BGS BGS

Editor: David Beaumont
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Issue 6
July 2006
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For debate
BGS relations with the pharmaceutical industry
ecent discussions on the
educational content of sponsored
symposia at the BGS national
conferences have reawakened interest
in the nature of the Society’s
relationship with the pharmaceutical
industry.
R
Here we present two opposing points of view,
neither designed to hi-jack the current policy of
the BGS, but rather to prompt discussion. Where
do you sit on this issue?
Educational Partnership, not
product placement
Speaking for the prosecution is Dave
Beaumont:
Attendees of the sponsored evening
symposium at Gateshead, on the
subject of
Falls, Fits
BGS President Elect
and Faints
Elections Results
will recall
hearing a lengthy
Doug MacMahon : 199
Graham Mulley : 207
discourse on the
Spoilt: 4
merits of a new
anticonvulsants in
Total Vote: 18.6%
younger patients and a
subsequent challenge to
the speaker by a Society
member as to whether the speaker wished to
declare any conflict of interest relating to his
presentation. At a previous meeting we thralled at
the merits of Probiotic agents; interesting subject
and maybe of relevance in certain situations,
particularly in antibiotic related diarrhoea, but
equally, I fancy there are topics more worthy of
discussion at a national BGS conference.
Now we all know that the support of the
pharmaceutical industry is vital to the financial
success of our conferences and indeed, in their
sponsorship of a variety of educational events.
We also acknowledge that whatever the
drawbacks, contact with representatives can be
informative, especially with regard to new
products. However, it is the nature of that
relationship which needs to be questioned, not
the fact of it. A recent article in the Journal of
the Royal Society of Medicine outlined how the
medical profession is complicit in the marketing
strategies of drug companies, by being too
passive in
7:30 a.m. and it’s standing room only
President: Dr Jeremy Playfer President Elect: Prof Peter Crome
Honorary Secretaries: Dr David Beaumont and Dr David Oliver Meetings Secretaries: Dr Juanita Pascual, Dr Michael Vassallo and Dr Jed Rowe
Honorary Treasurers: Prof Margot Gosney and Dr Tom Smith Chief Executive: Alex Mair Sub Editor: Recia Atkins
specialist medical society for health in old age
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BGS n e w s
July 2006
In this issue
Editorial
> 4
President’s column
> 5
Special Interest Groups update
> 8
President Elect’s column
> 10
Nurse Consultants’ Update
> 11
Deepa Sumukadas on doing
research
> 12
.....meet you at the drugs stand
Discharge or transfer of care of
frail older people for community
health and social support
> 14
Guidelines on capacity and
testamentary capacity
> 16
Nutritional advice in common
clinical situations
> 18
POPS and OPAL - progress
is possible!
> 20
NOTICES
> 23
Competitions
> 25
Letters to the Editor
John Gladman, Ian Philp,
Terry Aspray, Jed Rowe and
Dr C Cohen
> 26
More than a weekend
BGS National Trainees’ weekend
> 28
BGS Autumn meeting 2006
> 30
Chronic Venous Leg Ulcers
Invitation to a clinical trial
> 32
BGS Contact Details
Chief Executive - Alex Mair:
general.information@bgs.org.uk
Committees, Clinical Excellence Awards,
Elections, EUGMS, General Office Management Sarah Reeder
committees@bgs.org.uk
Membership, Age & Ageing subscriptions,
Abstracts, Scientific Meetings Liaison, CPEC,
NICE, Grants, CPD - Joanna Gough:
scientificofficer@bgs.org.uk
Finance - Susan Cox:
accountant@bgs.org.uk
Age & Ageing abstract supplements, Publications,
Newsletter, Newsletter advertising, Websites:
Recia Atkins: editor@bgsnet.org.uk
managing this relationship and
through their involvement in a
variety of drug company
sponsored activities from funded
research, presentations of this
research at meetings, attendance
at meetings to hear these
presentations and by creating
opportunities for opinion
formers to speak to their
colleagues. This is all fine but there
has to be transparency where
conflicts of interest exist.
Now we must not throw the baby
out with the bath water. I
personally do not take the view that
our sponsored symposia universally
lack educational content. I find
those relevant to my field very
helpful indeed but even some of
those border on the promotional.
So where might the BGS be
considered complicit? Consider the
“Falls” symposium mentioned
above. The speaker in question
gave his totally promotional
segment based on locally derived
audit data, in front of the BGS
logo, introduced by one of the
Society’s finest academic daughters.
The details appear on our published
programme and may well be
reported in the medical press. So
what control, as a Society, do we
have over the content of these
sessions that we seem to be
enthusiastically selling off to cover
The speaker in question
gave his totally promotional
segment based on locally
derived audit data, in front
of the BGS logo, introduced
by one of the Society’s
finest academic daughters
essential costs at the risk of tacit
promotion? In my view this was
blatant product placement of the
sort you might see in Coronation
street.
I think this is unacceptable. We
should take a polite but firmer line.
Events such as sponsored symposia
appearing alongside our national
conference and under our banner
should abide by a clear set of
governance rules. For example;
No promotion within the
presentations
Content of all presentations to
be agreed with the Society in
advance
Topics to be pertinent to the
health care of older people
Speakers’ fees to be within limits
agreed with the Society
No photographic links of
products with the Society’s logos,
badges, or intellectual property to
prevent apparent endorsement
Pharmaceutical company
n e w s BGS 3
July 2006
presence to be
provided through
stands or displays,
separate from but
adjacent to the
meeting room.
What we need is a
less laissez-faire and
more professional
approach to prevent the Society being
compromised - a relationship based on an ethical,
educational partnership, not promotion and
product placement.
Few can argue that the
industry is a keen
supporter of medical
education and serves as
a valuable resource
The other side of the coin
Speaking for the defence, Michael Vassallo says:
The organisation of the British Geriatrics Society
meetings is expensive. Registration fees over only
about 50% of the costs of the meeting. Income
needs to be generated from other sources and
the huge majority of this comes from the
pharmaceutical industry. They buy exhibition
space and pay to organise sponsored symposia.
Some BGS members dislike such sponsorship.
However, the economic reality is that without the
pharma industry it would not be possible to hold
meetings of the quality expected. Even the most
optimistic among Society members would not
think that in this age of declining study leave
budgets, members would be happy if the
registration fees were doubled. If anything, many
think that the meetings are already too expensive.
Let us remember that pharma companies self
regulate very effectively to a high standard
through the ABPI. They are private companies
that have been exclusively responsible for the
development of new drugs that have benefited
millions of patients, and have led to well
documented improvements in length and quality
of life. So one can have sympathy with their wish
to promote their products to generate a return
on their investment, particularly if they are
contributing to our CPD. We would probably be
in a sorry state if government’s (right or left
wing) were to be relied upon to take the
responsibility of drug development. The pharma
industry has made a significant contribution to
health improvement and had it not been for
them we would be practicing a very primitive
form of medicine today.
Apart from being able to hold our meeting, do
we get anything else from the industry? The issue
of their involvement with and sponsorship of
satellite symposia at BGS meetings is
controversial. Critics cite the fact that some of
the sponsored symposia at the BGS have been
overtly promotional and of poor educational
value. Lectures that are overly promotional and
unscientific are both annoying to delegates and
counterproductive to the pharma company.
Although criticism may be justified, one should
avoid the knee jerk reaction of labeling all
symposia “educationally poor”. Despite the best
intentions, even some of the presentations
delivered in the plenary sessions of the main
BGS meetings have been educationally poor. Self
respecting companies pride themselves in high
quality meetings that attract as many people as
possible. The fact that a meeting starting at
unsociable hours such 07:30 still manages to
attract a substantial number of delegates is a
reflection that the content is considered as largely
worthwhile. People vote with their feet because
the lectures cover important topics and are
chaired and delivered by opinion leaders, many of
whom are members of the Society. In addition,
although a talk may be promotional, it does not
mean that it lacks educational merit, provided
that it is delivered in a scientifically sound way.
Indeed, such symposia offer the opportunity to
discover aspects of medicine or pharmacology
that delegates would otherwise not know about.
If one looks at the number of meetings
supported by medical representatives throughout
the country, few can argue that the industry is a
keen supporter of medical education and serves
as a valuable resource. They often provide
considerable resources unconditionally, and
present opportunities of which even the critics
have availed themselves. Our relationship with
the pharma industry is a symbiotic one and we
must ensure that future relations remain mutually
beneficial.
Correspondence to the editor@bgsnet.org.uk,
please.
Dave Beaumont
Hon Secretary
Michael Vassallo
Meetings Secretary
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BGS n e w s
July 2006
Editorial
They think it’s all over - it is now!
or the last month the nation has
been gripped by the rising tension
of international competition. By the
time you read this, the result will be on
everyone’s lips and patriotic flags will be
lying discarded as the country returns to
normal life.
F
After two years of painstaking build up, the most
eagerly awaited final for years pitched Yorkshire
against Cornwall in the denouement of the BGS
President’s Chain. An interesting clash of styles was
evident - the studious Ericsson like figure leading the
Yorkshire challenge versus the passionate
Keeganesque man from the wild West. The question
in everyone’s mind was would the everyday aids and
appliances approach from Leeds be sufficient to
overcome the “shaky” defence of Truro? Would a
penalty shoot out be necessary with the star men
leaning over the bar to win? In the office we held our
breath until the Chain was passed, and looked
forward to our first post match interview with the
new Champion.
Two steps forward, one step back
The last few months have seen a flurry of activity in
terms of national guidance on services for older
people. The document by Prof Ian Philp, A New
Ambition for Old Age
has been warmly
I have to say that
received for its
peering around the
emphasis on dignity
for older people in
waiting room of my
hospital, concerns
outpatient clinic I don’t over end of life care,
see many older people
integrated falls
services and
who fit this profile of
developing new
affluent, comfortable
systems for dealing
with crises in the
“oldies”
community caused by
delirium. Although
there are legitimate concerns over whether these
aspirations can be made to stick, particularly in the
absence of designated and ring fenced resources,
nonetheless a
feeling
developed that
at last older
people’s health
issues are going
to be taken
seriously and
not bypassed for
the interests of
younger
economically
active patients.
And then we
have it - the next
draft of the NICE
guidance on the use of Cholinesterase inhibitors in
the treatment of Alzheimer’s disease, recommending
that treatment for new cases should be restricted to
those patients with moderate severity defined as a
MMSE score of between 10 and 20. Now, I am not
an expert in determining who would benefit most
from this form of therapy but it seems to me that
introducing narrowed arbitrary limits on who should
receive the drugs rather than evaluating individual
responses to therapy based on assessment tools
seems unjust. Yet again the speciality takes two steps
forward and then is pushed back at least one.
Contrast this ruling with the Herceptin debate.
Age Wars
One of the anarchic pleasures of my youth in the
seventies was rearranging the letters of “Star Wars”
on the board outside the Odeon cinema to form two
new words, the second of which was “warts”. I was
therefore intrigued to read in the Observer, a slightly
worrying concept known as “Age Wars”. There
seems to be resentment on the part of younger
people towards those approaching retirement with
mortgages paid off, company pensions, regular
holidays and comfortable lifestyles. These youngsters
of course, leave college with escalating debts, have
trouble finding satisfactory work and are unable to
climb onto the property ladder. Now it's tempting to
regard this as an extension of rebellious adolescence
into the mid-twenties but again, it may also be an
extension of the dismissive and sometimes hostile
attitudes towards older members of society which
lies at the root of ageism and inequality. I have to say
n e w s BGS 5
July 2006
that peering around the waiting room of my
outpatient clinic I don’t see many older people who
fit the above profile of those affluent, comfortable
“oldies”, because the reality here is that retirement
incomes and health expectations are very low, and we
need to redress this imbalance in the eyes of the
public.
suggestion of Tom Smith we are going to run a
competition (see page 25) to see if members can
come up with an improved, contemporary version to
accompany the logo. Please submit all entries to the
Editor at the usual address and the lucky[?] winner
will receive a modest prize of £50 plus a degree of
professional immortality. I expect the Northern
Region SpRs to be first in line with their entries.
Straplines
“Specialist Medical Society for Health in Old Age”. I
guess everyone recognises this strapline that
accompanies the BGS logo wherever it goes. But as
David Oliver pointed out at the UKMC recently, is
this still relevant? We commented in the last editorial
that the Society is becoming much more catholic in
membership and continuing to refer to a medical
society may not be appropriate. Perhaps, as we have
said before, we should take a more proactive stance
and emphasise the Society’s belief in promoting high
quality health care for older people. The President
Elect has therefore challenged the Secretaries to
develop a more relevant strapline, so at the
Final Word - Delayed discharges are
disappointing for Patients too
It is important to remember the frustration that
patients feel, as well as ourselves, when discharges
home are delayed. I was recently explaining to a
patient of mine that we were awaiting a care package
but we were certain that we would get him home in
time for the start of the World Cup, when a
disgruntled voice from the next bed chimed up,
“Which World Cup?”
