Introduction
As the survey carried out for this report shows, most older people are well most of the time. Many enjoy good and even excellent health well into their 70s or later. For the less fortunate, ill health may be carried over from middle age, and for others the common disorders of later life - such as arthritis, deafness, heart disease, and diabetes - can, alone or in combination, cause increasing problems as the years and decades pass.
In later old age, increasing frailty can bring greater risk of accidents and greater vulnerability to the effects of minor infections. Yet many such people can continue to live in their own homes, enjoyably and fairly independently, if the right kind of services are there for them when they are needed.
However, when chronic disease is established, or more serious illness strikes, good services for older people are even more important. This section of the report covers six major topics: chronic disease, cancer, heart disease, stroke, mental health, and falls.
Four of these topics - cancer, heart disease, stroke and mental health - have already been the subject of important recent reports:
Each report addresses perceived weaknesses in current services and recommends changes in service organisation and clinical practice that are designed to produce measurable improvements in care. Each will be followed up by an implementation phase to make sure that improvements happen.
Our report, Adding Life to Years, does not attempt to duplicate for older patients the detailed and expert work already carried out. Rather, it seeks to ensure that the improvements in care in every area are fully shared by older service users; and it does so because the Expert Group firmly believes that real progress in the care of older people is most likely if most of that care continues to take place within the mainstream services of NHSScotland.
This approach represents a positive assertion of the rights of older service users, and a refusal to countenance the evolution of two-tier services in important clinical areas where good care of all Scotland's adults, regardless of age, is the goal.
Of course care will always require to be matched to individual circumstances, and for some older people the issues of frailty, multiple pathology, limited expectations for outcome and personal choice will to varying degrees influence treatment. Such sensitivity has always been part of good healthcare.
But since age alone should not be a bar to appropriate treatment, and since the care of older patients is now the main business of NHSScotland, the Expert Group was unanimous that this "mainstreaming" of as much as possible of such care was the best way ahead. The Expert Group also took the view that recent developments in both primary and secondary care are encouraging, and give grounds for believing that this approach will succeed.
Better Care for Older People with Chronic Disease:
Care for older people with chronic disease such as diabetes, arthritis and chronic bronchitis varies greatly across Scotland. Good care actively involves the patient in the management of their own disease and its problems, and relies on good information for patients, locally available primary care services and easy access to more specialist hospital services if and when the need arises.
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WHAT WE HEARD: |
Developments in primary care in Scotland - including the establishment of LHCCs and the more recent initiative of the Personal Medical Services (PMS) contract for GPs - have encouraged the spread of good practice in chronic disease management, with local multidisciplinary and nurse specialist clinics, and better links between primary care and hospital services.
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Recommendation:
Cancer in Older People
Cancer is commoner in later life. Around one-third of all cancers are diagnosed in people over 75, who form only around 7% of the population. Some common forms of cancer may be less aggressive in older patients but in general terms results of treatment are less good. However, older people with cancer are less likely to undergo detailed investigation, and also receive less treatment than younger cancer patients.
Access to care
Older people with cancer are more likely to have other illnesses as well, and some of the physiological changes associated with age - such as declining kidney and lung function, and poorer drug absorption from the stomach - may make the various forms of cancer treatment less effective and also more risky. But even when these factors are taken into account it appears that substantial numbers of older patients do not receive cancer treatment that might benefit them considerably.
Treatment options
There is good evidence that some older people - particularly the "biologically young"- tolerate major surgery well and gain accordingly, often with a cure. For others, more limited surgery aimed at reducing symptoms will be more appropriate. Individual assessment, sympathetic explanation and patient participation in decision-making will maximise the benefits available from surgery for older cancer patients.
The risks of radiotherapy are higher in older patients, and an extended course of treatment may be uncomfortable and physically demanding for the more frail. Again, careful patient assessment and support will maximise gains of treatment.
Chemotherapy - the treatment of cancer with drugs - continues to advance in ways that are expected to improve the care of older patients. New drugs with fewer side effects are emerging, and many can be given by mouth.
