The evolution of Geriatric Medicine in the UK: Are there any lessons for Taiwan

1
The evolution of Geriatric Medicine in the UK
Are there any lessons for Taiwan?

• 12th January 2008
• Dr David Oliver
• Reading University and Royal Berkshire Hospital
• Secretary, British Geriatrics Society

2
Outline

• I How Geriatrics and BGS started in the UK
• II Evolution 1947 to 1977
• III Key developments from 1977-2007
• IV The state of UK geriatrics and the BGS 2007
• V Obstacles threats to our future
• VI Why we need geriatrics and how to convince
  others?
• VII Why the UK doesnt have all the answers
  our services are far from perfect!
• VIII Possible lessons for Taiwan
• From our successes in the UK
• And our mistakes!

3
I How Geriatrics Started in the UK

• And the role of the BGS (founded 1947)

4
Ignatz Leo Nascher (1863-1944 USA)

• Invented term geriatrics
• Two ancient Greek words
• Geras (Old-Age)
• Iatricos (Relating to the physician)
• There should be a separate speciality to deal
  with problems of senility
• Although conceived and named in US, geriatrics
  was first fully practiced in UK..

5
British Geriatrics Society Compendium
www.bgs.org.uk

• that branch of internal medicine which deals
  with the prevention, diagnosis and treatment of
  diseases specific to old age.

6
Marjory Warren the mother of British
Geriatrics
7
Marjory Warren

• Medical director West Middlesex Hospital
• Responsible for 714 bed poor law workhouse
  infirmary when it merged with the hospital
• Patients described as Incontinent, seizures,
  dementia, bed ridden, elderly sick, unmoved
  muscles
• For proper care, they require the full
  facilities of the general hospital
• Created specialised geriatric assessment unit
  the first in the UK
• Systematically assessed neglected, bedridden
  patients
• Determined capacity to improve
• Re-mobilised most. returned many to own homes
• Pioneer of discharge planning (a revolutionary
  idea!!)
• And Comprehensive Geriatric Assessment

8
Marjory Warren

• Reduced beds from 714 to 240 and increased
  turnover 300!
• Spare beds then used for TB/Chest Medicine
• Gifted advocate, innovator educator, mentor and
  teacher
• Attracted interest from health minister when
  discharge rate reached 25!
• Published 27 papers in the 1940s and 50s on
  rehabilitation and assessment of frail older
  people
• Most famously
• Warren MW. Care of chronic sick. A case for
  treating chronic sick in blocks in a general
  hospital. BMJ 1943ii8223. BMJ 1943
• Warren MW. Care of the chronic aged sick. Lancet
  1946i8413.

9
. Warrens classification of the chronic aged
sick 1946 Lancet

• Chronic up-patients (that is, out of bed).
• Chronic continent bedridden patients.
• Chronic incontinent patients.
• Senile, quietly confused, but not noisy or
  annoying others.
• Senile dementsrequiring segregation from
  other patients.

10
MD Thesis, The care of the elderly, N.H.Nisbet

• Dr Warrens routine was carefully studied, the
  method of admission, examination, diagnosis and
  treatment, the return home or transfer to Home or
  hostel, the careful follow-up, the close contact
  maintained with the relatives, the help obtained
  from almoner, physiotherapists, OTs and
  chiropodist. The metamorphosis of an utterly
  hopeless helpless patient into an active,
  energetic and everlastingly grateful one was
  observed again and again.

11
Wasnt Warren really pioneering..Comprehensive
Geriatric Assessment?

• a multi-dimensional, interdisciplinary,
  diagnostic process to determine the medical,
  psychological and functional capabilities of a
  frail older person in order to develop a
  co-ordinated and integrated plan for treatment
  and long term follow up
• Stuck et al Lancet 1994
• Applying CGA especially to patients with
  frailty, functional impairment and multiple long
  term conditions is what best defines what we do
  as geriatricians
• Rockwood K Age Ageing 2004

12
Some other early pioneers
13
N Exton-Smith (Lancet 1949)

• Advocated the speciality of Geriatric Medicine
  for medical management, rehabilitation and long
  term care of older people.
• UCH (1st geriatric unit in London teaching
  hospital)
• Worked with Lord Amulree (later civil servant)
• First English Professor of Geriatric Medicine
• Worked with Doreen Norton, the first professor of
  gerontological nursing (Norton Scale)
• Earlier discharges created beds for other
  specialities and high profile attracted students
  and interest from government
• Founded first memory clinic
• Pioneered early ripple mattresses
• Research interests in previously neglected
  clinical areas

