Geriatric Medicine an evidence based approach - 1st Edition
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Dedication—Prof. Peter Crome
Peter Crome has worked in the National Health Service, academic institutions,
and professional bodies since 1970. He has led the development of clinical and
academic geriatric medicine in local, regional, national, and international are-
nas. As head of Keele Medical School, chair of the Geriatrics Committee of the
Royal College of Physicians, president of the Section of Geriatrics and Geron-
tology of the Royal Society of Medicine, secretary general of the Clinical Sec-
tion of the International Association of Geriatrics and Gerontology, and
president of the British Geriatrics Society, he has given strategic direction to the
development of geriatric medicine nationally and internationally.
Peter has inspired a generation of geriatricians by promoting clinical excel-
lence, bringing a research ethos into every aspect of clinical practice, and
encouraging others to develop a wider vision and positive approach. His influ-
ence has been pervasive. Through the Master’s degree in Geriatric Medicine he
founded at Keele University, academic seminars and conferences, and mentor-
ing of students nationally and internationally, he has shaped a generation of
geriatricians. As president of the British Geriatrics Society, he has been instru-
mental in changing the clinical specialty of elderly care into the academic disci-
pline of geriatric medicine.
The chapters in this book are inspired by Peter’s interests and are written by
experts in the field in celebration of his work. They reflect Peter’s wide influence
within the specialty of geriatric medicine and the impact that he has had upon it.
His research includes publications on pharmacokinetics in older people, stroke,
dementia, involvement of older people in clinical trials, addiction, mental health,
pain, and frailty, with seminal papers and book chapters in all of these fields. His
interests have not just been theoretical. He has carried his studies through into
improvements in clinical practice, undergraduate and postgraduate education, and
policy implementation. Peter is not only an incisive thinker; he also has the ability
of making things happen in complex circumstances and difficult situations.
No one who knows Peter can fail to appreciate his optimism, realism, humour,
unfailing humanity, and his broad smile. However, most of all, he is a devoted
doctor, a trusted colleague, and an intuitive mentor, always eager to be support-
ive and inclusive.
With all of Peter’s admirers it would have been possible to fill this book sev-
eral times over. As it is, the chapters collected here will stand as a token of the
affection and esteem in which he is held by all of his friends and colleagues.
Preface
While it is fashionable to lament the perceived future adverse impacts of
increasing longevity on society, health care provision, and social services,
such doom may be misplaced, as increased longevity is a consequence of bet-
ter health, and life years gained may be productive and contented. While the
recent increase in retirement age can be seen as a purely economic expedient,
it also reflects the realities of better health in older people. Nevertheless,
towards the end of life, at whatever age this occurs, frailty, memory loss, pain,
and multimorbidity are likely to remain problems encountered in years to
come as they are now. Evidence on the effectiveness of preventative and ther-
apeutic interventions is increasing rapidly, and approaches to treatment of
the older person are changing apace. With more age-related problems
becoming treatable or preventable, simply caring for the elderly is no longer
an option.
More than in any other specialty, the way the service is delivered and how
support is provided in the community are important determinants of health
and quality of life in this population, and new models of care are being
developed.
This book will give the reader a grounding in current thinking in geriatric
medicine, highlight the research which has led to changes in management strat-
egies, point to key sources of up-to-date information on the topic, and probe
into questions that still remain to be answered.
The contributors to the book are leading UK specialists in their subject areas.
Chapters are written in a concise and economical style that conveys the latest
evidence-based practice in the treatment of older people along with expert
interpretation of the research literature from a specialist’s perspective. Learning
points and illustrations are provided where relevant, as well as up-to-date refer-
ences for further material, including useful websites.
The book is an easily accessible reference tool for a broad cross section of
health professionals who manage older patients in both primary and secondary
care, such as geriatricians, general practitioners, nurses, therapists, and clinical
researchers, as well as specialists in pain, stroke, dementia, and palliative care
services. The topics and issues raised will be of particular interest to profession-
als involved in the development of health and community services for older
people.
viii PREFACE
What emerges is the complexity of the care of older people requiring collabo-
ration between multiple agencies along with integration of services under-
pinned by robust channels of communication. Good quality clinical trials are
increasingly providing us with effective interventions to treat many of the con-
ditions of old age. Such advances need to be used to influence care provision at
the level of policymakers. In addition, legal and physical infrastructures associ-
ated with the provision of care of older people, such as access to services and
treatments, require updating and enhanced inclusivity. This book is both a
guide to best practice and a manifesto for further improvements of evidence-
based medicine for the older person.
