July issue of Age & Ageing now available

The May 2015 issue of Age and Ageing, the journal of the British Geriatrics Society is out now!

A full table of contents is available here, with editorials, research papers, reviews, short reports, case reports book reviews and more. Hot topics this issue include:

  • Pharmacotherapy for type 2 diabetes
  • Exercise regimens and bone health
  • Balance training for in-patient rehabilitations
  • What are frailty instruments for?
  • Oestrogen replacement in postmenopausal women

The Editor’s View can be read here.

This issue’s free access papers are:

Tailored care for older patients with cancer in Latin America: an imminent challenge

16352524103_e92527228c_oEnrique Soto Pérez-de-Celis and Ana Patricia Navarrete-Reyes work at the National Institute of Medical Science and Nutrition Salvador Zubiran, Mexico City. They tweet at @EnriqueSoto8 and @patsnavarrete

Although cancer can affect any person, regardless of their age, most people with cancer and most cancer survivors are older adults. Cancer is a disease of ageing, and in an ageing world, the role of the geriatrician in the management of the older adult with cancer is progressively becoming more and more relevant.

Between 2010 and 2050, older adults will represent the age group with the highest proportional expansion in the world. While the population of people younger than 64 will increase 0.2-fold, those over 65 will increase 1.8-fold. Even more alarming is the fact that the number of people aged 85 or older will increase 3.5-fold. As a matter of fact, by 2050 21.1% of the world population will be over 60 years of age, and 392 million people will be aged 80 years or over (the “oldest old”). This change in the demographic structure of the world’s population will inevitably bring a dramatic increase in the incidence of diseases associated with aging, cancer among them. This will be particularly challenging for low and middle income countries, since 8 out of 10 of the world’s older adults will live in the less developed regions of the world, where poverty and poor coverage by social protection systems are a pressing issue.

According to the projections published by the WHO and the GLOBOCAN in 2012, the number of incident cases of cancer (excluding non-melanoma skin cancer) will rise by 39% in people younger than 65 by the year 2035. On the other hand, for people aged 65 or older, this increase will be of 104%, with an estimated number of new cases of cancer among older adults of 13,689,934 in the year 2035 alone. This will inevitably transform the practice of all oncologists into a de facto geriatric oncology practice, and as such, the entire workforce will have to prepare for this “silver tsunami”. In 2013, The Institute of Medicine (IOM) of the National Academies of the United States published the report entitled: “Delivering High Quality Cancer Care: Charting a New Course for a System in Crisis”. In this report, the IOM underlined the fact that, in face of an ageing population and with a projected shortage in the number of providers with geriatric expertise, more emphasis on educating all members of the healthcare system in geriatric aspects of care was needed. Although in European nations, such as the UK, the number of geriatricians is high (with some regions having 1 geriatrician per 46,000 of the population), the predicted workforce requirement for oncologists is of a minimum of 500 posts, according to the Royal College of Physicians. However, in the United States, the demand for both oncologists and geriatricians far exceeds the supply, and this is even more of a problem in developing countries, were the shortage of specialized physicians is critical.

In the context of a worldwide workforce shortage and a rising vulnerable patient population, there is an increasing need to place a substantial focus on healthcare infrastructure in order to provide skilled care for older adults with cancer. A possible solution to this issue is to develop multidisciplinary teams guided by geriatric principles in which several healthcare professionals (physicians, nurses, rehabilitation technicians, nutritionists and social workers) can interact with the patient and his/her caregivers in order to deliver comprehensive, efficient and patient-centered care. In this model, members of the cancer care team can coordinate with each other and with other geriatric care teams in order to develop interprofessional education programs aimed at both, the rest of the workforce and the caregivers. Achieving such a model, of course, requires an increase in the geriatric training provided to healthcare providers during their education, and this should be one of our priorities going forward.

In our Institution (@geriatriainnsz), we have developed a multidisciplinary team aimed at providing comprehensive care for older adults with cancer. Our Cancer Care in the Elderly Clinic aims to be a highly functional model of a geriatric oncology clinic in the setting of a public academic hospital. Each patient is evaluated by medical oncology, geriatric medicine, nutrition and rehabilitation medicine. The patient is classified according to the stages of aging described by Balducci as fit, vulnerable or frail based on a comprehensive geriatric assessment. Fit patients have the highest level of health and are candidates for almost any cancer treatment with good outcomes. Frail patients have multiple comorbidities, geriatric syndromes and disability for activities of daily living and can be expected to have very poor outcomes during treatment. Vulnerable patients have some dependence in one or more instrumental activities of daily living and one geriatric syndrome. These patients require the most individualized approach and may have some benefit from modifications of the treatment plan in order to achieve a good outcome. Our team provides the treating oncologist with feedback regarding the functional status of the patients, as well as with recommendations regarding modifications of therapy. Additionally, we assess the priorities of the patient and help in establishing a patient-centered and goal oriented treatment plan.

