What is geriatrics for?

The face of healthcare in the UK is changing, driven in part by population demographics, associated changes in the burden of illness and dependency, and health policy changes in response to these challenges. The implications are central to the activities of the British Geriatrics Society (BGS) – now celebrating its own sixtieth year and the medical speciality it represents – geriatric medicine.

By 2025, there will be a projected 50% increase in the percentage of the population over 65 years and 80% in those over 80 years, with corresponding increases in the percentage of people dependent for two or more activities of daily living [1]. Many people with one or more long term (previously fatal) conditions now survive into old age [2, 3]. Whilst much of this is due to socioeconomic factors, both preventative and interventionist medicine have played a major part, and are victims of their own success. Whilst projections on the compression of morbidity may be disputed, it is indisputable that the practice of medicine in developed countries is increasingly concerned with the care of:

a) Older people (those over 65 years already account for 60% of admissions and 70% of bed days in UK general hospitals and a similar percentage of primary care contacts) [1];

b) People with one or more long-term conditions (in the UK, around 50% of those over 65 years have two or more conditions. Around 40% of all bed days are used by 5% of the local population over 65 years. Over 80% of GP consultations and 80% of bed days are taken up by patients with (usually multiple) long term conditions) [2];

c) People with frailty (i.e. those with poor functional reserve and who are likely to lose function or decompensate in the face even of apparently ‘minor’ medical illness) [4,5,6,7];

d) People with ‘geriatric syndromes’ [8] or what Sir Bernard Isaacs originally dubbed the ‘geriatric giants’ [9] i.e. falls, immobility, incontinence or confusion (delirium or dementia);

These are usually the result of genuine and potentially reversible medical illness. But they do not tend present to health or social care in ‘textbook manner’. Due to poor training, awareness or ageist attitudes, they are often inappropriately labelled as ‘social problems’ or ‘failure to cope’ [10,11]. These presentations are very common. For instance, 30% of the population over 65 years will fall at least once a year [12, 13]; one in two females will sustain a fragility fracture during their lifetime [13]; urinary incontinence affects around one quarter of women over 65 years and half those in long term care [14]; delirium (acute confusion) has a prevalence of 30-40% in hospitals and is often unrecognised and untreated [15]; there are 150,000 people suffering new strokes per annum in the UK [16] and an estimated 1.2 million persons live with some degree of dementia [17]. Many of these conditions are under-recognised, inadequately treated and have services with inadequate capacity or funding [13-18, 19]. In a recent survey of health service managers it was recognised that older people were the most neglected group in healthcare.

e) People with common illnesses of old age e.g. heart failure, stroke, osteoporosis, osteoarthritis, dementia, delirium, movement or gait disorders.

f) People with co-existent disability, dependency, impairments or poor cognition. There is considerable overlap with those who are frail. High users of hospital services and residents of long term care frequently have overlaps between ageing, social vulnerability, (multiple) long term illnesses and acute illness [1,4,6,7,21,22].

g) People who are often dependent to some extent on formal or informal social care.

What is geriatrics?

It is for these groups principally that our speciality exists. We do also focus on illness prevention and health promotion. But there are many other stakeholders in those ventures and it is unlikely within our lifetimes that prevention will obviate the need for better care for frailer patients with acute or long term illnesses. The BGS’ ‘unique brand’ is in the medical and interdisciplinary assessment and treatment of these groups and conditions and in education, research, service development and policy around them. A range of our (frequently updated) policies and resources on a variety of aspects of clinical assessment and care can be found on the BGS website [23].

These patient groups are not peripheral minorities but the core users of clinical (and social) services. Their needs should therefore be at the centre of service planning, education and training. This is manifestly not the case in 2007 [10, 24]. Although there are many pockets of excellent practice, many committed practitioners and teams, we know from recent government reports that ‘deep-rooted and negative attitudes persist towards older people among institutions and professionals’ [25], that patients still often receive ‘undignified care’ [26] and that we ‘still need to make services age proof and fit for purpose’ [27].

The BGS and the speciality of geriatric medicine aim to be key players in turning things round. To quote Kenneth Rockwood [5] “if you design a service for people with one thing wrong but people with many things wrong turn up then the fault lies not with the users but with the service. Yet too often these patients are deemed inappropriate”.

