Beyond the geriatric giants: moving from elderly care to evidence-based medicine for the older
person.
Service Models Finbarr Martin, Geriatrician
Guys & St Thomas’ Hospital and King’s College London
Conference to honour the career of
Professor Peter CromeKeele, March 21st 2013
Medicine - No Country for Old Men !
“We realize that for all practical purposes the lives of the aged are useless, that they are often a burden to themselves, their family and the community at large. Their appearance is generally unesthetic, their actions objectionable, their very existence often an incubus to those who in their humanity or duty take upon themselves the care of the aged.”Nascher IL. Geriatrics: the disease of old age and their treatment. Philadelphia: P Blakiston's Son & Co, 1914.
A surgeon rides to the rescue • Marjory Warren (1897 – 1960) at Isleworth Infirmary• 1935 took over an adjacent workhouse to form the
West Middlesex County Hospital. • Systematically reviewed several hundred inmates• Classified into 5 groups
Adapted from Barton A and Mulley GP, 2003
Her achievementsWarren MW A case for treating chronic sick in blocks in a general hospital.
BMJ 1943.Warren MW . Care of the chronic aged sick. Lancet 1946
• discharged many patients by providing rehabilitation and appropriate equipment.
• Upgraded wards, improved patient and staff morale• Advocated
– creating a medical specialty of geriatrics– providing special geriatric units in general
hospitals– teaching medical students about the care of
elderly people, by senior doctors with specialist interest in geriatrics.
Early experience at St Pancras, London
Lancet, 1951
Look at the age in 1950
Progressive patient care – first model designed to optimise use of acute beds
Lancet, 1962
22 beds LOS mean 10 days
30 beds, pre-discharge
32 beds, long stay
106 beds, post acute +rehab
Two models emerged in 1970sAge defined model (Sunderland)(O'Brien TD et al , No apology for geriatrics. BMJ 1973;i:277–80)• Became predominant model till 1990 as old hospitals closed
and DGHs absorbed older medical patients
Integrated model (Newcastle)(Grimley Evans J Integration of geriatric with general medical
services in Newcastle. Lancet 1983;i:1430–3)• Recommended by RCPL in 1977• Reduced beds and reduced doctors’ hours galvanised this• Withdrawal from rehab and long stay as consequence
Where are we now?
• People aged 65+ are ~ 17 % of the population• And use 65% of acute hospital bed-days• >50% of the patients having surgery, (>major)=================================• More older people• Older people are older• And older people are different
10
older people are older ( rectangularisation to elongation of age
distribution)
Source: mortality.org, originally ONS
Distribution of death England 1841 - 2006
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1 5 9 13 17 21 25 29 33 37 41 45 49 53 57 61 65 69 73 77 81 85 89 93 97 101 105 109
1841
1941
19811991
2001
2006
Around 18% of all deaths were before 65 in 2006 –same proportion as in 1991
As a result…………• Most older people now live long enough
– To have several long-term conditions (+ multiple medications)• eg Respiratory, cardiac, diabetes
– to develop sensory impairment, sarcopenia, inflammaging
• Many also develop – dementia, osteoporosis, cataracts etc– homeostatic dysregulation
• Resulting in frailty and “geriatric syndromes”
12
People with long-term conditions have high health service use, especially hospitals (69% total
spend).People with limiting LTCs are the most intensive users of the most expensive services
0%
20%
40%
60%
80%
100%
Number of people GP consultations Practice Nurseappointments
Outpatient and A&Eattendances
Inpatient bed days
Type of service
% o
f ser
vice
s us
ed
No LTC Non-limiting LTC Limiting LTCSource: 2005 General Household Survey.
