OXFORD MEDICAL PUBLICATIONS Oxford Handbook of Geriatric Medicine Published and upcoming Oxford Handbooks Oxford Handbook for the Foundation Program 3e Oxfor d Handbook of Acute Medicine 3e Oxford Handbook of Anesthesia 3e Oxford Handbook of Applied Dental Sciences Oxford Handbook of Cardiology 2e Oxford Handbook of Clinical and Laborator y Investigation 3e Oxford Handbook of Clinical Dentistry 5e Oxford Handbook of Clinical Dia gnosis 2e Oxford Handbook of Clinical Examination and Practical Skills Oxford Handbook of C linical Hematology 3e Oxford Handbook of Clinical Immunology and Allergy 2e Oxford Handbook of Clinical Medicine - Mini Edition 8e Oxford Handbook of Clinical Medicine 8e Oxford Hand book of Clinical Pathology Oxford Handbook of Clinical Drugstore 2e Oxford Handbook of Clin ical Rehabilitation 2e Oxford Handbook of Clinical Specialties 8e Oxford Handbook of Clinic al Surgery 3e Oxford Handbook of Complementary Medicine Oxford Handbook of Critical Care 3e Oxford Handbook of Dental Patient Care 2e Oxford Handbook of Dialysis 3e Oxford Handbook o f Emergency Medicine 4e Oxford Handbook of Endocrinology and Diabetes 2e Oxford Handbook of ENT and Head and Neck Surgery Oxford Handbook of Epidemiology for Clinicians Oxford Handbo ok of Expedition and Wilderness Medicine Oxford Handbook of Gastroenterology & Hepatology 2 e Oxford Handbook of General Practice 3e Oxford Handbook of Genitourinary Medicine, HIV and AIDS 2e Oxford Handbook of Geriatric Medicine 2e Oxford Handbook of Infectious Diseases an d Microbiology Oxford Handbook of Key Clinical Evidence Oxford Handbook of Medical Dermatol ogy Oxford Handbook of Medical Imaging Oxford Handbook of Medical Sciences Oxford Handbook of Neonatology Oxford Handbook of Nephrology and Hypertension Oxford Handbook of Neurology Oxford Handbook of Nutrition and Dietetics 2e Oxford Handbook of Obstetrics and Gynecology 2e Oxford Handbook of Occupational Health Oxford Handbook of Oncology 3e Oxford Handbook of Ophthalmology 2e Oxford Handbook of Oral and Maxillofacial Surgery Oxford Handbook of Pedi atrics Oxford Handbook of Pain Management Oxford Handbook of Palliative Care 2e Oxford Hand book of Practical Drug Therapy 2e Oxford Handbook of Pre-Hospital Care Oxford Handbook of P sychiatry 2e Oxford Handbook of Public Health Practice 2e Oxford Handbook of Reproductive M edicine & Family Planning Oxford Handbook of Respiratory Medicine 2e Oxford Handbook of Rhe umatology 3e Oxford Handbook of Sport and Exercise Medicine Oxford Handbook of Tropical Med icine 3e Oxford Handbook of Urology 2e Oxford Handbook of Geriatric Medicine Second edition Lesley K. Bowker Consultant in Medicine for the Elderly Norfolk and Norwich University Foun dation Hospital and Clinical Skills Director and Honorary Senior Lecturer Norwich Medical S chool University of East Anglia, UK James D. Price Consultant in Acute General and Geriatric Medicine Oxford University Hospita ls, UK Sarah C. Smith Consultant in Acute General and Geriatric Medicine Oxford University Hospita ls, UK 1 1 Great Clarendon Street, Oxford OX2 6DP, United Kingdom Oxford University Press is a department of the University of Oxford. It furthers the Univer sity \200\231s objective of excellence in research, scholarship, and education by publishin g worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries Oxford University Press 2012 The moral rights of the authors have been asserted First Edition published in 2006 Second Edition published in 2012 Impression: 1 All rights reserved. No part of this publication may be reproduced, stored in a retrieval s ystem, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license or under terms ag reed with the appropriate reprographics rights organization. Enquiries concerning reproduct ion outside the scope of the above should be sent to the Rights Department, Oxford Universi ty Press, at the address above You must not circulate this work in any other form and you must impose this same condition on any acquirer British Library Cataloging in Publication Data Data available Library of Congress Cataloging in Publication Data Data available ISBN 978 \200\2230 \200\22319 \200\223958609 \200\2237 Printed in China by CC Offset Printing Co. Ltd Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and c linical procedures with the most up-to-date published product information and data sheets p rovided by the manufacturers and the most recent codes of conduct and safety regulations. T he authors and the publishers do not accept responsibility or legal liability for any error s in the text or for the misuse or misapplication of material in this work. Except where ot herwise stated, drug dosages and recommendations are for the non-pregnant adult who is not breastfeeding. Links to third party websites are provided by Oxford in good faith and for information