Looking out, not in: a week at the European Academy for Medicine of Ageing

eamaDr. Thomas Jackson is a geriatrician and clinical research fellow, investigating delirium and dementia in general hospital settings. On January 26th – 30th he attended the European Academy for Medicine of Ageing, which aims to bring together mid-career geriatricians from over Europe and beyond to improve knowledge and develop into “future teachers and leaders in geriatrics”. Here he shares his experience and reflections on a stimulating week.

With a certain trepidation I flew into a snowy Munich airport, met with colleagues from across Europe and up the hills we went; the roads getting smaller and the snow deeper.  However any concerns I had were put to rest pretty much immediately.  After introductions of new students we were treated to our first Teacher’s State of the Art lecture, a tour de force by Professor Jeune from Denmark about the longevity dividend from which I also learnt a lot of Greek mythology (the Tithinos error anyone?).

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A big week for dementia

Tom Dening is Professor of Dementia Research at the Institute of Mental Health, University of Nottingham. He tweets @TomDening. Here he outlines why this week has many reasons to be a big one for dementia.

Although dementia is rarely out of the news and indeed often on the front pages of certain national papers, the start of this week (23rd February) is a biggie even by dementia standards. That’s for two reasons: one, the latest version of the Prime Minister’s Dementia Challenge (Monday), and, two, the launch of Join Dementia Research (Tuesday). Continue reading

Leading The Way

11116578645_3cacb41a9d_oSarah Blayney is a Clinical Fellow in the Calgary Stroke Program at Foothills Hospital, University of Calgary. In this blog, she recounts her experience of attending the first BGS Leadership Conference in November.

After nearly nine months of trying to fit into an academic neurology department, it was a huge relief to find myself surrounded by geriatricians once again. My sense of adventure took me to Canada on a stroke fellowship earlier this year, in what I thought would be a refreshing break from the trials and tribulations of life as a medical registrar in today’s NHS. The calibre of stroke training is second to none, and learning to think like a ‘Calgary stroke neurologist’ has sharpened my clinical approach far more than I anticipated.

However I have also come to fully understand the meaning of silos within healthcare, and the effect this can have for patients with multiple medical problems.  The department is well led, with highly motivated teams across acute and rehab units, outpatients, research offices and clerical staff, but it pains me every time our service backs off from the care of a frail elderly patient deemed unlikely to benefit from admission to the acute stroke unit (though occasionally I sneak one in when I can). Our response time to acute stroke patients is excellent, but for those that turn out not to be stroke, it can mean a delay in getting them to the right place as well as multiple reviews by different people along the way.

It was in this frame of mind that I returned to the UK for a fortnight of courses and conferences to ensure a smooth CCT sign-off when I return in the spring.  Word had got round about the first BGS Management Course run last year and I was keen to get back for this year’s course if at all possible; it proved to be the highlight of my trip.  We are all too aware of the problems currently facing the NHS, but the pre-course reading list opened my eyes to the volume of resources being generated to combat these problems.  I find everything I have seen so far from the King’s Fund to be particularly practical and insightful, unlike some of the political statements that come from elsewhere. This set the tone neatly for a well thought out two days of discussions and workshops. Aspirations are important, but sharing best practice and brainstorming potential pitfalls is essential when it comes to rolling up our sleeves and making these aspirations real, and the course delivered just that.

Simulation is such a useful way of making the leap from theoretical discussion to a real life interaction, so roleplay and “Dragons Den” style workshops were a fun and very practical way of exploring some of the issues we may face as future consultants. Birmingham City Council obliged in making this even more true to life by issuing a parking ticket just before one such mock ‘management meeting’, very effectively raising the frustration levels of our acting medical director! The opportunity to ask questions, as well as be put on the spot, created a stimulating environment. The course timetable had clearly been planned to reinforce this, as regular coffee breaks allowed conversations to continue and develop outside of the structured sessions.

Hearing anecdotes on the second day from our course facilitators about their own experiences in developing new services was a tidy way of drawing together the principles we had explored earlier.  It also prepared me well for the task ahead of finding the right consultant job, and clarified my thoughts as to the direction my career may take in the next five years.  My other half recently challenged me on my use of the term ‘dynamic young geriatricians’ when I described to him the BGS course faculty, and this did give me pause for thought (as a surgical registrar who has encountered Dr Wyrko at work, he has his own ideas of what dynamic might mean in this context).  The last thing I would wish would be to appear ageist towards my older and wiser consultant colleagues, many of whom have taught me a great deal over the last nine years, but I am sure they would agree that the hospital world is changing.

