NDA and Age UK
Improving Later Life
11 March 2013
London
Older people are changing and they're
here to stay.
Some interesting challenges
for healthcare!
Finbarr Martin, Geriatrician
Guys & St Thomas’ Hospital and Kings College London
Current public and media focus
Bad press and negative reports about
• Variations in access– post code lottery
• Dignity in care
• Continuity of care in hospitals and primary care
• Variation in performance of acute hospitals
• Poor integration with community and primary care
Older people are not all the same
“usual” older people are heterogenous re
– sensory impairments
– physiological ‘abnormalities’ eg lung function
– metabolic changes eg glucose impairment
– psychosocial factors eg. cognition, engagement
(Rowe and Kahn, Science, 1987)
These variable developments are life long and multi-factorial
And many are reversible/preventable
this justifies a more optimistic and holistic approach to public
health and clinical practice
How and why individuals differ
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
And older people are changing
( rectangularisation to elongation of age distribution)
Distribution of death England 1841 - 2006
100%
Around 18% of all
deaths were
before 65 in 2006
–same proportion
as in 1991
90%
1981
1991
80%
1941
70%
2001
60%
50%
1841
2006
40%
30%
20%
10%
0%
1
5
9
13
17
21
25
29
33
37
41
45
49
53
57
61
65
69
73
77
81
85
89
93
97 101 105 109
Source: mortality.org, originally ONS
5
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”
What is frailty about?
•
•
•
•
Widespread change just short of decompensation
Much of this is NOT condition specific
But variable between individuals - unpredictable
Propensity to additional minor stressors mental and
physical
• Thus possibility of multisystem failure
• And linkages between mechanisms of apparently
different problems,
– Eg delirium and sarcopenia – inflammaging and
low IGF-1
Frailty “summarises” prediction of outcomes
Rockwood and Mitniski A J Gerontol 2007
Getting healthcare fit for a modern population
• People aged 65+ are ~ 17 % of the population
• And use 65% of acute hospital bed-days
• >50% of the patients having surgery, (>major)
• Use nearly half the NHS total budget
• Over half social services’ budgets
• Over £3 billion for NHS continuing care
So, are the older population a challenge to the NHS?
OR, are older people core business??
People with long-term conditions have high
health service use, 69% total health spend.
People with limiting LTCs are the most intensive users of the most expensive services
100%
% of services used
80%
Limiting
LTC
60%
40%
20%
0%
Number of people
GP consultations
Practice Nurse
appointments
Outpatient and A&E
attendances
Type of service
Source: 2005 General Household Survey.
10
No LTC
Non-limiting LTC
Limiting LTC
9 April, 2015
Inpatient bed days
The official intention
“A comprehensive service available to all based on need
and irrespective of age, gender, ethnicity etc.....reflecting
needs and preferences of patients families and carers”
NHS Constitution 2008
“Discrimination has no place in a fair society which
values all its members. ...services should be differentiated
by age only when justifiable or beneficial”
Equality Act 2010
Some of the challenges to make this reality
•
•
•
•
•
•
Changing expectations
Overcoming the social – clinical divide in care
Elective and emergency surgery
Management of long term conditions
Reaching the most vulnerable people
Recognising and respecting the end of life
Right patient –wrong place?
• Many staff regarded their hospital wards as the
wrong place for older people
• And too many senior politicians and policy experts
seem to agree
Tadd W et al. Dignity in Practice: An exploration of the care of older adults
in acute NHS Trusts. NIHR Service Delivery and Organisation
Programme; 2011.
Right place - wrong skills
• Clinical challenges of sudden change
 Subtle presentation of serious illness
 Functional decline is always “suspicious”
• Co-morbidity is common
• Loss of reserve is common
– Physiological
– Psychosocial
Solution – embed the right skills as “routine”
NCEPOD Report 2010
• >1000 deaths of surgical patients 80+ years
• Report highlights suboptimal management of
common post-operative complications
• Gap between policies, guidelines and routine clinical
practice.
• Assessment and clinical skills were too narrow to
anticipate and react to likely events
• Interdisciplinary collaboration is essential
National inter-disciplinary collaboration
The Blue Book and the NHFD
Local proactive joint care - example from
GSTT: Proactive care of Older People having
surgery -“POPS”
Surgical Outpatients/PAC
Pre-operative CGA
Proactive referral of patients aged 65+
Consultant
Screen to identify risk
Clinical Nurse Specialist
Including “medically unfit for surgery”
Occupational therapist
Physiotherapy
Post Discharge
Social worker
Intermediate Care
Patient education
Links with primary care/ social care
Specialist clinic follow up (falls etc)
Preadmission Liaison
Hospital Admission
Surgical team
Post-op consultant geriatrician and
specialist nurse interventions
Anaesthetists
Therapy liaison
Discharge planning
GP and Community services
Patient
Long term conditions
• 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
• Enabling real co-decision making
• Relatively evidence free
End of life care - recognition
Trajectories in the final 12 months of life
What needs to be done?
• Older people with problems are to be expected
• Frailty and geriatric syndromes can be identified comprehensive geriatric assessment (CGA)
• “Complications” can be predicted
• Expert teams + up-skilling general services
• The future is multidisciplinary in clinical practice and
clinical governance
• Better care is often cheaper care in the end, so NHS
must get better to survive economically
Can gerontology research help?
• How to incorporate into clinical practice the
individual adaptive strategies to deal with
differences and difficulty
• How to enable older people to navigate and make
choices, even whilst receiving crisis stabilisation
• How to provide care without creating ghettos
• How to address the intergenerational difference
between care receivers and givers
…….As well as a host of bio-gerontology questions
about ageing frailty and promoting recovery