The term ‘geriatrics’ was devised by Ignatz Leo Nascher (1863 – 1944), an American physician [28]. In 1909, he created a special branch of medicine which he called ‘Geriatrics’, derived from two Greek words – geras (old age) and iatricos (relating to the physician). It was first widely practiced in the UK with the BGS at the cutting edge of the pioneering phase. Geriatric medicine is defined in the BGS compendium [29] as ‘that branch of internal medicine which deals with the prevention, diagnosis and treatment of diseases specific to old age’.

Comprehensive Geriatric Assessment (CGA) is the technology which perhaps best defines what we and the teams with which we work do, especially when applied to frail and complex older patients, and which sets us apart from other adult medical specialties [5]. It may be defined as ‘a multi-dimensional, interdisciplinary, diagnostic process to determine the medical, psychological and functional capabilities of a frail older person in order to develop a coordinated and integrated plan for treatment and long term follow up’. This technology also involves consideration of the social and environmental aspect of the older person’s care. There is a reasonable evidence base for the benefit of CGA [30] – especially when applied to hospital patients - as there is for interventions to treat for instance, falls, delirium osteoporosis, incontinence and stroke [12-19].

The pioneer of Geriatric Medicine in this country and effectively of CGA and discharge planning was Dr Marjory Warren, the medical director of the West Middlesex hospital, who assumed responsibility for the 714 bed poor law infirmary. She was initially a surgeon and underwent an epiphany and a mission, on encountering the long-term residents of workhouse infirmaries, describing her pioneering work in a series of articles, notably in the Lancet [31] and British Medical Journal [32]. She described the typical patients as being ‘incontinent, with seizures, dementia, bedridden, elderly and sick with unmoved muscles’ and stated that ‘for full recovery, they required access to the full facilities of the general hospital’. She created a specialized assessment unit, and began systematically to assess these patients, determined of their capacity for improvement. Most were re-mobilised and many returned to their own homes. She increased patient turnover by 300% and reduced the beds to 240 – leaving the rest for other medical specialties and attracting the interest of the health minister.

Strange though it may seem today, this was, at the time considered revolutionary – as was the concept that such individuals needed the full facilities of the hospital. To cite the visiting Dr MH Nesbitt in his MD thesis about his attachment to the unit ‘Dr Warren’s routine was carefully studied, the method of admission, examination, diagnosis and treatment, the return home or transfer to home or hostel, the careful follow-up, the close contact maintained with the relatives, the help obtained from almoner, physiotherapists, OTs and chiropodist. The metamorphosis of an utterly hopeless helpless patient into an active, energetic and everlastingly grateful one was observed again and again’.

Warren’s contribution has been characterised recently by Powell as ‘adequate assessment; accurate diagnosis; appropriate treatment, aftercare and advocacy' with, for the modern age, 'alliance and accountability’ [33]. These messages are just as relevant for the BGS and the speciality today. Alliance is increasingly a priority, with other professional disciplines, governmental and charitable bodies concerned with the care of older people. And accountability is increasingly important when we see how deficient many areas of basic care for older people still are.

By 1949, two years after the BGS was founded, Prof Norman Exton-Smith, another early pioneer and the first English Professor of Geriatrics, had stated in the Lancet that the speciality of Geriatric Medicine should exist for ‘medical management, rehabilitation and long term care’ of older people [34]. His unit at University College also attracted interest from the health minister and produced a variety of research in previously neglected areas, notably pressure area prevention and dementia. There were several other early pioneers in the 1950s and 60s, including Irvine and Cosin (who advocated surgery and mobilisation for even the frailest patients with fracture); Ferguson-Anderson, the first UK professor of Geriatrics; Sheldon, the first advocate of community preventative geriatrics; Adams, the first professor to teach geriatrics to undergraduates and Arie, the first professor of old age psychiatry. The contribution of these and other early pioneers is discussed in detail in an excellent historical piece by Barton and Mulley [35].

We must remember that in the late 1940s the landscape looked very different. The NHS was only founded in 1946 and was in its infancy. Hospital buildings were generally old and in a poor state of repair. Social care still depended to a large extent on charity. People aged over 85 years represented 1.6% of the 50-and-over population in 1951, but represented 5.5% in 2003, projected to be 9.1% by 2031. By 1947, there were only four geriatricians. At the same time, the founding of the NHS gave the early pioneers a chance to influence key figures in the government who took note of the whole systems gains apparent in those first units.

Why and how was the BGS founded?

The BGS is now a registered charity. It was originally called ‘The Medical Society for the Care of the Elderly’. The initial meeting was convened by Dr Trevor Howell – a GP by background but by then medical director of the Chelsea Pensioners’ Home. Nine doctors attended the first meeting. Its original aims were defined as ‘the relief of suffering and distress amongst the aged and infirm by the improvement of standards of medical care for such persons, the holding of meetings and the publication and distribution of the results of research’ [35].

The basic principles and work have not changed much 60 years on, but the environment in which we work could barely have been foreseen. The early influence of the BGS has been characterized as ‘persuading the health minister to appoint more geriatricians as the NHS grew; an emphasis on the assessment and care of frail or disabled patients by a geriatrician and multidisciplinary team; discharge home for those who recovered; patients who were frail, disabled and previously often classified as senile were reassessed and often found to have modifiable disease; in turn more patients were able to return home enabling the use of beds for other specialties and the updating and decorating of facilities’ [36].

Since then…

There was a rapid expansion of geriatrics from 1947 so that by 1977 there were 335 consultants (though geriatrics was still often patronisingly seen as a ‘Cinderella’ speciality for overseas doctors and those who could not make ‘the grade’ elsewhere). Academic departments were established and geriatrics began to feature in medical school curriculae. Multidisciplinary teams became increasingly common in general hospitals and there was a growing recognition of the need for patients with ‘atypical’ presentations to receive adequate diagnoses, rehabilitation and discharge planning. Increasingly sub-specialty services, such as those for orthopaedic rehabilitation, stroke, falls or continence were established.

The 1977 Royal College of Physicians Working Party on medical care of older people [37] made some telling recommendations still relevant today. ‘Geriatrics should be part of undergraduate and postgraduate training for every doctor and incorporated into the MRCP syllabus... GPs should become more involved in delivering specialist geriatric care. There should be multidisciplinary care for frail older people in every hospital and a review of elderly mental health services. And there should be more posts for doctors fully trained in both general internal medicine and geriatrics and integration of geriatrics into general medical units’. It was clear at this stage that despite the exponential growth in the speciality, there was still a great deal of misunderstanding or antipathy from other specialists and that services and training were patchy.

Since then, though some negative attitudes persist among colleagues, the number of consultant geriatricians in the UK has expanded to nearly 900, making us the second largest hospital speciality (a statistic not matched in any other health system). There has also been a sharp growth in medical research and a drive towards evidence-based practice, including interventions for illnesses of old age - many of which are now very well evidenced with benefits comparable to those for technologies in fitter younger patients. There have been numerous national re-organisations of healthcare – driven by attempts to drive up quality, choice and efficiency but with a range of unforeseen consequences, perverse incentives or failure fully to deliver the aims [38, 39]. There has been an equally exponential rise in performance frameworks, policies, regulation and legislation specifically around services for older people [1].

Perhaps key among these was the Community Care Act of 1990 which removed most long term care from the NHS and devolved responsibility to local authorities [40], signalling the end of NHS ‘long-stay’ wards and transforming long term care of the most vulnerable from a health to a ‘social’ problem, leaving behind a rump of NHS-funded continuing care which has become increasingly contested [41]. With geriatrics in the UK evolving historically as a predominantly hospital-based speciality (in stark contrast for instance to the USA) [42] and with the integration of geriatric and general internal medical services, this reduced at a stroke the speciality’s involvement in long stay and community care, further enhanced by the gradual reduction in community hospital beds [43].

Against this backdrop of chaos, change and complexity, the BGS has been at the forefront of developing evidence, good service models, campaigning and influencing to inform or alter policy, improve care or funding in a number of formerly neglected areas. These include specialist rehabilitation and care for patients with fracture and stroke, services for patients with falls, osteoporosis, incontinence, dementia and delirium, as well as better comprehensive assessment for residents of long term care and hospital inpatients. Many of the pioneers and opinion leaders in these fields have been geriatricians.