We as a generation of trainees have been in the thick of it when it comes to the current state of acute hospital medicine, and have developed a different expectation of what our future working life will look like as a result.  My experiences as both a UK stroke registrar and a Canadian stroke fellow have only served to strengthen my conviction that our frail elderly patients deserve faster, better care than the NHS can currently offer in many places.  My two days under the expert coaching of Drs Gordon, Wyrko, Conroy, Blundell, Long and Oliver have provided the insight and skills to play my part in making this happen.

Image credit: Ascent Magazine via flickr.

Perioperative Medicine

shutterstock_154668242On a freezing cold Friday in January, the Royal College of Anaesthetists held a stakeholder event launching their vision for the future of Perioperative Medicine: the delivery of integrated care to those undergoing high risk surgery, provided by a perioperative team, to enable better patient outcomes and experience within the context of more effective and efficient use of finite resources.

The morning was attended by the great and the good and whilst dominated by anaesthetists there was a wide representation including the BGS and the Royal College of Physicians.

A simple but effective five minute animated film introduced the concept along with a vision document both available on the website www.rcoa.ac.uk/perioperativemedicine

The speakers used powerful statistics:  16 billion pounds spent on surgery each year in the NHS, 20 million referrals for elective surgery which continues to increase year on year, 27,000 undergoing surgery each day of which 700 are high risk.  The overall on-table mortality lies in the region of 0.06% but with in-patient mortality at 3.6%.  There is also a significant morbidity with up to 15% of those undergoing elective surgery experiencing often predictable and potentially preventable complications with prolonged post-operative morbidity.

Yet it seems that we know the answers, supported by a reasonable evidence base and shown to be cost-neutral, if not cost-saving.  This has been demonstrated by Enhanced Recovery Programmes in a number of conditions, the successes of the hip fracture programmes with widespread implementation of orthogeriatrics and in the Proactive Care of Older People undergoing Surgery (POPS).  Jugdeep Dhesi eloquently presented the work of the POPS team and represented both acute medicine and geriatric medicine on the expert panel emphasizing the importance of recognising frailty and the benefits of comprehensive geriatric assessment.

It was suggested that the majority of the public would assume that joined up personalised care for those undergoing high risk surgery already exists in the NHS but sadly we know this not to be true.  All agreed that it should not be left to the overburdened medical registrar to sort out in the middle of the night.

The future is likely to be Perioperative Medicine.  Work on a curriculum, a training programme and workforce planning have already begun.  The BGS and the RCP both vocalised their support.  Those keen to be involved should register their interest at perioperativemedicine@rcoa.ac.uk

Helen Wilson, Consultant Orthogeriatrician 

Assisted dying: opening the flood gates or controlling the flow?

6361735901_c7cd4383b5_zDr Damien Bezzina is  a doctor at a large university hospital in the Midlands; he has a special interest in the care of older people, and holds a Diploma in Geriatric Medicine from the Royal College of Physicians. In this blog, he discusses the fallout from last year’s Falconer Bill on assisted dying.

I was watching the news on the 18th July 2014 when I heard about another Private Member’s Bill on assisted dying, put forward by Lord Falconer. A leading campaigner made the comment “Less suffering, not more deaths” and it made me think whether this is a true statement.

I believe strongly in care of the dying, and feel that we, as a medical profession, still widely miss the mark on ensuring we provide excellent care for patients who are coming to the end of their life. However, I’m not yet convinced that introducing an assisting dying law in the UK healthcare system as it stand is a good thing .

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Understanding frailty – a beginners’ guide

440x210_hands_hot_water_bottleGill Turner is Vice President, Clinical Quality for the British Geriatrics Society and Project Lead on the Fit for Frailty campaign. This blog, outlining the concept of frailty and highlighting the recent release of Fit for Frailty Part 2first appeared on the Age UK website.

It is hard to open a book, newspaper or listen to the news currently without hearing words like ‘the elderly’ , ‘dementia’ and ‘frail’. But what is meant by these words?

Frailty, for example. Many journalists use ‘frail’ to depict older people as victims of a failing NHS and underfunded social services. Doctors, nurses and relatives sometimes use ‘frail’ to describe people at the very end of their life, reinforcing its negative connotations.

And yet, work done by Age UK shows that older people see being ‘frail’ as akin to being weak, dependent and hopeless: they reject the idea of using it.

So, what if the word ‘frailty’ actually denoted a health condition which could be recognised, managed and even improved? What if the recognition of frailty opened the door to a range of health and social care services organised to address an older person’s wellbeing, independence and control over their own life? 

Frailty in scientific terms describes a situation where the body’s reserves are wearing out, meaning individuals are at risk of doing badly after a minor illness or stressful event. Decisions about health and social care for individuals with frailty need to be tailored to recognise their frailty, and in doing so address the problem.

The British Geriatrics Society, the Royal College of General Practitioners and Age UK have just published Fit For Frailty: a set of best practice guidance for managing frailty.
Part 1, published a few months ago, describes recognising  and managing frailty for individuals. Part 2, published last week, makes recommendations for the organisation of services for frailty. You can download both documents for free from the BGS website.

