A report from the British Geriatrics Society Autumn Meeting

Reclaiming the role of the ‘social’ in the care and support of older people

More than a million older people are not getting the help they need with essential daily living activities and the rate of pensioner poverty is increasing each year. This was the focus of a presentation by Professor Alisoun Milne, professor of social gerontology and social work, University of Kent, in her guest lecture at the BGS.

She said due to an ageing population, more people are living with chronic comorbid conditions and according to Age UK, eight million in England are living with three or more long-term conditions.

Over a third of the UK’s 6.5 million carers are older people and there are five times as many older people living in poverty in the UK now than in 1986. Living in poverty undermines physical health and it also has a profound social and mental health consequence for older people. It reduces the level of social participation, contributes to exclusion and isolation and leads to higher levels of loneliness, stress, anxiety and depression.

The rates of pensioner poverty are increasing despite a consistent trend to reduce it over many years. In 2016 in England two million older people lived in poverty. Of these one million lived in severe poverty and over six million older people lived in fuel poverty.

The pattern of rising care needs and falling state spending has led to tighter access to local authority care. There has been a shift away from public provision of care to private provision with 90% of all social care including care homes now provided by the third sector.

There is also a trend of self-purchased care which is consistent with the message about responsibility of care being located with the individual and family and not the welfare state. This has also coincided with a shift away from professional staff working with older people to less qualified workers.

There were £2.8 billion cuts to social care budgets between 2011 and 2013, and since 2010 central Government’s grants to local authorities have reduced by 40%. This has had a massive impact on older people and Age UK estimate that 1.4 million older people are not getting the help they need with essential daily living activities.

A recent study suggests that the combined cuts to health and social care have resulted in 120,000 excess deaths since 2010 amongst older people aged over 85 years living in the community or a care home.¹

There is an increasingly polarised group of service users. Those who are obliged to rely on tightly rationed publicly funded care and those that can afford to self-fund and buy their own care. This has led to a stigma being attached to relying on the ‘state’ for social care.

Professor Milne said the way forward was to address social and health inequalities and fund and improve conditions of social care workforce. It was also important for care services to take greater account of social perspectives and capture and evidence the value of social care.

1. Watkins J, et al. Effects of health and social care spending constraints on mortality in England: a time trend analysis. http://dx.doi.org/10.1136/bmjopen-2017-017722

To what extent are patients’ future care preferences shared between secondary and primary care?

When a doctor is informed of a patient’s future care preferences if they were to lose capacity, there is an ethical and legal obligation to share this information with the treating medical team. A study presented at the BGS found that communication from hospitals to GPs about resuscitation, ceiling of care and advance care planning (ACP) discussions is very limited.

Researchers sought to assess the communication of these preferences to the patient’s GP with a retrospective chart review of consecutive discharges from acute geriatric wards across seven hospitals. Records were excluded if the patient was admitted for less than 48 hours, was under orthogeriatric care, or died in hospital.

The study included 339 notes, 41-50 from each hospital. GPs were informed of the resuscitation status of 28% of all patients. 52% of patients had an inpatient DNACPR (Do Not Attempt CPR) and the GP was informed of 54% of these. 36% of patients had an inpatient ceiling of treatment documented, of which GPs were informed of 19%. 53% of hospital DNACPRs were converted into community DNACPRs on discharge: GPs were informed of only 24% of new community DNACRPs. 47% of patients discharged with a new community DNACPR lacked capacity to be involved in that decision; for just 6% of these was the GP asked to review the DNACPR order in the community.

Inpatient ACP discussions were held for 9% of patients, of which the GP was informed in 59% of cases. 49% of ACP conversations involved the next-of-kin but not the patient. Among patients who had a new DNACPR decision made during their admission (n=124), there was documentary evidence in only 25% that the patient or next-of-kin was informed whether this was time-limited or indefinite.

For patients who have expressed ongoing future care preferences, there is a legal obligation to share this information with the treating medical team, which on discharge is the GP. There is poor documentary evidence of discussions with patients about whether DNACPR decisions are time-limited or indefinite. Furthermore, many hospitalised frail patients lack capacity to make DNACPR decisions but they may subsequently regain capacity, particularly those with delirium. Despite this, GPs are rarely asked to review new community DNACPRs, including those made for patients without capacity.