Frank Lally and Christine Roffe
Acknowledgements
We would like to gratefully acknowledge the tireless support of Professor Ilana
Crome in the preparation of this book and the help of Dr David Roffe in the
editing process. We are also thankful to Mrs Kathryn McCarron for ensuring
the smooth running of the conference where the germ of this book took root.
The production of a book is always a difficult process, but Eloise Moir-Ford at
OUP has made this as painless a process as possible and we are most grateful for
her patience and understanding.
Contents
Contributors xiii
1 From gut feeling to evidence base: drivers and barriers to the
development of health care for older people 1
Paul V. Knight
2 Re-thinking care in later life: the social and the clinical 11
Chris Phillipson
3 Health and social care services for older people: achievements,
challenges, and future directions 23
Roger Beech
4 Service models 35
Finbarr C Martin
5 Therapeutics in older people 51
Stephen Jackson
6 Dementia and memory clinics 65
Alistair Burns, Richard Atkinson, Sean Page, and David Jolley
7 Frailty: challenges and progress 75
Peter Crome and Frank Lally
8 Incontinence, the sleeping geriatric giant: challenges and
solutions 89
Adrian Wagg
9 Depressions in later life: heterogeneity and co-morbidities 113
David Anderson
10 Substance misuse and older people: a question of values 127
Ilana Crome
11 Sleep in older people 137
Joe Harbison
12 Assessment and management of pain in older adults 149
Pat Schofield
13 Stroke units: research in practice 161
Lalit Kalra
14 Stroke care: what is in the black box? 173
Christine Roffe
xii CONTENTS
15 Involving older people in the design and conduct of clinical trials:
what is patient and public involvement? 187
Kate Wilde and Zena Jones
16 Under-representation of older people in clinical trials 201
Gary H. Mills
Index 215
Contributors
Dr David Anderson Hon. Professor Queen Mary
Consultant Old Age Psychiatrist & University of London,
Associate Medical Director, London, UK
Mersey Care NHS Trust, Prof. Peter Crome
Liverpool Clinical Business Unit, Research Department of Primary
Mossley Hill Hospital, Care and Population Health,
Park Avenue, University College London,
Liverpool, London, UK
Merseyside, UK
Prof. Joe Harbison
Dr Richard Atkinson Associate Professor of Medical
Consultant Psychiatrist Gerontology,
for the Elderly, Trinity College Dublin,
Lancashire Care NHS Foundation Dublin, Republic of Ireland
Trust,
Charnley Fold, Prof. Stephen Jackson
Cottage Lane, Department of Clinical
Bamber Bridge, Gerontology,
Lancashire, UK King’s Health Partners Academic
Health Sciences Centre,
Dr Roger Beech Denmark Hill,
Reader in Health Services Research, London, UK
Institute for Primary Care
and Health Sciences, Dr David Jolley
Keele University, Honorary Reader,
Staffordshire, UK Personal Social Services Research Unit,
The University of Manchester,
Prof. Alistair Burns Dover Street,
Institute of Brain, Behaviour Manchester, UK
and Mental Health,
The University of Manchester, Ms Zena Jones
Manchester, UK Senior Manager,
NIHR Clinical Research
Prof. Ilana Crome Network: Stroke,
Hon. Consultant Psychiatrist South Biomedicine West Wing,
Staffordshire and Shropshire International Centre for Life
Healthcare NHS Foundation Trust, Times Square,
Emeritus Professor Keele University, Newcastle upon Tyne, UK
xiv CONTRIBUTORS
Prof. Lalit Kalra Wepre House,
Department of Neurosciences, Wepre Drive,
Academic Neurosciences Centre, Connaghs Quay,
King’s College London, Flintshire, UK
London, UK Prof. Chris Phillipson
Prof. Paul V. Knight School of Social Sciences,
Director of Medical Education Humanities Building,
(Associate Medical Director), Bridgeford St,
Consultant Physician Medicine Manchester, UK
for the Elderly, Prof. Christine Roffe
Royal Infirmary, Stroke Research,
Glasgow, UK North Staffordshire Combined
Dr Frank Lally Healthcare Trust and
Institute for Science & Technology Institute for Science & Technology in
in Medicine, Medicine,
Keele University, Keele University,
Guy Hilton Research Centre, Stoke On Trent,
Stoke On Trent, Staffordshire, UK
Staffordshire, UK Prof. Pat Schofield
Prof. Finbarr C Martin University of Greenwich,