Today we know that factors other than chronological age predict morbidity and mortality in older adults with cancer. Functional status, comorbidities, nutritional status, cognition, psychological state and social support are all part of a very complex array of interactions that influence the way in which older adults tolerate both cancer and its treatment. Using a comprehensive geriatric assessment we can better understand the “functional age” of cancer patients and uncover problems which are usually not detected by a standard clinical interview. Additionally, we can use these tools to better predict the risk of side effects related to cancer treatments and to implement interventions aimed at improving patient outcomes.

In the next decades, we will be faced with the enormous challenge of providing high quality healthcare to an aging population. Although it is unrealistic to believe that someday every older adult with cancer will be treated by a geriatric oncologist, we should make every effort to offer geriatric training to all healthcare professionals and to create bridges between geriatrics and other medical specialties. By implementing multidisciplinary models, we must attempt to incorporate geriatric assessment into standard practice in order to better inform decision making and reach the goal of providing all older adults with cancer with personalized tailored care utilizing evidence based medicine with a comprehensive approach.

Picture credit: Paulisson Miura via flickr

Popular treatments for lower urinary symptoms may be doing more harm than good

aaA new study published in Age & Ageing, the scientific journal of the British Geriatrics Society, has revealed that many of the drugs commonly prescribed for older people with lower urinary tract symptoms may be doing more harm than good, and should either be used with caution or avoided altogether.

Researchers from the University of Heidelberg and an international rater team analysed data from 25 different clinical trials and other available evidence. Of the 16 drugs included in the study, only three were classified as beneficial for older people.

The majority were rated as questionable, meaning they should be avoided where possible, especially when patients are receiving other drugs at the same time. Five drugs were rated as “avoid”, with the authors recommending that they should not be used for older patients at all.

Drugs for the treatment of lower urinary tract symptoms rank amongst the most frequently prescribed medications for older people, and yet this new research is the first systematic comparative study looking at their appropriateness for older patients.

Speaking on behalf of the British Geriatrics Society, Professor Adam Gordon said:

“Lower urinary tract symptoms are common in older patients and can be a source of considerable distress. There is increasing recognition that many of the drugs prescribed for lower urinary tract symptoms may have harmful side-effects, particularly related to memory and thinking. 

Against that background, this study is a timely reminder that there is limited evidence of benefit in older patients for many drugs used. This has a number of implications. 

Firstly, drugs should only be used where non-drug treatments have been shown not to work. Secondly, they should be used with careful attention as to what side-effects they may be causing. Thirdly, more research is required to understand what combination of medications will achieve the best outcomes in older patients with lower urinary tract symptoms.”

Martin Wehling, corresponding author of the study said:

“The FORTA (Fit fOR The Aged) system – a simple approach to label drugs to be used in older people from A (indispensable), B (beneficial), C (questionable) to D (avoid) – was applied here to separate beneficial from less favourable drugs.

It is meant to provide guidance at a glance to improve often complex medication schemes which are all too common and carry considerable risk in this important age group. The respective FORTA list classifies drugs to treat major indications, with a new chapter on those used for lower urinary tract symptoms now added.”

Increasing participation of older people in research: an innovative study design

aaIn this blog, Andy Clegg, Senior Lecturer at Leeds University and Consultant Geriatrician at Bradford Royal Infirmary, expands on a recent Age & Ageing paper, looking at the use of the innovative cohort multiple randomised controlled trial (cmRCT) design to increase participation of older people in research studies

There are many challenges involved in recruitment of older people to research studies, particularly randomised controlled trials. Study exclusion criteria and refusal rates are a major issue and the presence of cognitive impairment and ethical decisions adds complexity. Concerns with study information and consent procedures are the most common reasons given for not participating in clinical trials. Understanding and weighing up the complex information about randomisation and control groups is not easy, particularly in the presence of sensory and cognitive impairment.

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A taste of your own medicine

6680441249_b6ed9537f5_oDipti Samani is a Speciality Registrar (ST6) in Geriatric medicine working in the East Midlands South Deanery, and tweets at @HmniDipti. In this blog she looks at an inventive approach to NHS Change Day.

“Treat others as you would wish to be treated” is something I have heard time and time again growing up. I wonder if this is only true in personal relationships and dealings. Can we, and should we, extend this out into our professional lives, both in terms of our colleagues and also to the patients that we treat?

After my 2014 NHS Change Day pledge to walk in my patients’ shoes for a day by wearing a continence pad: ‘Continence: My Conscience is Clear’; I decided this year to go back to the roots of NHS Change Day and Damien Roland’s idea to taste the medicines that we give to our patients.

