NDA and Age UKImproving Later Life

11 March 2013London

Older people are changing and they're here to stay.

Some interesting challenges for healthcare!

Finbarr Martin, GeriatricianGuys & 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

Specific diseasesFrailty

Spectrum of health and capacity

5

And older people are changing ( rectangularisation to elongation of age

distribution)

Source: mortality.org, originally ONS

Distribution of death England 1841 - 2006

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

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

1841

1941

19811991

2001

2006

Around 18% of all deaths were before 65 in 2006 –same proportion as in 1991

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??

10 21 April 2023

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

0%

20%

40%

60%

80%

100%

Number of people GP consultations Practice Nurseappointments

Outpatient and A&Eattendances

Inpatient bed days

Type of service

% o

f se

rvic

es u

sed

No LTC Non-limiting LTC Limiting LTCSource: 2005 General Household Survey.

Limiting LTC

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

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

Hospital Admission

Post-op consultant geriatrician and specialist nurse interventions

Therapy liaison

Discharge planning

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

Local proactive joint care - example from GSTT: Proactive care of Older

People having surgery -“POPS”

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