Yorkshire Comprehensive Research Network (Ageing Priority Group) & White Rose Netork

“Research into later life: the road less travelled”

John Young Geriatrician

Leeds University & Bradford NHS Hospital Yorkshire

The Road Less Travelled M Scott Peck (1990)

“Life is difficult. This is a great truth, one of the great truths It is a great truth because once we truly see this truth, we transcend it. Once we truly know that life is difficult – Once we truly understand and accept it – then life is no longer difficult. Because once it is accepted, the fact that life is difficult no longer matters”(!)

The Road Less Travelled M Scott Peck (1990)

“Research in geriatric medicine is difficult. This is a great truth, one of the great truths It is a great truth because once we truly see this truth, we transcend it. Once we truly know that research is difficult, once we truly understand and accept it – then research in geriatric medicine is no longer difficult. Because once it is accepted, the fact that research is difficult no longer matters”(!)

“Research into later life: the road less travelled”

Aims: 1. Identify and celebrate (some)

achievements

2. Expose (some) important gaps

3. (Find your hero!)

4. (Find your dragon!)

Odds ratios for living at home at end of follow-up (median 12 months) in elderly patients according to CGA after emergency admission

Ellis G et al. BMJ 2011 ©2011 by British Medical Journal Publishing Group

Specialist elderly care: good practice principles for rehabilitation

Comprehensive, multi-disciplinary assessment Appropriate skills, training & attitudes Prevention of complications (esp. loss of independence) Promotion of independence Person-centred care

Falls: 50 successful years of research

Medical cause

Multiple risk factors Environmental RFs Personal RFs TLoC Syncope Epilepsy J. H. Sheldon

“On the natural history of falls in old age”

BMJ 1960

Preventing falls in older people living at home

RCTs = 111; n = 55,303

• Group exercises effective • Home-based exercises effective • Tai Chi effective • Vit. D not effective • Home safety not effective • Snow shoes effective • PPM/Carotid sinus hypersensitivity effective • Cataract surgery effective

Gillespie L, Robertson M, Gillespie W, Lamb S, Gates S, Cumming R, Rowe B. Cochrane Library 2010

Preventing falls in older people in nursing homes and in hospitals

Nursing Home Hospital

Supervised exercise Uncertain (n=9)

Uncertain (n=3)

Multicomponent interventions Uncertain (n=7)

Effective, but … (n=4)

Medication review Uncertain (n=2)

Uncertain (n=2)

Vit.D supplementation Effective (n=5)

Uncertain (n=1)

RCTs = 41; n=25,442 Loads of heterogeneity

Cameron I, Murray G, Gillespie L, Roberson M, Cumming R, Kerse N. Cochrane Library 2010

(Hip protectors ??)

Falls in care homes are more injurious

Women Men All

Injury 39% 37% 38% Fracture 4.5% 0.5% 3% Head Injury

18% 22% 19%

Four care homes in Finland (Nurmi et al. 2002)

23rd April

Significance???

“St George slaying (sic) the dragon”

Dr Trevor Howell (1908-1988)

Dragons of old age:

• Pressure ulcers • Contractures • Falls • Incontinence • Confusion

Dementia & Delirium

Over 800,000 people in the UK have dementia Projected to rise to over one million by 2020 Estimated costs £23 billion in 2012

……. pledged to double the research budget for dementia to £66million a year by 2015. “Dementia is a terrible disease. It is a scandal we haven’t kept pace with it.”

• Improved diagnosis (currently

P – Person I – Interactions E – Environment

A ward based observational tool called P.I.E. which stands for……

43 hospitals; 105 wards (Medical, Surgical, Elderly Care)

5/105 wards provided evidence of care which appeared to be person-centred more often than not

National Institute for Health & Care Excellence (NICE): Delirium Guidelines

(2010) Guideline Development Group: we learnt many things, but ONE BIG THING!!

Complex, multi-component interventions for delirium treatment do NOT change outcomes

Complex, multi-component interventions for delirium prevention DO change outcomes

Imbalance between delirium treatment & prevention

Care in specialist medical & mental health unit compared with standard care for older people with cognitive impairment: RCT. Goldberg et al BMJ 2013 Specialist Standard Care Length of stay 11 11 days Mortality 22 25% Readmission 32 35%

Cost-effectiveness of multi-component delirium prevention for medical pts

£200

00 / Q

ALY

£300

00 / Q

ALY

-5,000

-4,000

-3,000

-2,000

-1,000

0

1,000

2,000

3,000

-0.100 0.100 0.300

incr QALY

incr

Cos

MTI vs UC CE Threshold = £20000/QALY CE Threshold = £30000/QALY

Akunne A, Murthy L, Young J. Age & Ageing 2012

The “Geriatric Giants”

• Falls • Incontinence • Confusion • Immobility

Prof Bernard Isaacs (1924-1995)

Frailty syndromes

The Frailty Paradox

National Audit of Community Rehab 2012

N = 3,150

Mean age 82y

One or more LTC 77%

Two or more LTC 41%

The frailty paradox: •We all recognise it! •But oddly behaves as an “invisible” condition

Earlier and systematic diagnosis of frailty = frailty as a chronic disease?

Frailty tends to present in crisis

New Care Paradigm for Older People & Frailty

Community-based: person-centred & co-ordinated (Health + Social + Voluntary

+ Mental Health)

Timely identification for preventative, proactive care by supported self-management &

personalised care planning

“An older person living with frailty"

(i.e. a long-term condition)

‘The Frail Elderly’ (i.e. a label)

Hospital-based: episodic, disruptive & disjointed

Presentation late & in crisis (e.g. delirium, falls, immobility)

TOMORROW TODAY

The 4m walking speed test detects frailty

Van Kan et al JNHA 2009; 13:881 Systematic Review of 21 cohorts

4M

Taking more than 5 seconds to walk 4m predicts future: Disability Long-term care Falls Mortality

Proportion alive

Time

Primary care electronic Frailty Index (eFI): Survival curves (n=227,648; >65y)

Fit Mild frailty Moderate frailty Severe frailty

So, “Research into later life: the road less travelled” BIG successes, but • care home medicine; • community based rehabilitation; • dementia care; • preventing delirium; • frailty programmes; ……..and lots more……….

Official “happiness” levels in UK (2012)

more

Yorkshire Comprehensive Research Network (Ageing Priority Group) & White Rose Netork��“Research into later life:�the road less travelled”The Road Less Travelled�M Scott Peck (1990)The Road Less Travelled�M Scott Peck (1990)“Research into later life:�the road less travelled”Slide Number 5Specialist elderly care: good practice principles for rehabilitationFalls: 50 successful years of researchPreventing falls in older people living at homePreventing falls in older people in nursing homes and in hospitalsFalls in care homes are more injurious23rd April��Significance???��Slide Number 12Dr Trevor Howell (1908-1988)Over 800,000 people in the UK have dementia�Projected to rise to over one million by 2020�Estimated costs £23 billion in 2012P – Person �I – Interactions�E – EnvironmentNational Institute for Health & Care Excellence (NICE): Delirium Guidelines (2010)Cost-effectiveness of multi-component delirium prevention for medical ptsThe “Geriatric Giants”The Frailty ParadoxNew Care Paradigm for Older People & FrailtyThe 4m walking speed test detects frailtySlide Number 22Slide Number 23