Community Geriatrics

1. Community Geriatrics Prof John Gladman University of Nottingham Nottingham University Hospitals NHS Trust

3. The case to answer Why do we need community geriatricians? We already have GPs who look after old people And Matrons And intermediate care And Consultants are expensive And geriatricians are general physicians And hospital based And should be shortening length of stay / attending to trim points And not avoiding admissions / income And there are no large RCTs and meta-analyses of community geriatricians with cost benefit analyses…

4. What community geriatric medicine is not Trying to replace core geriatric hospital care Trying to provide inefficient and ineffective out-patient services Perpetuating all that is bad about the traditional domiciliary visit Becoming a GP

5. From the basics … let us accept 16% of the population are “old” 2/3 of beds are filled by the “old” 39% of health care spending is on the “old” 49% of social care expenditure is on the “old” => the “old” are core NHS business => GPs, hospital doctors and everyone should be able to deal with issues about the “old”… Treatment benefits are often larger Activity limitations (disabilities) are often present But treatment principles are largely the same as adults of lesser years => it is impossible as well as groundless for all old people to be managed by geriatricians

6. Lets get this “old” thing right …

7. Old people NSF describes three types of “older person”:- healthy retirees, in 60s- those in transition, in 70s- the frail, in 80s Community geriatrics (all geriatrics) is for the latter

8. About frailty Vulnerability & disability (activity limitation and participation restriction) Physiology of old age Multiple chronic diseases (aka long term conditions) Proximity to death Particularly heavy service users Particularly represented in complaints

9. Long term conditions: Kaiser / NHS model

11. CORE PROCESSES FOR HEALTH CARE OF OLDER PEOPLE

12. Frailty management Comprehensive assessment:- medical & psychiatric conditions- psychological state- impairments- activity limitations (disability)- participation restriction (handicap)- physical and social environmental facilitators and hindrances- personal factors Co-ordinated delivery of multiple interventions Specialist, inter-disciplinary It needs medical specialists “Holistic”

13. Evidence base Stroke units: save lives, reduce institutionalisation, reduce dependency: cost saving Comprehensive Geriatric Assessment does the same SO THERE IS AN EVIDENCE BASE:needy people benefit from specialist co-ordinated comprehensive care and it is affordable. This means specialist medical input too. FAILURE TO PROVIDE THE ABOVE IS TO DENY (these) OLDER PEOPLE EVIDENCE BASED CARE

14. So we know what we have to do for frail older people, but where are they to be found?

15. Where frail older people are found AMU Acute hospitals (stroke, hip fracture) Community hospitals Day hospitals Matron caseloads Care homes Intermediate care (temporary frail) Can’t come / won’t come / shouldn’t come(“the looked after elderly”)

16. Community Matrons Principles: there is a cohort of frail people, care and its co-ordination by a matron can prevent admissions The first evaluation of the Evercare model showed they didn’t prevent hospital admissions: “radical system re-design” requiredBMJ, doi:10.1136/bmj.39020.413310.55 (published 15 November 2006) Targeting (a problem for frailty management too) Intervention: delivery of CGA, which requires a geriatrician (and many other necessary conditions, such as rapid access to social care) Examples: horrendous fluid balance, polypharmacy / polysymptomology, neuropsychiatry, PD…

17. Care homes 5% of all people >65 Immobility, confusion, incontinence RCTs: medication review, end of life planning Long term conditions not well managed Primary care haphazard Anecdotes: leg ulcers that won’t heal, faecal incontinence See BGS Primary & Continuing Care SIG session, Harrogate, November!