Dave Beaumont
President’s
column
ne of the nicest traditions of the
Society is that each President,
during his term of office, hosts a
lunch for past Presidents.
O
This took place on the 16 May at the Royal Society of
Medicine. Only two of our surviving Presidents were
unable to attend, George Adams, who is now in his
nineties, still sends us a message of support but
unfortunately is unable to travel to mainland UK
these days and John Brocklehurst was unable to
attend at the last minute because of illness of his
wife. It is very reassuring for me to see such good
health and longevity in past Presidents.
Following the meal we had a lively discussion about
the state of geriatrics past and present, which more
than demonstrated the benefit of collective memory.
Jimmy Williamson, President 1986-1988 had the
honour of being the most senior past president. As a
former mentor
of mine, it was
great to see him
in such sharp
form and so up
to date with
modern
developments. The
next most senior was
Marion Hildick-Smith 1988-1990. Marion was a
terrific influence on my career. She was one of the
first geriatricians to have a serious interest in
Parkinson’s disease and develop the rehabilitation
model of managing the condition. She was influential
in the Parkinson’s Disease Society and was also
instrumental in developing excellent services in
Canterbury. It is not surprising that Canterbury is
such a leading centre in geriatrics to this day,
following the foundations that Marion put in place. I
was particularly delighted that Brian Williams was able
to attend. He has just been elected President of the
Glasgow Royal College of Physicians and Surgeons.
It is a huge honour in its own right and it is great that
a geriatrician should fill this post for a second time -
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BGS n e w s
July 2006
another ex-president of the Society, Sir William
Ferguson-Anderson having also held this position. It
was particularly pleasing for Peter Crome and myself
that all Presidents of the last twenty years were able
to attend. I am keeping my fingers crossed that Peter
will continue this tradition so that I will able to attend
as an ex-President in two years time!
CME Journal
Two days later we had the UKMC meeting and
because of missing the March meeting, this was a
particularly long and arduous, not helped by Jackie
Morris inadvertently turning up the central heating!
One of the most difficult discussions we had was
regarding the provision a CME Journal for the
Society. Duncan Forsyth who is both a Council
Member but also the Editor of a CME Journal run
by RILA, put forward a proposition to the Society
whereby RILA would provide the Journal to the
members of the Society. Duncan made a strong case
as had our CME Director Ian Taylor.
As you know we have been asking for the views of
the membership in regional groups regarding this
matter and the feedback from this was still unclear.
After a rigorous debate, a vote was taken, and by the
narrowest majority, it was decided not to accept the
proposal at this time. Possibly the most serious reason
for the ambivalence of the committee is the fact that
the editorship of the A ge and A geing journal is
changing and it was felt that the views of the new
Editor on this matter were important before a final
decision was taken. I do hope however, that we do
soon have a paper form of CME to complement our
other excellent educational activities.
Age and Ageing
The Society has renewed its contract with OUP for
the publication of A ge and A geing. Our relationship
with OUP has been an excellent one (I am pleased
about this as the original contract was negotiated
during my time as deputy Treasurer). A ge and
A geing was originally produced at some expense to
the Society, but now contributes a substantial amount
to the BGS income. We have been lucky having
outstanding editors of A ge and A geing who have
raised the profile and respect in which the journal is
held. I would like to pay particular tribute to
Professor Gordon Wilcock who is standing down as
Editor. It is great that one of the foremost academic
geriatricians of his generation should have devoted so
much time and effort to the journal. As with Graham
Mulley before him, he stamped his own style on the
journal, particularly notable has been the growth of
research letters and the commissioning of very
thoughtful and excellent editorials. Research papers
have been attracted from a wide international base,
again, establishing our Society in the forefront of
academic geriatrics.
Hoarders and their hoardings
On the 23 May I had a pleasant trip to Brighton
where I engaged in a debate with Prof David
Brookes on the Geriatric v Neurological Approach to
the Management of Parkinson’s Disease. I was
particularly pleased to find amongst the audience two
old friends, Tony Martin and Ganesh Mankikar. I was
sad to hear from Ganesh that Tony Clarke had died
in recent months. He was a great clinical observer and
described Diogenes Syndrome and Salad arrhythmias.
He was one of the first, with Dr Mankikar, to
develop a Falls Service and research into falls. They
developed an excellent service in Brighton and it is no
surprise that this is now a thriving unit with Professor
Raj Kumar at its head and taking a leading role in the
development of the Medical School of Brighton.
Philosophically, I always felt that Tony Clarke was
guilty of a misnomer in describing Diogenes
Syndrome. Diogenes was known for his lack of
personal possessions, living in a barrel and reputedly,
when asked by Alexander the Great what favour he
would like bestowed upon him, he asked the great
man to take two steps to the left so that his shadow
would no longer block out the sun; whereas sufferers
of Diogenes syndrome often hoard a clutter of
possessions, particularly old newspapers and
demonstrate and an inability to get rid of needless
possessions over the many years.
Gary Andrews
To continue the note of mourning I was very sad to
hear of the death of Prof Gary Andrews. He was
one of the greatest internationally renowned
academics in geriatric medicine and gerontology from
Melbourne in Australia. He exemplified how one
could use gerontological concepts to develop clinical
models and was in the forefront of preventative
medicine in geriatrics. He gave a number of notable
presentations at international meetings and at the
BGS. It is a sad irony that as someone who had done
so much to promote increased health in older age, he
should not survive himself, dying prematurely in his
early sixties.
Science and Technology Committee
After a short visit to Sweden to learn about
developments in the pharma world and chairing the
national launch of an anti-parkinsonian drug in
Manchester (pharma names have been omitted in the
interests of eschewing product placement tactics!), it
was back to geriatric matters on the 7th June when an
extremely useful meeting took place at the
headquarters of Help the Aged, facilitated by Dr
Lorna Leyward of Help the Aged and Dr Sinead
n e w s BGS 7
July 2006
O’Mahony of the BGS, to look at Ageism in Clinical
Trials. This initiative started some eighteen months
ago and Sinead has taken the lead from our Society
and indeed has done significant research in this area.
The meeting on the 7th June will be seminal as we are
proposing to have a joint seminar in this area and also
to develop further research so as to draw attention to
both gender and age inequity in therapeutics. It
appeared to be a particularly appropriate time to do
this as on the 5th June there had been a Lords
Debate on Ageing, based on the report of the
Science and Technology Committee on Ageing, to
which Peter Crome contributed for our Society.
James Goodwin of Help the Aged attended the
debate and kindly provided me with a transcript of
some of the proceedings. It makes extremely
interesting reading. A great friend of our Society,
Lord Sutherland of Hamwood, was particularly
effective in pointing out the incoherence of much
government policy towards ageing and the necessity
of a serious co-ordinated approach with research
efforts and academic activity directed to the problems
of old age. This was followed by a chorus of support
from among others, Lord Turnburg, previous
President of the Royal College, Baroness Murphy,
psychogeriatrician of repute, and Lord May. Sir Prof
John Grimley-Evans found himself quoted with a line
‘live longer, die faster’ and much of the debate was
concerned on how science and medical research
could be more effectively used to cause compression
of morbidity. I hope, following this debate, we will
see increased support and the regeneration of
academic geriatrics, and that funding will be made
available in these areas.
Medicine for an ageing population
One of the highlights of my time as President of the
Society occurred on the 8 June, when the Society had
a joint meeting with the Royal College of Physicians
London on Medicine for an Ageing Population.
During my first meeting with Dame Carol Black
when I became President of the Society, I drew
attention to the fact that the Scottish colleges and the
Dublin College were far more generous in the time
they gave to topics of old age medicine than the
London college, where it had been five years since
they had previously had a meeting. Characteristically,
Dame Carol Black responded and our bid against
other specialist societies was successful. I think the
meeting will be regarded as a landmark event. My aim
was to encompass the whole spectrum of geriatrics
from epidemiology and biology of ageing, through
clinical science and practice, finishing with matters of
organisation of medical service. The meeting could
not have got off to a better start than a marvellous
lecture by Professor Shah Ibrahim on What an
Ageing Population Means for Health. Shah gave a
scintillating talk on the implications of demographic
change, showing us at the end, his top tips for a
prolonged active life – don’t smoke, regular exercise,
healthy diet, go to school, get married, get a ‘big
pension’, live in the South!
Programmed for survival
When setting up the programme for this meeting I
was determined to try not to have any overlap from
the previous meeting five years ago, but I made an
exception in the case of Tom Kirkwood as he has
always aligned gerontology with longer term medical
needs and he is such a superb communicator. In 1978
Tom first described the disposable soma-theory in
Nature. Although this claim was controversial at the
time its strength has continually grown. I feel that the
work of the Institute of Ageing and Health,
University of Newcastle is at the forefront
internationally in this field. Tom has done much to
overturn traditional fixed views of ageing. His lecture
concluded that we are genetically programmed for
survival, not death, and ageing is a process we can
influence. Many age related diseases share common
underlying mechanisms and this forms the bedrock of
the science on which the specialty of geriatrics is
based. It was a great pleasure to hear Howard
Bergman, President of the Canadian Geriatrics
Society, talking about frailty and making the case that
this concept should be the basis of our specialty. His
lecture was riveting and raised many intellectually
challenging points. The FE Williams Lecture, one of
the most important in the College’s calendar was
given by Professor Graham Mulley. Graham
honoured the memory of FE Williams magnificently
with a superb original lecture on the Myths of
Ageing, using art, poetry and popular media to
demonstrate the myths and subsequently knock down
many of the taught assumptions that culture gives us
about old age. The lecture will be published in the
College Journal and I strongly recommend that
people to read it.
The meat of the meeting was the engagement with
clinical problems and Dr Sinead O’Mahony on
Therapeutics, Dr Shaun O’Keeffe on Delirium,
Professor John Young on Rehabilitation and Dr John
Hindle on Parkinson’s Disease, all rose to the
challenge and giving tour de forces. The time
constraints of this meeting were severe. Each speaker
getting around twenty minutes with ten minutes for
discussion. I marvel at how all of them managed to
encompass vast topics satisfactorily in such a short
space of time. These presentations conveyed the
excitement and vitality of our speciality in a perfect
setting.
The final session was devoted to the logistics of care
8
BGS n e w s
July 2006
and once again two superb presentations, Professor
David Black on the Challenge of Ageing Population
in Education and Training, made use of his
outstanding career as a geriatrician and now as
Directorate Post-graduate Dean to spell out his vision
of the future of our specialty. He focussed not on
the specifics, but the general direction of travel. He
examined what the new professionalism in the NHS
meant for geriatricians and as always David managed
to make sense of an extremely complicated brief and
I am sure his map of the future of geriatrics is very
accurate. In the final lecture, Professor Ian Philp
gave a captivating and honest talk about New
Ambitions for Old Age. He captured the political
realities of changing policy for the benefit of older
people. When the history of this period of geriatric
medicine is written, Ian’s influence will be immense
and we are extremely lucky that the National Director
for Older People is not only a geriatrician to his
fingertips, but also has a broader societal view
combined with pragmatism of what is possible in the
political arena.
I would like to thank the College for facilitating this
meeting and putting so much effort into the
organisation, particularly Jo Summers and Anne
McSweeney. It is interesting that we had about 150
delegates. Not quite a sell out, but in stark contrast to
the week before, when a meeting on acute medicine,
(normally sold out) had to be cancelled due to lack of
support. As there is increasing pressure on study
leave and time off, I hope that meetings such as this
will not be jeopardised in the future. Everybody
attending will have come away with a very positive
feeling about the future of geriatrics and about the
confirmation that its status within the medical
community is higher than it has ever been before.
Finally a big thank you to Oliver Corrado who steps
down as Chairman of the Education and Training
Committee. All our committees are functioning
extremely well at the moment and the Chairman and
members of committees put in many hours of oftenunsung work. Oliver has kept me closely informed
about all developments and has orchestrated the
talent on his committee to superb effect.
Harrogate
The programme is now in place for the meeting in
Harrogate in October and it is perhaps timely
reminder to people to apply for study leave. I hope
very much that we will have a big attendance at
Harrogate. In the meantime I hope everyone has time
to enjoy the glorious summer weather and by the time
this gets to you England have won the World Cup!
Jerry Playfer
Special Interest
update on the BGS’ SIGs and Sections
epresentatives from the BGS
Special Interest Groups met at
Newcastle/Gateshead to report
on their activities.
R
Gastroenterology
Membership of this group is dwindling.
Nevertheless, affiliation with the BSG and
BAPEN continue, including the planning of joint
meetings. The SIG has contributed to several
NICE consultations. It has a stand alone annual
meeting, which is sponsored by the
pharmaceutical industry. Hitherto the sponsors
have identified one or more key speakers, but in
the light of BGS guidance this arrangement will
now change.
