Sir Muir Gray has worked for the National Health Service in England since 1972, occupying a variety of senior positions during that time. He is an internationally renowned authority on healthcare systems and has advised governments of several countries outside the UK including Australia, New Zealand, Italy, Spain and Germany. He tweets @muirgray
The British Geriatrics Society can be proud of the culture change it has achieved by providing leadership in the last seventy years. When the BGS was founded the prevailing beliefs of not only the public but also the medical profession, were that the problems of older people were due to the ageing process and not due to treatable disease – older people therefore needed “care” rather than accurate diagnosis, effective treatment and rehabilitation. The BGS and individual consultants should be proud of their achievements. There has been a revolution in the care of older people with disease.
The specialty of geriatric medicine needs to continue with this work to ensure that the change in culture persists, but it is now clear there is a need for a second cultural revolution – the preventive revolution.
The Second Revolution – prevention through fitness is possible at any age
There have been striking achievements in prevention but the focus has typically been on single diseases (e.g. heart disease or lung cancer). However, the evidence is already there, and getting stronger, about the potential to “prevent or delay the onset of disease, dementia and frailty” as set out in the NICE guidelines in 2015. We also have the report by the Academy of Medical Royal Colleges on ‘Exercise The Miracle Cure’, emphasising the role that exercise plays not only in preventing disease but in improving its outcome. There is also a growing evidence base about the prevention of disability and the factors that contribute to frailty – the BGS own report on frailty is titled Fit for Frailty The key concept that the second revolution needs to promote is the concept of fitness.
Closing the ‘fitness gap’
The ‘fitness gap’ is the difference between the best possible rate of decline and the actual rate of decline. For most people this gap starts in their early twenties; not because of ageing, but because they get their first job which involves that very dangerous behaviour – sitting down.
When disease occurs the fitness gap gets wider faster. Sometimes this is because of the direct effects of the disease. Often it is because the disease changes the beliefs and attitudes of the person affected, as well as those of the people who support them; they may now think it is ‘right and proper’ that people with long-term health problems should no longer have to struggle with the shopping and that things should be done for them. This accelerates the rate of decline of the actual rate of ability until the individual drops below ‘the line’, namely the line below which they cannot reach the toilet in time and the need for social care is defined.
The British Geriatrics Society therefore needs to lead a cultural revolution to emphasise that people of any age and with any number of conditions can become fitter, and that increased fitness can prevent or delay the onset of the need for social care.
Preventing the need for social care
Promoting fitness has many short term benefits for people in their 60s, 70s, 80s and 90s, for example in the prevention of depression, but it is the potential for preventing the need for social care that is of vital importance for individuals, their families, public services and the public purse.
Of course some people require social care as a result of severe disability caused by, for example, a major stroke. Others require it because of dementia, but even dementia should now be regarded as a disorder that can be delayed. The BGS needs to continue to promote the positive culture that people of any age can improve their fitness and maintain a level of ability that precludes the need, at that time, for social care.
Leading the second revolution
The message and the science need to be clear, and the impact of using nouns like ‘frailty’ and ‘sarcopenia’ to describe the tail-end of continuous distribution curves will need to be debated. This simple model developed in the 1980’s and reproduced in the diagram below might be one that the BGS could adopt and promote:
The message about the benefits of activity is now promoted in care homes with the bigger challenge being people who are still housebound in their own home.
In all this it is important never to lose sight of the broader economic pressures on people which increase for many people as they age. Too many older people are housebound and depressed not only because of disability but because of low income.
Viva the Revolution! Viva the Living Well SIG!
We would like to explore establishing a BGS ‘Living Well’ special interest group (SIG) to raise awareness among BGS members about the role of living healthily in order to prevent illness in old age, and thereby, in Lord Amulree’s phrase, to “add life to years”.
To register your interest in keeping in touch as plans develop, please contact Joanna Gough in the secretariat firstname.lastname@example.org