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Common cancers of later life: some key facts:
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Even for the oldest and frailest cancer patient, there is never "nothing we can do". Treatment, whether palliative or aiming at cure, should always be tailored to individual circumstances, and older patients should receive scrupulous attention to explanation of the possible options and their implications. As more selective and less toxic treatments become available, the gains of active treatment will grow in relation to its disadvantages, and older cancer patients should share fully in these developments as they emerge. The new Performance Assessment Framework will be used to hold NHS Boards accountable for the quality of care they provide. Among the standards they must meet are those set by CSBS for the management and support of cancer patients and their carers. CSBS should ensure that its standards adequately assess the care provided to all age groups including older people.
Recommendations:
Coronary Heart Disease
The burden of coronary heart disease (CHD) falls most heavily on older people, with 81% of all CHD deaths occurring in people aged 65 and over, and 54% of all hospital discharges with a main diagnosis of angina in the same age group. CHD in later life is in general under-researched in relation to its impact on society, and concerns have been expressed about older people's access to the full range of effective treatments.
Angina
There is evidence that both the more complex angina investigations and the non-drug angina interventional treatments such as coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA) are under-used in older people. Around two thirds of interventional treatments are carried out on patients aged 65 and under.
Reasons for this disparity between need and intervention are complex. Some older patients may prefer to accept medication and be less keen on surgery, but this requires further research. The nature of coronary artery disease in later life (it is likely to be more widespread and therefore harder to treat) may be a factor, but only adequate investigation by angiography can really determine this in individual cases.
Complication rates are higher for treatment in older people, but again more research is required on risks and benefits in the age group. Overall, there is an impression that many older people in Scotland could benefit from a more active approach to the investigation and treatment of their angina symptoms.
Acute myocardial infarction (Heart attack)
Mortality from this has been falling in Scotland over the last ten years, by around 50% in the under 65s but by only around 28% in the over 75s.
Again reasons are complex. Heart attack symptoms may be less clear-cut in older patients, leading to delayed or missed diagnosis. Older people are also more likely to have other illnesses - such as stroke and diabetes - which could worsen outcomes.
Specific information from Scotland about access to Coronary Care Unit (CCU) beds for over 75s is lacking, as is information about the use of thrombolytic (clot-dissolving) drugs in older people, though there is good evidence that older people do well with such treatment.
Older people can gain positive health benefits from multi-professional cardiac rehabilitation programmes.
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Heart failure
Heart failure, most commonly caused by CHD, affects about 20% of older people and is one of the commonest reasons for which they contact their GPs. Drug treatment is increasingly effective, but there are concerns that too little of the relevant research relates specifically to older patients.
Older patients with heart failure are less likely to be fully investigated (with echo-cardiographic imaging of the heart's function), and also less likely to receive some of the most effective treatments, such as the ACE (angiotensin converting enzyme) inhibitor drugs.
Heart failure is a chronic problem, and may require recurrent hospital admissions. Some service developments, based on specialist multidisciplinary teams, have improved care by promoting closer patient involvement and better compliance with drug therapy.
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Prevention
There is now good evidence that the "younger older" can benefit from drug treatment aimed at reducing blood pressure and blood cholesterol, with reductions in the clinical manifestations of CHD as a result. In the oldest age groups the evidence is less strong.
After a heart attack, the risk of recurrence is reduced by drug treatment with aspirin and beta-blockers. The effectiveness of beta-blockers in older patients is in fact greater than in younger age groups.
The new Performance Assessment Framework (PAF) should provide a means of assessing NHS Board's performance against the CSBS standards for secondary prevention following myocardial infarction.
The Expert Group expressed concern, however, that in this, as in other areas, the PAF does not adequately assess care provided to older people.
Recommendations:
Stroke Care and Rehabilitation
Stroke is an illness predominantly affecting older people. Its care is complex, and involves many clinical disciplines. Good care improves survival and minimises disability. High quality services in Scotland could reduce, by several hundred a year, the number of people dying or requiring long-term care as result of stroke.
