flavour of sip feeds could help to increase the food intake of older people, six out of ten of whom are at risk of becoming malnourished during a hospital stay, according to research at the University of Reading.

A workshop around nutrition presented the findings of studies to improve flavour-enhanced foods to increase consumption for older people whose sense of smell and taste deteriorate with age.

Delegates were asked to taste two samples of vanilla icecream, created to test the effects of sweetness, taste build-up and temperature on foods given to elderly patients in hospital, after focus groups gave a “fairly negative” feedback on existing sip feeds.

Margot Gosney, Professor of Elderly Care Medicine at the University of Reading said that MAPP-MAL, a three-year NDA (New Dynamics of Ageing) multi-disciplinary approach to developing a prototype for the prevention of malnutrition in older people was looking at products, people, places and procedures. Research includes trying to create the right environment and how to “deliver food at the right time in the right place to the right people.”

Commissioning
Jane Youde, Consultant Geriatrician, Derby Hospitals NHS Foundation Trust, chaired a fascinating session using falls as an exemplar condition to address joint working and commissioning. Our outgoing editor and Honorary Secretary, David Oliver, gave a tour de force presentation on the falls commissioning toolkit – coming to a hospital near you soon! It is extremely helpful to have the information to win commissioning arguments pulled together in one package. Kathy McLean, medical director of the East Midlands SHA, gave a the strategic perspective, which will increasingly focus on standard setting, metrics, accountability and financial rewards (CQUINs) for good performance. It is in our interest to help shape the strategic priorities and it is reassuring to know that, in the East Midlands at least, geriatricians are leading the way. Bringing us back down to earth, Matt Thomas (Consultant Geriatrician, Poole), highlighted the difficulties of establishing real joint working across health and social care, re-iterating Sir John Grimley-Evan’s view that the biggest mistake in the development of the NHS was the split from social services…

Goodbye Harrogate
This being our last conference at Harrogate, outside the conference business, delegates from around the world took the advice of Prof Mulley, who being a Yorkshireman himself urged delegates to enjoy for the last time, “this wonderful place – slap bang in the middle of the Universe...eat Fat Rascals and drink tea at the famous Betty’s Café, sample the finest ales and walk on The Stray”. And so it’s goodbye Harrogate and on to Spring in Edinburgh.

Lynne Greenwood
Freelance Journalist
Simon Conroy
Consultant Geriatrician/Senior Lecturer, Leicester

BGS Newsletter, November 2009
Issue 24 ISSN 1748-634000 24