Life and how to live it

So my page broke this week.  When I say broke more bits fell off but ever the stoical page that it is it’s kept going.  Over the years it has experienced many unexplained falls, there’s been several episodes of acute confusion as it struggled to tell me extension numbers (usually resolved by a new battery) and on occasion it just became unresponsive.  The exact cause of this has never been fully established but I strongly suspect it has an intermittent fault caused by degenerative, wonky wiring.

In short I think my page might be frail.

The assessment made I’ve made a few adjustments to it (micropore tape) and it continues to happily bleep me again.  We both know the time will come when we need to be honest about how it can continue fulfil its role but we’re not there yet. Until then I will do as much I can so my page can continue to enjoy many bleeping years to come.

Frailty is a concept I have struggled with over the years.  And yes I know as a Geriatrician that could be seen as blasphemy. I’m just being honest though.  I am frustrated that we are still to agree a formal definition that can be easily translated into operational use.  And yet I find myself in a position where I am trying to do just that.

So what is it exactly?  Well, I can tell you what it’s not so that seems as good a place as any to start.

You don’t have to be old to be frail.

My colleague Rowan Wallace gave a presentation years ago which sought to challenge the concept of frailty by showing a photo of her grandparents and asking who was the frailer of the two. Spoiler alert it wasn’t the ‘old looking one’.

It is true that in the very old (>85yrs) around a quarter will be frail but it’s worth remembering that some younger people will also be frail.

Think of it this way.  Take stroke.  It affects all ages but your risk of it increases with age.  The same is true of delirium when superimposed on dementia.  Heart failure is another example.

So I tend to think of it as a long term condition and that makes more sense. In thinking about it that way you might start to ask why is it bad? How do you screen for it?  What  do you about it?  Why should I care? And why is every man and their dog banging on about it?

I think we’re in uncharted territory at the moment and this is why no one can quite articulate why frailty is now a thing.

As I reflect on another weekend on call I am beginning to see why.  We have gotten used to good health such that when a person (especially an older one) becomes unwell it is met with surprise not just by families but by the person themselves.  I used to think it was just the concept of dying that we had lost the ability to talk about but I actually think it goes deeper than that.  People have this amazing contradictory expectation about their own health.  They expect to live for a very long time, with a good quality of life and with a NHS that will attend to their every person specific need.  Death also comes on their terms.  What I saw this weekend was a receiving unit full of broken, unwell people accompanied by their equally broken and exhausted relatives and carers.

This is frailty in action.  And this is what we need to be talking about as openly and honestly as possible.

However we continue to be surprised when these people turn up at our acute medical receiving units.  We are unprepared for them as we continue to function as a reactive service.  One that is risk adverse and offers little in the way of alternative options.

So we need to do things differently and that starts by changing up our approach.  It’s common sense really but when people are exhausted it can feel too difficult.  Of course we don’t make it easy either with increasing silo working which further reduces the ability to share information.

We need to start by how we define risk. I would argue there is a disconnect between what we mean versus what we do. Specifically we seek to manage our own risk but present it as managing the risk to the patient.

We need to be get away from this idea that if we had infinite resources we could deliver a much better service.  This is true to some extent but I predict we will see continued paternalism rather than re-enablement.  Seven day working is a fabulous concept but re-enablement shouldn’t stop just because there isn’t an OT on the ward on a Sunday morning…..

So lets begin again.  Lets agree that frailty exists.  These people will turn up at our front door so we need to be able to recognise who they are regardless of age. We need to be able to offer them some kind of intervention or model of care.  Lets call that Comprehensive Geriatric Assessment (should it even contain the word Geriatric anymore….???).  Let’s admit the very sick as that will always be the right thing to do.  For the others lets see what alternatives we can offer – it could be a community team of therapists, nurses, doctors, pharmacists and third sector.  We could deliver it in their own home or a local centre.  Why not even via Skype or FaceTime?  (crazy talk I know, it’s the stuff of Sci Fi!)

We should continue the conversation around what the person would and would not want as life progress.  We should share that information with as many relevant people as possible, most importantly with their own families.

We should talk to each other in health and social care with improved IT systems but also an actual conversation is pretty good too.

It shouldn’t be hard. This is life and it’s up to us how to live it……

education, geriatrics

A Whole New World

Three exciting things happened this week – I hosted my first ever Journal Club on Twitter, I attended the BMA Women in Medicine event and also presented at the Geriatrics for Juniors conference in Newcastle.