There is now good evidence about how patients with stroke should be cared for, much of it from the Scottish Intercollegiate Guidelines Network (SIGN). However, there is also evidence that the standard of stroke care across Scotland varies greatly. CSBS will commence preparation for stroke standards in 2002.
Early care of stroke patients
Most stroke patients are admitted to hospital, and there is currently no evidence to support major service developments designed to avoid hospital admission. Early assessment should include CT scanning and swallowing assessment, with early appropriate management of patients with swallowing difficulties. Fluid balance, pressure area care and prevention of DVT (deep vein thrombosis) should all receive attention.
Early mobilisation, and the active involvement of patients and carers in treatment planning, is recommended. Care should be provided by a ward-based multidisciplinary team including medical, nursing, physiotherapy, occupational therapy, speech therapy and social work staff; and should be co-ordinated through regular multidisciplinary meetings.
Discharge and follow-up
Discharge from hospital should be carried out according to a protocol agreed between hospital and primary care. There is recent evidence that early supported discharge schemes may allow up to 50% of stroke patients to get home sooner.
Following discharge, patients and carers should receive the services and support they need, including continuing access to rehabilitation where required, and have access to supportive organisations such as Chest, Heart and Stroke Clubs.
Service organisation
While there is strong evidence for the effectiveness of organised, ward-based, multidisciplinary stroke care, details of service organisation will vary with caseload and geographical circumstance. In large acute hospitals, comprehensive stroke units can combine acute care with rehabilitation of up to several weeks' duration, allowing one-stop care for a majority of patients. Separate post-acute rehabilitation beds may be needed for patients requiring prolonged care, and for those living far from the main hospital.
In remote and rural areas immediate care and subsequent rehabilitation arrangements will inevitably reflect local circumstances, but should include multidisciplinary care and should follow - so far as is possible locally - the national guidelines.
Recommendations:
Mental Health Problems in Older People
Mental health problems - particularly depression and dementia - are common in later life. In recent years there has been real progress in understanding the nature of these illnesses, and real progress, too, in drug treatment. Antidepressants are now more effective and have fewer side effects, and drugs are now available to treat some forms of dementia - though a cure is not yet in sight. It is important to remember that anxiety and alcohol abuse occur in older people too, and that social exclusion is most marked in those who have grown older suffering from severe and enduring psychiatric illness, notably schizophrenia.
For older people: and in society generally; the stigma of mental illness still looms large. As mental health services are uneven across Scotland, and because of lack of awareness and training on the part of some clinical staff, many older people with mental illness may be suffering unneccessarily - not receiving treatment that could help them, and missing out on support and services that could benefit both them and their carers.
Early diagnosis and effective support enable people to be cared for in their own homes for longer and with better quality of life.
Because older people with mental health problems have tended to suffer in silence, and because the kind of services that help them most involve a range of health professionals and agencies and are therefore quite challenging to organise, the Expert Group felt strongly that clear central guidance on service development should be matched by local commitments on the part NHS Boards in order to ensure generalisation of best practice in mental health care of older people across Scotland.
The Mental Health and Well Being Support Group, currently undertaking its second round of visits to Health Board areas, is concerned with the implementation of the improvements to mental health services set out in the Framework for Mental Health Services in Scotland and the modernisation agenda set out in Our National Health. The priorities include the development of a joint local strategy, agreed among the partner agencies, LHCC involvement in planning and delivery of mental health services and a co-ordinated inter-agency approach to dementia services and support.
The Expert Group recognised that better information systems are needed to support planning and delivery of mental health services for older people. They welcomed the fact that ISD and NHSScotland are running a project to improve integrated direct care through improved provision of the right mental health information at the right time and in the right place.
Depression
Depression affects 3-5% of over 65s at any point in time, with milder forms of mood disorder being present in another 10-15%. Forty percent of people who have suffered a stroke become depressed and rates of depression are particularly high in long-term care settings.
