Identifying health and social care costs for older people

queueRachel Elliott and Matthew Franklin are reporting on behalf of the Medical Crises in Older People (MCOP) research team at the University of Nottingham.

As part of a programme developing and evaluating care in older people, our team wanted to know the distribution of health and social care costs of older adults discharged from Acute Medical Units (AMU) in England across six care services (primary care, hospitals, intermediate care, mental healthcare, social care, and the ambulance service). This is the first study to do this in England.

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Open visiting: one year on

5157747099_6f301964c6_oLast year as part of my MSc. Module I planned and implemented a scheme to introduce open visiting in my Trust. The Trust  agreed to pilot it as flexible visiting in its older people’s wards and we launched a new Visitors’ Code

The scheme was partly a response to evidence of  Delirium prevention and Dementia care, but also to patient-driven campaigns such as John’s campaign ; a post Francis  response to incorporate PPI, and to settle the demons from my own personal and professional experiences over the years. One year on it is proving successful with positive feedback from patients, visitors and staff. Relatives have told me with relief what a difference it makes with many positive examples such as some families saving money by using cheaper public transport from remote villages instead of expensive taxis.

However, I see that some staff remain resistant to open visiting and wonder where such entrenched ideas originate. The lack of a supportive ward infrastructure was always a problem, but not insurmountable. Historically, hospital wards were of a Nightingale design, long wards with rows of beds with the nurses’ station at the head to facilitate maximum surveillance with minimum staff. I suspect the idea originated from Bentham’s 18th century Panopticon or ‘inspection house’ and was an effective means of control. Foucault took the idea further, using the metaphor for modern day surveillance which led me to wonder if the real reason for the rejection of open visiting and PPI is because it dilutes the power base and hinders the ‘medical gaze’ so cleverly constructed by not only architects but also healthcare professionals?

The tables appear to be turning with the public now, quite rightly, staring right back and old hospitals demolished with modern structures to replace them. But are we merely replacing one form of surveillance with another and entering a postmodern dystopian Orwellian nightmare?   Sanitised social quarantine is in danger of being replaced from the structural to the cerebral, from a panopticon to an oubliette, and has no place in care of older people with cognitive impairment. Coupled with sensory deprivation from necessary infection prevention measures and the omnipresent cultural hegemony in whatever era we find ourselves in, partnership working is a humanistic way to resist toxic organisational cultures and must be welcomed and embraced to promote excellence in the care of older people.

Liz Charalambous

Photo credit: Memphis CVB via flickr

Book review: Manual of Nutritional Therapeutics

$_58Margot Gosney is Professor of Elderly Care Medicine at the University of Reading and Consultant Physician at the Royal Berkshire NHS Foundation Trust. Here she reviews the Manual of Nutritional Therapeutics.

The 6th edition of this very detailed book has just been published: the fact that it has continued to be relevant and required reading since its first publication in 1983 indicates its usefulness. The American editors have gone out of their way to cover subjects not only in great detail, but also to provide very relevant and up to date references to support the chapters.

The section on “Recommendations for healthy elderly adults” is very detailed and some of the tables, particularly the recommended dietary allowances, are a good reference source. The detail delivered by this book enables the reader to understand many recommendations about RDA.  For zinc, they describe how endogenous losses decline as zinc absorption declines with age, and therefore help the clinician to understand areas that are potentially puzzling. They stress that zinc balance is preserved: whilst zinc is important for maintaining immune function, they are pragmatic in their advice about recommended zinc intakes; one hundred and twenty three references support this chapter.

There is careful consideration of nutrition in chronic diseases too: one of the most helpful tables is the nutritional alterations in starvation, cachexia and sarcopenia, which is used to illustrate how total energy expenditure decreases in all three conditions, even though the resting energy expenditure increases significantly in cachexia.  Whilst protein synthesis is severely diminished in starvation and declines in sarcopenia, it may increase or decrease in the condition of cachexia. The role of insulin resistance and serum cortisol in all three conditions is compared. Chapters also compare the findings of various international task forces on the modifiable dietary risks associated with cancer.  This is particularly interesting with the variability in the number of servings of fruit and vegetables per day that are recommended by different organisations. Probably of no surprise to many of us is that the recommendation is greater than five portions, although this is not consistent. Similar discrepancies are seen in the grams of salt per day dietary recommendation. These vary from < 2.3 gms to 6gms; a clear indication of differing interpretations of the same research data.

