Medicine for the Elderly at UCH

Dr Matt Hayman PhD MRCP

NHS 'failing to treat elderly with care and respect'By Nick TriggleHealth reporter, BBC News

Elderly NHS patients' harrowing plight is revealed in reportSome elderly patients were given no help to eat or left in urine-soaked clothes, according to the health service ombudsman

NHS ombudsman's report: how many times do we need to hear it?How many reports do we have to have before anything will change and patients will stop suffering?

Medicine for the Elderly at UCH

• Who are we?• Where do we work?• Who do we 'care' for?• What do we do?

Who are we?

4 Consultant Physicians− Tolu Adesina− Catherine Bond− Catherine Harvey− Matt Hayman

1 Nurse Consultant− Vicki Leah

Who are we?

Junior Doctors− 2 Specialist Registrars (SpRs)− 2 CMT, 2 FY2 & 1 FY1 doctors

St Pancras Hospital− 1 (locum) Consultant Physician− 2 SpRs, 2 FY2 doctors

Where do we work?

In-patient ward (T07) (38 beds)− Sisters – Sharon, Rebecca and Clee

Trained nurses and Healthcare Assistants

− Therapists (PT/OT/Dietitian/SLT)Acute Medical Unit (AMU)Out-patients clinic

Who do we 'care' for?

DemographyCurrent in-patient average age

The demographic timebomb

The demographic timebomb

“I'm getting so old that all my friends in heaven will think I didn't make it”

The demographic timebomb

The demographic timebombAge Probability

of dying ≤ 1 year

Male (%) Female (%)

100 39 35

101 41 37

102 41 39

103 42 40

104 43 44

105 46

106 46

107 46

Geriatric Medicine

'The primary role of a geriatrician is to meet and overcome breakdown in independent living among older people.'

» Prof Sir John Grimley-Evans

Who / What is geriatric?

Chronological definitions of age

The Friendly Societies Act (1875) enacted the definition of old age as, "any age after 50", yet pension schemes mostly used age 60 or 65 years for eligibility.

The UN has not adopted a standard criterion, but generally use 60+ years to refer to the older population.

In contrast to the chronological milestones which mark life stages in the developed world, old age in many developing countries is seen to begin at the point when active contribution is no longer possible.

Chronological definitions of age

The Friendly Societies Act (1875) enacted the definition of old age as, "any age after 50", yet pension schemes mostly used age 60 or 65 years for eligibility.

In contrast to the chronological milestones which mark life stages in the developed world, old age in many developing countries is seen to begin at the point when active contribution is no longer possible.

Who / What is geriatric?

The frailty balance

Who / What is Geriatric?

'The definition of a geriatric patient is one lucky enough to be under the care of a geriatrician'

What do we do?

Dr Tolu Adesina – Stroke liaison− Hyper-Acute Stroke Unit (HASU)− Acute Brain Injuries Unit (ABIU), NHNN− Oakwood ward, St Pancras Hospital

What do we do?Dr Catherine Bond – Surgical Liaison

Medical support to frail elderly surgical in-patients

Kingswood ward St Pancras Hospital

Dr Catherine Harvey – OrthogeriatricLiaison

Medical support to frail elderly fractured neck of femur patients.

What do we do?

Dr Matt Hayman – Acute Medical Interface− Early (<12 hours), comprehensive

geriatric assessment of frail medical admissions to Acute Medical Unit (T01).

− Lead clinician for 'Rapid Response' and PACE teams supporting early discharge home or to rehabilitation/assessment for appropriate patients.

What do we do?

Vicki Leah Consultant Nurse for Older People

− Dementia and Delirium Champion− Capacity and Deprivation of Liberty

Comprehensive Geriatric Assessment

− Medical diagnoses− Cognition and Mood− Drugs (OTC, herbal, prescription)− Nutrition, smoking & alcohol− Pain− Vision & Hearing− Problems with sleeping− Social problems− Pressure sore risk

The geriatric giantsBernard Isaacs (1924-1995)

Professor of Geriatric Medicine (Birmingham)

'Survival of the Unfittest' (1972)� Characterised "Geriatric Giants":

incontinence, immobility, instability (falls) intellectual impairment.

The geriatric giants

• Off legs

• Mechanical fall ?UTI

• Acopia

• Confused

Slaying the Geriatric Giants

Dr Matt Hayman

Immobility and Instability

Instability and Immobility

• Hip fracture – final common pathway of fallers

– Roche et al (2005)• 33% mortality at 1 year

– 10% directly attributable to the #

Immobility and InstabilityOtago Exercise Programme (A J Campbell)

Falls Prevention Exercise Programme4 premises:

Individually tailoredIncreased in difficulty with improvementSustainable (visits and calls from instructor)A walking programme should complementthe strength and balance programme

� 2-3 strength & balance and 2 walking / week

Instability and Immobility

Thomas S et al. Age Ageing 2010;39:681-687

Forest plot of comparison: ‘OEP’ versus ‘no exercise’; outcome: mortality.

Instability and Immobility

Incontinence

Incontinence

Percentage ofadults with faecalincontinence

Age Percent

Men & womenliving at home:

15-44 0.4 %

45-64 3-5 %

65 + 15 %

Percentage of adultswith urinaryincontinence

Age Percent

Women living athome:

15-44 5-7 %

45-64 8-15 %

65 + 10-20 %

15-44 3 %

45-64 3 %

65 + 7-10%

Men living at home:

Incontinence

Incontinence

Incontinence - Pharmacology• Anticholinergics – Oxybutinin, Tolterodine

• Topical oestrogen

• Duloxetine

• Intra-vesical Botulinum toxin

• Adrenergic drugs – Midodrine, Clenbuterol

• Oral oestrogens

Incontinence

Incontinence - Exercise

Dumoulin, Cochrane review (2009)

Pelvic floor muscle training (Kegel exercises) helps

women with all types of incontinence.

Women with stress incontinence who exercise for three

months or more benefit most.

Intellectual Impairment

Intellectual Impairment

Cochrane Review (Birks, 2006) Cholinesterase inhibitors for Alzheimer's disease

10 randomized, double blind, placebo controlled trials (>7000 pts)

Improvements in cognitive function, -2.7 points (95%CI -3.0 to -2.3, p<0.00001), in the midrange of 70 point ADAS-Cog Scale.

Study clinicians rated global clinical state more positively in treated patients. Benefits also seen on indexes of ADLs and behaviour.

None of these treatment effects are large.

Intellectual Impairment

Intellectual Impairment• Geda et al (2010) Ann. Neurol

1,324 individuals without dementiaModerate exercise (brisk walking, aerobics,strength training or swimming)39% RRR of developing MCI

Light exercise (golf) & vigorous exercise(jogging) NOT protective

Slaying the Geriatric Giants

Intellectual Impairment

Erickson et al (2010) Neurology - Physical Activity (PA) predicts gray matter volume in late adulthood.

299 adults (mean age 79).

PA = number of blocks walked in 1 week

CT at 9 years to assess gray matter volume

Cognitive 'adjudication' at 13 years

Intellectual Impairment

• Erickson et al (2010) Neurology

• Greater PA predicted ↑grey matter volumes.

• ≥72 bl/wk (3.6 miles) to detect ↑ grey matter

• Risk of MCI reduced by factor of 2

Intellectual Impairment

Slaying the Geriatric Giants

Slaying the Geriatric Giants

Slaying the Geriatric Giants

Thank you

• Now walk home!

• BUT not yet…