only . Oxford disclaims any responsibility for the materials contained in any third party websit e referenced in this work. v Foreword Geriatrics is medicine of the gaps \200\224such gaps as we see between surgery and social w ork, and between psychiatry and orthopedics. It is the medicine of the gaps between what do ctors need to know for their everyday work and what they are taught as medical students. Me dical curriculums are still struc- tured around diseases and technologies rather than peopl e with diseases and people needing technologies. The majority of such people are old. Even more importantly geriatrics has to transcend gaps in \200\230evidence-based medicine \200\231. This is only partly because older people, and especially frail older people, are left out of clinical trials; there is also a philosophical gap. We start life with differen t levels of health and function and we age at different rates. Older people come to differ from each other more than do younger people; logic requires that they are treated as indivi duals not as members of the homogeneous groups assumed in the rationale of conventional tri al evidence. Some generalizations are possible. It follows from the biology of ageing that the risk of complications, often preventable or curable, from physically challenging treatm ents will increase with age. But it follows, too, that the bene \201 ts of treatments that are not physically challenging will also increase with age. The n-of-1 trial is the releva nt but sadly under-used paradigm, its logic (though not its rigor) underlying the better-kn own \200\230Let \200\231s try it but stop if it does not work \200\231 trial. With the pat ient as an active and informed partner even this is better than the unthinking application of the results of a clinical trial of dubious relevance. Because of the evidence gap, geriatric medicine has to be an art as well as a science \200 \224as the authors of this handbook emphasize in their preface. The art of medicine depends , in William Osler \200\231s words on \200\230a sustaining love for ideals \200\231 and, a t a practical level, on ability to recognize similarities and to distinguish signi \201 ca nt differences. Good doctors can draw on structured experience and recognize patterns and w arning signals that are unrecorded in the cookbook medicine of trialists and managers. The cookbooks are based on what happens on average and our patients expect us to do better than that. For some of us its interplay of medicine, biology, and social sciences makes geriatrics a f ascinating central interest. But most doctors who meet with ill older people have other res ponsibilities as well. They will enjoy their work better and be more ef \201 cient if they feel able to respond con \201 dently to the commoner problems of their older patients. No t every older person needs a geriatrician any more than every person with heart failure nee ds a cardiologist. But all doctors need to know what geriatricians and cardiologists have t o offer and all doctors must be able to recognize when they are getting out of their depth. So here is a vade mecum written for the caring and conscientious clinician but it is not a cookbook. It outlines how to set about analyzing complex clinical situations, and the resou rces that can or should be called on. The authors are worthy guides; they have gained and g iven of their experience and wisdom in one of the best and busiest of British hospitals. Th eir aim is not to supplant but to facilitate thought and good judgment \200\224two qualitie s that our older patients need, deserve, and expect of us. John Grimley Evans vi Preface This pocket-sized text will function as a friendly, experienced, and knowl- edgeable geriat rician who is available for advice at all times. This is a handbook, not a textbook. It is not exhaustive \200\224we have focused on common problems, including practical help with common dilemmas which are not well covered by tradi tional tomes while excluding the rare and unimportant. In this second edition, in response to feedback we have increased the number of \200\230HO W TO \200\231 boxes and updated sections where there have been advances in evidence and pra ctice. We believe that the practice of geriatric medicine is an art-form and aim to provide guidan ce to complement the lists and protocols found in many textbooks. The evidence-based litera ture in geriatric medicine is limited, so advice is often opinion and experience based. The satisfaction of good geriatric care is lost to many who become overwhelmed by the bread th and complexity of seemingly insoluble problems. We provide a structured, logical, and \202 exible approach to problem solving which we hope will give practical help to improve t he care given to older patients in many settings. Lesley K Bowker James D Price Sarah