Drugs and prescribing
Stand alone meetings have not been helpful, but
joint meetings in which pharmacological issues are
applied to specific topics have proved viable and
constructive. Work by the SIG has exposed
ageism in clinical trials, and this is being taken up
outside the Society (e.g. influencing the thinking
of NICE). Links with the BPS continue.
Cardiovascular
A meeting with the British Society for Heart
n e w s BGS 9
July 2006
Failure is planned. An SpR training day in heart
failure was well attended and received. Further
days on similar topics are planned with the British
Cardiology Society. A one off fee is charged to
enrol in the Section, and nominal charges for
meetings are made to cover costs.
Law and Medical Ethics
The SIG has been active in review of BGS policy
documents including “Capacity and Testamentary
Capacity”, and “Nutritional Advice in Common
Clinical Situations”.
Primary and Continuing Care
A successful day was organised by the SIG at the
last Harrogate meeting, with external speakers.
Several BGS policy documents have been revised
and developed in the light of the re-emergence
of community geriatrics. A meeting with the
RCGP is planned in June 2006, aiming to
create a joint policy document to guide
BGS Special Interest
Groups
the process of community geriatrics.
Health Services Research
Standing officers have all exceeded their terms of
office and have now resigned with no new people
offering to take it on. It has been proposed to
“park” the SIG. It is not formally dissolved but is
currently dormant and can be resurrected should
suitable officers be found.
Parkinson’s Disease
The PD Section now has a better handle
on its membership and successful
twice yearly stand alone
meetings are being
organised. The group
will continue to
be run
according
to BGS
guidance on
the
relationship
between
educational
meetings and the
pharmacological
industry. The Masterclass
continues to be run, to be
well subscribed and to be
highly rated. Reports on these
activities are included in the
Masterclass Newsletter,
MasterStrokes. The section has also
instituted an essay prize - one for medical students
and one for professions allied to health. There
was significant interest in the first competition.
BGS Special Interest Groups, the
membership of which includes physicians,
scientists, nurses, therapists, and
pharmacists from outside the Society has
enabled the BGS to offer advice to
government agencies, drawing on a wide
range of expertise. The SIGs serve as the
Society’s source of clinical innovation,
deriving and maintaining high standards of
clinical care, and disseminating specialist
knowledge.
Falls and bone health
In addition, SIGs and Sections hold joint
meetings with national associations and
societies pertaining to the specialty. These
prove useful for interacting with colleagues
specialising in the SIGs’ areas of interest.
This is a growing SIG and it charges a small
subscription fee for membership. It has a healthy
multidisciplinary membership and has two annual
meetings, one of which is now international. SpR
training has been arranged with the British
Orthopaedic Association and the SIG has played a
major role in the RCP national falls audit.
A list of special interest groups and their
contacts is available on the BGS website
(select “Special Interest”) and also appears
in the BGS Handbook.
John Gladman
Vice Chair
BGS Academic and Research Committee
10 BGS n e w s
July 2006
President Elect’s
column
MRCP New Members Ceremony
The last time I attended the MRCP ceremony
was over 30 years ago when, miraculously, I was
successful. A relatively new innovation in
London is that the new members are addressed
by representatives of the Medical Specialties.
Their brief is to encourage recruitment to their
own specialty. In May, I spoke to the new
diplomates alongside representatives from
Rheumatology, Nuclear Medicine and Neurology.
I hope I was successful. It would be good to
know if any candidates who are seen at
interviews mention what I said.
Joint Specialty Committee,
London College
I chaired my first meeting of this committee at
which two new lay representatives were present. I
found their involvement useful and I think the
BGS needs to consider how best to involve the
public in our work. I intend to raise this at the
UKMC.
Clinical Excellence Awards
Consultants in England and Wales should be
considering whether they wish to apply for a
National Clinical Excellence Award in the 2007
round. The British Geriatrics Society will decide
on our nominations in the autumn. All eligible
consultants are encouraged to apply for a BGS
nomination and we will only consider applicants
who send us completed Curriculum Vitae
Questionnaires. This year we have extended the
deadline for the receipt of nominations until 30
September 2006 (see page 24).
I would recommend that all intended applicants
read all the latest information on the ACCEA
website including the Annual Report which gives
information on the ages at which candidates are
likely to be successful. It is necessary for
applicants to complete a new Curriculum Vitae
each year. Having been nominated by the BGS in
one year, it is not automatically guaranteed that
you will be nominated in the next year. Each year
is a separate
competition
with successful
candidates
dropping out
and new
applicants joining
the selection process for BGS nomination.
However, members of the nominating group are
aware of who was supported in the previous
round. I am afraid there are relatively few
absolute rules for success. It is, however,
uncommon for awards to be granted to those
less than 45 years old and those who have been
consultants for less than 10 years. Please use your
Regional Clinical Excellence Award Advisor for
advice. That is what they are there for!
Healthcare Commission
Associates
The Healthcare Commission is seeking
Associates from the field of geriatric medicine.
They are called upon to provide advice from the
analysis of events which led to a complaint to
involvement in the investigations. I’m told the
time commitment may range from a few hours to
many days. This work is remunerated.
For further information contact Nazneen
Chowdhury on 02074489274 or email
associates@healthcarecommission.org.uk
Halls of Marble
They say everything is bigger in the USA and
that’s certainly true of the Mayo Clinic where I
delivered Grand Rounds in the Department of
Medicine. I think the foyer of the new Gonda
Building is larger than some of our smaller
community hospitals! As always, one is struck by
the technological innovations that probably will
only come to my hospital well after my
retirement. All I can say is that if you are ever
admitted there, please opt to go on the Sleep
Enhancement Programme. Otherwise, blood
letting begins at 4.00 a.m. in order that the results
n e w s BGS 11
July 2006
can be available in time for the doctor’s ward
round at 7.00am! Thanks to Dr Greg Hanson
and his team for making the visit so enjoyable.
Similar expanses of marble were observed in the
Headquarters of the United Healthcare just
outside Minnesota. I met a number of people
involved with the introduction of the Evercare
pilots in the United Kingdom. They were
obviously interested in how the community
project was proceeding and made the comment
that they thought that insufficient attention had
been paid to relationships between Community
Matrons and established geriatric medicine
services, and that there was a lack of medical
mentoring in the project.
Canadian Geriatrics Society
Although Geriatric Medicine is a recognised
specialty and taught in the Medical Schools it has
failed to take off in the same way as it has in this
country. There were very few residents. I was
told the principal reason for this was the lack of
a decent pay structure to support geriatricians’
clinical work. An interesting promotional activity
was a Fellows Dinner when leaders of the
specialty sat at the same tables as residents and
students. Perhaps we should consider this rather
than having a top table at our Annual Dinner.
On the other hand, a whole evening with
somebody like myself may be sufficient to
discourage even our most enthusiastic trainees.
I hope to see as many of you as possible at the
EUGMS in August and/or the Autumn meeting
in Harrogate.
At the end of April I visited Vancouver to give a
guest lecture to the Canadian Geriatrics Society.
Peter Crome
Nurse Consultants
Establishing ourselves
he Nurse Consultants Special
Interest Group was established in
December 2005 and recently held
its first Annual General Meeting.
T
You will recall that the group was established in
order that the voice of Nurse Consultants who
specialise in the care of older people can
contribute to the BGS agenda.
We are pleased to note
that our intent to share
our expertise is already
being welcomed and
sought. For example,
both our Chair and Hugh
Chadderton are attending
a meeting with the
Academic and Research
Committee, looking to introduce a nurse focussed
poster section at future BGS scientific
conferences. We have also secured a parallel
session at the BGS Spring meeting 2007 in
Brighton and Nicky Hayes is coordinating
presentations for the event. Several of us are keen
to use these opportunities to share our practice
and research expertise.
Advance directives
We have also got our toes in the water of clinical
practice development with interest in contributing
to guidance on advance
directives and advance
Nurse Consultant Officers
statements. We intend to
explore the options for
elected at the AGM:
contributing within the
Education and Training
Chair:
Clare Abley
Committee.
Vice Chair: Dave Jones
Treasurer: Frazer Underwood
Secretary: Gwyn Grout
Topical discussions
As is customary at our
12 BGS n e w s
July 2006
meetings, we heard from three speakers and
engaged in much topical discussion. Lynne Phair
spoke of her involvement in the Continuing
Health Care agenda, both as an expert nurse and
as a relative embroiled within the complicated,
poorly understood process. Henry Minardi shared
his early research work about the development of
a DVD which will
be used to
examine the ability
Hide not thy light under
of people with
a bushel
dementia to
recognise and
We are keen to publish articles respond to the six
showcasing innovative practice basic emotions.
or research work in future
issues of this newsletter. Copy
deadlines are 15 August, 18
October and 16 December.
Word count is 400 - 800 words.
Please email submissions to:
Our guest speaker
engendered much
debate. Maureen
Morgan, Nursing
Lead for PCT
Development at
gwyn.grout@hantspt-n.nhs.uk
the Department of
Health, spoke
about the current
policy agenda. She focused particularly on the
current radical system reform programme for
England. There is appreciation that the speed and
unrelenting nature of the reform is extremely
challenging for everyone concerned, not least for
older folk themselves, who are confronted with
numerous people turning up on their doorsteps.
However, the changing nature of health care
requirements, alongside increased longevity and
decreased workforce, makes the changes essential
if the health service is to be sustained. Community
models of care, particularly for people with long
term conditions and multiple pathologies, are the
only way forward. A bumpy ride is anticipated,
with a probable 5 - 6 year period within which the
inevitable problems that occur in any new system
will be ironed out. Maureen expressed a desire that
nurse leaders continue to deliver the messages
about the necessity of change in as positive a light
as possible.
Concern from the floor centred on the change
from a National Health Service to a National
Health System and the development of practice
based commissioning which may be read as GP
lead commissioning. It was emphasised that
nursing, and indeed multi disciplinary engagement
is an essential component and that PCTs and
service providers are expected to facilitate such
engagement. It is, of course, for nurse leaders to
ensure that we are thus engaged and also to build
links with our new PCTs and StHA colleagues.
Following our regular update Deborah Sturdy of
the Department of Health, and commitment to
provide an article of interest for each Newsletter
henceforth, the meeting concluded that we are
pleased to have found our niche within the Society
and look forward to working together in advancing
care for older people.
Gwyn Grout
NC Group Secretary
Going into research
by Deepa Sumukadas
hen I started medical school, I
thought I would like to do
research, but the thought was
abandoned during the years at medical
school.
W
As a medical resident in India, it was necessary do a
small research project, but I must say the
compulsion and the lack of support completely put
me off the idea of research.
My interest was rekindled when I moved to the UK
and worked as an SHO in a department that was
academically oriented. Still, I stood by passively
because I did not know how to go about getting
involved in research. When a research post was
n e w s BGS 13
July 2006
I had always unconsciously assumed that
medical advances “just happened”. I have learnt
that all the medical advances we have today are
because somebody has painstakingly done the
research behind them.
advertised in the department, I tentatively expressed
an interest but my inertia persisted because the job
specification mentioned a requirement for the
applicant to be the holder of an MRCP and I was
still awaiting my MRCP results. Fortunately my
supervisor gave me a push necessary to apply for
the post.
I soon found myself doing research in Medicine for
the Elderly. The project – a randomised controlled
trial of the effect of ACE inhibitors on muscle
strength and function in older people - was all set
up. All I had to do was to start on the project.
Despite this it took a lot of time to get things
moving. I had not realised until then how much
effort and dedication was required to do research.
Thankfully, I had plenty of support from my
supervisors who were ready to offer advice and a
shoulder to cry on when things did not go as
planned. I also had the support of colleagues who
were already well into research.
I have learnt many of the things I expected to, for
example research methodology, computing skills
and statistics, but I have also learnt some things
that had never crossed my mind before. I have
learnt that all the medical advances we have today
are because somebody has painstakingly done the
research behind them. I had always unconsciously
assumed that medical advances “just happened”. I
also found out that medicine cannot progress if the
public does not help. I enjoy working with my
group of older people who so generously
contribute to future medicine. Their patience and
perseverance in completing the projects despite
other co-morbidities is extremely admirable.
Though there is a general
impression that research is easy
going, I do find that there is a lot
of work to do if you put your
heart into it. I have developed an
enthusiasm for literature searches,
to find new projects to work on
and to write up my findings for
publication. Seeing my name in
print had never been an incentive
for me to take up research, but I
must admit to a feeling of elation
when I had my first article
published. And the feeling does
not wear off as subsequent efforts
get framed in print!
To those uninitiated in research, I
would suggest:
i) Voice your interest in research at an early stage.
There is support out there to be tapped. Choose
your supervisor well - you will need their advice
and support.
ii) Do not undertake a project just for the sake of
doing some research. Research can be completely
off-putting if you are not interested in the project
and lack the motivation.
iii) Keep your data entry up to date. You will have
to work to deadlines and not having data entry
looming menacingly is a great comfort.
iv) Go for statistics courses early into your project
and try out the available statistical packages.
A lot of negative comments about doing research,
especially in Medicine for the Elderly, have come to
my ears. Friends and peers have told me time and
again that I am foolish to do research when SpR
posts are obtainable in this specialty without
undertaking research. I have been the brunt of
much good natured teasing about taking a job that
nobody else wanted. Has that put me off ?
Absolutely not! I enjoy the challenge of doing
research and I hope to do my bit for medical
science, however small my contribution. I am sure
many researchers will agree with me that the
enthusiasm for research gradually increases with
time spent doing research.
Deepa Sumukadas
SpR with Special interest in Research
Dundee
14 BGS n e w s
July 2006
Policy and good practice
BGS compendium updates
ne of the primary objectives of the BGS Policy Committee is to
respond to the need for statements of policy and good practice. The
BGS Compendium is on the BGS website (select “publications”). New
papers are published in this newsletter and members are invited to contact
the Chair of the Policy Committee, through the Editor, to propose new areas
where guidance should be developed and written.
O
The discharge or transfer of care of frail older
people for community health and social support
Older people discharged from hospital and living in
the community have higher levels of dependency and
more complex health and social care needs than other
patient groups. For frail patients with complex needs
it may be more useful to regard the process as a
“transfer of care” to community agencies.
This process requires careful planning and should be
timely, to an appropriate location and with adequate
resources available to support the discharge.[1]
Methods of working between Health and Social
Services differ across the United Kingdom.
Principles
1. The British Geriatrics Society is committed to
providing for older people, appropriate interventions
consistent with patient/client choice, the assessed
needs of carers and the highest quality health and
social care.
2. Person centered multi-disciplinary assessment
should be carried out at the earliest opportunity. The
discharge planning process should begin at the point
of hospital admission. However, it should be noted
that admission may be avoided if timely assessment
and interventions can be obtained in the community.
The appointment of community matrons, the single
assessment process and the implementation of case
management may impact on this aspect of planning.
3. Some older people require significant stays in
hospital in order to achieve optimal health status and
potential. Others may benefit from ongoing
community rehabilitation in residential units or at
home.
4. Older people who do not require community
support can be discharged by ward staff without the
need for referral to social services but may be given a
contact number for the Social Services Department to
self refer in case they need help in the future. For
others who already have a package of care, and whose
care needs have not altered, ward staff should need
only to inform the provider that the care package
needs to recommence. For others a re-assessment of
their needs will be required and a timely referral for
therapy assessments and social services input should
be made so that assessment and planning for
discharge can begin as soon as possible.
5. Older people with complex needs require
assessment from a range of health and social care
professionals coordinated through a multidisciplinary
meeting. It is important that care plans emphasise
promotion of independence.
6. Transfer of older people straight from an acute
hospital bed to a care home bed without
comprehensive geriatric assessment is not encouraged.
The opportunity of assessment and rehabilitation in a
short term residential environment or at home with
enhanced community support (e.g. by supported
discharge team) should be offered.
7. Decisions to fund a nursing home placement
n e w s BGS 15
July 2006
should take into account local eligibility criteria agreed
by the Primary Care organisation and local Social
Services department as part of joint continuing care
arrangements.
8. Each unit should have clinical governance processes
in place to audit the discharge process.
Practical Aspects of Discharge
Planning
Local arrangements
Discharge arrangements are dependent upon the
interface between social services, health authorities,
NHS trusts and primary care groups/trusts. Input
from the private sector and voluntary agencies are
increasingly important in constructing care packages.
Patient and carer involvement
Patients need to be involved early in the assessment
process and care plans should offer them real choice.
Carers who provide a substantial amount of care on a
regular basis are entitled by law to receive, if required,
an assessment of their ability to continue caring.
Executive Summary
The discharge of older people with high levels of
dependency and complex health and social care needs
requires careful planning, should be timely and to an
appropriate location.
For frail patients with complex needs it may be more
useful to regard the process as a transfer of care.
Methods of joint working between health and social
care agencies vary across the 4 countries of the United
Kingdom.
Person centred multidisciplinary assessment and
discharge planning should take place at the earliest
opportunity and ideally from admission.
The effects of the Community Care (Delayed
Discharges) Act 2003 and “Payment by Results” on
discharge and readmission processes are currently being
evaluated.
A multilayered approach to assessment and
rehabilitation co-ordinated by the multidisciplinary team is
recommended, with review at formal MDT meetings.
Input from the private sector and voluntary agencies
are an increasingly important component of care
packages.
Referral
A multi-layered approach to assessment is
recommended. The first step is screening by a
member of the health team who possesses
appropriate skills and knowledge of local eligibility
criteria and the available services. The multidisciplinary team will distinguish between patients
with simple needs (e.g. requiring only a single
domiciliary service such as home care) and those with
complex needs who require a full care assessment.
Where discharges are straightforward,
Timely discharge may be enhanced by a variety of
techniques including the following [2]:
Developing a treatment plan and estimated date of
discharge within 24 hours of arrival;
Nurse initiated discharge processes;
Daily ward rounds by senior staff (SpR, Staff Grade,
Associate Specialist or Consultant); and
7 day per week discharges where possible.
Accident and Emergency Departments
a n d M e d i c a l A d m i s s i o n s u n i t s should have
access to a discharge planning team, ideally
coordinated by either a discharge liaison nurse, or
social worker so that they can refer and discharge
appropriately. Arrangements for dealing with patients
"out of hours" should be in place.
Care planning
Social Service departments are required to work with
patients, their carers and relevant hospital and
community staff to construct appropriate care plans
and hospital discharge arrangements. All assessed
patients should receive a care plan before discharge.
The medical needs of the patient will continue to be
the responsibility of the general practitioner and it is
important that he/she is provided with adequate
information at discharge.
Role of the Consultant in geriatric
medicine
The professional responsibility for discharge
arrangements remains with the individual members of
the multi-disciplinary team, often but not always
under, the leadership of the Consultant in geriatric
medicine. Not all older people will be under the care
of geriatricians yet it is desirable that in all hospital
departments those patients with complex needs
should still have a full assessment by multi-disciplinary
teams. Communication must occur with the General
Practitioners and community or intermediate care
services in a clear and timely way, ideally in advance.
The Discharge Coordinator
Recently, Discharge Coordinator posts have been
developed in many NHS Trusts. They have a pivotal
16 BGS n e w s
July 2006
role in liaising with members of the multidisciplinary
team and can improve communication between these
individuals. They can also interface directly with the
patient and their spouse, family or other caregiver.
Link: www.bgs.org.uk/publications/compendium
BGS Policy Committee
Released May 2006
Conclusion
The discharge or transfer of care of an older person
from the hospital to the community is one of the
most satisfying aspects of geriatric medicine. The
complex health and social needs of this group
requires the experience and skills of a large number of
professionals from a range of different organisations.
Without careful coordination this process can
disintegrate to the detriment of the patient and
his/her family. The needs of frail older people with
cognitive impairment to EMI care homes are
considered in a parallel document.
References:
1. Discharge from Hospital Pathway, Process and
Practice (2003), Health and Social Care Joint
Unit and Change Agent Team, Department of
Health, London.
2. Achieving timely simple discharge from
hospital: A toolkit for the multi-disciplinary team
(2004), Department of Health London.
Guidelines on capacity and testamentary capacity
General Legal Rules
1. Mental capacity is a legal concept and any decision
as to whether a person does or does not have mental
capacity is ultimately a decision for a court of law[1].
A doctor assessing mental capacity does so as expert
witness for the court and owes a duty to the court as
well as to the person assessed.
2. Assessment of capacity applies to individual
decisions: an individual may be capacious in some
decision making but not in others.
3. A medical report on testamentary capacity, that is
the mental capacity to make a will, must have regard
for the legal rules as set out in the relevant case law.
The current legal requirements in England and Wales,
Scotland and Northern Ireland are set out below.
4. There are legal presumptions of competence and
continuance. Thus (i) a person is presumed to be
competent until the contrary is proved and (ii) once it
has been proved that someone is incompetent then
this is presumed to continue until the contrary is
proved.
5. A decision as to whether a person lacks or has
testamentary capacity is made on the balance of
probabilities. The assessing doctor should therefore
address the question: "Is it more probable than not
that this person lacks or has testamentary capacity?"
The standard of proof is not "beyond reasonable
doubt" as used in criminal cases.
6. a. Any assessment of mental capacity must be
made with reference to a particular task. Thus,
testamentary capacity has to be determined with
regard to a particular will. The more complex the
disposition, the greater the mental capacity necessary.
The doctor has to have some idea of the extent and
complexity of the estate and the number and nature
of likely claims.
b. These same considerations also apply when
assessing an individual’s capacity to determine their
own care needs and their ability to judge risk, e.g.
when considering care home placement vs care at
home.
7. Doctors who have to treat a patient who is unable
to give consent to treatment may need to seek the
guidance of the court before making a decision to
treat or not to treat. Such an application is not needed
in every case. Where the issues of capacity and best
interests are “clear and beyond doubt”, an application
to the court is not necessary. But “where there is any
doubt as to either capacity or best interests, an
application to the court should be made” [2]. Five
specific instances may occur when a judge would
expect doctors to seek the Court’s guidance on how a
patient should be treated. These are:
where there is any doubt or disagreement as to the
capacity (competence) of the patient;
where there is a lack of unanimity amongst the
medical professionals as to either (i) the patient’s
condition or prognosis or (ii) the patient’s best
interests or (iii) the likely outcome of the proposed
treatment being either withheld or withdrawn or (iv)
otherwise as to whether or not the treatment should
be given or withdrawn;
where there is evidence that the patient when
competent would have wanted the treatment to either
be given or not given, and this is contrary to the views
n e w s BGS 17
July 2006
of the clinicians;
where there is evidence that the patient (even if a
child or incompetent) resists or disputes the proposed
treatment;
where persons having a reasonable claim to have
their views or evidence taken into account (such as
parents or close relatives, partners, close friends, longterm carers) assert that a proposed course of
treatment or failure to treat is contrary to the patient’s
wishes or not in the patient’s best interests.
The Medical Assessment
1. Mental incapacity can arise either by reason of a
mental disability (including frontal dysexecutive
syndrome, mood and thought disorder) or by reason
of the fact that the person cannot communicate for
The Law in England and Wales
1. The criteria for testamentary capacity were set out in the
case of Banks v Goodfellow [5], where it was said that the
testator shall:
a.
understand the nature of the act and its effects
b.
understand the extent of the property of which he is
disposing and
c.
appreciate the claims to which he ought to give effect.
2. It is to be noted that the criteria refer to the extent and not
the value of the property.
3. It is not necessary that the testator behave in a wise and
prudent fashion [6].
4. Although it may be appropriate to explain in broad terms the
nature of will making and remind the person of the extent of his
assets, the person must be able to appreciate and
comprehend the claims to which he ought to give effect without
any assistance [7]. The mental capacity required to revoke a
will is the same as that required to make one [8].
5. If a person lacks the capacity to make a will an application
can be made to the Court of Protection for a statutory will.
Whether this is done is a matter for the person's solicitor
bearing in mind the cost of such an application.
6. The Mental Capacity Act 2005 [9], which comes in to force in
2007, sets out the clear legal requirements for assessing
competence in adults aged over 18 and may also be used in
those aged 16-17 whose incompetence is likely to persist in to
adulthood. A person lacks capacity if they fail one of the
following criteria:
a.
understanding the information relevant to the decision
b.
retaining the information (even if only for a short
period)
c.
using or weighing that information
d.
communicating the decision (by any means)
An unwise or irrational decision is not necessarily an
incompetent decision.
any reason [3]. The mere presence of mental illness
does not define mental incapacity. Patients detained
under the Mental Health Act 1983 or patients who are
under the care of the Court of Protection may have
testamentary capacity.
2. The assessing doctor should make a clinical
assessment of the person and review the relevant
medical notes. It may be necessary to seek the advice
of others as part of the assessment. Clinical
psychologists, nurses, social workers and relatives may
provide valuable information. It is prudent to discuss
the use of such information with the instructing
solicitor before seeking it. Care must be taken when
relying on information from relatives who may have a
financial interest in the outcome of the assessment.
3. There is no standard test of capacity, e.g. MiniMental State Examination (MMSE).
4. The assessing doctor owes a duty of confidence to
the person being assessed. Information relating to the
content of the will should not be passed on to other
parties except with consent. In exceptional cases
disclosure can proceed without the person’s consent
[4]. Such disclosures should be initially discussed with
the instructing solicitor.
5. The assessing doctor should seek to enhance the
mental capacity of the person. If full recovery from a
recent insult has not occurred or there are treatable
disabilities which interfere with capacity then these
facts should be conveyed to the solicitor and the
person fully advised. A person with borderline mental
capacity will perform badly in a hostile environment.
The assessing doctor should take steps to ensure that
the person is given the best possible chance to
demonstrate his or her mental capacity. The doctor
should be aware that capacity fluctuates and that a will
made during a lucid interval may be upheld.