The guidance shows that there are several methods to recognise frailty; for example taking more than 5 seconds to walk 4 metres. Gold standard for treatment is a process called Comprehensive Geriatric Assessment(CGA): it’s an unattractive name, but research has demonstrated its effectiveness. We need to embrace its value, regardless of title.

CGA involves an holistic review to consider troublesome symptoms and problems which might not have been previously reported to the doctor, and a discussion with the patient about goals and aims for their life.

This could sometimes mean reducing medications. For example, research shows that  reducing blood pressure can reduce stroke risk: however, if an older person’s blood pressure medication makes them feel faint and fall over, that threatens their ability to shop and choose their own food, and thus their independence. Keeping a high level of medication might be the wrong treatment for that individual.

For another person who feels that being able to walk to church on Sunday  is an important priority, it could mean changing the focus of their treatment from careful diabetes control onto an exercise programme.

Of course, you could think of a million examples here: there will be as many different approaches as there are people. The point is that the treatment plans must be centred around what an individual older person needs for their life and wellbeing.

Sometimes, several different professionals will be involved: perhaps a geriatrician, a therapist or a nurse. Each of these will need to work in  a team around the patient, helping formulate their own well-being plan which will need to be revisited as things change and new priorities emerge. CGA covers this whole ongoing process.

Ensuring that older people with frailty have access to holistic medical review and CGA will require some reorganisation of services. Part 2 of the guidance gives advice about what is needed when it comes to the commissioning and design of health services.

Our expectation is that services will support the concept of frailty as a condition with which people live well and hence are keen to be associated with, not from which they suffer and die.

Find out more about the British Geriatrics Society Fit for Frailty campaign

Watch Age UK’s video of older people sharing their perspectives on frailty 

The alchemy of teamwork: how do we transmute base practice into noble excellence?

5114199360_414703d434_oLiz Charalambous is a qualified nurse on a female, acute medical HCOP (Health Care for Older People) ward at Queen’s Medical Centre, Nottingham University Hospital Trust.

Recent weeks have seen a huge challenge to healthcare teams across the country. The NHS has had to rise to the demands of increased numbers of people accessing services in all areas.

My suspicion is that the areas performing the best were the ones who already had strong teams in place, positive leadership and supportive group cohesion, adding the extra strength and resilience to a burgeoning population of patients.

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Falling: is the heart to blame?

heartSofie Jansen is a research fellow at the department of Geriatric Medicine in the Academic Medical Center in Amsterdam, the Netherlands. Her PhD focusses on the contribution of cardiovascular diseases to falls in older adults. Last year she spent six months as a visiting researcher in Trinity College, Dublin. In 2015 she will start her training as a Medical & Geriatrics Registrar. In this blog she comments on her recent publication in Age and Ageing journal. 

People often consider falling to be an unavoidable consequence of old age – we’ve all heard stories of a grandmother or elderly aunt who has taken a tumble. As such, falls are often accepted as a fact of life by older persons and those who care for them. But is this really the case? There are a number of factors that individually, or in combination, can contribute to people falling: balance problems, poor vision, the side-effects of medication. Most of these factors can be treated or targeted, leading to a reduction in falls. Recognition of these treatable risk factors is therefore important.

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Free place to attend King’s Fund Conference on #dementia

this offer has now expired as places have been allocated

The British Geriatrics Society is delighted to be able to offer a complimentary place for a BGS member to attend the following conference at the King’s Fund:

Leading change in dementia diagnosis and support

Actions to inform future national strategy

http://www.kingsfund.org.uk/events/leading-change-dementia-diagnosis-and-support

Date: 24 Feb 2015
Time: 9.00am–5.00pm
Venue: The King’s Fund, London W1G 0AN
Event type: One-day conference
In return we would like you to write a blog about your experience for the BGS Blog, and to tweet your thoughts during the day.
If you are interested, contact Prof David Oliver at D.Oliver@kingsfund.org.uk

Which one is a better deal – home visits or phone calls?

Frances Wong is a professor at the Hong Kong Polytechnic University. telemed

Our recent research has revealed very interesting findings about the power of a telephone call as compared to home visits for post-discharged patients. Patients are discharged from the hospital as soon as the immediate problems are resolved. Some care issues only emerge when the patients return home. The issues usually involve patients’ confidence and ability for self-care, symptom management, adherence to medication regimen and so on. If these concerns are not addressed properly, the patients will present themselves to the hospitals again. Like a revolving door syndrome, patients returning to the community come back to the hospital within a short time. The mean readmission rate within 28 days after discharge is 15% and the rate can escalate to 35% for the chronically ill patients.  Continue reading