14
Others Pioneers e.g.

• Joseph Sheldon
• 11 older people housebound
• First described community geriatrics
• Advocated community physio, home adaptations
• Foot-care, continence etc to maintain
  independence
• George Adams.
• First Professor of Geriatrics in Belfast.
• First to teach geriatrics to undergraduates
• Studied Warrens work and followed her model to
  improve the human wreckage and overcrowded
  wards in workhouse infirmaries
• Opened first purpose built geriatric rehab unit
• Published in stroke and rehabilitation

15
Others e.g.

• Lionel Cosin
• General surgeon (war casualties)
• Originator of the geriatric day hospital (Oxford)
  1957
• Pioneer of orthogeriatrics and rehabilitation..
• Responsibility for 300 chronic sick beds.
• Admitted patients thought to require permanent
  care after hip fracture
• Operated then started early rehabilitation with
  the help of a physiotherapist, and many were
  discharged.
• Bobby Irvine
• Worked in Hastings with orthopaedic surgeon (who
  recognised his own lack of specialist knowledge)
• Established world famous orthogeriatric unit
  widely studied as an example
• Operated on even the frailest patients
• Mobilised them
• The first step in rehabilitation is the first
  step

16
Original Aims of the BGS 1947

• Meeting of small number of pioneering
  practitioners convened by Dr Trevor Howell
  (former GP and now medical director of Chelsea
  Pensioners Home i.e. war veterans)
• the relief of suffering and distress amongst the
  aged and infirm by the improvement of standards
  of medical care for such persons, the holding of
  meetings and the publication and distribution of
  the results of research

17
Early influence of BGS (Barton and Mulley 2003)

• This meeting was to begin a revolution in the
  delivery of elderly care services.
• These pioneers persuaded the Minister of Health
  to appoint more geriatricians as part of the
  hospital consultant expansion of the new NHS.
• Following Marjory Warrens example, frail or
  disabled patients were to be under the care of a
  geriatrician and comprehensively assessed by an
  interdisciplinary team.
• Those who recovered were discharged home
• Those who were frail but did not require 24 hour
  nursing care went to long stay annexes.
• Patients previously thought to be "senile" or
  disabled were reassessed, and often found to have
  modifiable organic disease many could be
  rehabilitated.
• As more older patients returned home, there was
  more space on the wards, which were repainted and
  upgraded.

18
Lessons from this pioneering phase
19
Adoption of change in systems (After Gladwell M
The Tipping Point)
Tip
KOLs
Enthusiasts
Chasm
20
Lessons for Taiwan?

• Pioneers and Innovators
• From variety of clinical backgrounds (just as in
  Taiwan) commitment and interest is what counts
• Challenging assumptions (thats the way weve
  always done things)
• Challenging ageism/therapeutic nihilism
• Publishing and publicising
• Developing evidence base
• Mentorship, teaching, role models
• Spreading good practice to other units by
  example and training

21
Lessons for Taiwan?

• Showing the benefits of geriatrics to the whole
  system
• Once people see what you can do they can be won
  over and usually want more
• Getting politicians and civil servants on board
• Alliances with other professions and
  organisations (strength in numbers)
• Put the patients first in your arguments.(not
  the profession)

22
II How geriatrics evolved in the UK from 1947 to
1977
23
The Geriatric Giants (just what Warren
described 30 years earlier)
Immobility
Adapted from Isaacs B The Challenge of Ageing
1982. Pioneer of stroke units
Confusion
Pressure sores
Geriatric Giants
Falls
Vision Hearing
Depression
Incontinence
24
The 1960s and 1970s expansion

• Improvements in medical care of patients
  managed on geriatric units.
• Rapid increase geriatrician appointments.
• 4 geriatricians in 1947. 335 by 1977
• Academic departments established.
• First UK Professor 1965 Glasgow. (William
  Ferguson-Anderson)

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But not all good. Still opposition..

• Many general physicians questioned need for
  separate specialty
• Considered inferior specialty for third rate
  doctors who could not make the grade elsewhere.
  
• Negative, disdainful attitudes from doctors in
  training
• Medical students generally not inspired by the
  image of geriatrics.

26
Key themes of this expansion phase (Barton and
Mulley 2003)

• Awareness of atypical/ non-specific presentation
  of acute illness in old age.
• Whole person approach to older people with
  co-morbidity and complex disability.
• MDT team working and CGA
• Central importance of rehab.
• Recognition of caregivers stress respite care.
  