Ageing and Health, Centre for Positive Ageing,
Guys and St Thomas’ NHS School of Health & Social Care,
Foundation Trust & King’s Avery Hill Campus,
College London, Grey Building,
St Thomas’ Hospital, Avery Hill Rd,
Westminster Bridge Road, Eltham, UK
London, UK Dr Adrian Wagg
Prof. Gary H. Mills Professor of Healthy Ageing,
General Intensive Care Unit, University of Alberta,
Northern General Hospital, Edmonton,
Sheffield, Yorkshire, UK Alberta,
Sean Page Canada
Consultant Nurse for Dementia Dr Kate Wilde
& Senior Lecturer in Dementia North Staffs Combined Healthcare
Care Nursing, NHS Trust,
Betsi Cadwaladr University Health Holly Lodge,
Board & Bangor University, Hartshill,
Memory Service, Stoke-On-Trent, UK
Chapter 1
From gut feeling to evidence
base: drivers and barriers
to the development of health
care for older people
Paul V. Knight
Key points
◆ Major advances in medicine, policy, and services for older people have
been made over the past 50 years.
◆ The numbers of older people in the UK and elsewhere are increasing and
will continue to do so.
◆ This increase has concomitant sociological, medical, and economic chal-
lenges that need to be met because they affect the provision of services at
all levels.
◆ These challenges are occurring at a time when resources are becoming
scarcer and budgets shrinking.
◆ Governments are faced with orchestrating infrastructure and policy in
this demanding and complex scenario.
◆ Managers are attempting to do more with less.
◆ Clinicians and other medical professionals are trying to base treatments
on sound evidence-based strategies.
◆ There is recognition of the need to include older people and the general
public in these processes.
◆ Research may provide us with information that can help resolve these
problems.
2 GERIATRIC MEDICINE: AN EVIDENCE-BASED APPROACH
1 The emergence of geriatric medicine
Prior to the NHS, illness and disability of older adults of average or low wealth
was largely met by local authority provision. Only acute illness preceded by rea-
sonable good health would have reached the ‘proper hospitals’ in the voluntary
and charitable sectors, including the teaching hospitals. With generally poor
housing stock, and little more than family and other informal care to fall back
on in the community, institutionalization was a much more common outcome
than it is now. The National Health Service Act 1946 was a defining event for
older people’s care as it brought these large and poorly staffed institutions into a
health care oriented universal service. The specialty of geriatric medicine was
made necessary by this political act, though it needed early clinical pioneers to
give it life.
Meanwhile the National Assistance Act 1948 empowered local authorities to
provide accommodation for older people whose frailty, old age, or poverty ren-
dered unable to manage at home. This arbitrary distinction of health and social
care was set down in law, and remains a challenge to the provision of a flexible
yet holistic approach.
2 Older people’s medicine into the mainstream
The initial focus of geriatric medicine was people with ongoing disability, most-
ly in long-stay NHS hospitals inherited from local councils. The buildings often
previously served as workhouses. The changes from the 1950s to the 1980s can
be summarized as follows:
◆ Application of conventional medicine to this previously underserved popu-
lation of patients rendered many able to recover sufficiently to leave
hospital.
◆ Early but quite basic developments in rehabilitation and devices reduced
disability.
◆ Organization of geographical areas under health boards (with various
names) brought some order to the distribution of resources and the gradual
spread of geriatricians to most areas.
◆ Closure of worn-out buildings and the rationalization of dispersed services
into larger district general hospitals brought geriatric medical beds into
the mainstream, with better access to facilities and staff, notably junior
doctors.
◆ Facility to admit older people directly, rather than from waiting lists or by
transfer from other hospital departments (usually less than satisfactory
recovery), gave geriatricians a role in their acute medical care.
