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• Holistic care needs to be met with holistic education
  James M Read
  Published on: 22 August 2014
• Less health care might be fair in the older patient.
  M. Justin Zaman
  Published on: 12 August 2014

• Published on: 22 August 2014

  Holistic care needs to be met with holistic education

  • James M Read, ST3 Elderly Care Medicine

  The increasing numbers of frail elderly patients certainly poses a challenge for all parts of the healthcare landscape within the UK and beyond. Whilst organisational change and modifications to where, when and how we deliver care is important this must be underpinned by appropriate education for doctors and allied healthcare professionals.

  Much of this needs to be aimed at more junior staff, especially medical...

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  The increasing numbers of frail elderly patients certainly poses a challenge for all parts of the healthcare landscape within the UK and beyond. Whilst organisational change and modifications to where, when and how we deliver care is important this must be underpinned by appropriate education for doctors and allied healthcare professionals.

  Much of this needs to be aimed at more junior staff, especially medical students and junior doctors. Elderly care medicine has been undervalued for too long and the complexities of older people have been underestimated. Education therefore needs to be focussed on two main areas:

  1. An ability to understand complex medical conditions, the interactions that these conditions have with each other and the medications that can improve and worsen these problems. This must be learnt in the context of the multi-disciplinary team and understand the complex psycho-social dimensions that exist within the ageing community.

  2. An understanding that over medicalisation of the health needs of older people can be detrimental to both physical and psychological care, in particular the understanding that just because we can investigate and treat problems doesn't mean that we should. These decisions are complex and should be made in conjunction with patients, their families and independant advocates if patients lack capacity and family.

  Changes to the care of older people must be made in a sustainable and holistic way which have education as the foundation to ensure modifications are successful.

  Conflict of Interest:

  Academic Clinical Fellow in Medical Education at Plymouth University

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  Conflict of Interest:
  None declared.

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• Published on: 12 August 2014

  Less health care might be fair in the older patient.

  • M. Justin Zaman, Consultant Cardiologist and Honorary Senior Lecturer

  Predicting prognosis in this older group of patients is complex due to their highly variable health status, driven by their fundamentally different prognosis to younger patients. We have published two recent pieces on this theme, showing that firstly though there was an incremental reduction in the use of evidence-based therapies for ACS (acute coronary syndrome) with older age and that better survival was associated with...

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  Predicting prognosis in this older group of patients is complex due to their highly variable health status, driven by their fundamentally different prognosis to younger patients. We have published two recent pieces on this theme, showing that firstly though there was an incremental reduction in the use of evidence-based therapies for ACS (acute coronary syndrome) with older age and that better survival was associated with intensive management at all ages, this benefit was attenuated the older the patient.(1) Secondly, higher troponin levels are associated with increasing risk of mortality, but we found very high mortality rates in older patients even at the lowest troponin values. There was an attenuation of the prognostic value of troponins in older age and thus, the prognostic value of troponins depends on patient age in ACS - essentially, age is the biggest prognostic marker, and arguably markers we use in younger patients are not as relevant in older patients.(2) Current risk scores to guide aggressive management of coronary disease in the older person perform poorly, over-estimating mortality and ignoring morbidity, perhaps of more relevance to this age group.(3) In a population of older adults, adjustment for 27 biological risk factors including co- morbidity, social status, lifestyle and disease factors, cognition and frailty substantially reduced the association between chronological age and 5-year mortality (ages 80-84 years: unadjusted relative risk, 4.1; adjusted relative risk, 1.7).(4)

  As outcomes are influenced by both age and co-morbidity, is the under -treatment of older people with ACS relative to younger patients thus 'appropriate'? Evidence suggests that risks associated with more intensive management in older people may be related more to their greater co- morbidity than age alone(5) and thus chronological age alone may not be the best measure by which to plan clinical management in older people. Trials also tend to focus on hard outcomes and also rarely take into account wider prognostic measures such as disability, repeated hospitalisation and return to independent living that are more relevant in older people. Others have also written that sometimes following exacting clincial guidelines that lead to more treatment may not be in the best interests of the older patient.(6)

  The ideal pathway in the older patient for example with an ACS should not assume early intervention with revascularisation is the optimum strategy (as is usually the case in the younger patient) but should be a more holistic management strategy based upon thorough comprehensive geriatric assessment. Frailty,(7) functional status, and social aspects of care in the elderly are rarely included as clinical parameters (read wider prognostic markers) in decisions pertaining to future care. Furthermore, outcomes beyond survival need assessing, and ones of particular relevance to the older patient.

  1. Zaman MJ, Stirling S, Shepstone L, Ryding A, Flather M, Bachmann M, et al. The association between older age and receipt of care and outcomes in patients with acute coronary syndromes: a cohort study of the Myocardial Ischaemia National Audit Project (MINAP). European Heart Journal. 2014 March 18, 2014.

  2. Myint PK, Kwok CS, Bachmann MO, Stirling S, Shepstone L, Zaman MJS. Prognostic value of troponins in acute coronary syndrome depends upon patient age. Heart. 2014 June 26, 2014.

  3. Zingone B, Gatti G, Rauber E, Tiziani P, Dreas L, Pappalardo A, et al. Early and late outcomes of cardiac surgery in octogenarians. Ann Thorac Surg. 2009 Jan;87(1):71-8.

  4. Fried LP, Kronmal RA, Newman AB, Bild DE, Mittelmark MB, Polak JF, et al. Risk factors for 5-year mortality in older adults: the Cardiovascular Health Study. JAMA. 1998 Feb 25;279(8):585-92.

  5. Rosengren A, Wallentin L, Simoons M, Gitt AK, Behar S, Battler A, et al. Age, clinical presentation, and outcome of acute coronary syndromes in the Euroheart acute coronary syndrome survey. Eur Heart J. 2006 Apr;27(7):789-95.

  6. Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: Implications for pay for performance. JAMA. [doi: 10.1001/jama.294.6.716]. 2005;294(6):716-24.

  7. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in Older Adults: Evidence for a Phenotype. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 2001 March 1, 2001;56(3):M146-M57.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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