6. On rare occasions the assessment may cause
problems with the doctors ongoing medical
relationship with the patient. If this is likely then it is
prudent to refer the solicitor to another practitioner.
Retrospective Assessment
1. Doctors may be asked for a retrospective
assessment of capacity. In such cases the legal
principles remain the same although the evidential
problems become greater.
The Law in Northern Ireland
1. The law in Northern Ireland is similar to that in
England and Wales.
References
1. Richmond v Richmond (1914) 111 LT 273
2. Burke vs General Medical Council 2004.
3. The Law Commission 1995. Mental Incapacity
Report 231
4. GMC 1995. Duties of a doctor.
18 BGS n e w s
July 2006
The Law in Scotland
1. To have testamentary capacity the person must comprehend
what a will is and what would be the consequences of making
one [10]. Scottish courts are likely to follow the tests defined
above for the making and revocation of wills under English law.
2. A will under Scottish law may be set aside for facility and
circumvention. Facility is "a weakness of the mind .... such that
the person can be easily imposed upon and induced to do
deeds to his own prejudice", but not amounting to incapacity
[11]. Circumvention is an "intimidation operating on the mind as
to bring the individual within entire control" [12]. To enable a will
to be set aside both facility and circumvention must be present.
The greater the degree of facility the lesser the amount of
circumvention necessary in order to set aside the will [13]. The
decision as to whether a will should be set aside on this ground
is obviously one for the court. The medical evidence in such a
case goes to defining the degree of facility.
3. The are no provisions for the use of statutory wills under
Scottish Law.
4. The Adults with Incapacity (Scotland) Act [14] states:
‘For the purposes of this Act, and unless the context otherwise
requires"adult" means a person who has attained the age of 16
years;
"incapable" means incapable of(a) acting; or
(b) making decisions; or
(c) communicating decisions; or
(d) understanding decisions; or
(e) retaining the memory of decisions,
as mentioned in any provision of this Act, by reason of mental
disorder or of inability to communicate because of physical
disability; but a person shall not fall within this definition by
reason only of a lack or deficiency in a faculty of
communication if that lack or deficiency can be made good by
human or mechanical aid (whether of an interpretative nature or
otherwise); and "incapacity" shall be construed accordingly.’
5. Banks v Goodfellow (1870) LR 5 QB 549
6. Bird v Luckie (1850) 8 Hare 301
7. Cartwright v Cartwright (1793) 1 Phill Ecc 90
8. re Sabatini (1970) 114 SJ 35
9. Mental Capacity Act 2005:
www.opsi.gov.uk/acts/acts2005/20050009.htm
10. Sivewright v Sivewright (1920) SC (HL) 63
11.Gibson v Alexander (1925) SLT 517
12. Love v Marshall (1870) 9 M 291 at 297 per Lord
Kinloch
13. Anderson v Beacon (1992) SLT 111.
14. Adults with Incapacity (Scotland) Act:
http://www.scotland.gov.uk/Topics/Justice/Civil/163
60/4927
Further reading
Ashton G R, The Elderly Client Handbook. The Law
Society's guide to acting for older people. The Law
Society, 1994
British Medical Association / Law Society (2004)
Assessment of Mental Capacity. Guidance for
Doctors and Lawyers. London: BMJ Books.
Bellhouse J., Holland A., Clare I et al, (2001)
Decision-making capacity in adults: its assessment in
clinical practice. Advances in Psychiatric Treatment, 7,
294-301.
Berghmans R.L.P. (2001) Capacity and consent.
Current Opinion in Psychiatry, 14, 491-499.
BMA’s consent tool kit:
http://www.bma.org.uk/ap.nsf/Content/consenttk2/
$file/toolkit.pdf (Must be BMA member to access)
Released by the
BGS Policy Committee
Mar ch 2006
Nutritional advice in common clinical situations
The General Medical Council (GMC) has defined
good practice in decision making on withholding and
withdrawing life-prolonging treatments [1]. This,
together with updated BMA guidance [2], has ensured
that clinicians in the UK have an explicit framework
for making the difficult and sensitive decisions
necessary to provide optimum care of patients who
are both unable to maintain their own nutrition and
hydration and not competent to make decisions for
themselves.
The publication of these documents, which are fully
referenced from both the medical and legal literature,
will help to reassure patients, their family and carers,
and the wider public that such decisions are made in a
transparent and open manner, free from ageism and
are not influenced by resource constraints in the NHS.
Indeed the GMC document makes clear that
individual clinicians are accountable for any deviation
from the published guidance.
In light of this it is felt that there are at least two
n e w s BGS 19
July 2006
conditions common in the care of older people where
some specific guidance on nutrition might be of help
to BGS members, namely stroke and dementia.
Nutrition and Stroke
1. A significant number of stroke patients are undernourished on admission and, as with other undernourished hospital patients, their nutritional status
tends to worsen after admission. Furthermore, undernutrition in hospital is a strong and independent
predictor of morbidity and mortality after stroke [3].
2. Routine administration of oral nutritional
supplements to stroke patients, in acute and
rehabilitation phases, has not been shown to improve
overall outcome and should, therefore, be reserved for
those who are under-nourished on admission or have
deteriorating nutritional status [4].
3. Enteral feeding should be considered for patients
who have dysphagia following stroke [1 ]. However,
early tube feeding has been shown to reduce mortality
but increase the proportion of survivors with severe
disability. Nasogastric (NG) tube feeding is safer and
the recommended route for those who require enteral
feeding in the first few weeks after a stroke. PEG tube
feeding has been shown to be associated with
increased mortality and poor outcome and should be
reserved for those who cannot be fed via an NG tube,
or where enteral feeding is prolonged [4].
4. Some patients who receive PEG tubes are in the
terminal phase of their illness, calling into question
the appropriateness of the intervention. The
physician's role is to provide best quality information
[2] on the short and long-term consequences of a trial
of NG or PEG feeding [6], having investigated the
options, listened to all relevant parties [2] and
considered the patient’s circumstances, quality of life
and prognosis [7], before deciding on the
appropriateness or otherwise of either procedure.
Nutrition and Dementia
1. Anorexia, weight loss and also dysphagia are
common in patients with advanced dementia. In these
patients intercurrent infection, environmental change,
depression, poor carer rapport, pain, oral hygiene, illfitting dentures and nursing availability are just some
potentially reversible and treatable causes of reduced
food and fluid intake. The role of enteral, mainly
PEG tube, feeding in such individuals is controversial
[14, 15], even in the ethical and theological literature
[11].
2. The best available evidence, in the absence of
randomised controlled trials, suggests that PEG tube
feeding does not improve overall prognosis in patients
with advanced dementia [9]. It does not prevent
aspiration [8], prolong survival, improve quality of life,
functional status or nutritional status [9,12]. The latter
is likely to be due to the presence of cachexia -
inducing cytokines such as TNF- and IL-612 [13].
PEG tubes are poorly tolerated by patients with
dementia and there is some evidence that hand
feeding can be as effective [5].
3. Despite the above evidence which questions the
value of enteral tube feeding in general in dementia
there remains a need for physicians to consider each
clinical situation on its merits [6]. Each individual has
a right to be treated with dignity and this can be used
as an argument both for and against the
administration of artificial nutrition and hydration.
Respect for individual autonomy is paramount, as is
extensive consultation, when acting in the best
interests of a patient who is not competent. There is
an acknowledged need for palliative care provision for
patients with advanced dementia [10].
4. Where dietary intake is insufficient but death is not
imminent, the GMC states that a second opinion must
be sought from a senior clinician not directly involved
in the patient's care, before the decision to withhold
artificial feeding is finalised and that where significant
conflicts remain, either within the healthcare team or
with those close to the patient, legal advice should be
sought [1].
Recommendations
1. Advice of dieticians and speech and language
therapists must be sought early to assess the most
appropriate method of meeting individual nutritional
requirements in patients at risk of under-nutrition.
2. Nursing, medical, catering staff and other health
professionals involved in the care of patients with
stroke or dementia should have access to the
necessary basic training which will enable them to
assess and meet the nutritional demands of those at
risk.
3. All members of the multidisciplinary team should
be involved in decisions to recommend PEG feeding
for patients with dysphagia. The treating doctor has a
duty to obtain informed consent from competent
patients and to undertake adequate consultation with
those closest to patients not competent to make the
decision.
4. There should be clear policies for short- and longterm review of patients with PEG feeding.
References
1. Withholding and withdrawing life-prolonging
treatments: good practice in decision making. General
Medical Council, London, 2002
2. Withholding and withdrawing life-prolonging
medical treatment: guidance for decision making.
BMA London, 2nd edition, 2001
3. Gariballa, S (2000). Nutritional factors in stroke. B J
Nutr 84, 5-17
4. FOOD Trial Collaboration ( 2005 ) Effect of
timing and method of enteral tube feeding for
20 BGS n e w s
July 2006
dysphagic stroke patients ( FOOD ) : a multi-centred
randomised controlled trial. Lancet 365 , 764 – 772.
5. Mitchell S. ,Buchanan J. ,Littlehale S. , Hamel M. (
2004 ) Tube-feeding versus hand-feeding nursing
home residents with advanced dementia : a cost
comparison.. JAMDA 5(2) S23 – 29.
6. Lennard-Jones J. (1999) Giving or withholding fluid
and nutrients: ethical and legal aspects. J R Coll
Physicians Lond 33, 39-45
7. Rabeneck L, McCullough L, Wray N (1997)
Ethically justified, clinically comprehensive guidelines
for percutaneous endoscopic gastrostomy tube
placement. Lancet 349, 496-98
8. Finucane T. Bynum J. (1996) Use of tube feeding to
prevent aspiration pneumonia. Lancet 348, 1421-1424
9. Finucane T., Christmas C , Travis K ( 1999 ) Tube
feeding inpatients with advanced dementia : a review
10. Hughes J. , Robinson L. ,Volicer L. ( 2005 )
Specialist palliative care in dementia. BMJ 330 57 –8.
11. Gillick M. (2000) Rethinking the role of tube
feeding in patients with advanced dementia. N Eng J
Med 342, 206-210
12. Mitchell S., Berkowitz R., Lawson F., Lipsitz
L.(2000) A cross-national survey of tube-feeding
decisions in cognitively impaired older persons. J Am
Geriatr Soc 48, 391-397
13. Yeh S-S, Schuster M. (1999) Geriatric cachexia: the
role of cytokines. Am J Clin Nutr 70, 183-197
14. Sanders D. , Anderson A. , Bardhan K. ( 2004 )
Percutaneous endoscopic gastrostomy : an effective
strategy for gastrostomy feeding in patients with
dementia .Clinical Medicine 4 ( 3 ) 235 – 41
15. Pennington C. ( 2002 ) To PEG or not to PEG.
Clinical Medicine 2 (3) 250 – 55
16. SIGN 78 ( 2004 ) Management of patients with
stroke : identification and management of dysphagia.
Released by the
BGS Policy Committee
Mar ch 2006
POPS and OPAL
progress is possible!
ike most of what we do, there is no
Class 1 level evidence for two
service developments in our trust
(Guy’s and St Thomas’ in London) as
service models. Nevertheless we
believe that they work and our
managers support them.
L
Their design was based on published studies and local
data. At a time when the planning initiative and the
money often seems to be out of grasp of geriatrician
leaders, you might be encouraged too. Both
developments are based on the National Service
Framework, particularly standards 1, 2 and 4 about
equity without ageism, assessment fit for purpose and
general hospital care of older people. Both employ the
comprehensive geriatric assessment (CGA) approach,
applied through multidisciplinary old age teams
working in new settings.
POPS (Proactive Care of Older
People undergoing Surgery)
Scoping the problem
The idea of POPS arose directly from discussions in
the trust-wide NSF implementation group, which
identified that clinical standards on ageing issues were
suboptimal among surgical patients. Danielle Harari, a
geriatrician and currently our head of service, secured
charitable funding for development work which
showed that:
older patients undergoing elective surgery had high
preoperative co-morbidity linked to significant postoperative problems (compatible with published
evidence),
preoperative assessments were inadequate to
identify most of the potentially remediable factors,
few patients were referred to our specialist services
or community therapists
GPs, assessment nurses and many surgeons
acknowledged the need for improvement.
The POPS team (geriatrician, specialist nurse,
physiotherapist, OT, social worker) was set up with
n e w s BGS 21
July 2006
further charitable funding. Patients with medical comorbidities and functional dependencies were targeted
through CGA 2-12 weeks pre-surgery. Treatment was
at home or in clinics. Patients were followed through
surgery to post-discharge (see Figur e1).
Winning support
A minority of surgeons were initially sceptical but preop assessment nurses enthusiastically supported and
used the referral criteria. It was soon clear that the exit
strategy from developmental to core funding would
need support and data to satisfy a range of
stakeholders.