The U.S. basis of this book influences some recommendations (e.g. the use of anabolic steroids for increase fat-free mass in patient with cancer) and may therefore not appeal to all countries. This book does not lack detail but the reader may find themselves overwhelmed with data in the absence of clear recommendations for all conditions that are relevant to everyday clinical practice.

For me, the most informative parts are the tables, where clinical and biochemical advice is given in parallel, e.g. monitoring the patient using tube feeding.  The book, for me, compares to a book of poetry: it is perfect to dip in and out of, individual parts may touch different people, and everyone’s interpretation of the same passages may be different. Look at it in the library and decide if you can do without the data.  I will be using a fact per day from it on Ward Rounds to enhance the science behind the clinical decision making.

Dropping the drugs: Who? What? Why?

UntitledDanielle Ní Chróinín is a geriatrician at St. Vincent’s Hospital, Sydney, who has a keen interest in research, education, and anything related to geriatric medicine. Her paper on deprescribing is published in the latest edition of Age and Ageing and can be accessed online now.

Mr. T. is an 85 year-old man who has been attending your Geriatric Clinic for the last couple of years. He has a background of hypertension, ischaemic heart disease, osteoarthitis of his knees, and constipation. He now has moderate dementia, with a progressively worsening Mini-Mental State Examination score, 17/30 today. His wife, with whom he lives, has taken over the shopping and financial duties.

Blood pressure is up, once again, at clinic today. His current medications include aspirin, a statin, a calcium channel blocker, an ACE inhibitor, laxatives, donepezil, paracetamol and tramadol. If you shook him, he just might rattle…

Polypharmacy is ridiculously prevalent- 42% of over-50s in Australia are taking five or more medications; terms such as ‘hyperpolypharmacy’ (≥10 drugs), have been coined, in an attempt to stratify polydrug recipients in the context of a multiple-medications epidemic.

So, would you stop any of Mr. T.’s drugs? Which ones? Why?

Immediately, or when he becomes frailer, more demented, more dependent, or when his life-expectancy has dropped to months? The evidence base for making these types of decisions is limited. And individual doctor (de)prescribing practices vary widely. In a survey of Antipodean physicians specialising in the care of older patients, we sought to explore the factors which influence our decisions to ‘stop the drugs’.

A hundred-and-thirty-four busy physicians kindly lay down their prescribing pens to answer our survey. Given a list of factors which might influence their deprescribing practices, these doctors most commonly rated limited life expectancy (96.2%) and cognitive impairment (84.1%) as very/extremely important to deprescribing practices. Interestingly, the age and gender of the doctor appeared to influence  the answers supplied. Older respondents less commonly rated functional dependency and limited life expectancy important when deprescribing. On the other hand, female participants, and trainees, more often rated adherence to evidence-based guidelines important.

Confronted with a series of five case vignettes, physicians were more likely to stop many of the listed medications as the case described a patient with increasing dependency and cognitive impairment.

So we asked: “Why are you stopping these medications?” The answers commonly centred on two central themes- dementia severity and pill burden. So it’s comforting to think that if I ever develop bad Alzheimer’s disease, one of these doctors might take a look at my medication list, and strike off a couple of tablets, so that I can enjoy an ice-cream unencumbered by hidden pills. Or that if I ever end up the victim of half-a-dozen different evidence-based guidelines, a sympathetic medic might kindly prioritise the top six or seven pharmaceuticals I really need.

But the fact is that the ‘right time’, the ‘right medications’ and the ‘right deprescriptions’ for frailer older persons aren’t always so clear. Such patients are most often notable for their absence from randomised trials. But a dramatic red pen-slash, crossing off the whole shebang, may not be appropriate outside of an end-of-life scenario. Our geriatric cohort can be the victims of missed treatment opportunities, and not just over-medication. Studies continue to evolve, assessing the benefit and harms of prescribing- and deprescribing- in such patients. In the interim, I admit I mostly rely on the good habit that my first bosses drummed into me: review the meds list regularly, and look at the whole person and not just the diagnosis list. It’s likely Mr. T. will thank you for it.