C Smith Dedication We dedicate this book to our children Nina, Jess, Helen, Cassie, Anna, James, Sam, and Harr y viii Acknowledgements We were delighted when the \201 rst edition of this handbook was used as the basis of the American Oxford Handbook of Geriatric Medicine (2010) and have consulted it extensively du ring the production of this second edition \200\224we extend our thanks to Professor Samuel Durso and colleagues. ix Contents Symbols and abbreviations xi 1 Ageing 2 Organizing geriatric services 3 Clinical assessment of older people 4 Rehabilita tion 5 Falls and funny turns 6 Drugs 7 Neurology 8 Stroke 9 Psychiatry 10 Cardiovascular 11 Chest medicine 12 Gastroenterology 13 Renal medicine 14 Homeostasis 15 Endocrinology 16 He matology 17 Musculoskeletal system 18 Pressure injuries 19 Genitourinary medicine 20 Incont inence 21 Ears 22 Eyes 23 Skin 24 Infection and immunity 25 Malignancy 1 13 51 71 101 125 151 179 203 255 311 351 383 403 419 451 465 501 507 531 547 567 585 605 627 x CONTENTS 26 Death and dying 27 Ethics 28 Finances 637 653 677 685 Appendix: Further Information Index 697 xi Symbols and abbreviations M b website cross-reference cross-reference to other sections of the book or to external materi al Caution! age-associated memory impairment arterial blood gas ankle \200\223brachial pres sure index angiotensin-converting enzyme adrenocorticotropic hormone advance directive anti diuretic hormone activities of daily living atrial \201 brillation acute kidney injury al kaline phosphatase age-related macular degeneration abbreviated mental test score antinucle ar antibody antineutrophilic cytoplasmic antibody angiotensin receptor blocker adult respir atory distress syndrome acute tubular necrosis atrioventricular abdominal X-ray bacille Cal mette Gu rin twice daily body mass index British National Formulary B-type natriuretic pep tide benign prostatic hyperplasia benign paroxysmal positional vertigo coronary artery bypa ss grafting Clostridium dif \201 cile- associated diarrhea clock-drawing test comprehensiv e geriatric assessment community hospital 2 AAMI ABG ABPI ACE ACTH AD ADH ADLs AF AKI ALP AMD AMTS ANA ANCA ARB ARDS ATN AV AXR BCG b d BMI BNF BNP BPH BPPV CABG CDAD CDT CGA CH SYMBOLS AND ABBREVIATIONS xii CHD CJD CK CKD CNS COPD COX-2 CPR CRP CSF CSS CT CXR DH DIC DNACPR DoLS DRE DVs DVT ECG ED EEG eGFR EMG EMI ERCP ESR FEV 1 FNA GCA GCS GDS GFR GORD GP GTN HbA 1c HDU HIV coronary heart disease Creutzfeldt \200\223Jakob disease creatine kinase chronic kidney dis ease central nervous system chronic obstructive pulmonary disease cyclo-oxygenase-2 cardiop ulmonary resuscitation C-reactive protein cerebrospinal \202 uid carotid sinus syndrome c omputed tomography chest radiograph day hospital disseminated intravascular coagulation do not attempt cardiopulmonary resuscitation Deprivation of Liberty Safeguards digital rectal examination domiciliary visits deep vein thrombosis electrocardiogram emergency department electroencephalogram estimated glomerular \201 ltration rate electromyography elderly men tally in \201 rm endoscopic retrograde cholangiopancreatography erythrocyte sedimentation rate forced expiratory volume in 1sec \201 ne needle aspiration giant cell arteritis Glas gow Coma Scale Geriatric Depression Scale glomerular \201 ltration rate gastro-oesophagea l re \202 ux disease general practitioner glyceryl trinitrate glycosylated hemoglobin high dependence unit human immunode \201 ciency virus SYMBOLS AND ABBREVIATIONS xiii HRT HUTT IHD im IMCA INR ITU iv IVC JVP LBBB LDH LFT LHRH LKM LMN LPA LTOT LUTS LVH MCA MCV MDT MEAMS MI MM MMSE MND MOAI MRI MRSA MSU N+V NG NGT NICE NIHSS NPH NSAID NSF hormone replacement therapy head-up tilt table testing ischaemic heart disease intramuscula r independent mental capacity advocate international normalized ratio intensive therapy/car e unit intravenous inferior vena cava jugular venous pressure left bundle branch block lact ate dehydrogenase liver function test luteinizing hormone releasing hormone liver-kidney mi crosome (antibodies) lower motor neuron lasting power of attorney long-term oxygen therapy lower urinary tract symptoms left ventricular hypertrophy middle cerebral artery mean corpu scular volume multidisciplinary team Middlesex Elderly Assessment of Mental State myocardia l infarction multiple myeloma Mini-Mental State Examination motor neuron disease monoamine oxidase inhibitor magnetic resonance imaging meticillin-resistant Staphylococcus aureus mid stream urine nausea and vomiting nasogastric nasogastric tube National Institute for Health and Clinical Excellence National Institutes for Health Stroke Scale normal pressure hydroc ephalus non-steroidal anti-in \202 ammatory drug national service framework SYMBOLS AND ABBREVIATIONS xiv NSTEMI OA OAB od OGD OT PCI PCT PE PEFR PEG PMR po POA PPD