• The teaching of geriatric medicine to medical
  undergraduates.

27
3 models of practice by the 1970s (fuller
discussion of pros and cons in BGS compendium at
www.bgs.org.uk)

• (1) Traditional or needs based, where
  geriatricians take selected referrals from other
  consultants, with a view to rehabilitation, or,
  if appropriate, placement in long term care.
• (2) Age defined care (regardless of patients
  needs) based on an arbitrary age cut off (usually
  75 years and over). (e.g. Bagnall et al)
• (3) Geriatric services fully integrated with
  general medicine. (e.g. Grimley Evans et al)
• Advantages and disadvantages to each

28
Recommendations of Royal College Physicians
(1977) working party on medical care of the
elderly (Note how little things have changed 30
years on!)

• General medical and geriatric facilities to be
  integrated.
• Posts for general physicians with an interest in
  geriatrics
• Multidisciplinary approach to elderly care.
• Undergrad/postgrad training in elderly care for
  every doctor.
• Elderly medicine to become component of MRCP
  syllabus.
• Increased involvement of general practitioners in
  the medicine of old age.
• Local authority residential care review.
• Review of elderly mental health services.

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III Key developments 1977-2007
30
Key Services pioneered before 1977 and expanded
1977-2007

• MDT case conference.
• Geriatric day hospital.
• Domiciliary visits requested by GP
• Community geriatrics.
• Outreach clinics in general practitioner
  surgeries.
• Old age psychiatry.
• Ortho-geriatric liaison.
• Stroke rehabilitation units and services.
• Specialty clinicsfor example, falls,
  parkinsonism, stroke.
• Rapid assessment clinics.

• But
• Geriatrics more and more hospital based
• Only 14 consultants with dedicated community or
  long stay care involvement
• And increasingly involved in acute general
  internal medicine
• Stroke becoming a separate speciality with more
  acute focus

31
Current NHS structure58.5 M Pop 70 billion
expenditure (8 b drugs, 6 b IT)1 M employees.
35,000 GPs. 34,000 hospital consultants, 350,000
nurses
Performance targets and star ratings for
Primary and Secondary Care. Quality and Outcomes
Framework (QOF) in GP contract
Regulation of Quality By HealthCare Commission,
complaints procedure, National Patient Safety
Agency
Local Social Services. Provide assessment, home
care and long term residential/nursing care
(means tested). Funding through local tax (20)
and national government. Elected local political
leaders. Regulation by National Commission for
Social Care and Inspection (CSCI)
32
Total UK health expenditure
33
Health expenditure (developed nations)
34
Key developments (general)

• Structural re-organisations of the NHS focus on
  efficiency, performance and reducing inequality
• Increase in spending to 8.8 GDP by 2006
• Introduction of internal market and
  purchaser-provider split between primary and
  secondary care
• Primary care now receives 70 of resource and
  commissions services from hospitals
• NHS Plan with performance targets for hospitals
  (efficiency, access, waiting times etc)
• Quality and Outcomes Framework (QOF) for GP
  contract with incentives to hit targets for
  screening, prevention, long term conditions
• Growing involvement of private sector in building
  hospitals and providing elective treatment
• Shortening and re-structuring of postgraduate
  medical training
• Overhaul of medical research funding and
  performance assessment

35
Evolution of Policy Since 1990

• For Older People, key themes have been
• Transfer of responsibility (1990 Community Care
  Act) to local government for social care and
  closure of NHS Long-stay beds
• Shifting balance back towards primary care
• Reducing inappropriate hospital bed use
• Better management of long term conditions
• Social Vs Medical Care (and funding)
• Quality and inspection
• More integrated working between primary and
  secondary care and social services
• Resource allocation/rationing
• (Policies and guidelines for older people/mental
  health tend to have come with few resources)

36
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37
NSF for Older People 2001 (Clear targets but no
real money or penalties)

• 1Rooting out age discrimination
• 2Promoting person-centred care (including a
  single assessment process for care records)
• 3Intermediate care
• 4General hospital care
• 5Stroke services
• 6Falls and Bone Health services
• 7Mental health in older people
• 8Promoting health and active life in old age

38
Progress against initial NSF

• Increase in provision of complex social care at
  home
• More stroke units
• More falls clinics and services
• More Intermediate Care places
• Less overt age discrimination
• Spin off benefits for older people from other
  targets
• But services still not fit for purpose or
  age-proof
• Breaches of Dignity and deep-seated negative
  attitudes to older people still common
• Skills, training and knowledge lacking
• General hospital care just as problematic
• Very few people actually receiving appropriate
  falls and OP treatment
• Many people still not getting to stroke units
• Single assessment process rarely implemented