18. Intermediate care Admission avoidance / Early discharge / At home / Residential Some of this can be cost effective and virtually geriatrician freeAge Ageing 2004;33:246. Sooner and healthier… Capacity (our trial took <3% of older people) Closure of Bramwell Clearing of Leawood- Parkinson’s- advice, information, prognosis Step-ups- from the at home service (CCF and PD)- from the residential service (CCF, delirium, brain tumours)

19. Can’t come / won’t come / shouldn’t come to clinic (DVs) Can’t come: too disabled (arthropathy, PD) Won’t come: too frightened, themselves a carer Shouldn’t come: disorientation worsens history, informants can’t come, others are part of the problem or solution (esp care homes) Reflection: patient centred care! The case of the ?pheo The case of the ?pheo: The case of the ? Pheo. This patient I was asked to see at home. Earlier she had been referred to an OAP for panic attacks, but they weren’t thought to be panic attacks. Then one Xmas eve she was sent against her better judgment to the ED after an episode of SOB. She was hypertensive. She spent much of the festive period being moved around hospital wards. Much of the time she was hypertensive, anxious and trembly. She was sent home with a number of VMA bottles with an op appointment and a diagnosis of ?pheo. She hadn’t attended the Op appointment. She told me that she was terrified of hospitals, and would tremble even if she drive past the hospital! She also told me that she wanted to walk to the nearby shops, but everytime she tried, she got short of breath. I walked with her, until she became breathless (also grey and indicating her chest) and this settled with a few moments rest. It recurred on the return journey. She had diabetes and was 84. The ED ECG showed LBBB. I diagnoses angina. It responded to GTN. Seeing her at home made all the difference to the assessment ie it took place, and it did so in a way that was effective. The case of the ?pheo: The case of the ? Pheo. This patient I was asked to see at home. Earlier she had been referred to an OAP for panic attacks, but they weren’t thought to be panic attacks. Then one Xmas eve she was sent against her better judgment to the ED after an episode of SOB. She was hypertensive. She spent much of the festive period being moved around hospital wards. Much of the time she was hypertensive, anxious and trembly. She was sent home with a number of VMA bottles with an op appointment and a diagnosis of ?pheo. She hadn’t attended the Op appointment. She told me that she was terrified of hospitals, and would tremble even if she drive past the hospital! She also told me that she wanted to walk to the nearby shops, but everytime she tried, she got short of breath. I walked with her, until she became breathless (also grey and indicating her chest) and this settled with a few moments rest. It recurred on the return journey. She had diabetes and was 84. The ED ECG showed LBBB. I diagnoses angina. It responded to GTN. Seeing her at home made all the difference to the assessment ie it took place, and it did so in a way that was effective.

20. Things a community geriatric service could support Care home services:- matrons- out reach iv teams- assessment panels- medication reviews- end of life planning- CDM programme eg glidepaths CGA from the ED or AMU:- DV & urgent clinics- virtual caseload- access to Matrons- access to Intermediate Care CG access from:- primary care / community falls teams- rapid response social services teams- old age psychiatry services (health and social) System wide education System wide governance / audit

21. Ideas that haven’t worked / are mis-understandings Provision of emergency opinions Pre-admission assessment for emergencies Clinics in GP surgeries Substantial community prescribing Replacing primary care instead of supporting it