The aim of doing this was not just to know how (awful) some medicines taste, but to give myself and others an appreciation and awareness of what our patients go through. I wanted to highlight some of the alternative medications where available and to increase our compassion towards patients.

I took some of the common medications prescribed to older people to a lunchtime meeting in our department. The medications included: laxatives (Lactulose, Laxido), food thickeners, Sando-K, various nutritional supplements, Calogen and Hypostop – I’m sure you can think of more, but these were the most benign, unpleasant ones I could think of. The experiment was completely voluntary and I was impressed that all grades of doctor from medical student (who seemed to think it was some kind of initiation) to consultant took part. Of course I couldn’t have done this without the support of our departmental pharmacist who sought permission to support us with samples.

Feedback given from the tasters included recognition of the difficulties experienced by patients, increased care when thinking about prescribing, and empathy with patients’ experiences. It shows that it is sometimes easy to forget about the person behind the patient, and by putting ourselves in their place, it is possible to re-awaken our compassion for them:

I would love to go one step further to see if we could all be more compassionate and kinder towards each other in the work place. Patients are here to get better and we could acknowledge that they may be having a rough time; meanwhile, each of us comes to work only to do our best and to help people, and a lack of compassion with unkind words or actions towards each other just serve to depress this aim.

I would wish that by giving ourselves a taste of our own medicine this NHS Change Day, we will hopefully be able to get closer to treating others how we would like to be treated ourselves.

Photo credit: Ian Lamont via flickr

Diabetes care in the very old. Beyond the limits of evidence?

aaDr. Shota Hamada is a Visiting Research Fellow in the Department of Primary Care and Public Health Sciences, King’s College London.

Very old people have rarely been included in clinical trials in sufficient numbers and treatment recommendations for them are largely based on professional opinion informed by evidence generated from younger patients. Selecting drug treatment for very old people may be influenced by distinct concerns including co-morbidities, declining physical and cognitive functioning, and perceptions of limited life expectancy, that may be less relevant in younger people.

Our recent research, published in Age and Ageing, investigates changing prescriptions for antidiabetic and cardiovascular medications for very old patients who were newly diagnosed with type 2 diabetes over a 20 year period.

The study included a representative sample of nearly 13,000 patients from primary care in the UK. From 1990 to 2013, use of sulphonylureas declined rapidly from 94% of patients to 29%, while metformin became the mainstay among antidiabetic drugs, increasing from 22% to 86%. Prescribing of antihypertensive (46% to 77%), lipid-lowering (1% to 64%), and antiplatelet drugs (34% to 47%) also increased substantially in this period.

These changes in prescribing seem to be motivated by evidence generated from clinical trials in younger people. From the 1990s onward, the results of several large clinical trials have been available, such as UKPDS, ACCORD and 4S, which promoted implementation of intensive multifactorial interventions for patients with diabetes to reduce mortality, cardiovascular diseases and other complications.

Do these major increases in the intensity of pharmacological management really improve survival or well-being in very old people? We do not have a clear answer to this question. Our present study is surely an initial step to evaluate drug therapy in very old people with diabetes. One of the challenges in making treatment decisions may be so-called “lag time to benefit” or “payoff time”.

For example, initiation or continuation of antidiabetic drugs should be determined carefully given that it requires several years to obtain benefits from antidiabetic drugs. Further research is needed to justify or adjust prescribing practices in terms of both effectiveness and safety outcomes. We should now prepare to develop evidence-informed strategies for diabetes management in very old people.

 

NHS Benchmarking Network publish older people in acute settings results

7382c36aab90e284dc2b6bbbb705b0f0_400x400Leigh Jenkins is Assistant Project Manager at the NHS Benchmarking Network. Dr. Gill Turner is a consultant geriatrician and Vice President, Clinical Quality for the British Geriatrics Society.

Wouldn’t it be great if you could benchmark the acute services provided for older people in your hospital, against others trying to do similar things? Might this be the start of a quality improvement process, allowing you to seethat other hospitals do things differently and possibly better?

This month saw the publication of a report which moved us closer to that ideal. The NHS Benchmarking Network have completed the first phase of a national benchmarking project looking at the care of older people in acute settings. Developed in conjunction with the British Geriatrics Society, the project explores the pathways that older people take through hospital by looking at four key areas of the acute pathway; admission avoidance in A&E, assessment units, inpatient care and supported discharge.

Over the course of the summer of 2014 the Network collected data from 47 Trusts and Local Health boards on a range of metrics. Within each area of the pathway the service models, activity, workforce and finance data was explored. A number of key quality and safety indicators were also collected, and participating trusts were encouraged to share any good practice and innovation that is happening locally. The findings of the first phase of the project provide a robust, up-to-date picture of the care of older people in acute settings in the UK.

