Monthly Archives: December 2013

There’s an order to things: Item response theory as a way to make sense of functional decline in dementia

Sarah McGrory is a PhD Student at the Alzheimer Scotland Dementia Research Centre at the University of Edinburgh. Reblogged from the British Geriatrics Society blog.functional decline

Are some activities harder than others for people with dementia? In our research, recently reported in Age and Ageing, we looked at how people with dementia differed in their day to day activities. 202 people with mostly mild to moderate dementia in Scotland were asked about their activities

Activities (using the telephone, shopping, food preparation, housekeeping, laundry, travelling, taking medications, handling finances) can be measured using a questionnaire called the Lawton Instrumental Activities of Daily Living (IADL) scale. Usually scores on the individual tasks are added together to give a total score ranging from 0 to 8. This number can hide a lot of information about a patient’s functional ability. It assumes every functional activity is equally difficult, which is rarely the case. For example, being able to manage your finances is likely to be harder for most people than being able to eat.

Our research used a statistical technique called item response theory (IRT) to get more information from a questionnaire about function. IRT allows the different activities to be ranked according to their difficulty. This can be especially useful for assessing progression of cognitive impairment. Knowing the expected order of decline can help to monitor progression, so any changes from the usual course, or changes in rates of decline, can be identified and studied. IRT can help to identify key tasks in a scale, and can also show in what order tasks might become more difficult as dementia progresses.  To do this, though, clinicians and researchers have to record answers to every task on a scale, not just to the total number.

We found that the tasks included in the scale could be ordered by increasing difficulty from being able to use the telephone (easiest) to the ability to shop (most difficult). This means a person may be having problems shopping independently may showing the first sign of functional difficulties related to cognitive impairment. Problems with this task should alert doctors as a possible early symptom of cognitive decline. Recognising these early stages is very important and can help people live independently for as long as possible with the help of medications, family education and counselling.  Looking at the individual tasks within a scale instead of relying on the total score can help us to understand more about dementia progression and help us to identify care requirements for patients.

Generation Geriatrician?

Felicity Jones is a final year medical student at King’s College London and current Junior Members Representative for the BGS: representing Junior Doctors and Medical Students on the Trainees Council. Reblogged from the British Geriatrics Society blogGG

Caring for an ageing population is a major challenge of our time. Across the world, societies are ageing, with wide-ranging impacts. Many overlook the huge contributions the over-65s make to our labour workforce, running the third sector, and as carers for friends and relatives. It’s easy for these contributions to be ignored in a narrative which at a societal level tends to focus the challenges of providing a comprehensive health and social care to an ever-increasing proportion of our society.

At only twenty-three, it’s unusual for me to be interested in these issues. Most of my fellow medical students struggle to comprehend what draws me to geriatrics. I tell them it’s because I’m interested in health systems, quality improvement and leadership, because I’m intrigued by the complexities of how to flourish in our society once you hit retirement age, because I care about each and every older person I meet and want to see them supported holistically… but most of all because I’m young.

Our generation will be caring for an unprecedented number of older people, and managing an ageing challenge on a scale that today’s consultant geriatricians, healthcare managers and government have never experienced. As we become consultants, we will inherit systems which are already failing to cope, and we will have to manage any chaos resulting from a continued failure to radically re-design policies. Therefore, as healthcare professionals of the future, do we not have a duty to not only learn about but also get involved in leading these developments?

‘But I don’t want to be a geriatrician, I want to be a neurologist, a dermatologist, or specialise in some medical specialty…’ I hear you cry. Do not kid yourself. Each and every one of us is going to be affected by this demographic shift, and we will all (ok, with the possible exception of paediatricians!) see increasing numbers of elderly patients, who are taking multiple drugs and have multiple comorbidities. Even you budding surgeons should sit up and take note – services such as POPS at St Thomas’ demonstrate we can expect increasing numbers of older patients to undergo surgery with successful outcomes if given the right support.  We all need to learn from the experience of existing geriatricians, and gain expertise in how to care for the complex elderly patient of today, who will become the commonplace patient tomorrow. As one of my friends at King’s said after our elderly care placement, ‘I just didn’t expect geriatrics to be so difficult – I thought it was just talking to people!’ He’s right that caring for this population is academically rigorous, but he is also right that communication skills are critical: working with the elderly means thinking holistically about social, psychological and spiritual circumstances. Therefore, what better place to gain the skills and expertise you are going to need whatever you choose to specialise in?

A specialist medical and mental health unit

Dr Rowan Harwood is‎ a consultant physician, professor of geriatric medicine at Nottingham University Hospital NHS Trust. Reblogged from the BGS Blog

Click here to go to video

Click here to go to video

There is a lot of criticism of how we manage cognitively impaired patients in acute hospitals. And advice on how to do it better. The hope has been that more expert and co-ordinated services would improve outcomes and save resources. But there has been little in the way of rigorous evaluation.

We developed a specialist medical and mental health unit with the ambitious objective of demonstrating best practice. We enhanced the ward environment, ward staffing and skill mix, including mental health specialist nurses, therapists and psychiatry, trained all staff to a high level in the person centred philosophy of care, and endeavoured to engage family carers more fully.

After 18 months of operation we ran a randomised controlled trial, published in the BMJ.This video abstract describes the intervention and trial results.To illustrate the challenges and capture the essence of compassionate person-centred care, we made a 23 minute documentary, called Today is Monday. Footage from this is used to illustrate the abstract.

The full 23-minute film is available for training purposes; interested readers are welcome to discuss this with me Rowan.Harwood@nuh.nhs.uk.

The frailty syndrome in the “frail” healthcare systems

Matteo Cesari, MD, PhD is Chargé de Mission at the Gérontopôle of the Centre Hospitalier Universitaire de Toulouse, researcher at the INSERM UMR1027, and Professor at the Université de Toulouse III Paul Sabatier (Toulouse, France). He is Editor-in-Chief of the Journal of Frailty & Aging. Reblogged from the British Geriatrics Society BlogFail lady

Our societies are ageing. The number of older people is steadily growing, threatening the sustainability of public services including healthcare. Age-related chronic and disabling conditions not only adversely influence older people’s quality of life, but also represent a burden for public health expenditures. It is a fact that something has to be done in order to prevent the (often irreversible) loss of physical function that occurs with advancing age. If we are to accomplish such an ambitious task, a major revision is needed in our approach to older people and, consequently, in the concept of geriatric medicine. Continue reading