Professor Richard SainsburyDepartment of Medicine

University of Otago

Christchurch

12:00 - 12:30 Reflections on a Career in Geriatric Medicine

SOUTH GP CME 2018 19th August 2018

REFLECTIONS ON A CAREER IN GERIATRICMEDICINE

DICK SAINSBURY

UNIVERSITY OF OTAGO CHRISTCHURCH

Funding: Nil Conflict of Interest: Nil

• How did I get there?

• Regrets (I’ve had a few, but then again too few too mention)

• What has improved?

• Future challenges?

Two Cogent Observations

• ‘Old Physicians let their patients die; Young Physicians investigate

their patients to death’. 76 year old woman. Hastings Sussex 1980.

• ‘Old age used to be a privilege; now everyone wants to make it a condition’. 84 year old

woman. Nottingham 1981.

WHAT ITS ALL ABOUT

•Preservation of Function

•Quality of Life

• But it can be about life extension in some circumstances

FEATURES OF ILLNESS IN THE ELDERLY

• Multiple pathology

• Non-specific or atypical presentation of disease

• Rapid deterioration of illness if untreated

• High incidence of secondary complications

• Prolonged recovery phase

• Importance of ecological factors -housing, income, social support etc

THE GIANTS

Immobility - “Off legs”

Instability - “Falls”

Incontinence

Intellectual Impairment - Delirium

- Dementia

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-Iatrogenic

Vigorous intervention or ‘let Nature take its course’?

• The problem is Nature’s third, and often most frequent option, worsened disability and increased frailty

• Before we ‘don’t treat’, we need to be sure what we are not treating.

• Older people can also suffer from under investigation and under treatment

MEANINGLESS HARMFUL PHRASES

• Acopia

• Social Admission

• Bed Blocker

• ‘For Nursing Cares’

Not helped by ‘The House of God’ Samuel Shem (Bergman) 1978.

The Medication Conundrum

• Older people often have a number of medical conditions

• Medications for some conditions have a preferential benefit for older people

• Medications are not tested on frail older people in drug trials

• Metabolism of drugs is slowed in older people with some medical conditions and sensitivity to drugs increases

• Iatrogenic illness accounts for around ten per cent of hospital admissions over 70 years of age

• Regular review of medications particularly with a view to reducing or stopping is an important part of health checks

WHAT HAS IMPROVED?

• Stroke management and rehabilitation

• Falls prevention and management (Prof John Campbell)

• Delirium recognition and management

• Dementia recognition and management

• Community rehabilitation initiatives

• Research Quality: InterRAI tool, Frailty, Falls, Service evaluation and Innovation

• Advanced Trainees: Australia and New Zealand 3 in 1983 plays 200 in 2017!!

FUTURE CHALLENGES

• DEMOGRAPHIC CHALLENGE

• PUBLIC EDUCATION AND ADVOCACY FOR LONELINESS AND SOCIAL ISOLATION

• DEVELOPING ELECTRONIC MODELS TO SUPPORT OTHER SPECIALISTS (e.g polypharmacy programmes for GPs)

• UTILIZING THE LARGE DATA BASE TO ENHANCE CARE

• DISTANCE PROGRAMMES

Thinking Ahead

• Driving

• Enduring Power of Attorney

Finance and Property

Health and Welfare

• Advanced Directives

Cardiopulmonary Resuscitation

Ceilings of Care

CAPACITY ASSESSMENT

Four Domains. Not Just Cognition.

• Communication

• Cognition

• Judgement

• Insight

Second opinion if doubt or dispute

Advanced Directives

To be encouraged but be aware of limitations

• They can’t cover every contingency

• Old Mexican Proverb: “the character of the bull changes when it enters the ring”.

• Should be used for consulted guidance.

KEY POINTS

• Preservation of function is the aim

• There may only be one chance

• Abnormal presentations may delay diagnosis

• The ‘giants’ are symptoms not diagnoses (with the exception of Iatrogenic)

• Regular Medication reviews

This drug really still needed?

This dose really still needed?

• Patient driven goal setting

• Be prepared to make an informed stop

The content of Geriatric Medicine

The content of Geriatric Medicine