39
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40
A new ambition 10 programmes under 3 themes

• Dignity In Care
• Dignity in care
• Dignity at the end of life
• Joined Up Care
• Stroke Services
• Falls and Bone Health
• Mental Health in Old Age
• Complex Needs
• Urgent Care
• Care Records
• Healthy Ageing
• Healthy Ageing
• Independence, Well Being and Choice

41
More than an ambition?

• No dedicated money
• No must do targets
• Many competing priorities in the hierarchy
• Little in the GP contract to incentivise them
• Still ageist attitudes in the system
• Focus on short term gains, not long term planning
• Box-ticking approach rather than real change?

42
Lessons for Taiwan?

• As the speciality grows you can begin to
  sub-specialise and expand range of services and
  outreach into other settings
• You must expect negative perceptions and attacks
  and work hard to improve the image of
  geriatrics and sell it to potential recruits
  and to colleagues in other specialities
• You need to think about the model of service
  delivery (needs, age, integrated etc) and how it
  fits with existing local services/facilities
• Be careful about being sucked into general
  internal medicine so much that you neglect the
  frail and the long-term

43
Lessons for Taiwan

• Pointless to have service frameworks and targets
  with no money, no incentives, non infrastructure
• Other incentives in the system (some perverse)
  may fight against what you are trying to achieve
  you need to battle this
• No good having Rolls Royce services if only a
  small percentage of people receive them
• Prevention and primary care matter
• Softer gains around attitudes and care are
  harder to achieve but vital to the patients
  experience

44
IV UK geriatrics and the BGS in 2007

• Where are we now?

45
BGS(for full range of our activities please join
or use www.bgs.org.uk)

• Geriatric Medicine is now the second biggest
  hospital-based speciality in the UK
• BGS membership 2007
• 2,500
• 589 trainees,
• 1,200 consultants
• 310 overseas
• 150 allied professionals

46
Roles of BGS

• Bi-ennial scientific meetings (600 delegates)
• Age and Ageing (700 submissions per annum)
• Sections (e.g. fallsbone, stroke, continence,
  prescribing)
• Education and training
• Continuing Professional Development
• Academic and Research (including grants and
  fellowships)
• Policy produces compendium of good practice
• National Audits
• Advice/input to government and medical colleges!
• Campaigning, influencing and highlighting issues
• www.bgs.org.uk

47
How healthy is geriatrics in the UK now?

• Strength in numbers?
• Growing evidence-base for what we do
• Ageing population
• Frailty, long term conditions are crucial
• Other physicians dont all want complex, frail
  older patients
• Current GP performance framework does not
  incentivise them to look after these patients
• Getting care of older people right will surely
  help every part of the system
• So the future looks good surely?

48
Not so simple.
49
V The obstacles in our way

• Threats, challenges or opportunities?

50
Threat 1Systems reform

• DH want old people out of hospital and in
  community
• (But to what alternative services?)
• But UK geriatrics has become largely
  hospital-based
• So now we must persuade primary care
  organisations to buy our services or take over
  the running of some intermediate care
• Many arent interested despite the
  evidence-base for CGA etc
• There is little in the GP performance framework
  about geriatrics
• But a perception from some GPs that geriatrics
  is easy and its what GPs do anyway .It
  doesnt need specialist training or a separate
  speciality

51
Threats 2 Funding and incentives

• Service frameworks around older people not funded
• Main performance targets for hospitals do not
  focus on acute/subacute frail complex older
  patients
• More around waiting lists and waiting times
• Payment systems mean that hospitals make money
  from elective surgery and lose money from acute
  unscheduled care
• So older people in beds are generally a
  problem for the system rather than being seen
  as the main customers!

