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 Crome

Keele, 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 1970s

Age 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 se

rvic

es u

sed

No LTC Non-limiting LTC Limiting LTCSource: 2005 General Household Survey.

Limiting LTC

pe

rce

nta

ge

s

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/PAC

Proactive referral of patients aged 65+

Screen to identify risk

Including “medically unfit for surgery”

Pre-operative CGA

Consultant

Clinical Nurse Specialist

Occupational therapist

Physiotherapy

Social worker

Patient education

Hospital Admission

Post-op consultant geriatrician and specialist nurse interventions

Therapy liaison

Discharge planning

Post Discharge

Intermediate Care

Links with primary care/ social care

Specialist clinic follow up (falls etc)

Preadmission Liaison

Surgical 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 - recognition

Trajectories 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