Especially in the past decade, older peoples’ services have been in the spotlight. The Older Peoples’ National Service Framework (NSF) in 2001 [44] set out standards and milestones in a number of areas including falls, stroke, general hospital care, intermediate care and single assessment. The primary care White Paper ‘Our Health Our Care Our Say’ [45] focussed on shifting services to primary care and the NSF on Long Term Conditions [2] further emphasised the need for proactive patient-centred management of people with long term conditions to minimise deterioration and prevent hospitalisation.

This priority has been further emphasised in Lord Darzi’s draft report on future directions for the NHS [46]. The Care Standards Act [47] further highlighted the needs of older people in long-term care settings. And the Healthcare Commission [25, 26] began to focus increasingly on dignity and basic care in healthcare settings. Specific NICE Guidelines on falls [13], osteoporosis [14], incontinence [48], dementia [49] and heart failure [50] have also been published. By 2006, the progress against the NSF had been partial [26], with services for older people often patchy, fragmented or not fit for purpose and A New Ambition for Old Age [27] set out the next steps in implementing the NSF, though just as with the original framework, accompanied by no earmarked funding or binding performance targets.

Current activities of the BGS

The British Geriatrics Society now has an all time high membership of 2,500 members. This membership is more interdisciplinary than ever, with over 150 nurses, therapists, pharmacists and scientists and more international than ever with over 400 overseas members. Almost all consultants and registrars in geriatric medicine in the UK are members, as are specialists in the psychiatry of old age, public health medicine and general practitioners.

The ‘shop windows’ of the society are our journal Age and Ageing and biennial scientific meetings (which attracted 600 and 500 delegates last spring and autumn respectively). These are still our biggest sources of revenue alongside our membership subscriptions. They provide a showcase for emerging research, a major element of Continuing Professional Development (CPD) and a forum for networking and debate. The attendance levels are threatened by increasing sub-specialisation with separate meetings for instance in stroke and osteoporosis and also by tighter job planning and reduced study leave budgets for doctors.

Age and Ageing has gone from strength to strength in recent years, receiving over 700 submissions per annum, with a steadily increasing impact factor and a truly international list of contributors. The Members’ Newsletter [51] often covers latest developments in policy, education or services and a well visited website with a range of reports and policy documents.

The education and training of members (both trainees and consultants) is a crucial function overseen by our Education and Training Committees. The Policy Committee produces a regularly updated compendium of guidelines, resources and statements and is frequently consulted on a range of policies from central government or the medical colleges. The Academic and Research Committee oversees the abstracts for the scientific meetings and the various BGS research grants.

The society also has a number of specialist sections – many with more multidisciplinary membership than the society as a whole. These include Ethics, Stroke, Movement Disorders, Palliative Care, Prescribing and Falls/Bone Health (which runs an annual conference attended by 300-400 delegates). These sections also often contribute to collaboration with other bodies and to consultation and development of national policies and guidelines. The society also administers a number of charitable funding streams for research and study. Finally, because performance frameworks and funding of health and social care now differ in each of the jurisdictions, we have separate councils for Wales, Scotland, England and Northern Ireland.

Further afield

The BGS and its members regularly contribute to discussions of older peoples’ health issues in the media. We are also increasingly involved in helping fellow geriatricians in countries where the speciality is emerging. For instance, for the past two years a number of our members have been delivering a fellowship training programme for the first wave of trainee doctors in Taiwan, with several of the Taiwanese visiting the UK. We are also part of the triumvirate of organisations in the British Council on Ageing and have worked closely with Help the Aged, Age Concern, the RCN and the Royal College of General Practitioners, Surgeons and Physicians. At the RCP, we have a clinical effectiveness unit which has recently performed large national audits on continence falls and bone health highlighting deficiencies in care provision and securing wide publicity.