FROM GUT FEELING TO EVIDENCE BASE 3
◆ This, along with expansion of social care provision, brought about marked-
ly better outcomes and reduced hospital lengths of stay.
◆ Closure of NHS long-stay hospitals, plus changes to statutory regulations
enabling older people to access various forms of supplementary income,
resulted in major expansion of the private and voluntary care home sector.
This coincided with a general loss of NHS long-stay beds, particularly in
England.
◆ This privatization had the consequence of transferring medical responsibil-
ity for thousands of hitherto ‘hospital patients’ into primary and commu-
nity care, with little transfer of the commitment or skills necessary for their
care. Thus the focus of geriatric medicine became acute hospital services,
with dwindling capacity for day-hospital activity such as elective multidis-
ciplinary assessment.
◆ The increasing public costs of funding care home places and domiciliary
social support associated with inadequate assessment of disabled older
people led to the NHS and Community Care Act 1990. This created a
framework for better health and social care collaboration.
◆ Geriatricians’ presence on the acute hospital site and better access for older
people to higher-tech medicine resulted in many of them developing sub-
specialty skills and roles (e.g. in stroke, cardiovascular conditions, endos-
copy, and orthogeriatric rehabilitation).1
3 Demographics
When Marjory Warren published the first of her much-quoted articles in the
BMJ in 1943 (1), she annotated no references to support her conclusions but
drew on her personal observations of the many patients who had alighted in the
wards of the West Middlesex County Hospital. One of the main drivers to sup-
port her assertion that a modus operandi of care was needed was the fact that
the absolute numbers of elderly people in the population was rising and would
continue to do so.
The numbers of people over the age of 65 years has continued to increase in
the UK and elsewhere. The trend is set to continue according to many national
surveys (Box 1.1). This increase in the older population carries with it socio-
logical, medical, and economic burdens that are likely to affect the provision of
services at all levels. These challenges are occurring at a time when resources are
1
The author gratefully acknowledges the contribution of historical background information
(sections 1 and 2) by Prof. Finbarr Martin.
4 GERIATRIC MEDICINE: AN EVIDENCE-BASED APPROACH
becoming scarcer and budgets shrinking. Due to the complexity of these chal-
lenges, governments alone are unlikely to be able to deal with them. Instead
there will likely be a need for collaboration between multiple agencies with inte-
gration of services nationally and across different disciplines at multiple levels.
Box 1.1 Ageing statistics
◆ ‘The UK has now reached a point where there are more people over State
Pension age than children. By 2020, the Office for National Statistics
(ONS) predicts that people over 50 will comprise almost a third (32%) of
the workforce and almost half (47%) the adult population’.
Text extract reproduced from Gov.UK (2) under the Open Government
License v2.0.
◆ ‘The number of older Americans increased by 6.3 million or 18% since
2000, compared to an increase of 9.4% for the under-65 population.
However, the number of Americans aged 45–64—who will reach 65 over
the next two decades—increased by 33% during this period’.
Text extract reproduced from Administration on Ageing USA (3).
◆ The European population over 65 years was 17.5% in 2011 and is project-
ed to be 29.5% by 2060. ‘The share of those aged 80 years or above in the
EU-27’s population is projected to almost triple between 2011 and 2060’.
Text extract reproduced from Eurostat (4) © European Union, 1995–2013.
4 Integrated services
Governments and commentators have recognized the fact of an increasing
population but have been perplexed as how to best deal with the increased
longevity of our Westernized populations. Longevity is seen as a problem rather
than a triumph. Lately, the language has been somewhat hysterical and a sug-
gestion has been raised in some quarters that older people are being specifically
targeted (5). A survey of health professionals across Europe showed that many,
particularly in the UK, felt that ageing was a threat to the viability of individual
health systems (6). Initially, geriatricians sought practical solutions to improve
the care of older people but lacked the impetus or resources to conduct specific
controlled trials; descriptions of successful services were published instead (7).