pr PRN PSA PT PTH qds RBBB RCT R EM RIG SA SALT SAP s/c SIADH SLE SMA SNRI SPECT SpR SSRI STD STEMI SVT T3 non-ST elevation myocardial infarction osteoarthritis overactive bladder once daily oesopha gogastroduodenoscopy occupational therapy (or therapist) percutaneous coronary intervention primary care trust pulmonary embolism peak expiratory \202 ow rate percutaneous endoscop ic gastrostomy polymyalgia rheumatica orally power of attorney puri \201 ed protein deriva tive per rectum (anally) as-needed prostrate-speci \201 c antigen physiotherapy (or therap ist) parathyroid hormone four times daily right bundle branch block randomized controlled s tudy rapid eye movement radiologically inserted gastrostomy sinoatrial speech and language therapy (or therapist) single assessment process subcutaneous syndrome of inappropriate ADH secretion systemic lupus erythematosus smooth muscle antibody serotonin and noradrenaline reuptake inhibitor single photon emission computed tomography specialist registrar selectiv e serotonin reuptake inhibitor sexually transmitted disease ST elevation myocardial infarct ion supraventricular tachycardia triiodothyronine SYMBOLS AND ABBREVIATIONS xv T4 TB tds TENS TFT TIA TIBC tPA TSH TTO TURP U,C+E UMN UTI UV VATS VBI VT VTE V/Q WBC WHO levothyroxine tuberculosis three times daily transcutaneous nerve stimulation thyroid funct ion test transient ischaemic attack total iron binding capacity tissue plasminogen activato r thyroid stimulating hormone to take out (discharge drugs) transurethral resection of the prostate urea, creatinine and electrolytes upper motor neuron urinary tract infection ultra violet video-assisted thoracoscopy with biopsy vertebrobasilar insuf \201 ciency ventricul ar tachycardia venous thromboembolism ventilation-perfusion white blood cell World Health O rganization This page intentionally left blank 1 Chapter 1 Ageing The ageing person 2 Theories of ageing 3 Demographics: life expectancy 4 Demographics: popu lation age structure 6 Demographics: ageing and illness 8 Illness in older people 10 2 CHAPTER 1 Ageing The ageing person There are many differences between old and young people. In only some cas es are these changes due to true ageing, ie due to changes in the characteristic(s) compare d with when the person was young. Changes not due to ageing \200 Selective survival. Genetic, psychological, lifestyle, and environmental factors in \202 uence survival, and certain characteristics will therefore be over-represented in older people Differential challenge . Systems and services (health, \201 nance, transportation, retail ) are often designed and managed in ways that make them more accessible to young people. Th e greater challenge presented to older people has manifold effects (eg impaired access to h ealth services) Cohort effects . Societies change, and during the twentieth century, change has been rapid in most cases. Young and old have therefore been exposed to very diff erent physical, social, and cultural environments Changes due to ageing \200 Primary ageing . Usually due to interactions between genetic ( intrinsic, \200\230nature \200\231) and environmental (extrinsic, \200\230nurture \200 \231) factors. Examples include lung cancer in susceptible individuals who smoke, hypertens ion in susceptible individuals with high salt intake, and diabetes in those with a \200 \230thrifty genotype \200\231 who adopt a more pro \202 igate lifestyle \200 Additionall y there are genes which in \202 uence more general, cellular ageing processes. Only now are speci \201 c genetic disease susceptibilities bein g identi \201 ed, offering the potential to intervene early and to modify risk Secondary ageing . Adaptation to changes of primary ageing. These are commonly behavioral, eg reduction or cessation of driving as reaction times increase Ageing and senescence Differences between old and young people are thus heterogeneous, and individual effects may be viewed as: \200 Bene \201 cial (eg increased experiential lear ning, increased peak bone mineral density (re \202 ecting the active youth of older people )) Neutral (eg graying of hair, pastime preferences) \200 Disadvantageous (eg decreased reac tion time, development of hypertension) However, the bulk of changes, especially in late middle and older age, are detrimental, esp ecially in meeting pathological and environmental chal- lenges. This loss of adaptability r esults from homeostatic mechanisms that are less prompt, less precise, and less potent than they once were. The result is death rates that increase exponentially with age, from a nad ir around age 12. In very old age (80 \200\223100 years), some tailing off of the rate of i ncrease is seen, perhaps due to selective survival, but the increase continues nonetheless. Further reading Evans JG , Williams TF , Beattie BL , et