Challenges and future directions

To reiterate, the population is ageing, illnesses of old age are increasing in prevalence and an increasing amount of health and social care is taken up by the care of older people, often with multiple long term conditions and frailty. And getting the care of older people right will have dividends for access and capacity across the whole health system. On the face of it, it may seem that we won’t be out of a job any time soon then. In parallel, other physicians are becoming ever more specialised and do not necessarily have the relevant interest, skills or training to care for older people.

If only it were that simple! All the current policy imperatives centre on reducing acute beds and shifting the care of older people to primary care. In the UK, geriatrics has become a largely hospital-based speciality. Despite the evidence that consultant-led comprehensive specialist geriatric assessment works, there is a zeitgeist towards devolving care to GPs or specialist nurses. We will therefore need to be far more proactive in working with primary care and becoming more involved in the community if older people are not to be denied our specialist skills and our role is not to be marginalised.

As we will not have the capacity to care for all older people, it is important that we spread the word to doctors and nurses in other fields. Many health professionals still have very little specialist training in the assessment and care of older people with complex needs [26, 27]. The BGS’ own survey [52] showed that there is little or no specialised teaching in many undergraduate medical curriculae (partly due to the closure of academic departments of Geriatric Medicine) and there is currently insufficient content around geriatrics in the postgraduate training curriculae.

Another potential threat is to academic Geriatric Medicine. Research Assessment metrics and the policy push to centre research in a small number of centres of excellence [53], combined with the fact that a speciality such as geriatrics does not generally have the capacity to raise major income streams, poses a problem. There are several vacant chairs or closed academic departments in the Medical Schools. Universities must appoint non-geriatricians to some chairs on the grounds of potential to generate income. A further challenge is that it may become harder to recruit trainee doctors into the speciality as ‘Modernising Medical Careers’ [54] tends to force very early career choices. Our speciality has often attracted doctors from diverse professional backgrounds who have chosen us a little later in their career.

A further challenge is illustrated by recent studies of the impact of the older peoples’ NSF or NICE guidelines on services for older people and their experiences of receiving them. There were no earmarked funds to accompany the NSF, nor the more recent ‘New Ambition for Old Age’ [27]. We know for instance that incontinence [15], delirium [16], falls and osteoporosis [13] are still under-recognised and under-treated. Even for a condition such as stroke [17] where there has been more of a policy push, many patients still never get to a specialised stroke unit. And outcomes for older people outside specialist areas (e.g. trauma or general surgery) are still very variable. There is therefore a need to effect a transformation in services so that we move from ‘box ticking’ to a change in the investigation and treatment that older people actually receive.

We know that there are still routine problems with dignity or communication which are not easy to solve. Moreover, despite all the rhetoric and the policy drives around ‘joined up’ and ‘integrated care’, the schisms between secondary primary and social care are arguably as great as ever, with contested funding for long term and continuing care, growing numbers of ‘delayed transfers’ etc. This leads us onto whether we should have a more proactive and campaigning role. One could argue that the whole history of the speciality has been about campaigning – highlighting deficiencies in care and suggesting solutions, pushing forward new directions for policy rather than merely responding to them. The society is still approached for advice and consultation in many areas. But we are not always seen as a ‘go to’ organisation – even though we have a unique message about the need for adequate, assessment, diagnosis and treatment for older people. However, should we be far more pro-active and militant, without going so far that we antagonise government and are marginalised.

For any predominantly medical organisation, there is always a risk that however hard we bang the drum on behalf of patients, we will be portrayed as a priesthood; a self-interest group. One way to combat this of course would be to be much more interdisciplinary. Our speciality is par excellence an interdisciplinary one and the membership should perhaps begin to reflect this more. Again, there is an issue about how proactive we should be in seeking wider membership. Finally, the issue of our name is a perennial one. Although we have an established ‘brand’, the term ‘geriatrics’ has unfairly developed negative connotations. There is often surprise expressed along the lines of ‘I thought you would be older!’ when doctors from the society attend meetings. It could be that our name is a hindrance – but what to change it to which reflects our particular mission and role? ‘The Society for Health in Ageing?’ perhaps.

Whatever we style ourselves, I hope the society will be key player, a source of expertise, an opinion leader and a vehicle for training tomorrow’s clinicians and researchers for at least another sixty years.

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End of Education and Careers section.