52
Threats 3Negative attitudes and ignorance

• Negative societal and media attitudes to older
  people
• Most students, doctors and nurses still say they
  dont want to work with old people (though that
  will be their job!)
• Negative attitudes to doctors/nurses who work
  with older people
• Medical values still favour high-tech
  treatment, curative, individualistic and basic
  science over
• low tech, long term incurable conditions, health
  services research and multidisciplinarity
• Working with dementia, incontinence, falls or
  frailty isnt sexy
• Little private practice income in geriatrics
• Patients with legitimate and treatable medical
  illness still labelled as having social
  admissions or acopia or bed blocking
• Older people themselves often do not wish to be
  on specialist wards for older people and may not
  see themselves as old.
• Many professionals still dont see the need for a
  separate speciality

53
Roger DobsonDoctors rank myocardial infarction
as most "prestigious" disease and fibromyalgia as
leastBMJ, Sep 2007 335 632 doi1

• diseases and specialties associated with
  technologically sophisticated, immediate and
  invasive procedures in vital organs located in
  the upper parts of the body are given high
  prestige scores
• Respondents were asked to rank 38 diseases as
  well as 23 specialties on a scale of one to nine.
  The authors say that the prestige scores for
  diseases and for specialties were remarkably
  consistent across the three samples.
• Myocardial infarction, leukaemia, spleen rupture,
  brain tumour, and testicular cancer - highest
  scores by all three groups.
• "The existence of a prestige rank order of
  medical specialties has been known for a long
  time,"
• They add that disease is a "nexus around which
  many medical activities are organised, such as
  categorising patients, planning and allocating
  work, setting priorities at all levels, pricing
  services, and teaching and developing medical
  knowledge.
• "A widespread, and at the same time tacit,
  prestige ordering of diseases may influence many
  understandings and decisions in the medical
  community and beyond, possibly without the
  awareness of the decision makers."

especially where the typical patient is young or
middle-aged." In the study, the authors, from
the University of Oslo and the University of
Science and Technology, Oslo, sent questionnaires
to 305 senior doctors, 500 general practitioners,
and 490 final
54
Meyrowitz J (1985) No Sense of Place The impact
of electronicmedia on social behavior. New York
Oxford Oxford University Press.

• Old people today are generally not appreciated
  as experienced "elders" or possessors of special
  wisdom.........Old people are respected to the
  extent that they can behave like young people,
  that is, to the extent that they remain capable
  of working, enjoying sex, exercising and taking
  care of themselves.

55
Negative perceptions

• Derek Chan Taipei 2006
• How do we convince all our colleagues in Taiwan
  of the need for geriatrics and help them
  understand what we do?

• My mother (again and again!)
• David. I dont understand why there needs to be
  a separate speciality for older people. Why
  couldnt you be a proper doctor?

56
Dr Felix Silverstone, (Quoted in Gawande A New
Yorker 2007)

• Mainstream doctors are turned off by
  geriatrics,because they do not have the faculties
  to cope with the Old Crock. The Old Crock is
  deaf. The Old Crock has poor vision. The Old
  Crocks memory is impaired. With the Old Crock,
  you have to slow down because he asks you to
  repeat what you are saying. And the Old Crock
  doesnt just have a chief complaintthe Old Crock
  has fifteen chief complaints. How in the world
  are you going to cope with all of them? Youre
  overwhelmed. Besides, hes had a number of these
  things for fifty years or so. Youre not going to
  cure something hes had for fifty years. He has
  high blood pressure. He has diabetes. He has
  arthritis. Theres nothing glamorous about taking
  care of any of those things....

57
Threat 4 Education, Training and Academia

• BGS survey suggested that in 50 of medical
  schools, little or no geriatrics being taught
• Funding structure and performance framework for
  research makes it hard for academic departments
  of geriatrics to survive
• Several professorial units closed or professors
  not replaced
• Which weakens position within medical schools
• Still insufficient geriatric medicine content in
  postgraduate curriculae
• And NSF Standard for all health professionals to
  receive appropriate training and have appropriate
  skills has not happened

58
VI Convincing colleagues, commissioners (and
older people) that we are needed
59
The best arguments (and the ones to use in Taiwan
in answer to Derek Chans Question)

• Older people are the main customers of health and
  social care
• Demographic change means this will continue
• So older patients with frailty, multiple
  long-term conditions and disability, needing CGA
  multidisciplinary input will continue to be
  central to health care (not marginal)
• There is plenty of evidence for interventions
• If we apply them, both patients and the whole
  system will benefit so win/win (quality, access,
  capacity, cost)
• These might be the right arguments BUTwe have to
  be more outspoken and unreasonable in making this
  case

60
Gawande ( a neurosurgeon). The way we age now.
New Yorker April 2007

• There is, however, a skill to it, a developed
  body of professional expertise.
• Until I visited my hospitals geriatrics clinic
  and saw the work that geriatricians do, I did not
  fully grasp the nature of that expertise
• The job of any doctor. is to support quality of
  life, by which he meant two things as much
  freedom from the ravages of disease as possible,
  and the retention of enough function for active
  engagement
• Most doctors treat disease, and figure that the
  rest will take care of itself. And if it
  doesntif a patient is becoming infirm and
  heading toward a nursing homewell, that isnt
  really a medical problem, is it?
• To a geriatrician, though, it is a medical
  problem. People cant stop the aging of their
  bodies and minds, but there are ways to make it
  more manageable, and to avert at least some of
  the worst effects....