al. (eds) ( 2003 ). Oxford Textboo k of Geriatric Medicine , 2nd edition, Section 2. Oxford : Oxford University Press . THEORIES OF AGEING 3 Theories of ageing With few exceptions, all animals age, manifesting as increased mortality and a \201 nite lifespan. Theories of ageing abound, and over 300 diverse the- ories exi st. Few stand up to careful scrutiny, and none has been con \201 rmed as de \201 nitely p laying a major role. Four examples follow. Oxidative damage Reactive oxygen species fail to be mopped up by antioxidative defenses and damage key molecules, including DNA. Damage builds up until key metabolic processes are im paired and cells die. Despite evidence from in vitro and epidemiological studies supporting bene \201 cial effec ts of antioxidants (eg vitamins C and E), clinical trial results have been disappointing. Abnormal control of cell mitosis For most cell lines, the number of times that cell divisio n can occur is limited (the \200\230Hay \202 ick limit \200\231). Senescent cells may pre dominate in tissues without signi \201 cant replicative potential such as cornea and skin. The number of past divisions may be \200\230memorized \200\231 by a functional \200\230c lock \200\231 \200\224 DNA repeat sequences (telomeres) shorten until further division cea ses. In other cells, division may continue uncontrolled, resulting in hyperplasia and pathologies as diverse as atherosclerosis and prostatic hyperplasia. Protein modi \201 cation Changes include oxidation, phosphorylation, and glycation (non-en zymatic addition of sugars). Complex glycosylated molecules are the \201 nal result of mu ltiple sugar \200\223protein interactions, resulting in a structurally and func- tionally a bnormal protein molecule. Wear and tear There is no doubt that physical damage plays a part in ageing of some structu res, especially skin, bone, and teeth, but this is far from a universal explanation of agei ng. Ageing and evolution In many cases, theories are consistent with the view that ageing is a by- product of genetic selection: favored genes are those that enhance reproductive \201 tness in earlier life but which may have later detrimental effects. For example, a gene tha t enhances oxidative phosphorylation may increase a mammal \200\231s speed or stamina, whil e increasing the cumulative burden of oxidative damage that usually manifests much later. Many genes appear to in \202 uence ageing; in concert with differential environmental expo sures, these result in extreme phenotypic heterogeneity, ie people age at different rates a nd in different ways. 4 CHAPTER 1 Ageing Demographics: life expectancy \200 Life expectancy (average age at death) in the develope d world has been rising since accurate records began and continues to rise linearly Lifespan (maximum possible attainable age) is thought to be around 120 years. It is determi ned by human biology and has not changed \200 Population ageing is not just a minor stati stical observation but a dramatic change that is easily observed in only a few generations \200 In 2002, life expectancy at birth for women born in the UK was 81 years, and 76 years for men This contrasts with 49 and 45 years, respectively, at the end of the nineteenth century Although worldwide rises in life expectancy at birth are mainly explained by reductions in perinatal mortality, there is also a clear prolongation of later life in the UK as shown by calculations of life expectancy at 50 or 65 (see Fig. 1.1 ) \200 Between 1981 and 2002, life expectancy at age 50 increased by 4.5 years for men and 3 years for women While projections suggest this trend will continue, it is possible that the modern epidemic of obesity might slow or reverse this Individualized life expectancy estimates Simple analysis of population statistics reveals t hat mean male life expect- ancy is 76 years. However, this is not helpful when counseling a n 80 year old. Table 1.1 demonstrates that as a person gets older their individual life exp ectancy actually increases. This has relevance in deciding on healthcare interventions. Table 1.1 Predicted life expectancy at various ages for men, UK Age at time of estimate Median years left to live That is, death at age 40 36.5 76.5 60 17.9 77.9 80 5.6 85.6 90 2.8 92.8 More accurate individualized estimates should take into account sex, previous and current h ealth, longevity of direct relatives, as well as social and ethnic group. DEMOGRAPHICS: LIFE EXPECTANCY 5 Fig. 1.1 Expected further years of life at age 50 and 65, UK. Reproduced with permission fr om M www.statistics.gov.uk . 