Introduction
The entire symposium was conducted as a virtual meeting due to the unprecedented circumstances of the COVID-19 pandemic. All delegates delivered their talks remotely and all registered attendees were able to either watch the content live or from recordings at a later date. The symposium was delivered by healthcare professionals from a breadth of specialties on topics that will equip clinicians to meet the challenges of modern geriatric medicine.
Session 1: Optimising nutrition in the older adult
Ms Iona Bell (Dietician, Addenbrooke’s Hospital, Cambridge) highlighted the need for all older adults to be screened for malnutrition on admission with a validated tool. Enteral feeding should not be used in patients with end-stage dementia as this is more likely to cause aspiration pneumonia and less likely to provide longer term benefits.1 Decisions about long term feeding should involve multidisciplinary assessment considering patient/family preferences and advance directives. Ms Jessica Baggallay (Specialist Speech and Language Therapist, Addenbrooke’s Hospital) explained how dependence for feeding and oral care are the key predictors of aspiration pneumonia whereas dysphagia alone is not.
Professor Alasdair MacLullich (Royal infirmary of Edinburgh) gave a comprehensive overview of assessment and management of delirium. The 4 As test (4AT) is currently the most validated tool worldwide to assess delirium.2 However, diagnosis of delirium should be based on clinical judgment, identifying precipitating causes to optimise brain recovery.
Session 2: Quick updates: tolerability of new and established medications especially in older and frail adults
Dr Diane Barker (Royal Stoke University Hospital) delivered an informative talk on heart failure explaining how diuretics to relieve congestion remain the mainstream treatment, irrespective of the mechanism of heart failure. As a consequence, deterioration of renal function can be expected and therefore close monitoring is needed. There are many trials on multiple disease-modifying drug therapies for heart failure with reduced ejection fraction; however, the effect of these therapies in older patients is limited. Interestingly, there is growing evidence that shows sacubitril/valsartan and dapagliflozin improve survival and reduce hospital admissions in older adults.3,4
Dr Prina Ruparelia (St. Bartholomew’s Hospital) discussed the challenges in diagnosis and treatment of COPD in geriatric patients. The ageing lung can mimic pathological changes that are seen in COPD. Cognition and physical limitation are some of the difficulties with inhaler therapy in elderly patients.
Professor Mark Strachan (Western General Hospital, Edinburgh) discussed problems associated with the use of insulin, sulphonylurea and metformin in elderly patients. Hypoglycaemia in the elderly is associated with increased mortality and morbidity. Reduction in blood pressure and cardiovascular events are benefits of SGLT2 inhibitors, while euglycaemic ketoacidosis and urinary tract infection are serious adverse effects. DPP-4 inhibitors (sitagliptin) are much less potent than GLP-1 agonists (exenatide) in lowering blood glucose levels in older patients.
Dr Hema Bhat (Western General Hospital, Edinburgh) explained that early diagnosis and aggressive treatment with disease modifying drugs reduced radiological damage and improved long term outcomes of inflammatory arthritis in older patients.
Session 3: What can we do for your frail older patients?
Dr Magda Sbai (Guy’s and St Thomas’ NHS Trust) demonstrated that the number of older patients undergoing surgery is increasing due to advances in healthcare. However physiological decline, multimorbidity and geriatric syndromes result in poor postoperative outcomes in frail older patients. The evolution of the proactive care of older patients undergoing surgery (POPS) services which use comprehensive geriatric assessment methodology and intervention throughout the surgical pathway have led to favourable outcomes.
Dr Jemima Smith (Western General Hospital, Edinburgh) explained that pro-inflammatory states of cancer lead to sarcopenia, anaemia and fatigue, making frail older patients more prone to infections, pressure damage, poor healing, deconditioning and death. Moreover, patients who undergo comprehensive geriatric assessment (CGA) prior to aggressive cancer therapy are more likely to complete planned treatment and have a better quality of life.
Dr Robert Caslake (Aberdeen Royal Infirmary) explained the Silver City Project as a community-based multidisciplinary (MDT) model that aims to improve health outcomes and wellbeing of older patients and thereby reduce hospital admissions and referrals to secondary care. The MDT meetings established in GP surgeries focused more on enabling older patients to pursue their personal goals rather than focusing merely on treatment.
Session 4: Neurology
Dr Richard Davenport (Western General Hospital, Edinburgh) elaborated on diagnosis and treatment of epilepsy in older patients being a challenge due to atypical seizure presentations, broad differential diagnosis and pharmacological changes associated with ageing.5
Dr Jerry Brown (Addenbrooke’s Hospital, Cambridge) used case studies to explain different types of dementia and emphasised that clinical history is key for diagnosis. It is also important to screen for depression in any patient with dementia and vice versa.
Dr Louise Davidson (Western General Hospital, Edinburgh) explained that ageing is associated with changes in the nervous system. Therefore, understanding what is normal at different ages is essential. Functional movement disorders (FMD) are difficult to diagnose but can be the predominant cause of disability in the elderly. Physical health poses as a trigger for late onset non-epileptic attacks and they are more likely to present with hypokinetic movement disorders. Incidence of late presentations of myasthenia gravis in the elderly is increasing, and the diagnostic challenge is attributed to clinical manifestations being often mistaken for changes due to old age.
Take home message
This symposium provided a comprehensive overview of how different specialties can adapt to care for older patients and the challenges encountered. It is paramount that we provide evidence-based, patient-centred care for our older patients with the aim of improving their quality of life.
References
1 National Institute for Health and Care Excellence guidelines. Enteral (tube) feeding for people living with severe dementia. https://www.nice.org.uk/guidance/ng97/resources/enteral-tube-feeding-for... (accessed 10/4/20).
2 Shenkin SD, Fox C, Godfrey M et al. Delirium detection in older acute medical inpatients: a multicentre prospective comparative diagnostic test accuracy study of the 4AT and the confusion assessment method. BMC Med 2019; 17: 138.
3 McMurray JJ, Packer M, Desai AS et al. Angiotensin-neprilysin Inhibition versus enalapril in heart failure. N Engl J Med 2014; 371: 993–1004.
4 McMurray JJV, Solomon SD, Inzucchi SE et al. Dapagliflozin in patients with heart failure and reduced ejection fraction. N Engl J Med 2019; 381: 1995–2008.
5 Johnston A, Smith P. Epilepsy in the elderly Expert Rev Neurother 2010; 10: 1899–1910.
