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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