BGS Spring Meeting

4451736917_75a0098a01_oTom Dening is a Professor of Dementia Research at the Institute of Mental Health, University of Nottingham. 

Spring in Nottingham! What could be finer? Little spring flowers bursting out all over University Park, Nottingham Forest on the verge of play-off contention, the ice floes beginning to break up on the Trent, students shedding their furry parkas and starting to sit on the grass….

And what better way to spend your time than to check into to the East Midlands Conference Centre at the end of April for the BGS Spring Meeting? Even better, stay at the eco-friendly Orchard Hotel next door and barely have to move for 3 days. The programme has been finalised, and booking is in full swing! I’ve even forgiven them for spelling my name wrong in the advertising booklet.

I have been (peripherally) involved in the organisation of this event, which has been led by my colleague Rowan Harwood form Nottingham and the BGS events team; it’s the first time I have worked with the BGS on something of this kind. The planning for the event started about 2 years ago, so clearly a lot of time and thought has gone into the final agenda. The programme has got something for everyone and most people will probably be interested in quite a lot of the sessions. I’m of course pleased to see that there’s a whole day for the Dementia Special Interest Group but also a session on the first morning of the main conference about aggression, with three top class psychiatrists/psychologists.

My own contribution is to co-facilitate a workshop on The Geriatrician as Manager, with Stephen Fowlie, who is the Medical Director of Nottingham University Hospitals NHS Trust. He’s the real deal, being a current MD (as opposed to being an ex, in my case) and a real geriatrician (as opposed to a psycho-, as in my case). Why have we suggested this session, and what relevance has it alongside topics like falls, respiratory disease, infections and so on?

Everyone probably has their own thoughts on doctors and management, but in many ways management and clinical medicine are inseparable. In almost every case, it’s not just us doctors dealing with individual patients and their families. There are hosts of other people, especially in the typical geriatric medicine scenario of multiple complex morbidity, where the outcomes are damage limitation or end of life care, rather than cure and restitution of full function. Some of these others are members of your own clinical team, but many of them are not. They include the support staff in the hospital, for example cleaners, caterers and porters, but also (obviously indirectly!) the finance team and ultimately the Trust Board. These latter folk help to determine the success of the hospital, dealing with commissioners, regulators, the media and the public, and these things in turn influence what your hospital is like to work in.

The job of the doctor starts with assessing and treating patients as they are admitted, and extends beyond this into the relationship that they have with their clinical team. But it goes further: what we do at the coal face gets translated into the data supplying both the people who buy our services (commissioners) and those who oversee them (regulators, the CQC in particular). There is no clear cut-off point dividing our clinical activity and these other processes. Some doctors relish the complexity and the challenge of dealing with hospital systems: they may  for example show an aptitude for the politics, or they may see engaging with management tasks as a potent way to get things done. It is this area that Stephen and I will be looking to explore in our workshop, and we look forward to meeting you in Nottingham

Photo credit: 3dpete via flickr.

Calling all students: win a BGS essay prize of £500!

BGS Logo CMYKThe BGS Movement Disorders Section award an annual prize for an essay on various aspects of Parkinsons Disease (title of which is decided upon by the section) for medical students, nursing students, therapy students and science students.

The first prize is a whopping £500; second and third prizes are also substantial at £300 and £200 respectively. The winning essay is also published on the British Geriatrics Society website.

This year’s title is “If I Had Parkinsons Disease” and the deadline for entries is 1st July 2015. Full details can be found on the BGS website, and  all entries should be sent to Joanna Gough at scientificofficer@bgs.org.uk.

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G4J Connect: Bristol

Hot on the heels of evening events in Leeds and Glasgow, a team in Bristol will be running a free teaching event on behalf of the Association for Elderly Medicine Education (AEME) on 26th March 2015. AEME tweets at @ElderlyMedEd.

This event is open to any junior doctors who look after elderly patients as part of their job, and would be particularly suitable for foundation doctors and core medical trainees. The programme consists of snappy, interactive talks on topics such as interface geriatrics and Parkinson’s disease. Towards the end, those considering pursuing a career in geriatric medicine will have the chance to address a panel of specialist trainees from across the Severn region regarding being the med reg and applications to ST3. If this last part would not be for you, you are welcome to attend the rest of the evening and leave beforehand.

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The Acute Frailty Network – solutions for urgent care for older people?

