Changing the conversation about health
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Joshua Harvey won first prize in our Michael Pittilo Essay Prize 2012. Here is his essay.

In the context of constricted health budgets and a rapidly growing population of service users with multiple long-term chronic conditions, what strategies can we as health practitioners use to encourage healthy ageing?

Placing patients at the top of the pyramid: a new model for healthy aging. 

Introduction

Mr Stevens waves at me; despite telling him not to, he has covered his arm with the entire packet of nicotine patches. Later we will explain to him why he has been coughing up blood. The sleeping patient next to him is recovering from a coronary artery bypass. Opposite him, I see a familiar pattern, diabetes, amputation, infection, debridement, infection. I ask my registrar where Mr Jones has gone. “He’s in x-ray; he slipped and broke his right femur.” As I look around bay 7 of the general medical ward I am reminded that population demographics are in a period of change with a substantial increase in the number of over 65s.I have an endless list of jobs to do. If I just could have had an hour with these patients before it was too late, my list would be much shorter, but what would I of said?

Lead a healthy lifestyle                                                      

Regular exercise is extremely important for healthy aging. Exercise has been shown to: maintain cognitive function, reduce cardiovascular risk, improve mood, reduce the risk of falls as well as other benefits.1 These benefits include many of the so called, geriatric giants, the major causes of disability in elderly populations. 

Exercise can be a daunting prospect for many elderly patients, barriers to compliance include: other time commitments, risk of injury, or lack of confidence.2It is important that health practitioners continue to provide support and encouragement for such concerns and the WHO and the Department of Health have published guidelines on possible responses to the above issues and more.2, 3

Text Box: Case Study 1 – Walk Wise
Unsafe roads and pavements can deprive the elderly of one of the most accessible forms of exercise – walking. Walk Wise, Drive Smart is a scheme in 2005 that has educated city officials and residents in North Carolina, US, which has improved the safety and walkability of many walking routes. This has had a noticeable impact on the elderly feeling safe to walk.4

Multifaceted problems demand multifaceted solutions and it is important that efforts from health practitioners do not stand alone. Public health measures play an important role in encouraging exercise in the elderly. An example of which is outlined in Case Study 1. 

A balanced diet of an appropriate calorific content is also extremely important for healthy aging. Obesity in the elderly is a particular problem: age causes an upward shift in the BMI-mortality curves – that is to say age increases the harmful effects obesity has on life expectancy.5Obesity has been linked with increased risks in: cardiovascular disease, type 2 diabetes, osteoarthritis, some cancers, hypertension among others.6A good diet is also important in preventing vitamin and mineral deficiencies e.g. iron deficiency anaemia. In line with the Department of Health’s Every contact counts initiative, a scheme which ensures all NHS staff are trained to provide information on healthy aging, initiative all Health practitioners must spend some time impressing on patients the importance of a good diet and the consequences of obesity in old age.7For patients who are not capable of cooking for themselves a public health solution is outlined in Case Study 2.

Text Box: Case Study 2 – Community Meals
An important requirement for healthy aging is a balanced diet. Some patients may not be able to provide this for themselves. The Corner Centre in Oxfordshire offers people over the age of 50 a nutritionally balanced meal in a group setting.8 In addition, education and fitness activities are provided in conjunction with the food.

The Every Contact Counts initiative also applies to other lifestyle changes, one of the most important of which is quitting smoking. Smoking is one of the most important modifiable risk factors for diseases such as cancer and heart disease.9There are already several dedicated schemes to reduce smoking such as the Quit-Kit provided by the NHS.9The importance of these schemes must be stressed by all healthcare professionals if they are to be effective.

Use preventive services

Breast, bowel, cervical and prostate cancer are all screened for by the NHS. Screening has shown considerable benefits: one study suggests that prostate screening has reduced the rate of prostate cancer death by 37%.10 It is believed that failure to attend screening is one of the biggest contributors to mortality for certain cancers.11Screening therefore remains a cost-effective way to reduce morbidity and mortality and health practitioners should encourage patients to attend screening services as well as make services accessible and well-advertised. 

Similarly the NHS Health Check programme can catch many serious diseases early. The scheme involves a health screen to assess risk of heart disease, stroke, kidney disease and diabetes to people once every 5 years between the age of 40 and 74.12

Preventative services also include immunisation programmes which are a cost-effective way of reducing mortality and morbidity. In the UK, around 600 people a year die from a complication of seasonal flu.13The NHS also has a very effective childhood immunisation program which reduces the burden of childhood illness and potential morbidity in the elderly e.g. Haemophilus influenzae B meningitis leading to lifelong mental disability, as well as providing herd immunity to the elderly. Although vaccination rates are good there is room for improvement.14It was shown that in 2011 coverage for seasonal flu in the over 65s was 72.8%, below the WHO target of 75%.15Additionally child immunizations were below target with only 84.2% of children having completed their course of Hib/MenC boosters. Health practitioners must encourage patients of all ages to use vaccination services to improve coverage. 

