The patient population
Patients presenting directly to geriatric medicine will, in the majority of cases, be receiving urgent or unscheduled care, with a relatively small proportion seen in an outpatient or domiciliary setting. A review taking place in the community will still often have been triggered by a crisis. The increasing involvement of geriatricians with other specialties such as oncology, general surgery and orthopaedics means that they also have an evolving role in scheduled care.
Geriatricians are trained to treat people with a wide variety of general medical conditions, and have the specialist skills to diagnose and manage illness, often both physical and mental, in those who have multiple comorbidities and frailty. There is no defined age at which geriatric medicine starts to apply, and strict age-based services risk denying expertise to younger patients with complex needs who would gain from the care of a geriatrician.
Older people often present challenges to health and social care systems designed predominantly for younger people because:
- multiple comorbidities result in complex interactions between acute and chronic health issues
- their care and social needs can be intricately related to health state
- a multidisciplinary team is essential as part of their management, to perform evidence-based comprehensive geriatric assessment and devise individualised plans
- physical and mental illness frequently co-exist
- they are at risk of harm in a hospital environment from falls, delirium and hospital-associated infections.
Patients under the care of geriatric medicine may be best managed in an acute hospital, in a bedded intermediate care setting, or in their own home with enhanced support. This distinction can, however, only be made after an appropriate assessment by a skilled professional.
Although geriatric medicine is the biggest internal medical specialty, there are insufficient resources to look after all patients with frailty and therefore a wider systems approach is needed. The King’s Fund publication Making our health and care systems fit for an ageing population (opens PDF, 792.8KB) and the NHS Confederation report Growing old together (opens PDF, 385KB), have more information on whole system approaches to care for older people and the roles of geriatricians and other medical, nursing or allied health professionals.
Prevention of disease
Progression in health promotion and prevention has undoubtedly contributed to the success story of societal ageing, with greater numbers of people living into extreme old age in varying degrees of health.
Age UK and NHS England have published a practical guide to healthy ageing (opens PDF, 1.04MB). This is a resource for older people aimed at optimising opportunities for good health. It includes chapters on self-assessment (a modified timed up and go test), making the home safe, getting vaccinations, eating well, keeping active and getting ready for winter.
A number of conditions managed by geriatricians are amenable to health promotion and prevention, as advised by national guidelines. These include:
- NICE guidance for the management of atrial fibrillation
- NICE guidance on osteoporosis: assessing the risk of fragility fracture
- NICE guidance for the management of hypertension
However, consideration of risks versus benefits of pharmacological therapy to prevent rather than treat illness is key to the work of the specialty. For example, very frail older people may not be able to safely adhere to oral bisphosphonate therapy, while the risks of adverse drug reactions such as postural hypotension may outweigh treatment benefits in those prone to falls.
Between a quarter and a half of people aged over 85 years live with frailty (opens PDF, 339.43KB). Frailty is an ageing-associated syndrome related to the loss of physiological reserves across multiple body systems. An increasing body of evidence shows that by assessing for, and then managing frailty through the mechanism of comprehensive geriatric assessment, the process can be slowed or reversed. The British Geriatrics Society guidance Fit for Frailty provides more detail on this. Fit for Frailty Part 1 (opens PDF, 339.4KB) gives advice and guidance on the care of older people living with frailty in community and outpatient settings. Part 2 (opens PDF, 339.21KB) provides guidance on the development, commissioning and management of services for people living with frailty in community settings.
Planning effective services
Commissioners of care across the four nations of the UK are increasingly interested in designing services to support frail older people as they move between primary, community and secondary NHS care, and in and out of social care. Increasingly, there is recognition of the need to identify when a change in focus to end-of-life care becomes appropriate. Clearly, establishing the wishes and priorities of the older person are key in moving towards such a ‘gear change’.
The British Geriatrics Society (BGS) has produced a number of documents to guide and support such commissioning, and to identify best practice, both across services and in the acute hospital.
Fit for Frailty Part 2 contains associated commissioning guidance.
The ‘Silver Book’, developed by a multidisciplinary group of stakeholders including the BGS, RCP and Royal College of Emergency Medicine, describes how to deliver quality care for older people with urgent and emergency care needs, and includes specific advice for commissioning bodies.
The RCP acute care toolkits provide guidance, some of which is specific to older people, and the Future Hospital Programme with its associated report, gives further examples of service provision and excellence.
The ‘Blue Book’, jointly published by the BGS and BOA, provides commissioning guidance for older people with fragility fractures.