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A seasoned approach to care

The HSE’s Health in Ireland Key Trends 2015 showed that the ageing trend of the population is going in a definitive direction.

The Executive itself noted that the growth in the number of people aged over 65 years was the “striking feature” to emerge from its own report.

“Each year, this cohort increases by 20,000 people,” according to the HSE.

“This trend is set to continue into the future and will have implications for future planning and health service delivery.

“Ageing of the population, in conjunction with lifestyle-related health threats, continue to present major challenges now and into the future in sustaining and further improving health and health services in Ireland.”

Global

But these trends are not confined to this island, or even the developed world. The World Health Organisation (WHO) predicts that from 2000 until 2050, the world’s population aged 60 years and over will more than triple, from 600 million to 2 billion.

An ageing population is a “global phenomenon”, Prof Rose Anne Kenny, who is Chair of Medical Gerontology at Trinity College Dublin (TCD), told delegates at the recent IPHA annual conference in Dublin, which the Medical Independent (MI) attended.

It is a challenge “particularly experienced by us in the Western world but is now very much an issue in developing cultures as well”.

Prof Kenny is also the founder and Principal Investigator of the Irish Longitudinal Study of Ageing (TILDA). Established a decade ago, the work of TILDA has fed into various policy documents, said Prof Kenny.

“Prior to this, there was no Irish-based evidence to inform policy,” she said.

“Bottom line, this will be an issue for our healthcare services globally. How can we deliver healthcare effectively to those who experience multimorbidity when we will not have the human resources and manpower we have traditionally used to deliver those services?” asked Prof Kenny.

“This is where new technology and new discovery comes in.”

Prof Kenny outlined the role that health professionals would have to play. “Everything gets more common as we get older,” she said.

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Professor Rose Anne Kenny

Heart disease

“Heart disease is very much more common in advancing years. Cancer becomes much more common as people get older. Half of all new cancer cases in the UK occur in people over the age of 70.”

Prof Kenny noted that in this country, we do not have an oncologist who has geriatric expertise. She said this is “a very important factor that we need to address”.

Those working in geriatric medical care speak of positive developments, but also some significant issues that still need to be addressed.

Prof Des O’Neill is Consultant Physician in Geriatric and Stroke Medicine and Professor of Medical Gerontology at Trinity College Dublin and Tallaght Hospital, Dublin.

When he takes a look at his area of medicine, he notes: “Ireland has made progress and steps in areas such as gerontological nursing, geriatric medicine and old-age psychiatry, so it has made a start in European terms.”

However, when MI asks Prof O’Neill whether there are enough geriatricians working in Ireland, he says: “I think the answer is, there is not.”

“Particularly [because] geriatricians get quite consumed by the general medical role, looking after general medical take or also looking after a range of things such as stroke.

“So I think there does need to be quite a significant increase. Also, there needs to be an increase in things like old-age psychiatry and particularly in gerontological nursing.”

Prof O’Neill, who is also Chair of the RCPI Policy Group on Ageing, says there are currently four projects taking place at sites, including Tallaght Hospital, that are looking at integrated care and “beefing-up the whole integration of care for complex and frail older people to help prevent inappropriate hospitalisation for them.”

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Professor Des O’Neill

“There are starts and improvements but we have a major challenge, in that it has been seen as politically alright to choke-off home care packages [for older people] in a way that wouldn’t be seen as alright to choke-off chemotherapy for cancer [patients],” he says.

“On balance, on a score card there have been many advances, but unfortunately, older people can often be very easily put to the back of the queue around things like the home care packages.”

The Medical Workforce Intelligence Report (2016) published by the Medical Council found that there were 112 doctors registered in Geriatric Medicine on the specialist register for 2015. This represented 1.2 per cent of doctors on the specialist register and compared to 107 specialists registered in Geriatric Medicine the previous year.

The Irish Gerontological Society (IGS) tells MI that it believes the rise in numbers is welcome but that the next “phase of growth must see the development of geriatrician posts that have dual roles in the community and acute sectors”.

“There is certainly an impetus to see greater numbers come through training who will be able to meet the increasing demand for specialist skills,” Ms Mo Flynn, IGS President, informs MI

“However, gerontology by its very nature is not delivered by one profession or specialty; it requires medics, health and social care professionals and carers.

“Older people can be admitted to any specialty and therefore it is essential that doctors and health and social care staff are gerontologically attuned and have the experience and training where they recognise frailty and the many comorbidities that older people may present with.