6 CHAPTER 1 Ageing Demographics: population age structure Fertility Fertility is de \201 ned as the number of live births per adult female. It is cur- rently around 1.9 in the UK. If this rate were ma intained, then in the long term population would fall unless \200\230topped up \200\231 by net immigration. In con- trast during the \200\230baby boom \200\231 years of the 1950s, fertility rates reached almost 3. This bulge in the population pyramid will reach old age i n 2010 \200\223 2030, increasing the burden on health and social services. Deaths and cause of death The driver of mortality decline has changed over the twentieth ce ntury, from reductions in infant/child mortality to reductions in old age mortality. \200 Infant mortality accounted for 25 % of deaths in 1901, but had fallen to 4 % of deaths by 1950. Currently over 96 % of deaths occur > 45 years \200 Deaths at age 75 and over compr ised 12 % of all deaths in 1901, 39 % in 1951, and 65 % in 2001 The most common cause of death in people aged 50 \200\22364 is cancer (lung in men, breast cancer in women); 39 % of male and 53 % of female deaths are due to cancer. Over the age of 65, circulatory diseases (heart attacks and stroke) are the most common cause of death. Pn eumonia as a cause of death also increases with age to account for 1 in 10 among those aged 85 and over. All these statistics rely on the accuracy of death certi \201 cation (see b \200\230Docum entation after death \200\231, p.648) which is likely to reduce with increasing age. Population \200\230pyramids \200\231 These demonstrate the age/sex structure of different populations. The shape is determined by fertility and death rates. \200\230Pyramids \200 \231 from devel- oping nations (and the UK in the past) have a wide base (high fertility bu t also high death rates, especially in childhood) and triangular tops (very small numbers o f older people). In the developed world the shape has become more squared off (see Fig. 1.2 ) with some countries having an inverted pyramidal shape \200\224 people in their middle years outnumber younger people \200\224 as fertility declines below replacement values for prolonged periods. DEMOGRAPHICS: POPULATION AGE STRUCTURE 7 Fig. 1.2 Population pyramid for England and Wales 2004. Reproduced with permission from M w ww.statistics.gov.uk . 8 CHAPTER 1 Ageing Demographics: ageing and illness Healthy life expectancy and prevalence of morbidity Health y life expectancy is that expected to be spent in good or fairly good health. As total life expectancy rises it is better for society and the indi- vidual to spend as much of this ex tended life in good health as possible. It is not known whether \200\230compression of morbidity \200\231 \200\224 where illness and disability is squeezed into shorter periods at the end of life \200\224 can be achieve d. Trends in data from USA suggest that compression of morbidity is occurring, but challeng es to public health are different in the UK. Obesity and lack of exercise may negate dimini shing morbidity from infectious diseases; as more people survive vascular deaths they might develop dementia (and other old age-associated diseases). The jury is still out; some data gathered in the UK using self-rated health measures show that in 1981 the expected time li ved in poor health was 6.5 years (men) and 10.1 years (women); by 2001 this was 8.6 and 10. 7 years. Social impact of ageing population Those > 80 are the fastest growing age group in UK. Curr ently around a fourth of the population is > 60 years old but by 2030 this will rise to a t hird. Governments can encourage migration (economic migrants are mostly young) and extend w orking lives (eg increase pensionable age for women) but these will have little effect on t he overall shift. The impact of this demographic shift on society \200\231s attitudes and e conomies is huge. Examples include: \200 Financing pensions and health services \200\224 in most countries these are \201 nanced on a \200\230pay-as-you-go \200\231 system, so will have to be paid for by a smaller workforce. This will inevitably mean greater levels o f taxation for those in work or a reduction in the state pension. Unless private pension in vestment (which works on an \200\230insurance \200\231 system of personal savings) improve s there is a risk that many pensioners will continue to live in relative poverty Healthcare and disability services \200\224 the prevalence and degree of disability increases with age. American Medicare calculations show that more than a fourth of healthcare expenditure is on the last year of a person \200\231s life, with half of that during the last 60 days \200 Families are more likely to be supporting older members \200 Retired people comprise a growing market and companies/industries that accommodate th e needs/wishes of older people will \202 ourish Transportation, housing, and infrastructure must be built or adapted \200 Political power of older people (the \200\230gray lobby \200\231 in America) will grow DEMOGRAPHICS: AGEING AND ILLNESS 9 Successful versus unsuccessful ageing How can success be