1. Conference to honour the career of Professor Peter Crome
Beyond the geriatric giants: moving from elderly care to evidence-based medicine for the older person.
Conference to honour the career of Professor Peter Crome
Keele, March 21st 2013
Service Models
Finbarr Martin, Geriatrician
Guys & St Thomas’ Hospital and King’s College London

2. Medicine - No Country for Old Men !
“We realize that for all practical purposes the lives of the aged are useless, that they are often a burden to themselves, their family and the community at large. Their appearance is generally unesthetic, their actions objectionable, their very existence often an incubus to those who in their humanity or duty take upon themselves the care of the aged.”
Nascher IL. Geriatrics: the disease of old age and their treatment. Philadelphia: P Blakiston's Son & Co, 1914.

3. A surgeon rides to the rescue
Marjory Warren (1897 – 1960) at Isleworth Infirmary
1935 took over an adjacent workhouse to form the West Middlesex County Hospital.
Systematically reviewed several hundred inmates
Classified into 5 groups
Adapted from Barton A and Mulley GP, 2003

4. Her achievements Warren MW A case for treating chronic sick in blocks in a general hospital. BMJ Warren MW . Care of the chronic aged sick. Lancet 1946
discharged many patients by providing rehabilitation and appropriate equipment.
Upgraded wards, improved patient and staff morale
Advocated
creating a medical specialty of geriatrics
providing special geriatric units in general hospitals
teaching medical students about the care of elderly people, by senior doctors with specialist interest in geriatrics.

5. Early experience at St Pancras, London
Lancet, 1951

6. Look at the age in 1950

7. Progressive patient care – first model designed to optimise use of acute beds
Lancet, 1962
30 beds, pre-discharge
32 beds, long stay
106 beds, post acute +rehab
22 beds LOS mean 10 days

8. Two models emerged in 1970s Age defined model (Sunderland)
(O'Brien TD et al , No apology for geriatrics. BMJ 1973;i:277–80)
Became predominant model till 1990 as old hospitals closed and DGHs absorbed older medical patients
Integrated model (Newcastle)
(Grimley Evans J Integration of geriatric with general medical services in Newcastle. Lancet 1983;i:1430–3)
Recommended by RCPL in 1977
Reduced beds and reduced doctors’ hours galvanised this
Withdrawal from rehab and long stay as consequence

9. Where are we now? ================================= More older people
People aged 65+ are ~ 17 % of the population
And use 65% of acute hospital bed-days
>50% of the patients having surgery, (>major)
=================================
More older people
Older people are older
And older people are different

10. ( rectangularisation to elongation of age distribution)
older people are older
( rectangularisation to elongation of age distribution)
Around 18% of all deaths were before 65 in 2006 –same proportion as in 1991
Source: mortality.org, originally ONS 10

11. As a result………… Most older people now live long enough
To have several long-term conditions (+ multiple medications)
eg Respiratory, cardiac, diabetes
to develop sensory impairment, sarcopenia, inflammaging
Many also develop
dementia, osteoporosis, cataracts etc
homeostatic dysregulation
Resulting in frailty and “geriatric syndromes”

12. People with long-term conditions have high health service use, especially hospitals (69% total spend).
Limiting LTC
Non limiting LTC
percentages
No LTC
Older people GP consults Practice nurse Outpatients Inpatients
Type of Service used
Source: 2005 Household Survey 12

13. Spectrum of health and capacity
And older people vary
Genetics inc chance changes in development
Maternal and early life factors
Society and Lifestyle etc
Events and illnesses and chance
Frailty
Specific diseases
Spectrum of health and capacity

14. Frailty “summarises” prediction of outcomes
Rockwood and Mitniski A J Gerontol 2007

15. Implications for health care
(Tinetti Am Med J 2004)

16. Age attuning health services
Expect older people with problems
Identify frailty and geriatric syndromes routinely
Use comprehensive geriatric assessment (CGA)
Predict “complications”
Use experts judiciously
Up-skill general services
Promote multidisciplinary clinical practice and clinical governance
Better care is often cheaper care in the end, so NHS must get better to survive economically

17. The scope of geriatric medicine
Acute and episodic illness
Post acute recovery and rehabilitation
Long term management of diseases and frailty
Support for people living with high dependency
End of life care

18. Acute and episodic illness
Interface geriatrics - between community and hospital in response to acute clinical change
support Emergency Departments
liaison with intermediate care (IC)
Provide part of the acute medical admission service
proactive case finding in acute medicine
CGA approach with selected patients
Support hospital approach to age attuning all services
design and delivery of services
leadership in quality improvement with geriatric syndromes
Support education and training of the workforce

19. Implications for Surgery NCEPOD Report 2010
>1000 deaths of surgical patients 80+ years
Report highlights suboptimal management of common post-operative complications
Gap between policies, guidelines and clinical practice.
Assessment and clinical skills were too narrow
Likely events not anticipated or responded to
Interdisciplinary collaboration sporadic

20. Proactive support for frail older people having surgery
Systematic responses 1
Proactive support for frail older people having surgery
developing risk assessment in surgical services
pre-op CGA for selected high risk patients
ongoing medical input to peri- & post-operative care

21. Eg. Local proactive joint care - example from GSTT: Proactive care of Older People having surgery -“POPS”
Surgical Outpatients/PAC
Proactive referral of patients aged 65+
Screen to identify risk
Including “medically unfit for surgery”
Pre-operative CGA
Consultant
Clinical Nurse Specialist
Occupational therapist
Physiotherapy
Social worker
Patient education
Post Discharge
Intermediate Care
Links with primary care/ social care
Specialist clinic follow up (falls etc)
Preadmission Liaison
Surgical team
Anaesthetists
GP and Community services
Patient
Hospital Admission
Post-op consultant geriatrician and specialist nurse interventions
Therapy liaison
Discharge planning

22. Provide shared care for patients with fragility fractures
Co-design and supervise the hip fracture clinical pathway
Provide daily medical care to selected patients
Share clinical governance responsibility to achieve the best practice standards of care and secondary prevention

23. Eg Fracture services National inter-disciplinary collaboration
The Blue Book and the NHFD 23 23

24. Post acute recovery and rehabilitation
Design and quality assure post acute care pathways
assist clinical systems to identify inpatients’ ongoing needs
specialist input to bed based or domiciliary IC services (EVIDENCE?)
Provide “hot clinics” for CGA and other key conditions
Link to A&E, acute admission units and community assessment in a whole system approach to urgent care
Link with community based services to optimise recovery, ameliorate frailty and target secondary prevention
(EVIDENCE PATCHY AND NARROW)

25. Long term conditions and Frailty
Estimating potential benefit is complex
Attributing risk in context of co-morbidity
Effects on LE, independence and quality of life
Estimating risks and burdens is complex
Factoring in frailty
So geriatrician- primary care co-working is needed
So far, relatively evidence free zone

26. Support for people living with high dependency
CGA for older people at transitions of dependency
diagnostic input prior to institutional care
design and delivery of pathways for frequent hospital attendees
(LOTS OF INITIATIVES, LITTLE EVIDENCE)
Specialist support for care home residents

27. End of life care - recognition
Trajectories in the final 12 months of life

28. Summary Its not just about our wards anymore
Its still about diagnosis but through CGA
Its more about frailty more than age
Its about getting it structured and simple and reliable
It will be about new therapies for frailty etc
Geriatrics is coming of age