“This has implications for educators as they plan and develop professional training programmes in medicine, nursing, therapies and social care.”

Despite some concerns, the IGS President is hopeful that gerontology will prove increasingly attractive for doctors.

“Gerontology is certainly a very attractive area and if the huge increase in the range of research activity and the numbers attending IGS meetings and conferences is anything to go by, Ireland has become a major centre for research in ageing and the quality of the work being produced is recognised on an international basis,” says Ms Flynn.

“Our uniqueness is that we have adopted the true multidisciplinary and holistic approach to research on ageing.

“Indeed, Prof David Oliver, President of the British Geriatric Society, commented at our recent scientific meeting that the high-quality and multi-disciplinary research papers presented truly represented the diversity of the ageing field.”

Guardians of the longevity dividend’

“It has been very simplistic,” says Prof Des O’Neill, in respect of the political and media focus on the age-related ‘time bomb’ in the health service. “The key thing is welcoming ageing.”

“The cover of The Lancet highlighted a few years back the importance of the medical profession turning from viewing ageing as some kind of threat and challenge, to saying ‘hold on, ageing is a remarkable advance’. Actually, our role, if it doesn’t sound too grandiose, is to be guardians of the longevity dividend,” Prof O’Neill tells MI.

“There is a huge amount we can gain from older people.”

However, Prof O’Neill argues that it is dangerous to talk about ageing merely in terms of economic productivity, as this may move the focus away from the intrinsic value of people.

“But sometimes it can be a one-two punch. Firstly, ageing is described as a burden and a ‘drag’, and then secondly, you don’t provide the proper services for it.”

Prof O’Neill has a particular interest in the crossover between health and the arts so, unsurprisingly, he dips into music when finding interesting examples of ageing.

“One of the metaphors I use is ‘late-life creativity’. Just look at Leonard Cohen — I would call him an example of not so much positive ageing, as optimal ageing.

“One of the nice things in his recent albums is, he is able to present his frailties and vulnerabilities as well.

“In his album You Want It Darker, there is a sense that he is able to understand this complexity.

“One of the interesting theories about ageing is why things become more meaningful and relevant as we age. There is a thing called ‘socio-emotional selectivity theory’, which looks [at how] the nearer we are to death and serious illness, the more meaningful the choices and decisions we make.”

This is not just a challenge to rethink ageing in wider society — the medical profession has its part to play.

“The challenge quite often in the health sector is that very often, we only see the sick and vulnerable and we very often don’t see the broader spectrum of what people bring to the table.”

Ageing strategy

The National Positive Ageing Strategy (NPAS) was published in April 2013 and “provides a framework for co-operation to address age-related policy and service delivery across Government and society in the years ahead”.

While across the sector there was much in the plan that was welcomed, NGOs and other experts have become increasingly concerned with a possible “implementation deficit” with the plan.

“We [RCPI Policy Group on Ageing] would share concerns with the NGOs that, for example, the National Positive Ageing Strategy actions are meant to be reported back to Cabinet each year,” Prof O’Neill tells MI.

“We have requested these reports; we haven’t got them yet. And there does seem to be a lack of impulse and drive in its implementation. We certainly feel that there has been a loss of momentum.”

Ms Naomi Feely, Senior Policy Advisor at Age Action Ireland, told the Oireachtas Joint and Select Committee on Health in September that there was an “implementation deficit” when it came to the NPAS. However, she said that this problem might not be unique to this area of policy implementation.

“While we have the National Positive Ageing Strategy, we do not have an implementation plan for it,” Ms Feely informed the Committee.

“There is an implementation deficit here, although when I attend other events across the community and voluntary sector, I find that it is not unique to the National Positive Ageing Strategy.

“There is an implementation deficit in terms of policy across Government.”

The Department of Health admitted to MI that “many of the objectives included in this Strategy are quite broad”.

Minister for Health Simon Harris told the Dáil earlier this year that his Department was working on a new implementation proposal for the Strategy. The Department has provided this newspaper with some information on what this proposal would include.

 “The Department has recently formulated new arrangements to implement and monitor the National Positive Ageing Strategy,” a Department spokesperson informs MI

“These structures will re-commit to the core principles of the Strategy and inform how the State approaches older persons’ services into the future.”