Take care of your mind

Cognitive impairment is one of the most expensive disabilities in the elderly due to its direct cost for the NHS but also human costs and loss of output. It was estimated in 2003 that the cost of mental illness in the UK was £77.4 billion.15 

Stroke is a big cause of disability in the elderly and diabetes increases both the risk and morbidity.16Health practitioners can reduce the incidence of stroke by employing the aforementioned strategies: the effects of diabetes, a major stroke risk factor, can be reduced through lifestyle measures e.g. diet and exercise. 

Text Box: Case Study 3 – Tea Dance
An underground movement of “tea dancing” has been spreading across London.18 Tea dances are early-evening dances where both young and old people can come and dance together. The elderly have a chance to exercise, socialise and most importantly, “show the youngsters who the real dancers are!” Dancing has been shown to decrease cognitive decline, reduce risk of falls, help weight loss and improve mood in the elderly.19,20

Depression and suicide rates are increased with aging.17Depression is a major cause of morbidity and health practitioners should have a high index of suspicion and seek specialist support for aggressive treatment. There are a number of important risk factors for depression in the elderly including: death of friends and family, chronic illness and social isolation. GPs should be aware of these risk factors and use them to trigger more specific questioning in consultations. The problem of social isolation is difficult to target solely by health practitioners and so is role for public health measures, see case study 3.

The Pyramid Model of healthy aging

The pyramid model of healthy aging visualises the necessary steps to ensure healthy ageing. The patient is at the top of the pyramid as the centre of multidisciplinary care. Each layer of the pyramid is supported by those underneath with primary care and public health measures being the cornerstones of healthy aging. 

Conclusion

Many fear that the changes in population dynamics will push the cost of health care to unsupportable levels. Old age is in itself not costly but rather it is poor health, a consequence of unhealthy aging, which is costly. In fact healthy older people are a precious resource as they are able to make important contributions to their families, communities and the economy through employment or volunteering. As medical practitioners we have not only a privileged position but a duty to influence aging for the better and thus change the stereotype of the elderly being costly. We have a responsibility to educate the elderly in how to age healthy and support them in this with the same vigour we might support a critically ill patient, after all this is what we are trying to stop them becoming. 

I saw Mr Jones later and the side rails of his bed were not up. I went over to pull them up fearing he might fall out of his bed again. He laughed, “It’s been a while since I was treated like a child, still…” He tapped on the cast covering his right leg “…a prevention is better than a cure.” How right he was. 

Joshua Harvey, Year 4 Medical student, Oxford University

joshua.harvey@balliol.ox.ac.uk

References

  1. Chief Medical Officers. Start Active, Stay Active: A report on physical activity for health from the four home countries’. Department of Health (2011).
  2. WHO. Age-Friendly Primary Health Care Centres Toolkit. WHO (2008).
  3. Department of Health. Physical Activity Guidelines for Older Adults (65+ years). Department of health. Factsheet 5 (2011).
  4. Anon. HealthAging, Improving and Extending Quality of Life Among Older Americans, National Center for Chronic Disease Prevention and Health Promotion. 2011.
  5. Elia, M. Obesity in the Elderly, Obesity Research,(2001) 244-288. 
  6. Van Leeuwen, P.J. Prostate cancer mortality in screen and clinically detected prostate cancer. European Journal of   Cancer (2009).
  7. Department of Health. Every Contact Counts Guidelines. NHS (2011).
  8. The Corner. Evaluation of the Adding Life to years programme. Working paper 2 (2008/2009).
  9. Anon. http://smokefree.nhs.uk (Accessed 20/02/2012)
  10. Macnair, P. http://www.netdoctor.co.uk/health_advice/facts/obesity.htm (Accessed 20/02/2012)
  11. NHS and Cancer Research UK. Cancer Screening Programmes, Cervical Screening – The Facts, (2009).
  12. Anon. http://www.healthcheck.nhs.uk/(Accessed 20/02/2012)
  13. NHS Choices – Flu Pages –                                                          www.nhs.uk/conditions/Flu/Pages/Introduction.aspx (Accessed 20/02/2012)
  14. NHS Immunisation Statistics England, The Information Centre (2010-2011).
  15. The    Sainsbury Centre for Mental Health. The economic and social costs of mental illness, Policy paper 3 (2003). 
  16. Megherbi, S.E. Association between diabetes and stroke     subtype on survival and functional outcome 3 months after        stroke: data from the European BIOMED Stroke Project.     Stroke, (2003) 288-94. 
  17. NIH. National Institute of Mental Health, Older Adults: Depression and Suicide Facts (2007).
  18. Baird, S. http://www.timeout.com/london/alternative-nightlife/features/4775/Tea_dances_in_London.html (Accessed 20/02/2012)
  19. Vergese,J.D. Cognitive and Mobility Profile of Older Social Dancers, J Am Geriatr Soc.  (2006) 54(8) 1241-1244. 
  20. Earhart, G.M. Dance as Therapy for Individuals with Parkinson Disease. Eur J Phys Rehabil Med, (2009) 45(2) 231-238.