Equitable access to surgery has been improved by
replacing eyeball impressions about surgical fitness
with evidence based medical judgements. By timely
medical optimisation based on surgeons and nurses
employing simple assessment based referral criteria
late cancellations have been reduced, increasing
efficient use of theatre time. Preventing and better
treatment of postoperative complications has
improved clinical effectiveness and service
efficiency through, for example, reductions in
hospital stays (25%) and unplanned readmissions
(over 50%) in elective orthopaedics. Further details
have been presented to the BGS i.
Unsurprisingly, questionnaire-based evaluation of
patients and surgical staff has demonstrated high
satisfaction. Key factors to gain support were the
iterative development process which increased
understanding and acceptability of key clinical
stakeholders, and a flexible approach to solving other
pressing clinical issues such as emergency surgical
longstayers.
Based on quantitative and qualitative data supplied by
this evaluation, the surgical department’s business case
for 2005/2006 proposed that mainstreaming the
POPS service costing £320K annually could reduce
trust costs by double this amount. Hence a new team
with consultant geriatrician was established with trust
funding from April this year.
OPAL (Older Persons Assessment
and Liaison Team)
This team was driven by the need for reduced hospital
bed use but again addressed this through a CGA
approach with the expectation of improving clinical
standards as well.
Service context
Since we became part of the acute trust (in 1988) we
have retained separate elderly care wards with ward
based multidisciplinary teams, taking patients on a
needs basis. In recent years, several factors including
junior doctor hours and the 4 hour wait rule in the
A&E have resulted in fewer direct admissions to us
from primary care, most patients spending 24 hours
or more on the admission wards (60 beds with HDU).
Subsequent access to our service (84 beds plus a
stroke unit) was referral based, with consequent
inconsistencies and delays.
Funding context
A financial decision to close 30 medical beds was seen
by geriatrician Adrian Hopper, now head of the medal
service, as an opportunity for service development
through reinvestment. The idea was to apply CGA
skills more pro-actively in general medicine. The
business case was based on comparative
benchmarking work as well as local data showing
delays and inefficiency related to clinical decision
making.
The service and its effect
The published literature provided evidence on factors
associated with clinically adverse outcomes, long
hospital stays and readmissions. A CGA case finding
tool (one page of A4) was designed. The specialist
team (‘OPAL’) [ex ward manager nurse, senior
physiotherapist, half-time geriatrician] screened all
acute medical patients aged 70+ within 24 hours of
admission (M-F) to identify moderate-high clinical
risk. The geriatrician saw the patients in the Clinical
Decision Unit each morning. Depending on clinical
need, actions included:(1) rapid transfer to elderly care
unit (ECU) (2) case management on general medicine
wards (3) referrals to specialist geriatric clinics (e.g.
falls, continence). Essential to the approach is
agreement with GIM consultant colleagues and bed
managers for this pro-active approach. Particular
clinical situations which have been helped by OPAL
include:
identification and management of delirium
end of life issues of care home residents
rapid discharge and investigation of patients with
falls and syncope
management of potential re-admitters by discharge
and rapid access to day hospital.
Quick and dirty evaluation was what the trust
management required to approve ongoing funding.
Prospective comparison was made of two cohorts of
patients: ‘before-OPAL’ (August 2004) and ‘afterOPAL’ (August 2005) with blinded data abstraction
from hospital notes/OPAL database. Prevalence of
“geriatric” problems was similar, but their
identification and clinical management improved,
delay to appropriate transfer to the ECU was reduced,
and total hospital length of stay fell 31%(LOS) ii. By
the end of the 22 month period since the inception of
OPAL, the adult GIM service ran on 50 fewer beds,
22 BGS n e w s
July 2006
LOS for all GIM patients over 70 has fallen
significantly, and despite taking a more problematic
caseload to the ECU wards, LOS has also fallen there.
Whilst many factors may have played a part in this, the
independent opinion of the NHS Institute for
Innovation and Improvement is that our service is a
top performer for the index frail elderly condition of
urinary tract infection (personal communication).
Research and Generalisability
So, our experience is that CGA can work. Not a
surprise perhaps. Are there any lessons for other
hospitals? To secure funding is always a mix of luck
and planning. Capitalising on the opportunities
presented and meeting the urgent local expectations is
good for getting new things started but also impedes
the creation of class 1 evidence. Does this matter?
The effectiveness of clinical services like these is likely
related to: a) casemix, which could be described in
detail in an RCT and therefore lend weight to
generalisability, local “usual care”, which is difficult to
capture and is constantly changing; and b)
enthusiastic clinicians, also an elusive quality.
So the research approach of “realistic evaluation”
SURGICAL OUTPATIENTS
PRIMARY CARE PREADMISSION
NURSES WAITING LIST
SCREENING
Proactive referrals of patients aged
65 years or over
Elective cases - Patients
undergoing major surgery at risk
according to screening criteria
which explores context-mechanism-outcome
relationships is as applicable as an orderly RCT. Our
ongoing work therefore includes this approach,
incorporating evaluations of specific components
such as the OPAL case finding tool and the
adjustments of POPS that may be necessary for
different surgical groups.
Finbarr C Martin
Consultant Geriatrician: R & D lead for Medicine
Acknowledgments to Danielle Harari, Adrian
Hopper, and the POPs and OPAL teams
References
i
Harari D, Babic-Illman A, Lockwood L, Hopper A,
Martin FC. Proactive Care of Older People
undergoing Surgery (‘POPS’): Pilot Evaluation. BGS
Autumn 2005 Scientific meeting, abstracts on line at
http://ageing.oxfordjournals.org/archive
ii Hopper A, Martin FC, Buttery A, O’Neill S,
McGovern R, Shillo P, Harari D. The Older Persons
Assessment and Liaison Team ‘OPAL’: Pilot
Evaluation of Comprehensive Geriatric Assessment
(CGA) in Acute Medical Inpatients. BGS Spring 2006
Scientific meeting, abstracts on line at
http://ageing.oxfordjournals.org/archive
POPS
PRE-OPERATIVE
Multidisciplinary assessment and
treatment and liaison with
surgical/anaesthetic team
Clinical Team
Geriatrician
Nurse Specialists
Occupational Therapist
Physiotherapist
Social Worker
Semi-urgent cases - e.g. patients
diagnosed with cancer (open
referral)
HOSPITALISATION
Post-operative consultant
geriatrician/specialist nurse
intervention on surgical wards
Patients diagnosed as medically
unfit for surgery (refer all cases)
Therapy liaison
Discharge planning
Community liaison
Consultant assessment:
Comprehensive medical
management
Specialist Nurse: Comprehensive
assessment
Patient/carer education
Physiotherapy: Cardiovascular
training, breathing exercises,
muscle strengthening
Occupational Therapy:
Home visit – provision of
equipment
Social Care:
Post-operative discharge planning
POST DISCHARGE
Intermediate Care
Follow up home visit
Links with primary health care and social care
Referrals to specialist clinics: Continence, Falls, PD etc.
Staff training
underpinning the
clinical liaison work
Figure 1
n o t i c e s BGS 23
July 2006
VACANCY - NEW
ZEALAND
Specialist Geriatrician/Specialist
Old Age Psychiatrist
Two full time posts, Palmerston
North Hospital, NZ
Job descriptions and application
forms are available on our website:
www.midcentral.co.nz/ or by
contacting Gail Lucinsky, HR
Administrator, email:
gail.lucinsky@midcentral.co.nz
or phone +64 6 350 8907.
www.bgs.org.uk [Select Notices
- Vacant Posts]
VACANCY - NEW ZEALAND
Clinical Director ATR & Older
Persons Service
Health Professionals International is
a retained search company
specialising in the placement of
medical professionals across all
specialties throughout New Zealand, Australia and the United Kingdom.
We are currently on assignment with one of the largest District Health Boards in
New Zealand, searching for the following professionals to join their Rehabilitation /
Older Persons Service department:
- Clinical Director / ATR & Older Persons Service
- Geriatricians
Assistance will be given with relocation, registration & immigration procedures.
For further information, please contact
Darryl Cooksley
Phone: +1 917 577 4877
Email: darryl@nyheadhunter.com
Or visit our website at www.healthprofessionalsinternational.com
VACANCY
AGE AND AGEING
Webpage Review Editor
Applications are invited for the post
of webpage review editor for Age
and Ageing.
The post entails a regular
contribution to the journal that
reviews current sites on the
internet of interest to the
readership in terms of their
relevance to the health and social
issues of older age. The work
should critically evaluate new
developments on the internet in
relation to clinical guidance,
education, training, research, audit
and clinical effectiveness in
geriatric medicine. Applicants
should be prepared to commit
around two to three hours per
week for this purpose.
Expressions of interest to:
sarah.reeder@bgs.org.uk
To discuss the role further, contact
the current webpage review editor:
Dr Jolyon Meara:
jolyonmeara@hotmail.com
AGE AND AGEING EDITOR
Professor Gordon Wilcock will be retiring as Editor of the Age and Ageing
journal and expressions of interest are invited from qualified candidates to
succeed him.
Requirements
The Editor (in Chief) has responsibility for the overall editorial process. He/she
needs to become fully conversant with the editorial software used to manage the
editorial process. At present this is Manuscript Central, and decisions have to be
made from time to time about the need to update it to later versions of the
software.
The Editor is responsible for ensuring a close and efficient working relationship
between him/herself and the Editorial Assistant, presently Katy Ladbrook.
The Editor is responsible for appointing and maintaining an effective working
relationship with a number of Associate Editors, each of whom takes responsibility
for advising the Editor about submissions within a specified area or discipline. The
Associate Editors take responsibility for appointing referees, and then advising the
Editor about the suitability of each submission for publication. This will involve the
Editor in considering the Associate Editor’s own opinion of the submission, and of
the relevance of the referees’ advice. The Editor should take into account the
advice of the Associate Editor and referees, but is free to override this if he/she
feels that it is appropriate.
A full job description is available on the BGS website: www.bgs.org.uk (Select
Notices and Posts Vacant).
Expressions of interest to reach Sarah Reeder by end August:
sarah.reeder@bgs.org.uk
24 BGS n o t i c e s
July 2006
VACANCY
BGS DIRECTOR OF CONTINUING PROFESSIONAL
DEVELOPMENT
Expressions of interest are invited for the post of Director of Continuing
Medical Education and Professional Development as Dr Ian Taylor will be
demitting from the post in the near future.
Requirements
The DCPD must be a full member of the Society, of consultant or senior academic
status, with a comprehensive understanding of geriatric medicine and the role of
the geriatrician, and their needs, coupled with a good knowledge of developments
in medicine and in the delivery of care. A good knowledge of medical education,
CPD, and validation are essential; an understanding of IT technology and its
potential in education would be desirable.
Role of the DCPD
The DCPD will use his/her best endeavours to ensure that the Society, through its
scientific meetings, publications and electronic media, provides its members with
every opportunity to keep up to date with developments in geriatric medicine and
the management of older patients across the United Kingdom. The DCPD also
represents the BGS views at meetings of the Royal Colleges on CPD.
Term of office
The DCPD serves for a period of 4 years.
More details to be found on the BGS website www.bgs.org.uk (select Notices and
Posts Vacant)
Expressions of interest to reach Sarah Reeder by end August:
sarah.reeder@bgs.org.uk
BGS BRANCH AND
SPECIAL INTEREST
BGS West Midlands
14 Sept 2006: National Motorcycle
Museum, Solihull
BGS South East Thames
21 Sept 2006: Queen Elizabeth
Hospital, Woolwich
BGS Trent Branch
19 Oct 2006
BGS North West and North East
Thames
8 November 2006 : Barnet Hospital
Details/ programmes will be posted
on the BGS website
(Notices/Regional_sig_meetings)
as they become available
MEDICAL LAW AND
ETHICS
Masterclass and Workshop
19 August 2006
CLINICAL EXCELLENCE AWARDS 2007 ROUND
The British Geriatrics Society process for the 2007 round of the Clinical Excellence
Awards is now open.
In order to comply with the requirements of ACCEA the Society must seek its
candidates through self nomination.
All eligible Consultants are encouraged to apply for a BGS nomination and we will
only consider applicants who send us completed Curriculum Vitae Questionnaires
(Form A). This year we have extended the deadline for the receipt of nominations
until 30 September 2006.
All intended applicants should read the latest information on the ACCEA website
www.advisorybodies.doh.gov.uk/accea. It is necessary for applicants to
complete a new form each year. Unfortunately there are no forms currently
available on the ACCEA web site so please visit the BGS web site
www.bgs.org.uk where you will be able to download and complete last years form
(2006).
In the autumn those who have been successfully chosen by the BGS for
nomination will be invited to complete a 2007 form.
Applicants are asked to note that nomination by the BGS in one year does not
automatically guarantee nomination in the following year.
Please use your Regional Clinical Excellence Award Advisor for advice.
Applications need to reach Sarah Reeder at the BGS Office by 30 September.