The Department says these new proposals will include an annual forum of stakeholders, departments and agencies that will examine how the Strategy’s principles will be applied. No extra detail was provided, except to say that arrangements are currently being made for this forum.

It will remain to be seen whether these new developments will assuage some of the concerns out there.

Experts urge investment in community

NGOs and organisations such as the Irish Gerontological Society (IGS) want to see greater focus on the needs of older people in the community.

“In terms of social care, the lack of planned and sustained investment, as well as the continued erosion of existing home supports [means] it is incredibly difficult for frail older people to live in our communities,” Ms Mo Flynn, IGS President, tells MI.

“This not only increases the likelihood of them being admitted to acute hospitals, but also diminishes the opportunities for them to return home after an acute illness. The eternal focus on providing nursing home beds as a response to delayed discharges continually diverts the funding and masks the requirement for well-funded and available community supports.

“This, aligned with a structured and responsive primary care system, would enable far more older people to remain in their own homes and communities.”

But the IGS also wants a focus on integrated care.

“In terms of integrated care, we would like to see more than verbal support and commitment to the Integrated Care Programme,” the IGS President says.

“The initiatives developed within the programme would contribute significantly to improving the opportunities for older people to get the care and support where they need it and as a consequence, improve their health outcomes as well as impact positively on the flow of patients through our acute hospitals.”

A spokesperson for ALONE informs MI that it believes “a considerable development of responsive services and supports, particularly at community level, is urgently required”.

“Due to the current uneven provision, there is evidence that many older people are admitted to acute hospitals and nursing homes when the availability of appropriate community-based supports might have enabled them to remain at home, at least for longer,” says ALONE’s spokesperson.

“Also, we know that older people consistently state their preference for continuing to age at home, even if such findings need to be contextualised in the light of the prevailing circumstances.

“We strongly believe that there is an urgent need to considerably expand the range of flexible support options available to support older people to remain at home within their communities for as long as possible.”

The Irish Alzheimer Society tells MI there are “no clear care pathways of care for people living with dementia, so there’s a greater potential for people to fall between age-related care, disability services and mental health.”

“And some may never get to see a geriatrician,” according to a Society spokesperson, “bearing in mind also that in some cases, an old-age psychiatrist or neuro-rehab team is more appropriate for the individual.

“Consider also the importance of multidisciplinary teams in relation to the medical care of people with dementia. It’s more than a question of whether there are enough geriatricians, but it’s having appropriately-trained staff and a full complement of health and social care professionals working in this area.

“The national dementia audit of acute hospitals gives very relevant recommendations on staffing in relation to dementia care in hospitals.”

Age attuning

A spokesperson for ALONE notes that the NPAS “achieved considerable unanimity on the key policy priorities and substantial buy-in and support from a broad range of stakeholders”.

Asked what would be the one measure it would like Government to implement, its spokesperson says: “Move more money into a regulated and quality-approved system of support in the community, to support the goals of the National Positive Ageing Strategy, Age Friendly Ireland and the county programmes.”

The Alzheimer Society of Ireland says it believes that the “full implementation of the Irish National Dementia Strategy, which was first published in 2014, would significantly alter the lives of people with dementia and their families in Ireland”.

“To date, there are three elements of the Strategy which have received some funding: The delivery of intensive home care packages; a public awareness campaign; and GP training, but no funding is available to implement the remainder of the Strategy.”

At a wider policy level, Prof O’Neill says “there is really good evidence that age-attuning our health system makes a difference”.

“We know, for example, if an older person comes in the door in the emergency department and they go under a geriatric medical service as opposed to a general medical service, you reduce the chance of death and disability by 25 per cent.”

Prof O’Neill also challenges the oft-made argument that it is the older population that is costing the health service most.

“Where the spend in the health service comes from is increased technology and is largely spent on people in late middle age and early old age,” he says.

“In fact, you spend most of the money you are going to spend in the last year of life, and the last year of life for an 89-year-old is cheaper than the last year of life for a 45-year-old.”

Crunching the numbers on ageing

Life expectancy in Ireland has increased by two-and-a half years since 2004 and has been consistently higher than the EU average throughout the last decade.

Since 2005, there has been a reduction in mortality rates for most major causes. The overall mortality rate has reduced by 19 per cent since 2005.

The numbers of people over the age of 65 years is projected to almost double to around 1 million by 2031.

From 2000 until 2050, the world’s population aged 60 years and over will more than triple, from 600 million to 2 billion.

Source: HSE and WHO

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