61
Argument 1 DEMOGRAPHICS 1901 57,000 gt65
years2001 8.1 Million
62
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63
Source D Wanless Report 2006
64
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65
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66
Argument 2 LONG TERM CONDITIONS (people now live
with them)
NHIS 2000
67
Challenge of long-term illness (UK)

• 80 GP consultations
• 80 hospital days
• 70 admissions
• 70 health spending
• 95 spending on 65 population
• 10 of inpatients account for 55 bed days and 5
  account for 40 of bed days
• Evercare Pilots, Case Management and Community
  Matrons

68
Argument 3 GERIATRIC GIANTS e.g.

• Falls 30 of over 65s per annum will fall. Falls
  are 7th commonest reason for hospital admission
  and commonest reason for emergency attendance in
  over 60s
• Fractures 1 in 2 women and 1 in 12 men or
  200,000 p.a UK.
• Incontinence 24 of gt65s, 40-60 in institutions
• Dementia (e.g. 40 of long term care. 20
  emergency admissions gt65)
• Delirium 11-40 prevalence in hospital gt65s
  (often unrecognised)
• Stroke 150,000 per annum. 85 65, usuall
  multiple co-morbidity

69
Argument 4 Frailty

• Frailty is a failure to integrate responses in
  the face of stress. This is why diseases manifest
  themselves as the geriatric giants.functions
  such as staying upright, maintaining balance and
  walking are more likely to fail, resulting in
  falls, immobility or delirium
• Rockwood Age Ageing 2004
• i.e. Poor Functional Reserve

70
Fried 1999
71
Frailty Syndrome Epidemiology

• 3 or more of 5 criteria
• 6.7 of community residing elderly
• 3 year incidence 7
• Increases with age 3-65 26 -85-89
• Fried L, et al J Gerontol Med Sci 2001 560
  M146-M156

72
High users of hospitals have overlap of physical
and social vulnerabilities
73
UK National Care Home Census Bowman et al Age
Ageing 2004
74
Example Hip Fracture

• 90,000 hip fractures per annum
• 50 injury admissions and 66 of bed days from
  injury in the NHS
• Median Age 81 years
• Falls, ostepporosis, multiple co-morbidity,
  cognition, nutrition, confusion, intercurrent
  illness, polypharmacy
• Following hip fracture high mortality, morbidity,
  dependence
• Are Systems designed around needs?
• Are orthopaedic surgeons the right people to care
  for them?
• Could outcomes be improved?
• What system would we design in an ideal world

75
Argument 5 Growing EVIDENCE-BASE for effective
interventions

• For example

76
Comprehensive geriatric assessment for older
hospital patients systematic review and
meta-analysis G Ellis, P Langhorne British
Medical Bulletin 2005 71(1)

• In-patient comprehensive geriatric assessment
  (CGA) may reduce short-term mortality, increase
  the chances of living at home at 1 year and
  improve physical and cognitive function.
• 20 RCTs (10 427 participants) of in-patient
  CGA.
• Newer data confirm the benefit of in-patient CGA,
  increasing the chance of patients living at home
  in the long term.
• For every 100 patients undergoing CGA, 3 more
  will be alive and in their own homes compared
  with usual care 95 confidence interval (CI)
  16. Most of the benefit was seen for ward-based
  management units
• CGA does not reduce long-term mortality.
• This evidence should inform future service
  developments.

77
Langhorne P et al 1993. Do stroke units save
lives? Systematic Review

• 10 RCTs.
• 1586 stroke patients were included 766 were
  allocated to a stroke unit and 820 to general
  wards.
• The odds ratio (stroke unit vs general wards)
  for mortality within the first 4 months (median
  follow-up 3 months) after the stroke was 0.72
  (95 CI 0.56-0.92), consistent with a reduction
  in mortality of 28 (2p lt 0.01). This reduction
  persisted (odds ratio 0.79, 95 CI 0.63-0.99, 2p
  lt 0.05) when calculated for mortality during the
  first 12 months.