All very different but all with one thing in common – bringing people together.

My feeling over the past few months is that within healthcare there has been a creeping return to silo working. Whether it’s staffing on a ward area, the rota or teaching it all feels like people are in self preservation mode. It was nice to be pulled out of that for a while and see what was going on in the wider world

I’m not sure how many of you still run journal clubs at work?  They’re something that seem to have fallen out of fashion. I’ve got to be honest, in the past I didn’t like them.  For those who are unfamiliar, the premise was that some unfortunate soul was nominated to present a ‘topical’ paper at a lunchtime meeting.  This paper would then be dissected by the audience.  It was an opportunity for scientific ‘show pony-ism’ for the statistically minded. Usually I forgot to read the paper and when I did there seemed to be far too many statistics which I didn’t understand. I learnt nothing.

Years later I have come to appreciate their value in appraising evidence which is clinically relevant to my day to day work. I am still not keen however on the traditional design of a Journal Club.

What the @GIMJClub guys have done is take the same principal – ‘have paper, now discuss….’ and refreshed the format for a wider social media audience (#genmedjc)

In the week leading up to the Journal Club the paper and its supplementary links were shared across several social media platforms.  This allowed people the time and the flexibility to read it on a device of their choosing.  I must admit though, I still printed it off and sat with a pink highlighter pen – old habits!

The discussion was fast paced and hugely interesting. I learned loads!  The bonus part was it allowed people from all over the UK to take part from the comfort of their own home.

Using Storify, I was able to capture the main points reflecting a happy couple of hours of educational community.

This energy followed me to the Women in Medicine BMA event a couple of days later (#BMAWomenMedicine). The workshops I found the most useful were those on Less Than Full-Time (LTFT) working.  It struck me that people were somewhat left to get on with it when it came to LTFT working.  As someone who has trained and currently works, correction, is paid less than full time it is a subject close to my heart.  We are seeing a change in the workforce with more people choosing to work flexibly where possible.

The BMA have recognised this and have introduced the concept of ‘LTFT Champions’. An informal go-to person to ask advice on the practicalities of LTFT working and to also  provide local guidance.  It’s something I’m looking to introduce to Forth Valley in the coming months.

To round off the week I was asked to present at the Geriatrics for Juniors conference (#G4J17).  The guys at @AEME are heroes of mine. Not only have they advanced Geriatric education they have raised the profile of the speciality a million fold.

On a cold Saturday in Newcastle ~200 mostly junior doctors attended a day of very entertaining presentations on the different facets of Geriatrics. To my mind this reflects the growing interest in our speciality, which I hope ultimately translates into more people training as Geriatricians.

What continues to impress me most about @AEME is that they not only recognised the need for a different way to deliver Geriatric teaching but they went out and did it.  They also managed to attract like-minded individuals to give up their time and contribute too – whether through a Connect event, a Podcast or their newly formed Mentor network.  Silo working just does not exist in their world.

Now of course you don’t have to go to these lengths to get out and talk to people. Pick up the phone, email (yes, I said it; its still a convenient communication tool), grab a coffee together or meet up with other specialty colleagues before a lunchtime meeting. One of my colleagues is trying to do this very thing by booking an area next to the lecture theatre.

Either way just get out there, people. You’ll be amazed by what you find….

geriatrics, nhs

Free, free, set them free


This week I’m in Nashville for the American Delirium Association Conference (#ADS2017).  Day one was heavy on education and although I was familiar with most of the content I always find it interesting to hear how others interpret and explain things. One session on delirium in the Intensive Care got me thinking:

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Now when you mention restraints to people in healthcare they will generally think about the kind that have people strapped to a chair or cot side.  Thankfully these types of restraints are no longer routinely used in the NHS.

There are some kinds of restraint that can be a good thing for example, the plaster cast that stops a fracture becoming displaced.

However what about the restraints we use by proxy?

As I sat in the lecture I got to thinking about what happens to a person when they are in hospital.  Last week I talked about the role of the environment in particular how it can be damaging to the person with delirium or dementia.  By making simple changes there is evidence that the person will get better more quickly, so of course the environment was number one on my list.

The #endpjparalysis campaign on social media also highlights it.  I recently had a patient comment she would like to get dressed but unfortunately her family had only packed her a nightdress. Most equate a hospital admission with serious illness however the aim is to get the person better as quickly as possible so we do need to see beyond that.  One could argue that a person’s dignity is restrained by having them rehabilitate (walk, eat etc) only in nightwear.