Authors: SA Hopkins, Department of Public Health and Primary Care, University of Cambridge; P Athauda, H Mark, North West Anglia Foundation Trust; A Halliday, Ipswich Hospital; K Honney, D Ondhia, A Balogun, S Barclay M Vincent, Queen Elizabeth Hospital, Kings Lynn; A Jakupaj, Watford General Hospital; C Pampali, L Van der Poel, Z Fritz, Cambridge University Hospitals; M Kaneshamoorthy, Princess Alexandra Hospital, Harlow;

Changes in muscle strength in older patients during hospitalisation

A study looking at hospital-associated deconditioning including skeletal muscle wasting and/or loss of muscle strength found that there was an impact of sedentary time on muscle strength during and post hospitalisation.

The primary aim of this study was to investigate changes in knee-extension muscle strength in older patients during and after an acute-hospital admission. It also aimed to explore the potential contributions of frailty, acute-illness severity and sedentary activity, with changes in knee-extension strength.

It was a prospective repeated-measures cohort study and measurements of muscle strength and functional mobility were taken at recruitment, on day seven of admission (or at discharge if earlier) and again 4-6 weeks post-hospitalisation. During the first seven days of admission, daily measurements of muscle strength were taken.

Researchers recruited 70 participants, of which 65 had at least one repeated measure in hospital. Median age was 84 years, and participants participated in the study for a median of six days whilst in hospital, on average participants were ‘active’ for less than 4% of the day.

Knee-extension strength significantly reduced by approximately 11% during hospitalisation, but no significant changes occurred post hospitalisation. A repeated-measures mixed model included 292 observations from 62 participants and showed a significant decrease in the reduction in muscle strength as patients’ sedentary time decreased on day two to seven of the study.

Additionally, the model showed that a higher frailty score, higher baseline knee-extension strength, lower baseline c-reactive protein levels were associated with greater loss in knee-extension strength during hospitalisation. Association between change in functional mobility after hospitalisation and change in knee-extension strength during hospitalisation was non-significant.

It concluded that the findings provide an important link in understanding the mechanisms and relative contributions of risk factors to hospital associated deconditioning but further research is needed to confirm these findings and examine the impact of reducing sedentary time on muscle strength during and post hospitalisation.

Authors: P Hartley, I Wellwood, C Deaton, Department of Public Health and Primary Care, University of Cambridge, Cambridge; R Romero-Ortuno, Discipline of Medical Gerontology, Trinity College Dublin, Mercer’s Institute for Successful Ageing, St James’s Hospital, Dublin

Building with biosimilars: Improving access for eligible osteoporosis patients to anabolic therapies

The number of people living with osteoporosis is set to increase dramatically in the coming decades due to the ageing population and an increase in sedentary lives, according to Professor Mike Stone, consultant physician and director of bone research, University Hospital Llandough.

It is estimated that more than 200 million people worldwide suffer from osteoporosis with 3.2 million living in the UK. It affects 50% of women and 20% of men over the age of 50 years. At least 40% of postmenopausal women and 15-30% of men with osteoporosis sustain more than one fragility fracture in their remaining lifetime.

The economic cost of new and prior osteoporotic fractures in 2017 was estimated at ‚¬37.5 billion per year across six European countries and the economic burden across Europe is growing with an estimated 25% increase in health costs by 2025.¹

NICE guidance states that teriparatide is recommended as an alternative treatment option for the secondary prevention of osteoporotic fragility fractures in postmenopausal women who are unable to take alendronate and risedronate, or have a contraindication to or are intolerant of alendronate and risedronate or who have had an unsatisfactory response to treatment with alendronate or risedronate.