This has led to a diversity of service and much debate about what seems best in
different settings. Unlike an organ specialty such as cardiology, geriatric medi-
cine depends not only on the skill and training of its physicians, but the
FROM GUT FEELING TO EVIDENCE BASE 5
availability of other team members and the relationship the service may have
with social care professionals often employed and funded by different organiza-
tions. Take a cardiologist from Glasgow to Geneva and the coronary care unit
and basis of service setup will be essentially very similar; but take a geriatrician
from Manchester to Milan and the same will not be the case.
Physicians have realized that our systems for dealing with multimorbid older
patients need a new paradigm (8). Not only that, but if these changes do not
come about then hospital care, in particular, will fail (9). Geriatricians have
endeavoured over the years to publish trial evidence that proves a particular
system of working best benefits older people. They have coined the term com-
prehensive geriatric assessment (CGA) (10–12) to describe what happens,
although, as CGA seems to be a black-box assessment, exactly how it acts is still
open to debate. The benefits have been variously described until recently, when
systematic reviews showed significant and sustained benefits for older hospital
inpatients in a variety of acute and restorative settings when they were treated
by a dedicated multidisciplinary team in a dedicated area. Benefits included
reduction in mortality, reduction in nursing-home admissions, and improved
function (10–12). Such evidence is being used to persuade policymakers and
health service commissioners to purchase the best care for older hospitalized
patients so that, provided certain processes are followed, it can be the same no
matter what the geographical location.
5 Frailty and geriatric syndromes
Most organ specialists have the ability to look at treatments specifically designed
towards a particular organ outcome; for instance, reduced cardiovascular
events in those with triple coronary vessel disease. In geriatric medicine the
metric of definition has been harder to grasp until the more recent descriptions
of frailty, with proponents oscillating between phenotypic and index methods
of identification (13). (See also Chapter 7.) In any event, it is clear to most geria-
tricians that frailty is our basic science and a unifying population description
for those who would benefit most from service trials and from specific pre-
ventative interventions. Frailty also describes one of the main differences
between geriatric medicine and organ specialties, as frailty is the non-specific
presentation of disease which has a final common pathway of symptom com-
plexes. Frailty is often described collectively as geriatric syndromes. This leads
the unwary into the trap of being unable to distinguish disease modification
from the normal ageing process (14).
Bernard Isaacs coined the expression the geriatric giants or the four Is: impair-
ment of intellect (cerebral dysfunction), incontinence, immobility, and instability
6 GERIATRIC MEDICINE: AN EVIDENCE-BASED APPROACH
(falls). The term giant reflects frequency and enormous burden to sufferers (15).
The geriatric giants do not quite translate into the entirety of geriatric syndromes
although there is considerable overlap.
6 Legislative frameworks
Although geriatricians espouse treating the whole person within a multidiscip-
linary construct this still requires the use of specific treatments for organ-
specific illnesses. These treatments are often engineered through trials that
specifically exclude older people (Chapter 16) and thus lead to the wrong t argets
for treatments in that specific population (16). This has led to collaborations
between geriatricians and organ specialists creating a more realistic view of
what treatments can do and how they should be deployed in a frail population;
for example, cholesterol-lowering agents (17). However, the exclusion from
clinical trials of ‘unvarnished free-range older people’ remains an obstacle to
the use of new pharmaceutical agents. Currently there seems little appetite in
Europe to recognize this issue in regulatory agencies.
7 Access to facilities and treatment
Older people are known to have lower treatment rates for most forms of cancer.
Geriatricians have used CGA as standard practice for some time. CGA improves
outcomes for frail older people and it has now been used with some success in
oncology. Improved outcomes have made oncologists more willing to give
older, particularly frail older people, access to treatments. Access to treatments
in mental health and addictions is, similarly to oncology, poor.
There is a need to be aware of the non-specific presentation of geriatric syn-
dromes and how this affects treatment outcomes. Although outside geriatric
medicine the use of CGA is mainly used in oncology, there seems no reason
why this approach could not be employed in many other treatment settings
such as addiction and mental health, where access to services and outcomes can
be equally as poor (18).
8 The utilization of the CGA approach to non-elders
The ethos of geriatricians has developed over time to ensure that the team they
lead performs a holistic assessment, considering not only disease entities but
also the function of the person and the environment in which they live. Some
organ specialists are also now aware that this approach can work for younger
patients who have complex needs. Thus the culture of geriatric medicine is sim-
ply good medicine (19).