de \201 ned, ie towards what aim should public health and clinical medicine be striving? The following de \201 nitions are to some extent stereotypical and culture-sensitive. More \202 exible de \201 nitions wou ld acknowledge individual preferences. \200 Successful ageing . Without overt disease, wi th good physical and cognitive function, a high level of independence and active engagement with broader soc iety. Usually ended by a peaceful death without a prolonged dying phase Unsuccessful ageing . Accelerated by overt disease, leading to frailty, poor functional status, a high level of dependence, social and societal withdrawal, and a m ore prolonged dying phase where life quality may be judged unacceptable Further reading National statistics online : M www.statistics.gov.uk . EPIC (Elderly Networ k on Ageing and Health) online : M www.nut.uoa.gr/EPICelderlyNAH . 10 CHAPTER 1 Ageing Illness in older people One of the paradoxes of medical care of the older person is that th e frequency of some presentations ( \200\230off legs \200\231, delirium ) and of some diagnoses (infection, dehydration ) encourages the belief that medical management is straightforward, and that investigation and treatment may satisfactorily be inexpensive an d low skill (and thus intellectually unrewarding for the staff involved). However, the objective reality is the reverse. Diagnosis is frequently more challenging, an d the therapeutic pathway less clear and more littered with obstacles. However, choose the right path, and the results (both patient-centered and societal (costs of care etc.)) are s ubstantial. Features of illness in older people \200 Present atypically and non-speci \201 cally \200 Cause greater morbidity and mortality \200 May progress much more rapidly \200\224 a few hours delay in diagnosis of a septic syndrome is much more likely to be fatal Health, social, and \201 nancial sequelae. Failures of treatment may have long-term wide- ranging effects (eg nursing home fees > 800/week) Co-pathology is common. For example, in the older patient with pneumonia and recent atypica l chest pain, make sure myocardial infarction (MI) is excluded (sepsis precipitates a hyper dynamic, hypercoagulable state, increasing the risk of acute coronary syndromes; and a prop ortion of atypical pain is cardiac in origin) Lack of physiological reserve. If physiological function is \200\230borderline \200\231 (i n terms of impacting lifestyle, or precipitating symptoms), minor deterioration may lead to signi \201 cant disability. Therefore, apparently minor improvements may disproportionate ly reduce disability. Identi \201 cation and correction of several minor disorders may yie ld dramatic bene \201 ts Investigating older people \200 Investigative procedures may be less well tolerated by ol der people. Thus the investigative pathway is more complex, with decision-making dependent on clinical presentation, sensitivity and speci \201 city of test, side effects and discomfort of the test, hazards of \200\230blind \200\231 treatment or \200\230watchful waiting \200\231 an d of course the wishes of the patient Consider the signi \201 cance of positive results. Fever of unknown cause is a common pres entation, and urinalysis a mandatory investigation. But what proportion of healthy, communi ty-dwelling, older women have asymptomatic bacteriuria and a positive dipstick? (A: around 30 % , depending on sample characteristics). Therefore in what proportion of older people p resenting with fever and a positive dipstick is urinary tract infection (UTI) the signi \201 cant pathology? (A: much less than 100 % ) The practical consequence of this is the under-treatment of non-urinary sepsis. ILLNESS IN OLDER PEOPLE 11 Treating disease in older people When treating disease in older people, they: \200 May be ne \201 t more than younger people from \200\230invasive \200\231 treatments \200\224 eg thrombolysis. On a super \201 cial level, think \200\230which is more important \200 \224 saving 10 % of the left ventricle (LV) of a patient with an ejection fraction (EF) of 60 % (perhaps a healthy 50 year old) or of a patient with an EF of 30 % (perhaps, an 80 yea r old with heart failure)? \200\231. Note that the signi \201 cant criterion here is more the LVEF than the age, the principle being that infarcting a poor LV may cause long-term di stress, morbidity, and mortality, whereas infarcting a part of a healthy myocardium may be without sequelae May bene \201 t less than younger people. Life expectancy and the balance of risks and bene \201 ts must be considered in decision-making. For example, the priority is unlikely to be control of hypertension in a frail 95 year old who is prone to falls May have more side effects to therapies. In coronary care: B -blockade, aspirin, angiotensi n-converting enzyme (ACE) inhibitors, thrombolysis