We were keen to explore the availability of different teams in A&E who are dedicated to admissions avoidance. The results show that 24% of the Trusts who participated in the project have a dedicated geriatric team located in the A&E department, typically available for 9 hours per day during the week, reducing to 6.5 hours at weekends. Nearly two thirds of the 47 participating trusts have rapid access to social workers in the ED to support early turnaround and admission avoidance – whilst commendable – this means that over a third don’t have this facility- already an important comparator and a stimulus to discussion in those trusts.

We collected data on assessment units, with a particular interest in the use of Comprehensive Geriatric Assessment (CGA). 29% of participants have a frailty unit, and 90% are using CGA on the frailty unit. Senior medical cover on the frailty unit averages 13 hours per weekday, and 10hrs at weekends. It is perhaps disappointing that more than 10 % of specialist geriatric units do not provide CGA- again food for further discussion in those trusts.

77% have a short term assessment unit (up to 12 hrs expected LoS), with 44% of these performing CGA on this unit. Senior medical cover is available 17hrs per day during the week, and 6hrs at weekends. Finally, 85% report having an ‘other’ assessment unit (12 to 72 hrs expected LoS), with around a third of these units performing CGA. Senior medical cover availability averages 15.4hrs on weekdays and 14.4 hrs at weekends.

It was also found that 87% of elderly care wards deliver Comprehensive Geriatric Assessment, which reduces to just 23% of speciality wards delivering CGA, suggesting that outlying patients are not receiving CGA.

We were also interested in the staffing skill mix at each element of the pathway, particularly the nursing staffing ratio. We found a richer nursing skill mix is available at the front and back end of the hospital, with the use of unregistered nurses significantly higher within assessment units and care of the elderly wards. In the admissions avoidance teams in A&E the ratio of nurses was 80% registered and 20% unregistered, compared to 55% registered and 45% unregistered on the elderly care wards.

Excitingly the Network has already made the decision to repeat the audit this summer, and we anticipate increasing momentum with a greater number of trusts and health boards getting involved. The BGS Clinical Quality group are working alongside the project team to develop the measures of quality in several domains – we are keen to see how routinely collected data can help to assess efficiency, effectiveness and safety. We are looking at developing a Patient Reported Experience Measure (PREM) and examining how this could practically be incorporated into the project.

Data collection will open on 3rd August 2015, and is open to all member organisations of the NHS Benchmarking Network. To find out if your Trust is a member or for more information on the project please contact Leigh Jenkins of the NHS Benchmarking Network on leigh.jenkins@nhs.net, 0161 266 2113.

We don’t have all the answers – but we are starting to understand what questions we should ask. Please get involved and take a look at the report and contact us if you have things to say. We really want to hear from you.

Hundreds more metrics can be found in the full report, which can be accessed here.

Stand by me: dementia care in Liverpool

brenda_staggEd Gillett speaks to Brenda Stagg, the winner of the BGS’s  Special Medal – an award which was inaugurated in 2015 to celebrate the achievements of people who are not members of the Society, who promote the health and wellbeing of older people throughout society.

It’s a warm summer afternoon in Toxteth, and I’m standing in a church hall breaking out my best disco moves to “Dancing Queen” by ABBA. It’s fair to say I hadn’t planned for the day to turn out quite like this.

I’m in Liverpool to meet Brenda Stagg, a Dementia Support Manager at Alzheimer’s Society: she has recently been awarded the 2015 British Geriatrics Society Special Medal in recognition of her work with older people across the city, and I’m here to find out more about her work.

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Strengthening the link between geriatrics and oncology

Mr Kwok-Leung Cheung is Clinical Associate Professor, Faculty of Medicine & Health Sciences at the University of Nottingham and Honorary Consultant Breast Surgeon at Royal Derby Hospital. He is the UK National Representative for the International Society of Geriatric Oncology (SIOG) and member of its Surgical Task Force and Science and Educational Committee.

As the UK National Representative of the International Society of Geriatric Oncology (SIOG), I last wrote to you following our 14th Conference in October 2014. I mentioned the importance of ‘bringing the two worlds (oncology and geriatrics) together’, given our shared goals to improve the holistic care for older adults, including those with cancer.

I would like to continue to work with you as the UK specialty association in geriatrics to enhance the link between these two ‘worlds’ in the UK. Continue reading

Where The Heart Is

thwb_smEd Gillett is Communications & PR Manager at the BGS. In this blog, he looks at a new project placing writers ad other artists on creative residencies within care homes.

Think of poets, artists and writers working with care homes, and you might initially think of arts-based therapy and other activities for residents Where The Heart Is, a recent arts-based programme run by Age Concern, has taken a different approach, placing artists from various disciplines within care homes, and inviting them to create work inspired by their experiences.

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