Bolton
Interactive day including topics:
Negligence - how to avoid claims;
Artificial Nutrition - To feed or not to
feed; Capacity - How to assess
mental states
Download programme from BGS
website: [Select Notices non_bgs_meetings]
The BGS regrets that owing
to restrictions on space, we
are not always able to
publish all events we have
been asked to publicise.
Please visit the Notices
section of www.bgs.org.uk
for details of more events,
courses related to geriatric
medicine and for
downloadable programmes
and registration material
n o t i c e s BGS 25
July 2006
! ! COMPETITIONS ! !
EUGMS CONGRESS
Richard’s Helpful Hints
23 - 26 August 2006
It is just over a year since Richard Lynham passed
away and readers may remember his epistle to
the Editor at the time of what was to be his final
illness
www.bgsnet.org.uk/July05NL/01_editorial.htm
The UKMC feels it would be appropriate as a
Momento Mori to have a competition which
would serve the aspiration Richard’s views on
improving the patients’ lot in simple ways vide his
postal issues.
So we call on readers to give us some practical
ideas which we might all apply at no/little cost and
are implementable without too much fuss.The
ideas should be easily transportable.
Examples:
1. In our ward occasional off-days for patients
mean they fail their assessments for placement in
Care Homes. We will, with their permission,
videotape their activities of daily living on an
ordinary day and send it on to the Care home.
Such evidence will often reverse an adverse
decision without the need for the assessors to
return to the hospital when time is at a premium.
2. One member of the "Friends League" makes a
special effort every week to contact the Next-of
Kin of patients with moderate-severe cognitive
impairment to ascertain what they might enjoy as
a "treat", be it a food item, toiletry etc.
There is a small budget from voluntary funds to
provide the appropriate item.
Submissions to: editor@bgsnet.org.uk. Closing
date: 31 December 2006
The editor will adjudge the winner(s) and will
publish the best two (Two prizes of £50)
Acknowledgement: Kevin Kelleher suggested this
competition in lieu of accepting the honorarium
paid to the editor and Hon Secretary at the end of
his term of office.
Geneva, Switzerland
Programme and online registration: www.eugms2006.org/
The 2006 EUGMS congress will update geriatric knowledge in
traditional topics but also highlights new upcoming areas in the field of
caring for the frailest older people. The Geneva congress will pursue its
work on the highest scientific level with state-of-the-art lectures,
innovative topics sessions and promising young geriatricians research
lectures. Moreover, a special geriatric core curriculum is included in the
programme to better respond to the need for continual life long training
of GP’s, specialists and geriatricians.
Awards will be given for the best posters and free oral communications.
The social programme includes a 3 hour tour of the city of Geneva; a
visit to a chocolate factory; and an 8 hour trip to Montreux, Chillon
Castle and the Olympic Museum in Lausanne (price for this excursion
includes a 2 course lunch)
OLD AGE PSYCHIATRY
Medicine for Old Age Psychiatrists
7 - 8 September 2006
RSM London
A refresher and update: To revise the clinical symptoms and signs of
medical conditions common in the elderly; To provide an update on the
latest developments in the investigation and management of medical
conditions common in the elderly; To improve the working knowledge
of geriatric medicine.
Download programme from BGS website: [Notices - nonbgsmeetings]
FALLS AND POSTURAL STABILITY
7th International Conference on Falls and Postural Stability
14 September 2006
Coventry
BGS Strapline
The BGS has several straplines: Specialist
Medical Society; Adding life to years; For health in
old age. Readers are invited to submit their ideas
for an “official” strapline which reflects what the
Society is and does, and takes account of our
increasingly multi-disciplinary face.
Submissions to: editor@bgsnet.org.uk. Closing
date: 31 December 2006
The UKMC will adjudge the winner. (Prize: £100)
Highlights include:
The role of the ambulance service in falls management ; the role of
occupational therapy in falls prevention; Fear of falling – an
underestimated problem; The relationship between neurological
conditions and falls; Updates on : Results of the National Falls Audit;
identifying those at risk; working with black and minority groups to
prevent falls; falls prevention – what are the gaps in the evidence
Contact: Secretariat (Falls)
Email: hmc@hamptonmedical.com
Tel: 020 8979 8300
www.fallsbonehealth.ukevents.org
26 BGS n e w s
July 2006
Letters
to the Editor
On raising your head above the parapet : DNR policies in residential homes
Dave
We were dismayed by the initial responses to the publication of our paper on DNR policy in
residential homes, particularly the suggestion that it was ageist. We think that fortunately, most
people must realise that this was partly due to sensationalism in reporting elsewhere and knee-jerk
responses. Since then a more mature debate has begun. Dr Conroy, the brave first author of this
piece who encouraged us all to put our head above the parapet, is continuing research into ethical
matters (in his case, Advance Directives) and contributes to the ongoing debate that our paper has
ignited.
Over time, the impression I have gained from colleagues, and others, commenting about our paper is
that there is in some an unease and in some an abhorrence about the general issue of the use of
CPR in people who are frail. Until recently geriatricians were fighting a hard battle against ageism
and by this they meant that it is unacceptable for a 75 year old to be denied access to a coronary
care unit and effective CPR on the grounds of age alone. Such outrages were taking place in the UK
as recently as 5 years ago. Perhaps a by-product of this argument, but by no means can this be laid
out our doors alone, there has passed into common (mis)understanding the idea that CPR is almost
universally effective. Once this fallacy is held, of course it makes sense to insist that all frail people
should be offered CPR, that withholding CPR is bad or ageist (if the frail person is old), and so on.
The trouble with this fallacy is that it ends up with, to my mind, the unethical position that no-one
should die until their ribs have been broken and this procedure has been applied. Withholding this is
not ageist: not to recognise the special needs of the frail could, in itself, be called ageist – but
throwing around the word “ageist” is rather like throwing around insults: it isn’t constructive. Many
people do not understand how inhumane CPR can be. An anecdote that stays vividly in my mind is a
chat I had with an excellent, fully trained senior SHO about CPR decisions in an educational session.
At one point, bringing to mind the real life events that take place behind the curtains, she looked at
me with welling tears in her eyes and said, “Dr Gladman, as an SHO I’ve been on dozens of cardiac
arrests in the last few months. I have never seen anyone survive yet. I feel sick with what I am asked
to do….I didn’t go into medicine to do this.” She was not simply reflecting her personal distaste, but
the sense that this was actively contrary to the humane purpose of a civilised health care system. I
haven’t seen this on TV medi-dramas (mind you, I don’t watch them).
It is all the more a problem when one looks at the state of medical care in the care home sector,
where investment in CPR training and equipment surely has to be balanced against investment in
other areas such as preventing institutional abuse, better medicine management, improved symptom
control, sensible disability management, good terminal care, and effort to improve quality of life as
opposed to warehousing. We know these problems exist and people suffer from them. There must be
a debate about where our priorities lie, and whether our policies prevent us from responding to
priorities properly. This is not merely an arm chair debate: I have been contacted by people who have
been faced with implementing CPR policies in care homes and the current policy climate in this area
gives them little scope to act in a way that seems reasonable, given their limited resources and the
huge range of problems facing them. They found our article a help in supporting the case for
something other than mass implementation of a policy that was more suited to a setting, such as a
hospital, where going home is the intended outcome as opposed to care homes where death is the
usual outcome.
Exactly how the care home sector and the policy makers will respond must be through a process of
debate in which our paper is but one part. We are glad that at least our paper has contributed to this
debate. We also hope that, over time, our paper will be part of a process that dispels the publicly (and
sometimes professionally) held myths about the real nature and effectiveness of CPR, and hence that
debates about CPR policy will be more rational.
John Gladman
n e w s BGS 27
July 2006
Dear Dave
I detect a new confidence amongst geriatricians. Geriatricians led the battle against age discrimination which
denied many older people access to NHS treatments and services simply because of their age. Access to acute
hospital services such as intensive care and cardiac procedures has been transformed. Access has also been
improved in disease prevention programmes such as smoking cessation and blood pressure control.
Geriatricians with interest in stroke care have helped ensure that two out of three people with stroke now receive
the majority of their hospital care in a stroke unit compared with only one in four a few years ago.
However, with the National Service Framework for Older People in England, now halfway through its ten year
implementation programme, there is still so much to do. I recently published "A New Ambition for Old Age",
mentioned in David Oliver’s article, which sets out my aims for what I think we can achieve in the next five
years. These are grouped under three themes: dignity in care, joined-up care and active ageing. The plans were
developed with the help of the Older People's Specialists' Forum. The Forum consists of older people's specialist
leaders from nursing, occupational therapy, physiotherapy, psychiatry and medicine. Jerry Playfer, James
Barrett, Duncan Forsyth and Alex Mair ably represent the British Geriatrics Society on the Forum. I am indebted
to them for their tremendous support and good advice. The finishing touches to "A New Ambition" were made at
the BGS Conference in Gateshead where I had the benefit of advice from many colleagues.
One of the biggest challenges we face is to develop more joined-up care for older people with complex needs. I
believe that geriatricians' expertise is undervalued and underused. Early access to geriatricians is needed for
people with complex needs, falls and confusion at times of crises. We would improve outcomes for patients and
reduce emergency bed days in hospital and the need for long-term residential and nursing home care if most
people with these needs were quickly transferred to the care of geriatricians.
I was interested to see David Beaumont's and David Oliver’s suggestion in the last BGS Newsletter that the
Society's core messages are to promote comprehensive geriatric assessment and the training of all practitioners
in the care of older people. I agree with this. In particular, I would like the Society to continue to press for
comprehensive geriatric assessment prior to long-term placement and to provide training opportunities for
practitioners in centres of excellence in acute and community hospitals where comprehensive geriatric
assessment is undertaken for older people with complex needs, falls and confusion.
I would be interested in colleagues' views about urgent care reform and in the development of community
hospitals as centres for assessing people with complex needs, falls, confusion and for step-down and step-up
intermediate care with geriatrics providing the bridge for patients between acute and community hospital care.
When I talk to national policy leads for older people's health from other countries, there is admiration and envy
about the strength of British Geriatric Medicine. The speciality continues to expand. I believe its influence will
become even greater as it helps shape reforms to urgent care, the development of community hospitals and the
implementation of comprehensive geriatric assessment prior to long-term placement.
Prof Ian Philp
National Director for Older People
On being mistaken for the vicar
Dear Dave
BGS newsletter arrived today and I enjoyed
your column. By coincidence, I had a more
Catholic experience on my ward round as my
patient (MMSE of 29) said, "Do sit down,
Father", at which I offered to hear her
confession! She declined, saying that it would
take too long...
Terry Aspray
On the demise of the AMT
Dear Dave
I welcome the demise of the AMT, but adopting the
MMSE has a new caution. Recently the Journal that
published the Folsteins original paper was taken
over and the new owners are trying to enforce
copyright. It now costs $1 each time you use it.
There has been a lot of debate about this in the
International Journal of Geriatric Psychiatry. Threats
of legal action have been received by those who
have put the MMSE on web sites etc. See the links
for details:
www.ehr.chime.ucl.ac.uk/demcare/mmse.html
www.ajp.psychiatryonline.org/cgi/content/full/162/3/6
27-a
Regards
Jed Rowe
28 BGS n e w s
July 2006
Geriatric Medicine - the care pathway for older people
Dear Editor
In recent years there have been significant changes to the structure and function of the NHS - and not
least, to the language that is used. Re-configuration, re-location, re-designing and modernisation are
new words for the old-fashioned "closing down"; stakeholders (or is it steak holders?) - all those who get
their teeth into a service!; capacity building - providing premises to house all members of staff; joint
working - using illegal substances; introduction of market forces, competition, foundation hospitals mean what they say! And what about the Long Term Conditions Alliance for Scotland?
The introduction of specialist registers has seen the demise of the the general physician and surgeon
and new contract arrangements for general practitioners has encouraged the introduction of nurse-led
clinics with the loss of the holistic approach to patient care. Managed clinical networks could become a
minefield for older people with co-morbidity i.e. old-fashioned multiple pathology.
But, all may not be lost - we still have Physicians in Geriatric Medicine, supported by teams of Allied
Health Professionals - and a holistic approach should be sustainable for our older patients.
The "medical model" of health care may have been discredited, but there is still a place for some of the
fundamental principles of Geriatric Medicine.
1. Diagnosis before prognosis, with assessment of co-morbidity - assessment of a person`s physical,
mental, social and economic problems which can be associated with disease and/or disability. The
former will require medical or surgical treatment and the latter, rehabilitation.
2. Rehabilitation - perhaps the old name for what is now called "step down", "step up" and "intermediate"
care.
3. Review of the older person`s medicines and general health whenever their health status changes wherever they may be cared for; at home, NHS premises or private/voluntary sector accommodation.
4. Rapid response pre-admission assessment visits, wherever the patient may be, including other
hospital wards, will prevent inappropriate admission and prevent delayed discharge. Such visits avoid the
patient`s need to wait for an out-patient appointment and the artificial atmosphere of a clinic`s setting.