Dr Simon Conroy is Head of Geriatric Medicine, University Hospitals of Leicester, Honorary Senior Lecturer, University of Leicester and an Associate Editor for Age and Ageing journal.

Urgent care of frail older people is rapidly becoming the core business of acute hospitals; it is often described as a ‘wicked problem’. This year has been one of the most challenging periods for staff and patients in the NHS in many years. The debrief is on-going, but candidate theories include ‘too many old people’ (sic), lack of primary care, poor ED staffing, and reduced outflow relating to social care cuts. The truth is likely to be a combination of all of these factors, and many others. An important output from the post-mortem is to determine what we can do about it in the future?

Undoubtedly one of the drivers is the ageing demographic, which does mean that hospitals need to expect more older people coming though their doors, many of whom will be frail. Whilst there have been significant improvements over the last few years in the acute care response to older people, there is still a long way to go. There have also been some significant misunderstandings about what is required for older people accessing urgent care. It is not just geriatricians! Rather it is the technology to which geriatricians can usefully contribute to or even coordinate – Comprehensive Geriatric Assessment (CGA). But CGA is not an exclusive club. Every physician involved in managing frail older people should be able to play a useful part in CGA. It’s just that geriatricians are specifically trained to do it, although increasingly other physicians are developing their skills in this area which is key for future-proofing urgent care. Yet we see significant variation in the interpretation of what constitutes CGA. I have taken the liberty here of illustrating some of the key concepts.

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Still Alice – film review

cdn.indiewireDr. Vikas Bhalla is a Consultant Geriatrician at the West Suffolk NHS Foundation Trust and tweets as @drvkb

Still Alice is a film I have been looking forward to seeing for a long time, not only in my role as dementia lead for my hospital but also as a self-confessed film geek. There has also, of course, been huge hype surrounding Julianne Moore’s performance, for which she has won virtually every single “Best Actress” award this year, including an Academy Award, BAFTA, Golden Globe and Screen Actors Guild.

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Right Assessment, Right Time

image1This blog is part of a semi-regular series on team working: if you work as part of a “dream team” and want to blog about it, please let us know! Email communications@bgs.org.uk and we’ll be happy to help.

This blog comes from Angela Moore, an Older People’s Specialist Nurse at Hinchingbrooke Hospital.

Our team has started small but we are aiming high: high standards, high levels of satisfaction, and high levels of engagement. We started 8 months ago when my colleague Caroline and I were employed by Hinchingbrooke Hospital to meet our frailty CQUIN. How things have grown in such a short time! We’ve had some amazing support including that of our director of nursing Deirdre Fowler, our orthogeriatric consultant Sally Bashford and our divisional lead. I’m sure we’ve driven them all a little insane with our boundless enthusiasm!

We are both passionate about providing high quality patient centred care; we believe our patients are at the heart of everything we do and deserve the best care we can provide. In the few months that we have been in post we have implemented the use of Comprehensive Geriatric Assessment (CGA), and raised awareness of its importance with both medical and nursing staff. We have been able to implement training programmes for new staff and support information governance training.

Through raising awareness of CGA we’ve improved patient experience and communication. We have been able to develop links with community matrons and Community MDT coordinators; this has improved the communication between primary and secondary care. Our plans are to improve even further on this by arranging hospital community interface MDT meetings. I’m sure this will enable us to support further training for all nurses, giving them some insight into how we can better improve collaborative working with community teams.

We’ve had fun recently raising awareness within the hospital of our dementia café, which is supported by volunteers and the Rotary Club. Poor turnout had left the Rotary Club feeling rather deflated, so we were asked what we could do to support them: we had a fab reminiscence day at the front of hospital, donning period nursing costumes and displaying memorabilia.

Our next steps are aiming higher: we hope to see all patients over 75 admitted to our hospital at point of contact, as suggested by the Silver Book guidance and the BGS. We’ve been supported with the purchase of a geriatric simulation suit which has proved to be a valuable training resource.

I love the variety and challenges that this role brings But most of all I enjoy the pleasure of training and education to improve awareness of the needs of older people. It is important that we act as patient advocates to raise awareness of the vulnerability of this patient group, and reduce the risk of hospital acquired harm. It is important that we remember that many of this age group have lived enriched lives: they deserve respect and dignity.