and heparin may all have a greater life (and quality-of-life)-saving effect in older patients. Studies show these agents are underu sed in MI patients of all ages, but much more so in the elderly population. The frequency o f side effects (bradycardia and block, profound hypotension, renal impairment and bleeding) is greater in older people, although a signi \201 cant net bene \201 t remains May respond to treatment less immediately. Convalescence is slower, and the doctor may not see the eventual outcome of his/her work (the patient having been transferred to rehabilita tion, for example) \200 The natural history of many acute illnesses is recovery independe nt of medical intervention, particularly in the young. Beware false attributions and denial s of bene \201 t: \200 The older person frequently bene \201 ts from therapy, unwitness ed by medical staff The younger person recovers independent of medical efforts, though his/her recovery is falsely attributed to those interventions (by staff and patient) This page intentionally left blank 13 Chapter 2 Organizing geriatric services Using geriatric services 14 Acute services for older people 16 The older patient in intensi ve care 17 The great integration debate 18 Admission avoidance schemes 20 Day hospitals 22 Specialty clinics 24 Intermediate care 26 The National Service Framework for Older People 2 8 Community hospitals 30 Domiciliary (home) visits 32 HOW TO Do a domiciliary visit 33 Care homes 34 HOW TO Advise a patient about residential care 35 Funding of care homes 36 Delayed discharge 37 Home care 38 Informal carers 40 Other service s 42 Chronic disease management 44 Primary care 46 Careers in UK geriatric medicine 48 Dipl oma in Geriatric Medicine (DGM) 49 14 CHAPTER 2 Organizing geriatric services Using geriatric services Geriatric services have developed rapidly since the inception of t he specialty in the 1950s. They have different forms, depending on local resources, experts , and enthusiasts. Every district will offer different serv- ices, each with a different sp ectrum of options. There are some broader national differences within the UK; services in S cotland and Northern Ireland lean more towards rehabilitation and long-term care than those in England and Wales. The following is intended as a generic guide to utilizing geriatric services in the UK. Diversity will limit applicability. Services for acute problems Urgent assessment of the acutely unwell patient, where the dise ase process is new and severe (eg acute MI, stroke) or the deterioration is rapid (eg delir ium). Examples: General practitioner (GP) emergency services (see b \200\230Primary care \200\231, p.46) Emergency departments (EDs; see b \200\230Acute services for older people \200\231, p.16) Acute medical admission service \200 Rapid Access (admission avoidance) services (see b \200\230Admission avoidance schemes \200\231, p.20) Urgent domiciliary visits (see b \200\230HOW TO Do a domiciliary visit \200\231, p.33) Choosing which is most appropriate will depend on patient characteristics (eg if unstable, then an ambulance to an ED is appropriate; if no change is expected over a few days then ur gent outpatient assessment may be used) and local service characteristics (availability of urgent clinic slots etc). Services for sub-acute problems Assessment of a patient with a progressive disease process (eg increasing falls, worsening Parkinson \200\231s in a frail patient) or unexplained pote ntially serious problems (eg iron de \201 ciency anemia, weight loss) or for diagnosis and management plan (eg cardiac failure). Examples: Routine outpatients \200 Specialty clinics (see b \200\230Specialty clinics \200\231, p. 24) \200 Day hospital (see b \200\230Day hospitals \200\231, p.22) \200 Intermediate c are facilities (see b \200\230Intermediate care \200\231, p.26) \200 Elective admission (to acute hospital, rehabilitation wards or community hospital) Domiciliary visits (see b \200\230HOW TO Do a domiciliary visit \200\231, p.33) Agai n, choice of service will depend on patient factors. Single organ problems can be referred to specialist clinics, less well-de \201 ned medical problems to a geriatric outpatients, and problems suggesting the need of multidisciplinary input to the day hospital. Local avai lability, waiting times and consultant interests will also affect choice \200\224 while mo st cardiologists have chest pain clinics, not all will run heart failure services, which ma y be provided by general physicians or geriatricians. USING GERIATRIC SERVICES 15 Services for chronic problems This includes active, elective management of slowly progressi ve conditions by GPs, community teams, specialist nurses, and secondary care physicians (se e b \200\230Chronic disease management \200\231, p.44) and the provision of care for estab lished need.