If frailty is viewed by some as a “commissioning Trojan Horse” this should be admitted

Dr Shibley Rahman is currently an academic physician in dementia and frailty. His contribution on the diagnosis of behavioural frontal frontotemporal dementia, published while he was a M.B./Ph.D. student at Cambridge in 1999, is considered widely to be an important contribution to the field, even cited in the Oxford Textbook of Medicine. Here he responds to Steve Parry’s recent BGS blog, The Frailty Industry: Too Much Too Soon?  He tweets at @dr_shibley.

In response to Steve Parry’s recent BGS blog, The Frailty Industry: Too Much Too Soon?, I would simply in this article like to set out some of the strengths and weaknesses in the conceptualisation of frailty, with some pointers about “where now?

There is, actually, no international consensus definition of frailty (although there is one of a related term “cognitive frailty”).

In a world of fierce competition for commissioning, and equally intense political lobbying in health and social care, the danger is that a poorly formulated notion becomes merely a “Trojan Horse” for commissioning.

I must humbly depart from the views of some colleagues – for me, frailty is not just a word. I could likewise point to other single words which cause gross offence, which are unrepeatable in my blogpost here. Continue reading

The Frailty Industry: Too Much Too Soon?

Steve Parry works in acute medicine and older people’s medicine. He has a special interest in investigation and treatment of falls and blackouts in adult patients of all ages. He is BGS Vice President – Academic and Research.

Fashions come and go, in clothing, news and even movie genres. Medicine, including geriatric medicine, is no exception. When I was a trainee, falls and syncope was the next big thing, pursued with huge enthusiasm by a few who became the many. But when does a well-meaning medical fashion become a potentially destructive fad? Frailty, quite rightly, has developed from something geriatricians and allied professionals always did to become a buzz word even neurosurgeons bandy about. No bad thing for all professionals who see older people to have awareness of the recognition and management of this vulnerable and resource intensive patient group. Continue reading

The Challenges of Research in the Care Home Setting

Annabelle Long is a Chartered Physiotherapist working as a Research Assistant at the University of Nottingham on a Dunhill Medical Trust funded PEACH study, which considers the role of Comprehensive Geriatric Assessment in UK care homes. She has a developing research interest in wellbeing for people with dementia in community environments. In this blog she outlines the potential challenges and solutions in doing research at the health and social care interface.

As practitioners and researchers in care of older people, it is important for us to be continually working to include more dependent groups in research. The reason for doing so is to ensure that the evidence base can reliably be applied to the patients we see in everyday practice. However involving older people with dependency in research can be challenging because cognitive and physical impairments can make standard procedures for recruitment and data collection difficult. Continue reading

What has CGA ever done for us?

Graham Ellis discusses the NIHR funded research project looking into the effectiveness of Comprehensive Geriatric Assessments. As part of the project an extensive Delphi exercise is being undertaken which will include staff, patients carers and researchers.  As part of the Delphi exercise a CGA consensus meeting will be held at the BGS Autumn Meeting in Glasgow on the 24th November at 9:30-13:30.

seccWe are used to the idea that CGA is effective.  That still leaves us with a few problems.  Who does CGA help?  How does CGA help?  What are the crucial elements that make it effective?  Are wards better than teams and how can we be sure?

The challenge with black box interventions (complex interventions of multiple parts) is properly understanding the component parts and how they relate to each other.  If you don’t know how something works it can be hard to replicate it or even to improve on it.   Continue reading

Geriatric conditions, are they recognized as relevant problems by community dwelling older people?

Marjon van Rijn is a PhD candidate at the department of Geriatric Medicine in the Academic Medical Center in Amsterdam and lecturer at the School of Nursing, Faculty of Health, Amsterdam University of Applied Sciences the Netherlands. In this blog she comments on her recent paper in Age and Ageing.

aaComprehensive Geriatric Assessment (CGA) is increasingly implemented in community care settings and involves an assessment of physical, psychological, functional and social geriatric conditions, such as urinary incontinence, memory problems, fall risk and loneliness.

In this study, CGA is part of a complex intervention to prevent disability in community dwelling older people. Older people with an increased risk of functional decline, according to the Identification of Seniors at Risk questionnaire that was validated for primary care, were invited for a CGA at home. A community care registered nurse visited older persons to conduct the CGA, and if necessary, made an individual care plan with several follow up visits. Continue reading

Comprehensive Geriatric Assessment in Primary Care

Lynn Lansbury is NIHR CLAHRC Principal Investigator in Academic Geriatric Medicine at the University of Southampton. Here she talks about CGA in Primary Care, which she shares on Twitter @CGA_GP

GP SurgeryAdam Gordon’s blog introduced a timely study. With an ageing population it is important that we develop services that are fit for the changing demographic. There is convincing evidence that Comprehensive Geriatric Assessment (CGA) has a place in best practice for the care of older people. The evidence base is particularly strong in acute settings and studies have also been carried out in people’s homes. The Proactive Healthcare for Older People in Care Home (PEACH) study explores CGA in care homes Thus there is interest in identifying the place of CGA in other settings. Our new study, Comprehensive Geriatric Assessment in Primary Care (CGA-GP): The Fit for Later Life Project funded by NIHR CLAHRC Wessex, investigates the GP surgery as a setting. Continue reading

Can Comprehensive Geriatric Assessment make a difference to care home residents?  

Adam Gordon is Clinical Associate Professor in Medicine of Older People at the University of Nottingham, a visiting Professor at City University London and an Honorary Consultant Geriatrician at Derby Teaching Hospitals NHS Foundation Trust.  He tweets @adamgordon1978.  Here he talks about a new research project considering the value of CGA in care home residents

Comprehensive Geriatric Assessment (CGA) works. At least, it does when performed in an inpatient setting in an acute hospital. This has been shown over numerous systematic reviews and meta-analyses to be the case.  Older people with frailty who receive CGA experience better outcomes in terms of functional status, cognition, readmissions to hospital and numbers of days spent at home.

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Top of the POPS: the future of perioperative care

POPSJason Cross is an Advanced Nurse Practitioner for the Proactive Care of Older People Undergoing Surgery (POPS) team at Guy’s and St Thomas’ Hospital and is a member of the BGS POPS Special Interest Group. He Tweets at @jdcross1970

It’s been an exciting and challenging three years since I last wrote in the BGS blog, and while the messages haven’t changed much, the field of perioperative medicine continues to gather momentum.

In 2012 I wrote about the publication of An Age Old Problem (2011) and Access All Ages (2012) and how both these reports highlighted the deficiencies in surgical care for the older patient, and how geriatrician input was cited as an essential component to improving these issues.

These recommendations have been further supported by the recent publication of the new perioperative pathway vision document from the Royal College of Anaesthetists, titled Perioperative Medicine: The Pathway to Better Surgical Care. Here we note an emphasis on collaborative working with a focus on improving the outcomes and efficiency throughout the surgical pathway.

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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.

Elvis is alive and based in Malta

tashDr Simon Conroy is a geriatrician at University Hospitals of Leicester, Honorary Senior Lecturer, University of Leicester and an Associate Editor for Age and Ageing journal. 

Have you ever been to Malta? It’s a beautiful country with a warm Mediterranean climate and an enthusiastic team of clinicians engaged in improving the care of frail older people.

Along with Professor Tash Masud from Nottingham, I was privileged to be invited to speak at their inaugural geriatric medicine conference in May 2015.

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