Which brings me on to 7 day access to a multi disciplinary team (MDT).  We know that early access to physio and occupational therapy can have huge benefits not only on the physical but also cognitive health of a person.  Could limited access to the MDT be a restraint by proxy?  I’m not so sure.  I do think they are spread far too thin.  I also think that some of the tasks could be done by others, in particular, our healthcare assistants.  I just wonder if they perhaps need to be more empowered to do so instead of just doing unto the patient….?

One thing that does not help in the early mobilisation of a person is the use of sedation.  It’s not just an issue for ITU, many of our older people are on medications that actively sedate them e.g. the ‘little sleeping tablet at night’, strong painkillers even some antihistamines.  I would argue that Geriatricians in conjunction with our pharmacy colleagues are good at trying to rationalise medications.  The community, especially care homes are not quite as good.

So coming back to the hospital setting both in acute and rehab here are a few other things that could be considered restraint by proxy;

  • urinary catheters
  • hearing aids that don’t work or are not fitted
  • no glasses
  • buzzers that are out of reach
  • empty water jugs and cups
  • inappropriate walking aids
  • no walking aids
  • no ‘getting to know me’ or ‘what matters to me’ discussions

Most would be horrified at the idea of going back to the use of physical restraints but I wonder if we realise all the other ways we achieve the same effect? Perhaps we ought to reframe the discussion so that as with straps, belts etc other restraints by proxy can become a thing of the past….


True Colours


Our lunchtime meeting this week featured a talk by George (@ilovehermind), one of our junior doctors on health issues in older LGBT people.  It was incredibly thought provoking.  It’s rare that a presentation makes me want to immediately go and learn more. However as I soon discovered there was very little to find.

First up I went to the British Geriatrics Society website and typed ‘LGBT’ into the search facility. No results.  Hmmmm…. disappointing.  I then tried typing ‘Gay’ – nothing again.  In fact despite typing an array of acronyms and looking amongst the various headings I couldn’t find anything.

I tried Health Improvement Scotland. They’re bound to have something I thought.  Eh, that’s a no too.

I was starting to get annoyed….

Eventually I was able to find the articles that George had referenced in her talk.  What I hadn’t really appreciated until now was the range of issues that our older LGBT community faces.  More over how little attention or recognition they receive.

I am also slightly ashamed to say the issues raised had never really crossed my mind.  I guess I have always considered myself to be the type of person who doesn’t pay all that much attention to perceived differences. I will treat people the same whoever they are.

That said over the next couple of days I began to reflect on my own practice.  To my knowledge I have looked after only a few older LGBT people.  I have never asked nor have I made assumptions.

Is this wrong?

I’m beginning to wonder if it is.

I have been corrected on many occasions by the women who I have said hello to as ‘Mrs’ only to be told ‘it’s Miss’.

Then there was the man who I looked after years ago with the low impact hip fracture.  He told us some weeks later that in fact he had been born female but had been brought up and identified as being male.  This was told to us in confidence and I’m very honoured that he felt he could share that.  However when a well intentioned Healthcare Assistant shaved the beard he had been trying to grow for months the devastation felt by all was awful.  He never said not to and she just assumed he would want to look well groomed.  Now I appreciate that’s a very specific story but it has stayed with me.  What could we have done differently?  Each time I come up blank…. The story came back to mind when I read this quote:

‘Coming out’ is an on-going, dynamic process. Every unfamiliar person and place (such as a hospital or nursing home) demands yet another decision about disclosure. (Age UK)

So as we talk about frailty and all the other conditions that occur in old age I don’t recall any conversation about the needs of the LGBT community in old age.

Are they any different?  In some respects yes but in ways I hadn’t really considered before.  There is a higher proportion who drink alcohol and/or take drugs.  We are also now seeing approximately a third of newly diagnosed HIV cases in the over 50yrs and 5% are >65yrs.

However what I hadn’t appreciated was the issue around social care and loneliness. The combination of family estrangement and/or no children leading to social isolation and lack of support network. Some good news and an attempt to address this lies in Manchester City Council opening the first LGBT care home:

To be honest George’s talk was a real eye opener for me. I became a Geriatrician because I believed that older people were largely the forgotten mass who got a rubbish deal from the NHS. I wanted to be their advocate. I now realise that I have been somewhat blind to a group of people within this. I am delighted that Geriatrics is now front and centre in the NHS.  However I feel we may have some way to go to ensure that all older people receive the care they deserve and are entitled to.

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