Limiting LTC
perc
enta
ges
Older people GP consults Practice nurse Outpatients Inpatients
Type of Service used
Source: 2005 Household Survey
Non limiting
LTC
No LTC
And older people vary
Genetics inc chance changes in development
Maternal and early life factors
Society and Lifestyle etc
Events and illnesses and chance
Specific diseasesFrailty
Spectrum of health and capacity
Frailty “summarises” prediction of outcomes
Rockwood and Mitniski A J Gerontol 2007
Implications for health care(Tinetti Am Med J 2004)
Age attuning health services• Expect older people with problems • Identify frailty and geriatric syndromes routinely• Use comprehensive geriatric assessment (CGA)• Predict “complications” • Use experts judiciously• Up-skill general services• Promote multidisciplinary clinical practice and
clinical governanceBetter care is often cheaper care in the end, so NHS
must get better to survive economically
The scope of geriatric medicine
• Acute and episodic illness • Post acute recovery and rehabilitation• Long term management of diseases and frailty• Support for people living with high dependency• End of life care
Acute and episodic illness
• Interface geriatrics - between community and hospital in response to acute clinical change– support Emergency Departments – liaison with intermediate care (IC)
• Provide part of the acute medical admission service– proactive case finding in acute medicine– CGA approach with selected patients
• Support hospital approach to age attuning all services– design and delivery of services– leadership in quality improvement with geriatric syndromes– Support education and training of the workforce
Implications for SurgeryNCEPOD Report 2010
• >1000 deaths of surgical patients 80+ years• Report highlights suboptimal management of common post-operative complications• Gap between policies, guidelines and clinical practice. • Assessment and clinical skills were too narrow• Likely events not anticipated or responded to• Interdisciplinary collaboration sporadic
Systematic responses 1
• Proactive support for frail older people having surgery– developing risk assessment in surgical
services– pre-op CGA for selected high risk patients– ongoing medical input to peri- & post-
operative care
Surgical Outpatients/PACProactive referral of patients aged 65+
Screen to identify risk
Including “medically unfit for surgery”
Pre-operative CGAConsultant
Clinical Nurse Specialist
Occupational therapistPhysiotherapy
Social worker
Patient education
Hospital AdmissionPost-op consultant geriatrician and specialist nurse interventions
Therapy liaison
Discharge planning
Post DischargeIntermediate Care
Links with primary care/ social care
Specialist clinic follow up (falls etc)Preadmission LiaisonSurgical team
Anaesthetists
GP and Community services
Patient
Eg. Local proactive joint care - example from GSTT: Proactive care of Older People having surgery -“POPS”
• Provide shared care for patients with fragility fractures– Co-design and supervise the hip fracture
clinical pathway– Provide daily medical care to selected
patients– Share clinical governance responsibility to
achieve the best practice standards of care and secondary prevention
Eg Fracture services National inter-disciplinary
collaboration
The Blue Book and the NHFD
Post acute recovery and rehabilitation
• Design and quality assure post acute care pathways– assist clinical systems to identify inpatients’ ongoing needs– specialist input to bed based or domiciliary IC services
(EVIDENCE?)• Provide “hot clinics” for CGA and other key conditions
– Link to A&E, acute admission units and community assessment in a whole system approach to urgent care
– Link with community based services to optimise recovery, ameliorate frailty and target secondary prevention
(EVIDENCE PATCHY AND NARROW)
Long term conditions and Frailty
• Estimating potential benefit is complex– Attributing risk in context of co-morbidity– Effects on LE, independence and quality of life
• Estimating risks and burdens is complex– Factoring in frailty
• So geriatrician- primary care co-working is needed• So far, relatively evidence free zone
Support for people living with high dependency
• CGA for older people at transitions of dependency– diagnostic input prior to institutional care– design and delivery of pathways for frequent
hospital attendees (LOTS OF INITIATIVES, LITTLE EVIDENCE)
• Specialist support for care home residents
End of life care - recognitionTrajectories in the final 12 months of life
Summary
• Its not just about our wards anymore• Its still about diagnosis but through CGA• Its more about frailty more than age• Its about getting it structured and simple and reliable• It will be about new therapies for frailty etc
Geriatrics is coming of age