It is also recommended in women over 65 years who have a T-score of 4.0 SD or below, or a T-score of 3.5 SD or below plus more than two fractures, or who are aged 55-64 years and have a T-score of 4 SD or below plus more than two fractures.²

In the Fracture Prevention Trial, treatment of postmenopausal osteoporosis with parathyroid hormone (1-34) decreased the risk of vertebral and nonvertebral fractures and increased vertebral, femoral, and total-body bone mineral density.³

The VERO study compared the anti-fracture efficacy of teriparatide with risedronate in patients with severe osteoporosis. It found that among post-menopausal women with severe osteoporosis, the risk of new vertebral and clinical fractures is significantly lower in patients receiving teriparatide than in those receiving risedronate.⁴

Teriparatide was licenced in 2003 but many centres are constrained by strict adherence to NICE guidance and a new health technology for non-bisphosphonates is in preparation but the main obstacle remains cost.

Professor Stone said that it was more logical to treat first with teriparatide and then sequential treatment with antiresorptives so a biosimilar at lower cost would be well received if it gave the same support and had a good pen device.

1. International Osteoporosis Foundation. https://www.iofbonehealth.org/data-publications/regional-audits/osteoporosis-european-union-medical-management-epidemiology-and
2. https://www.nice.org.uk/guidance/ta161
3. Neer RM, et al. Effect of parathyroid hormone (1-34) on fractures and bone mineral density in postmenopausal women with osteoporosis. N Engl J Med 2001; 344(19): 1434-41
4. Kendler DL, et al. Effects of teriparatide and risedronate on new fractures in post-menopausal women with severe osteoporosis (VERO): a multicentre, double-blind, double-dummy, randomised controlled trial. Lancet. 2018; 391(10117): 230-40

Session sponsored by Gedeon Richter

A case-based exploration of real-life challenges in overactive bladder

A holistic multidisciplinary team approach across primary and secondary care is pivotal for improving the quality of life of patients with overactive bladder. This was the view of Dr Ash Patel Consultant Geriatrician and General Practitioner, Leicester Royal Infirmary, who presented a case-based exploration of real-life challenges in overactive bladder at the BGS Conference.

He said that OAB symptoms include the sudden strong desire to urinate, eight or more visits to the toilet per 24 hours, and sudden and involuntary loss of urine. European prevalence of OAB in the EPIC study is 10.8% of the population in men and 12.8% in women.¹ According to the US-based NOBLE study, the prevalence of OAB increases with age and estimates are twice as high in those over 65 years compared with those under 45 years.²

Yet despite being one of the geriatric giants, incontinence is not always seen as a priority even by geriatricians.

Persistence with OAB medications is also lower than that other conditions. An analysis of adherence and persistence across a sample of six chronic therapies found variable but uniformly suboptimal medication use. Adherence to prostaglandin eye drops and OAB medications was lower than to cardiovascular, oral antidiabetic, and oral osteoporosis therapies.³

This poor persistence leads to medication switches, invasive investigations and treatments, high urinary symptom burden, inappropriate increases in dose and increased cost of disease management.

The reasons are usually multifactorial and include the patient-physician relationship, comorbidities and medical burden, adverse effects and either symptom improvement or unmet treatment expectation.

A study investigated why persistence with antimuscarinic therapy in OAB is poor, and whether it was different for β3-adrenoceptor agonists with a different adverse event profile. It found that persistence and adherence were statistically significantly greater with mirabegron than with tolterodine ER and other antimuscarinics prescribed for OAB in the UK.⁴

Dr Patel closed by saying that comorbidities are common in OAB and should be considered when initiating management as small interventions can have a huge impact.

Session sponsored by Astellas Pharma UK Ltd

1. Irwin DE, et al. Population-based survey of urinary incontinence, overactive bladder and other lower urinary tract symptoms in five countries: results of the EPIC study. Eur Urol 2006; 50(6): 1306-1315
2. Stewart WF, et al. Prevalence and burden of overactive bladder in the United States. World J Urol 2003; 20(6): 327€“336
3. Yeaw J, et al. Comparing adherence and persistence across 6 chronic medication classes. J Manag Care Pharm 2009; 15(9): 728-40.
4. Chapple CR, et al. Persistence and adherence with mirabegron versus antimuscarinic agents in patients with overactive bladder: a retrospective observational study in UK clinical practice. Eur Urol 2017; 72(3): 389-399