Depression can be difficult to diagnose. Some older people simply put up with its symptoms - such as inappropriate sadness, low mood, poor appetite and poor sleep - because they do not realise that they may have a treatable illness.
About 25% of suicides occur in older people, although they form only 15% of the population. Ninety percent of such cases have serious depression, and most have visited their doctor in the three months prior to death.
Better recognition of depression - through greater awareness of the part of health professionals - could reduce much suffering and also prevent a proportion of suicides. The Geriatric Depression Scale, a simple 15-question checklist, is useful in arriving at the diagnosis. Modern drug treatment is increasingly effective, but it is not always given in adequate doses - particularly in primary care.
The effective use of antidepressants, supplemented by psychological intervention, can improve the quality of life.
Dementia
About 5% of people above age 65 suffer from some form of dementia, a figure that rises to around 25% above age 85. The commonest form is Alzheimer's Disease, accounting for about 60% of cases. Vascular dementia - caused by a series of small strokes - is the next commonest, with a proportion of cases having both. Less common causes, for example Lewy Body Disease, which combines features of Parkinson's Disease with dementia, account for the rest.
Treatment for Alzheimer's Disease is improving; early and accurate diagnosis
is now very important. Initial assessments in primary care should ideally be
followed through with brain imaging and more detailed assessment at specialist
memory clinics
where available. In a proportion of cases treatment will reduce symptoms and
slow the rate of progress of the disease, easing the burdens on patients, carers
and services.
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Sixty percent of dementia patients live at home. The best care for them can be achieved when Community Mental Health Teams for older people and primary care work together and with other agencies to deliver earlier diagnosis, followed by treatment and support tailored to individual circumstances and changing needs. Meeting the long-term care needs of older women with dementia who have previously lived alone is a particular challenge for providers of joint services.
Good joint working like this will support individuals and their carers, minimise the need for patients to go into hospital, and will provide patients and carers with practical and continuing help. But carers themselves are entitled to expect support, and carers' groups can be highly effective: providing local networks, sharing problems and feelings, and sharing skills and knowledge, too.
A small number of older people with more serious mental health problems will require hospital treatment and rehabilitation, and a few will need care in hospital. Given that such patients commonly have physical problems, too, there are advantages in some integration of in-patient care for older people with serious mental health problems with specialist care of the very frail elderly.
Older people with mental health problems who need admission for the treatment of physical illness face additional difficulties. They are more prone to acute confusional states and may become distressed and even disruptive. However, they should not be excluded from appropriate treatment simply because their mental problems make that treatment difficult. Good psycho-geriatric consultation and liaison services in acute hospitals will be of great help in their care and may even reduce delayed discharges or inappropriate placement in long-term care settings.
Recommendations:
Falls and Fracture Prevention
Falls and unsteadiness are very common in older people. Roughly 30% of over 65s report a fall in the past year, a figure that rises to over 40% in the over 80s, and even higher in the frailest and those with dementia.
Most falls do not result in injury but the vast majority of fractures in older women result from falls, including over 90% of hip fractures. Osteoporosis - thinning of bone structure - increases the risk of fracture. And even in the absence of falls the fear of falling limits activity and increases the risk of admission to care.
A simple test screens for instability and mobility problems.
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The Get Up and Go Test The older person is observed:
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If there is no difficulty or unsteadiness, no further assessment of balance and gait is required.
Most falls are multifactorial in origin, and there is now a clear understanding of the risk factors involved. The more risk factors present, the greater the risk of falling. Successful interventions are those which address multiple risk factors and there is now substantial evidence from randomised controlled trials that these interventions are effective.
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Collaboration between the American and British Geriatrics Societies and the American Orthopedic Association has resulted in evidence-based guidelines for the prevention of falls in older people. The Health Education Board for Scotland (HEBS) is developing proposals for project work to evaluate the development of local services in line with these guidelines. The Royal College of Physicians (London) has published an evidence-based guideline on the prevention and treatment of osteoporosis.
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Recommendations: