Ageism and risk of technological Darwinism

Glòria Galvez

Image by Flickr

According to the Spanish National Institute of Statistics (INE), in 2020 about half of the people over 75 years of age-connected to the internet daily. The pandemic and the need to feel integrated into society have forced them to enter the digital world, although their opinions, aptitudes or preferences have not been taken into account in the design of the tools used.

"Carried me with you": the objectives of integrated care are a matter of more than one

Mònica Almiñana
 

This song from the Onward soundtrack, one of Disney's latest animated productions, bring about a good mood because, in addition to having a country touch, I have always liked lyrics that speak of how important it's that they accompany you, guide you and help you achieve your goals.

The delirium epidemic in frail hospitalized patients

Marco Inzitari
 

 

Cardiff Delirium Study

Delirium, formerly known as acute confusion syndrome, affects around 20% of patients older than 70 years admitted to hospitals, such as reflected a recent study from Australia, a country of 24.6 million inhabitants with a population less aged than ours. This syndrome significantly increases the stays of hospitalized patients, for example, due to femur fracture (7.4 days on average), or aortic valve replacement (4.2 days), with avoidable extra costs.

Medicine based on customs

@varelalaf

The universe of my childhood was full of incontestable rules; most of them had to do with the precepts of religion, although the matter affected all aspects of daily life. I remember that you could not bathe in the sea or in the pool if you had eaten or drank within a minimum period of two hours, a period that the strictest families extended to three. When you were a teenager and you protested, the parents told you all kinds of calamities that could happen to you if you failed to comply with the rule, according to a lot of legends that were passed down from generation to generation.

Surgery and the elderly

@varelalaf

More and more elderly people are being seen in the operating room, especially for large joint replacement interventions, for colorectal cancer resections or for vascular pathologies, to cite the most frequent casuistry. Many of these actions are aggressive and generate risks of postoperative complications, which often require catheters, serum, transfusions, intubations, etc. Therefore, a lot of clinical circumstances are generated that induce immobilization, a situation that adds a new chain of risks, especially thromboembolism, bedsores, infections, disorientation, delusions, malnutrition and dehydration.

Precision health: recommendations for preventive strategies in the elderly

Marco Inzitari

In a post in this column more than three years ago (May 2016), I spoke about the need for a "precision medicine" approach regarding older adults with complex needs, because of ageing,  characterized intrinsically by complex and multi-factorial changes and aspects, including biological and clinical, vulnerability and prognosis, social and environment, and also the preferences of the individual.

"Precision care for older adults" was the motto of the 24th Catalan Congress of Geriatrics and Gerontology that was held in Barcelona. The event focused on how to take advantage and synthesize technological and big data aspects with an adequate care, centred on the individual within geriatrics and gerontology, but also on the many other disciplines and specialities that now face various problems of older adults.

The congress showed that it is essential to combine the management of complex situations, advanced or acute, with preventive strategies. For this broader context, we had chosen the motto "Precision Care" instead of just "Precision Medicine". In the optics of carrying out a personalized approach in the prevention, let's prepare to adopt the motto "Precision Health", already used by different institutions in the United States for the marketing of preventive programs.

Here is both good and bad news. The bad: implementing preventive strategies is also difficult, as it is to approach the complexity of the tip of the pyramid, if we aspire to have some impact. The base is also multi-factorial, and requires multi-component interventions. The effect is not entirely predictable given the individual response, so that we should avoid “stereotypes”; this is why the best interventions get the name of "complex interventions." As claimed by Mrs Mercè Mas a retired social worker, gerontologist and representative of the elderly FATEC delegate who joined us at the opening table of the congress, talking about "older people" does not make much sense either because they are a heterogeneous collective.

The painter and writer Miquel S Jassans, during the creation process

The good: in this sense, we have some progress. I’ll pass on the discovery from one of the findings of my research group. We were frankly tired of the studies and clinical trials applied to frail elderly people, in this case, those with relative autonomy and independent living, but with some indicators of imminent downturn risk and negative health consequences (I defined this population and described some successful studies in a previous post). If they are well designed and financed, they usually show benefits, at least in the short term.

We moved towards "border" projects on the threshold between organizational innovation and implementation. One of these, + ÁGIL Barcelona, a collaboration between Pere Virgili Sanitary Park and the primary care of the ICS of Barcelona, ​​focuses to this same group and tries to transfer to a real context, without specific finalist financing and a "final date", the evidence of clinical trials through the integration between primary care, geriatrics and community resources. We recently published in the European Journal of Internal Medicine a methodological work where, thanks to a consensus of experts based on international references and a practical application test, we proposed a Decalogue of principles of implementation of complex interventions for the management of frailty and disability prevention that could be applied to other similar complex interventions in other areas.

The principles of the "Decalogue" are:

1. Design and implement multi-component programs that incorporate physical activity and nutritional interventions.
2. With a patient-centred approach, taking into account their preferences and values.
3. Empower the person and their caregivers.
4. Implement interventions that are flexible and easily adaptable to the context.
5. Implement them near the person's environment, preferably in primary care or in the community.
6. Develop comprehensive care models that involve all agents, including those in the community.
7. Use opportunistic screening strategies to identify vulnerable older people.
8. Adapt them through user participation and co-design strategies.
9. Make dissemination and raise awareness among the population and decision-makers.
10. Design investment plans or evaluation of the appropriate results.

Apart from + ÁGIL Barcelona, other "allied" interventions in this area are emerging such as the "Presentes" program of primary care of the ICS in Barcelona, led by EAP Sant Antoni with Dr Ylenia García, which promotes the intergenerational interaction of high school students that help boost physical activity in older people. Scaling this type of intervention presupposes that we cannot simply replicate them exactly, but rather that the adaptation process described in the Decalogue is repeated (basically by users adapting the intervention to the specific context, which will have to be known first) and reinforcing other points such as communication, investment plan, enc., according to each case.

In addition, as Adelina Comas, a researcher at the London School of Economics insisted, in her brilliant presentation at the congress, that one must always reassess the impact on health, but also efficiency within the local context and not simply transfer it from studies of other latitudes given that local factors (system, costs, etc.) can affect the results. 

There may not be any program that can save the world on its own, but it is beginning to draw a network of initiatives with a solid scientific base and enough realism that we hope will allow us to have a good range of resources to offer “Precision Health ".​

The urgencies and the elderly

Reflections (and proposal) in the face of the impending winter emergency crisis

@varelalaf

If nothing is done, vulnerable people will increasingly go to the emergency room because of their multi-pathology, the presence of certain symptoms that are difficult to manage from home or the problems of their environment, they call 061 increasingly often. And that is how hospital emergency services become refugee camps within health systems. A clinical trial conducted in 24 French hospitals, which included more than three thousand people over 75 years of age in a clinically critical situation, showed that the centres most likely to enter older people in critical units, in addition to not reducing their long-term mortality term, neither improved their functional capacity or their quality of life.

The hospital at home, one of the challenges of the upcoming integrated care systems

Marco Inzitari

The content of this week's article has been developed, over the past few years, with my colleague and friend Miquel Àngel Mas (@DrMqAgMas), a geriatrician, former PhD student in our research group and currently a member of the expert nucleus in chronicity of the Gerència Territorial Metropolitana Nord de l'Institut Català de la Salut. We’ll discuss the subject from two points of view in the hope of generating interest and debate among the blog followers.

Our health and social system experiences periods of rethinking, mainly due to the changing requirements in the need of attention of older adults. This fact suggests that the approach to problems solving from the big acute hospitals, as structures that works separately from the community, loses centrality. The logic that follows is the evolution towards increasingly integrated systems, adapted to the different territories, with primary care and attention to the community in the middle. As Professor Dennis L. Kodner said in his classic - Integrated care: meaning, logic, applications, and implications - without a discussion at different levels, all aspects of the provision of attention suffer: patients lose (and get lost), the services are not provided correctly (or arrive late), the quality and the satisfaction of the patients goes down and the potential for sustainability of the system diminishes.

ICUs and the elderly

There is concern about the misuse of hospital resources by the elderly, assuming that in many circums-tances, the services received, apart from being disproportionate, may also be more harmful than beneficial. The last post analysed the syndrome of post-hospitalization, a pathology that contracted the vulnerable people by the fact of them having been admitted to a hospital. In the same vein, I would like to comment on a clinical trial carried out in 24 French hospitals, with more than 3,000 people over 75 years of age in a clinically critical situation, of which half entered a program that promoted ICU admission , while the other half simply followed the standard criteria of each centre, without any external pressure. In the observed results, the patients in the intervention group logically entered the critical units (61% versus 34%), but this did not lead them to live longer, since, despite the fact that the gross mortality at 6 months was higher in the group that had observed greater use of ICUs (45% versus 39%), after adjusting the numbers*, relative risk was reduced to 1.05 (not significant).

The post-hospitalization syndrome

Harlan Krumholz (Yale) is a cardiologist who focuses his research on the impact of health services on health outcomes (Center for Outcomes Research and Evaluation - CORE), and on "Post-Hospital Syndrome. An Acquired, Transient Condition of Generalized Risk" focused its attention on readmissions, a problem that affects 20% of people who are discharged in the US. In this context, Krumholz's most prominent finding in the article was that of Jenks and colleagues (with 12 million Medicare discharge records), which enabled them to conclude that patients who had been admitted with decompensations of the most common chronic pathologies: heart failure, pneumonia, COPD or gastrointestinal disorders, if they were readmitted before 30 days, they did so in two-thirds of the time, for reasons other than the diagnosis of the previous admission.

Focusing on the daily life of frail people

The PACE (Program for All-Inclusive Care for the Elderly) model was born in 1971 when a dentist and a social worker working for the San Francisco Department of Public Health in Chinatown-North Beach realized that older people were reluctant to move to a social residence when, instead, with some complementary services, they could continue to live in their own homes, in a more friendly and stimulating environment. Nearly fifty years later, PACE enjoys good health and "The Commonwealth Fund" has published a "Case Study" analysing its operation and results.

Dysphagia and "minimal mass interventions": ethics, management and value

Marco Inzitari

In recent times there is an increased risk that the relevant becomes unseen. I understand that readers are mainly from the world of health but did you know that in Barcelona, ​​at the end of September 2017, the European and world congress on swallowing disorders was organized? And that the current president of the European Society of Swallowing Disorders is very close to us because he’s Dr. Pere Clavé, gastroenterologist and academic director, teaching and innovation at the Hospital de Mataró?

I was fortunate to be invited to talk about Dysphagia in older people in this meeting, with the opportunity to review the advances in this area. I don’t aim to venture into any clinical treatise on Dysphagia, but I think it’s useful to disseminate some aspects that are in line with the "value practices" advocated by this blog.

Break the "ill-fated trio": falls-immobility-delirium, an outstanding issue in the quality of hospitals

Marco Inzitari

The pressure on the safety of patients and medical errors to which we are all subject, together with the fear of professionals for possible complaints resulting from adverse events within the hospital (Hospital Acquired Conditions - HAC, for Americans), are changing the hospital culture, prioritizing the prevention of falls, in many cases, on top of mobility, functionality and, finally, the well-being of patients.

This is what happened in the US from 2007-2008, when the Centre for Medicaid and Medicare Services decided to penalize the billing of episodes of patients affected by different HAC, including falls with injury, to the Affordable Care Act (Obamacare), which penalizes hospitals with worse results in this sense. In our context, in recent years some care areas have also been rewarded or penalized, at the contract level, according to an indicator of intra-hospital falls.

Capacity, environment and diversity: changing the vision of aging

Marco Inzitari

Judging by appearances, one might think that health professionals build their fortune on the misfortune of others. Traditionally, in fact, we deal with risk, diseases and their negative impact, more or less catastrophically. And, in the face of an aging population, we focus on multi morbidity, chronic disease, geriatric syndromes, disability and the end of life.

The recent report of the World Health Organization (WHO), entitled "World Report on Aging and Health" (September 2015), is committed to a change of focus. The report, which is positioned as a reference of health policies on aging, is long and complex, and addresses many dimensions of aging, from prevention to manifestations and consequences, to the need for long-term care (not in the mere sense of resource, if not of necessity continued in time, no matter how it’s provided).

Precision medicine in the elderly care

Marco Inzitari

One of the challenges launched by President Barack Obama ($215 million for 2016) is the "Precision Medicine Initiative" a concept that goes against the treatment focused on the "average-patient". According to this initiative, as a first step, cancer treatments should be oriented to the specific genetics of the patient. For this reason, we often refer to the future of oncology as a "precision medicine". As another example, to continue with oncology, the Watson Intelligent System (IBM) will provide support to oncologists for informed and well fitted decision-making, analyzing patients' medical records and looking for possible evidence-based options.

An extensive model for complex chronic patients

The emergent phenomenon of multi-chronicity and geriatric fragility is analyzed from all points of view: demographic, epidemiological, the use of resources and the economic impact, to mention only the most outstanding. Now familiar with the tendency, we’re facing the challenge of finding out how to provide appropriate services to patients who, due to the precariousness of their health, or their social circumstances, or both, suffer instability and become frequent and directionless visitors.

This group of complex patients, although not too large, is stressing the rigidities of health systems in three ways: a) the saturation of hospital emergency services consuming ambulances and observation beds is unable to give effective responses to the needs of these people, b) lack of coordination of transfers between levels, especially between the hospital and primary care, and c) poly-medication due to prescription fragmentation.

What do chronic patients want?

Fragmentation of services is a disgrace for complex chronic patients, for people with combined health and social needs, for fragile people and, in short, for the elderly population. Hence, most governments are engaged in service integration initiatives, but progress is slow and the results are disappointing because systems are too fragmented: in budgets, in access rights, in circuits, in professional cultures, in institutions, in public and private providers, etc. However, the British have proposed a merger of services by 2020, and since they recognize that, as things stand, offering people-centred care will be a bulky process, in the summer of 2013 they launched a project, “People helping people", a project that is ambitious in vision but modest in methodology and budget.

What is "People helping people"?

The program is working on 25 pilot areas that volunteered to test (as previously done in Torbay) different ways of coordinating and integrating services in order to promote patient-centred care, for which they rely on a single operative objective of elaborating, on the part of all the actors, of individualized plans that adapt to each person’s particular needs and way of life. In terms of methodology, the project has adopted the "triple aim" (Institute for Healthcare Improvement), which develops the following principles: a) improve patient experience, b) improve the health and well-being of the population, and c) reduce the waste and, therefore, the cost per capita.

Untangling the skein of frailty to leave the maze of disability. From detection to prevention

Marco Inzitari

Following on from Ariadne’s thread which was extended across the concepts of aging, complexity and disability, I will build this new contribution on my previous post entitled “Frail, cracked or broken?”. In that post, I defined as "frail" a person with apparent good health and overall functions but with concomitant alterations of different organs and systems, often sub-clinical, that increase the vulnerability to progress towards disability in case of injuries of a different nature (clinical, such as illness, or social, such as widowhood, etc). The main goal of the detection of frailty is prevention, because frailty and disability are reversible.

In this new post, I will try to move towards the exit of the maze, although this may be an even more complex task than Theseus’ challenge. The metaphor of frailty and, more generally, of aging as a "Minoan" maze, is not accidental: it’s a complex phenomenon where multiple systems and organs begin to be simultaneously altered, different pathologies appear and drug treatments are added. The social situation of the person and their environment can represent added elements of frailty. Besides coexisting, all these factors are interacting, determining an intricate tangle of threads of different colours that are really hard to discern. It’s as if the aging tended towards entropy, just like too many electric cables tend to become entangled. Given this complexity, it’s hopeless to pull a single thread and expect the skein to untangle. This is why "magic" recipes such as an alleged "pill" to combat aging, have failed so far. If we want different results we need a focus shift when looking at the classic "risk factor - disease - treatment".

Integration of social and health services: 3 issues and 3 solutions

Aging population has many interpretations, some of them very positive such as the fact that more and more people are fortunate that they live for longer with a fairly healthy life. The other side of the coin is that there are also problems such as increased multiple combined chronic diseases, social deprivation and the fact that many people reach an advanced stage of geriatric frailty. And this is where service delivery models that have been consolidated in recent decades are still struggling to give satisfactory answers. Governments know it and, for this reason, are launching initiatives to address chronic disease and frailty in a more effective manner but these programs often face political difficulties, resistance to change and difficult to overcome bureaucracies.

From everything I've seen in this issue, I think the British are the most daring, so I chose the report of the "Commission on the future of health and social care in England" published by King's Fund, because it synthesizes very well what the problems of current models are and what are the solutions to be put on the table.

First problem: the current model is unfair. The health system is universal and free, while access to social services is restricted. Let's say two examples: people affected by cancer enjoy global coverage, regardless of process costs and economic level of the patient, while Alzheimer's patients suffer from limited access to services, especially in more advanced stages when their needs are more social than medical.

Second problem: funding sources are different. The health system feeds directly from the public budget, while social funding source is hybrid, with participation of different administrations, including the local, and with a variety of complex management copayments.

Hospitals: 10 necessary structural reforms

Hospitals are structures that generate a powerful influence on the overall health system. Their effectiveness in the resolution of certain acute diseases, especially surgical, gives them a great social prestige. This fact should not, however, hide two structural problems that are burdening their perspective:

a) The first problem is internal. Bureaucracies themselves are showing signs of fatigue and this affects the quality of services, especially in the safety of admitted patients.