78
Young and Inouye BMJ 2007 (Delirium)

• studies investigating such interventions in
  medical patients and those who have had hip
  fracture have reported significant reductions (of
  about a third) in incidence of delirium and/or
  reduced severity and duration of delirium

79
Falls e.g.

• Individually targeted, falls? 31
• Postural hypotension
• Sedative medications
• Use of 4 medications
• Transfer skills, grab bars
• Environmental hazards
• Gait training, assistive device
• Balance exercises, exercises against resistance
• Cost saving in higher risk group (4 of 8 risk
  factors)

Tinetti ME et al. N Engl J Med 1994331821-7
80
Falls

• Referred from A E
• Clinic based assessment and referral
• Postural hypotension
• Visual acuity
• Balance
• Cognition
• Depression
• Carotid sinus studies
• Medication
• Home safety assessment and advice
• Falls? 61, cost neutral

Close J et al. Lancet 199935393-7
81
Argument 6 Getting treatment right doesnt just
benefit patients but whole health system

• If we can get people to listen to the arguments
  and respect the evidence
• Remember the data from Marjory Warren 1946 (714
  beds down to 204)?
• Replicated by Adams in Belfast
• Or from Dr Bagnall in Leeds 1976 (40 reduction
  in length of stay for older patients on needs
  based unit)
• The benefits for the whole system are just as
  relevant 60 years on
• E.g. recent real-life examples from St Thomas
  hospital

82
Harari D et al The older persons' assessment and
liaison team OPAL evaluation of comprehensive
geriatric assessment in acute medical
inpatientsAge Ageing July 2007

• Setting urban teaching hospital.
• Subjects acute medical inpatients aged 70
  years.
• Intervention multidisciplinary CGA screening of
  all acute medical admissions aged 70 years
  leading to (a) rapid transfer to geriatric wards
  or (b) case-management on general medical wards
  by Older Persons Assessment and Liaison team
  (OPAL).
• Results pre-OPAL, 0 fallers versus 92
  post-OPAL were specifically assessed
• . Over twice as many patients were transferred to
  geriatric wards, with mean days from admission to
  transfer falling from 10 to 3.
• Mean LOS fell by 4 days post-OPAL.
• Only the OPAL intervention was associated with
  LOS (P  0.023) in multiple linear regression
  including case-mix variables (e.g. age, function,
  geriatric giants).

83
Harari D et al Proactive care of older people
undergoing surgery (POPS) Designing,
embedding, evaluating and funding a comprehensive
geriatric assessment service for older elective
surgical patients Age Ageing 2007

• Intervention multidisciplinary preoperative CGA
  service with post-operative follow-through
  (proactive care of older people undergoing
  surgery POPS).
• Results Comparison of 2 cohorts of elective
  orthopaedic patients (pre-POPS vs POPS, N 54)
  showed
• POPS group had fewer post-operative medical
  complications including pneumonia (20 vs 4 p
  0.008) and delirium (19 vs 6 p 0.036),
• significant improvements in areas reflecting
  multidisciplinary practice including pressure
  sores (19 vs 4 p 0.028), poor pain control
  (30 vs 2 plt0.001), delayed mobilisation (28
  vs 9 p 0.012) and inappropriate catheter use
  (20 vs 7 p 0.046).
• Length of stay was reduced by 4.5 days. There
  were fewer delayed discharges relating to medical
  complications (37 vs 13) or waits for OT
  assessment or equipment (20 vs 4).

84
These are all the right arguments but we have to
make sure they are heard and acted upon

• Less nice and more unreasonable?
• Geriatricians tend to have high service values
  and concern for a neglected group of patients
• But not always very outspoken
• We know what the benefits are of geriatrics
• We know that older people do have special needs
• And that there is a logical basis and need for
  our speciality
• We can define what we do well by how badly we see
  others doing it.
• all progress is achieved by the actions of the
  unreasonable man (George Bernard Shaw)
• Does this translate to Taiwanese culture?

85
And we still need to convince older people
themselves! (How can I make you love me?)

• They may not see themselves as frail
• Or old
• And may be reluctant to see specialists in
  elderly care
• Or be admitted to elderly care wards
• We have to sell it to them in the right way
• (i.e. more rehabilitation, experts in the
  conditions they are suffering from, better chance
  of getting home and staying there etc)

86
VII Why the UK doesnt have all the answers.

• We still have a long way to go. Some examples

87
Health Care Commission Report Caring for
Dignity 2006

• Negative attitudes towards older people persist
• Insufficient education and training for staff
• Routine breaches of dignity e.g.
• Respect for personhood
• Communication
• Confidentiality
• Privacy
• Toileting/Continence
• Nutrition
• End of life care

