Ageing societies: extra years or

extra tears?

Challenges for 21st century primary care

Louise Robinson

Professor of Primary Care and Ageing

RCGP Clinical Champion for Dementia

Care of the elderly

• Our ageing society

• Health of oldest old: reality not rhetoric

• Challenges for primary care

• New ways of working

Our Ageing Society

• Oldest old” (>85 years) - fastest growing sector! • Worldwide 377 million >85 by 2050

Apocalyptic demography

• “Frail, vulnerable and high users of care”

•Oldest old” - >85 fastest growing sector of population

' Councils 'will struggle with

ageing population’ BBC Feb 2010

Councils will struggle to cope with the financial challenge posed by England's ageing population...

The Audit Commission said the £9bn a year social care bill

will double by 2026 if current practices continue.

Councils needed to look at new and innovative ways to

provide services, particularly by embracing technology…

It highlighted a number of examples of how "telecare" was

being used… to link older people to services

Complexity of ageing

Health of older people

• Lack of empirical data; >85s excluded • Service development = research

• Primary care research: cohort studies• MRC CFAS: 13,000 participants >65• Newcastle 85+ study: 800 >85

•Oldest old” - >85 fastest growing sector of population

UK disability profile

MRC Cognitive Function Ageing Study (2000) • 62% require daily formal care• 21% dependent on formal services• Impairment: physical, functional and cognitive

• Majority living in community

MRC CFAS II Is ageing changing? (2009)

7500 participants; 3 centres (Newcastle)

Newcastle 85+ study

Joanna Collerton, Karen Davies, Carol Jagger, Andrew Kingston, John Bond, Martin Eccles, Louise Robinson,

Carmen Martin-Ruiz, Thomas von Zglinicki, Oliver James, Tom Kirkwood (PI)

Newcastle 85+ study: Aims

1.Describe in biological, medical and social terms the health of >85s

2.What factors are associated with health maintenance >85s?

3.Describe the functional status of >85s and associated health/social care usage

Newcastle 85+ study: Methods

GP record review Home assessments with nurse interviewers

Interview (validated questionnaires) Physical, psychological, social, lifestyle Health/social care use

Test (bloods, ECG, spirometry, hand grip)

3 phase data collection over 5 years

Newcastle 85+ study: Methods

GP record review (RR) Home Assessments (HA): nurse interview

Physical, psychological, social, lifestyle Health/social care use Tests (Bloods, ECG, spirometry, hand grip)

Study sample 851/1453 (58.6%): HA + RR 188 RR (12.9%): 3 (0.2%) HA

Newcastle 85+: Results

Multi morbidity the norm! Median count: 5 women; 4 men

58% Hypertension 51% Osteoarthritis 31% Ischaemic heart disease 20% Stroke/TIA 16% Chronic chest disease 12% Moderate/severe cognitive impairment

Undiagnosed disease 1

diagnosed undiagnosed

Geriatric syndromes

56.9

40.7

53.0

38.2

26.6

63.9

31.6

45.038.4

12.6

0102030405060708090

100

Hearingimpairment

Visualimpairment*

Pain lastmonth*

Fall(s) UrinaryIncontinence*

Per

cen

tag

e

Women Men

* Significant gender difference

Newcastle 85+: Results

Self rated health (SRH) 77% excellent/very good/good 4% poor

Interval of need 41% independent: 1976 20% (Bond 1982)

12% daily help; 8% 24 hour care

Functional ability (Activities of daily living) 20% no difficulty with 17 ADL Median 3/17 ADL

Support for those living at home 66% Family (31% spouse; 35% child) 25% Social Services

Health care use (in last year) Primary care: 93% GP contact Secondary care: 1/3 had OP appointment; low

use of A/E; hospital admissions!

Newcastle 85+: Conclusions

Diversity of health (Collerton et al BMJ 2009)

Good SRH and function despite multi-morbidity Is 85 the new 70?

Are this group a healthy elite?(Life expectancy at birth 1921: 61 men, 68 women)

Care in the community by the community

Primary care challenges!

• Multi-morbidity and poly-pharmacy• Functional problems but less disability?

• Falls; Incontinence; Immobility • Frailty• Carer support (55-85 years)• Increasing social isolation • Risk assessment and management• Assessment of mental capacity: decision making

Complexity of care

A GP’s Xmas list……….

Dear Santa, My practice manager says that I have been a very good

GP. I have 100% in all my QOF targets and have only had 1 patient complaint in the whole year! Please, please, please can I have a geriatrician, a social worker AND a physiotherapist for my practice…….

Louise aged x years

Ps Don't worry about the gift wrapping !

21st century primary care

• 21st century GP (geriatrician!) • Longer consultations: RCGP 15 mins • Training...fit for purpose? • Commissioning role

• Primary care team - ? fit for purpose• Nursing roles: nurse practitioners;

chronic disease nurses; community matrons• Voluntary sector: better links?• Integrated health and social care• Community geriatric teams

21st century geriatric care

• Geriatric care: new approaches• Geriatric assessment teams• Medical Crisis in Older People programme

– ‘Front door’ assessment and care teams (FACT)– Integrated medical and mental health acute wards

• Role of assistive technologies • DoH Demonstrator project: AT and long term conditions• Integrating telecare into LTC care in UK (May et al 2009)

– Lack of ownership: failure to translate research – practice– GPs not involved and not keen to been involved!

21st century community care

• Integrated health and social care budgets

• Collaborative care model • Case manager: 1’/2’ care link (nurse; social worker• Evidence-based guidelines on common issues• Therapeutic skills: counselling/prescribing • Knowledge of community care services

• Evidence base: US studies • Depression (Callahan et al 2005): Dementia (Callahan et al 2006)

Collaborative care model

• Vulnerable older people (Counsell et al 2009)

• 2 years of home-base care management• Case management: Nurse practitioner and SW• 12 protocols for common geriatric problems• Integrated care: GP/interdisciplinary geriatrics

• Improved quality of care/health-related QOL

Conclusions

• Services informed by research

• New ways of working: NCS not NHS

• Integrated, seamless care• Commissioning: combined health and social care budgets

• Primary care • 21st century GP/primary care team: training• Primary care and geriatric care

One T shirt we

will all wear !

a.l.robinson@ncl.ac.uk