Physicians in Geriatric Medicine have much experience of joint working and may have created managed
clinical networks without realising it - so, despite the demise of the medical model, let`s revive it under
the guise of Modernisation of Care of the Older Person.
Dr C Cohen
Hon. Fellow
Dundee University
More than a weekend
BGS National Trainees’ Weekend
he first BGS National Trainees’
weekend for many years was held
at the Marriot Hotel in Worsley,
Manchester at the end of June.
T
What began as an “over coffee discussion” at the
BGS Spring Meeting in Birmingham last year (Jed
Rowe is to blame for this), developed into this twoday event which has been declared an outstanding
success.
Trainees from as far afield as Aberdeen and London
n e w s BGS 29
July 2006
At this time of great
change, geriatricians
need to use MMC to
create opportunities for
the specialty to promote
itself and recruit high
quality physicians to the
field.
made the journey to
Manchester to hear
nationally - renowned
figures in geriatric
medicine present subjects
as diverse as aspects of
geriatric clinical practice
to the recent changes in
training with
Modernising Medical
Careers.
Saturday morning began with a welcome from cohost Dr Sally Briggs, former Chair of the Trainees
Committee. She introduced Dr Ed Dunstan who
began proceedings with a discussion on the concept
of frailty and its relationship to geriatric medicine.
This was a difficult topic, covered well. Dr Jessica
Beavan concluded the session by considering how
we might want to be preventing frailty in the first
place. She suggested the use of “Prehabilitation” as a
means of attempting this, leaving us all reaching for
our Su-Doku and crossword puzzles.
We were delighted to have Dr Adrian Wagg, Chair
of the Bladder and Bowel Special Interest Group talk
to the meeting on the management of urinary
incontinence. During a very informative presentation
he also argued strongly that this was not such as
benign condition as it seems and reminded us how
simple management interventions might have
significant impact on patients under our care.
Professor Margot Gosney spoke on the relationship
between nutrition and disease in the older people,
and in particular the effects of minerals and trace
elements in the diet. Her description of the
nutritional management of in-patients under her care
made many of us reflect on our own units, and how
we might go about improving this ourselves.
Lunch provided ample opportunity to meet other
Trainees and discuss the morning presentations in
more detail.
In the afternoon, co-chair Dr Emily Feilding
introduced Professor Jennifer Adgey from Belfast,
who talked about the management of Acute
Coronary Syndromes. Dr Jed Rowe next took to the
floor to give an entertaining talk about gait disorders
and mobility problems in the older people. With the
assistance of video clips he described how we should
be thinking about classifying different gait disorders,
and in particular those higher level gait disorders
associated with cerebrovascular disease. It was
satisfying to have what is a complex subject
approached in a logical manner (and with a nod of
the head to Bernard Isaacs at the same time).
The end of the day was completed by Dr Duncan
Forsyth enthusiastically discussing delirium in a
presentation entitled “Bewitched, bothered and
bewildered”. It’s not often that one listens to music
during presentations in order to illustrate something,
but Dr Forsyth did this very eloquently and brought
the day to a refreshing close.
Before the evening meal there was another chance to
socialise with other delegates at the drinks reception
and discover how training works in other areas of
the country. The initial absence of Dr Jerry Playfer
caused some anxiety, although this was allayed on his
arrival to a warm round of applause during the
second course. After dinner there was an open
session with Dr Playfer around the issue of what the
BGS can do for Trainees. This was continued in the
bar afterwards, and by some accounts into the small
hours of the morning.
On the Sunday morning Drs Oliver Corrado and
Chris Turnbull took the meeting through the
current changes with Modernising Medical Careers.
There was general agreement that they made a very
complicated and contentious issue much clearer, with
opportunity for questions and debate. At this time of
great change geriatricians need to use MMC to create
opportunities for the specialty to promote itself and
recruit high quality physicians to the field.
After coffee, Dr Jayne Wainwright gave a
comprehensive presentation on Stroke, with
particular emphasis on management issues and an
intriguing glimpse into future treatment options and
opportunities.
The final session of the meeting was introduced by
Dr Jessica Beavan. Dr Jonathan Treml describing
from first hand the highs and lows of starting as a
consultant geriatrician in the NHS. He provided great
tips, including advice about interview preparation
and what to do (and what not to do) on commencing
a post.
Feedback from the delegates was unanimously
positive. The weekend was a huge success, and plans
are already in place for another similar event next
year; so watch this space!
Our thanks to speakers and delegates for attending
the event and to Sanofi-Aventis for their invaluable
support.
Sandy Thomson
SpR Geriatric Medicine
North-Western Deanery
30 BGS n e w s
July 2006
BGS Autumn meeting 2006
Harrogate International Centre - 4-6 October
he Society’s forthcoming Autumn
Meeting will once again be held in
Harrogate.
T
This has proved an excellent venue for the past
two years, providing modern facilities and plenty
of space in the setting of this lovely old
Yorkshire spa town which combines history and
scenery with shopping and Betty’s Tea Rooms.
In keeping with the Betty’s tradition, we have
prepared a “layer cake” of essential clinical
updates, filled with original research and iced
with innovative thinking from some of our
specialty’s most inquiring minds.
The meeting opens on Wednesday 4th with a halfday symposium on Clinical Effectiveness
Evaluation (CEE). Speakers include the Chair of
the NICE Technology Appraisals Committee and
the Director of the CEE Unit at the RCP. The
focus will be on how CEE has developed,
incredibly rapidly, in recent years to drive forward
implementation of evidence-based improvements
in service delivery and patient management in
Geriatric Medicine.
Thursday 5th has a packed programme of clinical
updates covering Valvular Heart Disease,
Cataract, Depression and Paranoid States, Lung
Cancer, Myelopathy and Constipation. All these
sessions are leavened with research presentations
chosen from the best original work currently
pushing our specialty forwards.
This year’s Marjory Warren guest lecture is
given by the distinguished geriatrician Professor
Colin Powell from Halifax – Nova Scotia, not
West Yorkshire. He will use the example of Dr
Warren herself, whom he knew personally, to
challenge us to consider the future direction of
our specialty. After lunch, the SIGs and Sections
will cover topics in Medical Ethics and Drugs
and Prescribing. There will also be plenty of
opportunity to visit the Exhibition area and
discuss the Research and Clinical Effectiveness
poster presentations with their authors. Each day
of the meeting will be book-ended by Sponsored
Symposia, which this year cover Parkinson’s
Disease, Dementia, Pain, Restless Legs and
Osteoporosis.
On Thursday evening, the Society’s Dinner will
be held at the Majestic Hotel, where the food has
been consistently excellent, affording delegates
further opportunities to network and socialise
with colleagues from home and abroad. Our
after-dinner speaker needs no introduction to
many of our members – Professor Ray Tallis is
a colossus in our specialty whose deep insights
on the philosophy of the mind and the future of
healthcare have been widely published.
On Friday morning we have parallel sessions on
Venous Thromboembolism and Modernising
Medical Careers. The Trevor Howell lecture will
be given by Professor Cillian Twomey from
Cork, who will take us on a journey through the
development of geriatric medicine in Ireland.
The final session of the meeting is a Symposium
on hepato-biliary disease covering developments
in hepato-biliary surgery, liver failure and the
perennial conundrum of what to do about
abnormal liver function tests.
Our colleagues from abroad
As always, we extend a warm invitation to our
colleagues from Europe and beyond. We value
their participation at our meetings. Presenters
from developing countries are also reminded that
the BGS waives the registration fees. See the
BGS website for more information.
For young doctors and SpRs who have been
accepted to present work at the BGS Autumn
meeting, but who are unable to secure study
leave allowance, the BGS offers help here too.
n e w s BGS 31
July 2006
Harrogate,
England’s floral
town.
houses dominate a charming market town
perched on high cliffs above the River
Nidd. Narrow streets and ginnels enhance
the olde world feel of the place.
Attractions abound, including Mother
Shipton's Cave and Petrifying Well,
castle ruins, Court House Museum,
boating, riverside walks and a
colourful market.
Eleven miles north of Harrogate, the
medieval city of Ripon has a
magnificent cathedral. The Ripon
Hornblower maintains a 1,100 year old
tradition by sounding his horn at the
Market Place obelisk at 9pm every evening,
"Setting the Watch".
See the
BGS
website
(select
Grants Young
Doctor’s
Education Grant) for
more information.
The Dales towns of Pateley Bridge, in
Nidderdale, and Masham, home of
Theakstons and the Black Sheep Breweries
beside the River Ure to the north, are well
worth a visit, as are Aldborough, with its
extensive Roman remains, and the neighbouring
town of Boroughbridge, once an important
coaching post on the Great North Road from
London to Edinburgh.
Harrogate and surrounds
While some people (especially we Southerners
who have so long benefited from being close to
London where the Autumn meeting was held for
so many years) have grumbled that Harrogate is
not easy to reach (one has to change at York, if
coming by train), the visit to Harrogate and
Yorkshire makes the trip worthwhile. Harrogate
itself is known as England’s floral town, with a
rich spa heritage and dignified architecture.
Harrogate town centre is very “shopper friendly”
with a wide range of shops in relatively
pedestrianised areas to make for pleasant
browsing or some serious retail therapy.
The surrounding countryside is one of the most
spectacular in England - Knareborough, just a
few minutes from Harrogate, where Georgian
Helpful Websites:
Natural wonders include Brimham Rocks,
consisting of ancient outcrops of weathershaped millstone grit and the subterranean
splendours of Stump Cross Caverns. Great
houses, parks and gardens of worldwide renown
include Ripley Castle, Rudding House and
Newby Hall.
Other attractions within the Harrogate District
include Fountains Abbey and Lightwater Valley
Theme Park and just beyond its borders, yet well
within reach of visitors, are such delights as
Harewood House, Castle Howard, the City of
York, Bronte Country ... the list is limited only by
the time.
I hope you will agree that the programme has
something for everyone, both in meeting your
CPD requirements and in stimulating the mind. I
look forward to welcoming you to Harrogate in
the Autumn.
www.yorkshirenet.co.uk
www.bgs.org.uk (Select Notices/Autumn Meeting)
Juanita Pascual
Meetings Secretary
32 BGS n e w s
July 2006
Chronic Venous Leg Ulcers
Invitation to participate in clinical trial
As readers are no doubt aware, venous leg
ulcers exert a huge morbidity on patients
affected with chronic venous disease and can
cause deterioration in patient’s quality of life.
Four-layer bandaging is the gold standard for
treatment of acute venous ulcers. If patients
don’t respond to compression in the first 12
weeks of treatment it
is of limited benefit
thereafter. Treatments
of chronic venous
ulceration are at the
forefront of wound
healing research and
development.
There have been
many developments
over the years to
improve healing. We
at Intercytex share
your enthusiasm for
improving on existing
wound care for this patient group. Intercytex is
a UK based, cellular therapy company and we
are developing a unique wound healing
PUBLICATIONS INFORMATION
The BGS Newsletter is published every second
month by:
British Geriatrics Society
Marjory Warren House, 31 St John’s Square, London EC1M 4DN
Tel: 020 7608 1369 Fax: 020 7608 1041 Url: www.bgsnet.org.uk
Email: editor@bgsnet.org.uk
The opinions expressed in articles and letters in the BGS
Newsletter are the views of the authors and contributors, and
unless explicitly stated to the contrary, are not those of the British
Geriatrics Society, its management committee or the
organisations to which the authors are affiliated.
The mention of trade, corporate or institutional names and the
inclusion of advertisements in the Newsletter does not imply
endorsement of the product, post or event advertised.
©British Geriatrics Society 2006
Production: Recia Atkins
application specifically to treat persistent
venous leg ulcers. In previous studies Expert
Wound Care Hospital Clinical Teams
discovered that by delivering young cells to
their patients, contained in the Intercytex gel
normal, natural healing of the skin could be
restored. The cells in the gel produce growth
factors that in turn
stimulate wound
healing. 80% of ulcers
treated showed
significant
improvement in the
previous trial.
Intercytex is now
running an
international clinical
trial for this product,
which it has called
ICX-PRO, at leading
centres in the United
Kingdom, Canada and
USA. The trial is designed to treat 20% of
patients who have not responded to current
clinical treatment. 216 patients will be enrolled
into the study that is designed to prove this new
treatment works.
In the UK, Intercytex has started the next phase
of the trial in Wirral, Manchester, Dudley,
Birmingham, Bradford and Leeds. The sites are
currently looking for patients with leg ulcers
which are currently being treated with
compression bandaging and have persisted for
more than 3 months.
If you live in one of these regions and would be
interested in participating in this trial, please
contact our information line on 0800 032 9945.
Alternatively if you have a large population of
patients who would benefit from participation in
this trial, you run a dedicated leg ulcer clinic,
have clinical trial experience and are interested
in becoming a site for this trial then please
contact Intercytex clinical team direct on 0161
904 4564.