88
Stroke (from national stroke strategy 2007)

• The chance of dying after a stroke has remained
  constant at around 24 while the risk of dying
  after a heart attack has fallen by about 1.5 per
  annum
• Around 40,000 people per year have suspected TIA
  or minor stroke but currently only 35 per cent
  are seen and investigated in a neurovascular
  clinic within seven days.
• Only 12 per cent of hospitals have protocols in
  place for the rapid referral of those with
  suspected stroke and less than 50 per cent of
  hospitals with acute stroke units have access to
  brain scanning within three hours of admission to
  hospital.
• 91 of hospitals now have a stroke unit
• Although two-thirds of stroke patients are
  managed on stroke units at some time during their
  hospital stay, only about 10 per cent of patients
  are likely to be admitted directly to an acute
  stroke unit.33
• 62 of patients were admitted to a stroke unit at
  some point in their stay, compared to 46 in
  2004. 54 spent over half their stay in a stroke
  unit (40 in 2004).

89
Falls and Bone Health (from RCP Audit)

• 74 hospitals now have part of a service
• Only 20 Directors Public Health H reports
  include falls and only 8 fracture rates
• Only 50 falls services have referral to
  Osteoporosis Pservices
• lt50 acute trusts had links between casualty and
  falls services around hip and fallers
• Even if admitted lt50 have links to OP and falls
• Only 1.7 new patients per week/100,000 receive
  falls or OP assessment
• Only 40 all patients with fragility fractures
  receive any OP assessment or advice or falls
  assessment
• Even for people admitted with hip fracture only
  50 receive falls assessment or bone health
  intervention

90
Continence (from RCP audit)

• The audit has demonstrated that
• Where a continence problem is identified, an
  assessment or management of that problem is not
  guaranteed.
• Whilst most of the structures required to
  provide continence services exist, ,provision of
  integrated services is variable and incomplete.
• Documentation of continence management is
  inadequate.
• Management consists predominantly of
  containment rather than treatment of the problem.

91
VIII So can you learn anything from us at all?
92
We certainly dont have all the solutions

• And your health system
• Culture and patient expectations
• System incentives
• Primary care and social services are different
• But
• You do have a rapidly ageing population
• You do have state funded health care with means
  tested social care
• You have recognised the health challenges of the
  ageing population
• You are beginning to train geriatricians of the
  future

93
The Taiwanese Exton Smith, Warren and Irvine??
94
Perhaps you can learn

• As much from our mistakes
• As our successes
• Lessons for geriatricians
• Allied professionals
• Other clinicians in the system
• Government and Health Service Management

95
Lessons from the UK I

• You need champions, campaigners and early opinion
  leaders.
• We need to be outspoken, challenging and campaign
  sometimes. (Geriatricians are usually too nice
  by nature and easily undermined by more powerful
  high-tech specialties)
• Ally yourself with other interested bodies,
  charities, and professional groups strength in
  numbers
• Get the ear of government ministers and show them
  how you can solve some of their problems in the
  system

96
Lessons from the UK 2

• Expect colleagues in other specialities (and even
  patients) to be hostile or not convinced. Dont
  let it worry you. We know we are right! You just
  need to sell the benefits
• Keep emphasising that older frailer people will
  be the main users of health and social care
  not a minority
• And that getting their care right will benefit
  the whole system
• You can be the solution to problems (and to other
  doctors who dont really want to look after these
  patients)
• Keep emphasising the strong evidence base for
  much of what we do
• Grow the evidence base through your own research
• And keep good enough data to demonstrate the
  impact of your service
• When people see what you can do they usually want
  more of your service

97
Lessons from the UK 3

• Geriatrics is a major part of healthcare so it
  needs to be a major part of undergraduate and
  postgraduate training for all adult specialists
  you cannot treat everyone
• You need to be a strong presence in the medical
  schools
• So avoid research funding and performance
  frameworks which prioritise basic science over
  clinical and health services research

98
Lessons from the UK 4

• You need to think about the model of care for
  service delivery which makes most sense locally
• Primary care needs to focus more on the needs of
  older people
• Generalists have advantages over
  super-specialisation for complex patients with
  multiple illness patients dont enjoy being
  passed around specialists with no overall
  co-ordination
• But we have to convince patients themselves
• Finally, there is no point having targets or
  plans to improve services without the right
  financial investment and performance frameworks
• Perverse incentives in the system can make the
  care of older people worse not better

99
Xie Xie Nimen