22. Clinical matters: geriatric medicine! Death in non-malignant conditions End stage CCF (end stage anything!) Parkinson’s and related disorders Anxiety, depression and dementia in physical illness Non-specific presentations with complex formulations Prognosis (goal setting & care planning) If one carves out a practice looking at the frail, and where a GP or community service for older people needs help, then a lot revolves around the ultimate consequence of frailty: death. Our hospital experience gives us special experience of what and when restorative and life prolonging interventions can help, and when they cannot. Note the GP will also have an experience and perspective on this. Particular consequences of such input leads to the permission of the preparation of end of life care planning, and with this the removal of “preventative” drugs, greater focus on palliative approaches, etc. The particular examples where I get involved is where there various active managements options to be considered. A particular one is CCF. Very often I find that fluid balance is not done well (under treated and over treated CCF goes un-noticed). The previous advice of cardiologists (given before the patient became frail) may require reversal. Permission needs to be given to use opiates and to withdraw some drugs, or to use simpler remedies such as GTN. Particular examples are beta blockers, ACE inhibitors, and anti-anginals in people too weak to get angina. We can also pick up the anaemias, renal failures, or hypoalbuminaemias that occasionally masquerade as CCF. Another example is PD. Or extra-pyramidal states. Lewy body disease, vascular disease, extrapyramidal syndromes associated with delirium, and of course drug related states are common. Diagnoses are often poor, with everything that starts out as ?Parkinson’s being called Parkinson’s disease. For those with PD, I often see those who have accumulated all the fancy drugs the neurologists can think of, but then get too frail to attend, and so appear to be consigned to them indefinitely. There is often a lot to achieve. I have upped my CPD in this area, and I’d recommend that trainees with an interest in the community should also pay particular regard to their movement disorder training. The other area that causes great problems are the psychiatric problems. Those of you who know the Nottingham ethos are aware that our approach has always been that the health care of older people is inextricably a function of medical and psychiatric issues, and so patients often need expertise from both areas. Many services for “physical” problems are unskilled in “mental” problems, and our joint training gives us skills and knowledge that can help these teams. Note GPs too have expertise in this area. It reminds us that we at least need as much special knowledge of old age psychiatry as our GPs (tiddly exposures for a small number of weeks during training is inadequate). I suspect that many GPwSIs will have greater expertise than geriatricians in some cases. If one carves out a practice looking at the frail, and where a GP or community service for older people needs help, then a lot revolves around the ultimate consequence of frailty: death. Our hospital experience gives us special experience of what and when restorative and life prolonging interventions can help, and when they cannot. Note the GP will also have an experience and perspective on this. Particular consequences of such input leads to the permission of the preparation of end of life care planning, and with this the removal of “preventative” drugs, greater focus on palliative approaches, etc. The particular examples where I get involved is where there various active managements options to be considered. A particular one is CCF. Very often I find that fluid balance is not done well (under treated and over treated CCF goes un-noticed). The previous advice of cardiologists (given before the patient became frail) may require reversal. Permission needs to be given to use opiates and to withdraw some drugs, or to use simpler remedies such as GTN. Particular examples are beta blockers, ACE inhibitors, and anti-anginals in people too weak to get angina. We can also pick up the anaemias, renal failures, or hypoalbuminaemias that occasionally masquerade as CCF. Another example is PD. Or extra-pyramidal states. Lewy body disease, vascular disease, extrapyramidal syndromes associated with delirium, and of course drug related states are common. Diagnoses are often poor, with everything that starts out as ?Parkinson’s being called Parkinson’s disease. For those with PD, I often see those who have accumulated all the fancy drugs the neurologists can think of, but then get too frail to attend, and so appear to be consigned to them indefinitely. There is often a lot to achieve. I have upped my CPD in this area, and I’d recommend that trainees with an interest in the community should also pay particular regard to their movement disorder training. The other area that causes great problems are the psychiatric problems. Those of you who know the Nottingham ethos are aware that our approach has always been that the health care of older people is inextricably a function of medical and psychiatric issues, and so patients often need expertise from both areas. Many services for “physical” problems are unskilled in “mental” problems, and our joint training gives us skills and knowledge that can help these teams. Note GPs too have expertise in this area. It reminds us that we at least need as much special knowledge of old age psychiatry as our GPs (tiddly exposures for a small number of weeks during training is inadequate). I suspect that many GPwSIs will have greater expertise than geriatricians in some cases.

23. Community CGA

24. BGS RCGP model for frailty management Practices / clusters should identify their frail older people And have a designated team for them And a regular review of this case load Referring to the community geriatrician when in need Larger teams should be responsible community hospitals, intermediate care, care home support services: members drawn from local teams and community geriatrician http://www.bgs.org.uk/Publications/Compendium/compend_4-14.htm

25. My prediction for clinical duties of geriatric departments 1/3 acute care: not undifferentiated general medicine but specialist support to CGA in front door settings (ED, AMU) 1/3 ward based care (e.g. orthogeriatrics) 1/3 community care (community & day hospitals, intermediate care, care home, matrons, etc) New arrangements with PCTs: not solely primary, secondary or intermediate care but all three Leading other “hospital based specialties” in this matter Even more managerial roles

26. Summary messages The care of frail older people requires CGA: this is evidence based practice There are frail people in community settings A community geriatrician is one necessary condition for the delivery of community CGA My workload supports matrons, intermediate care, care homes, the can’t, won’t & shouldn’t come I provide expert opinion, offers secondary care where needed – also education, governance, etc Develop with primary care