Love it or loathe it, at least understand Kaiser Permanente
Dr Adam Harper and Dr Gill Turner outline nine of the latest developments in their field
Thrombolytic therapy has established itself as an option for hyperacute anterior circulatory infarcts, with a number of units now trialling the practicalities of providing this service.
Progress with this may be hampered by the short three-hour window from symptom onset and difficulties accessing appropriate scanning, public awareness, and transportation issues.
However, stroke remains a devastating condition and we would all welcome any option that could reduce its impact.
Preventive measures, such as carotid endarterectomy for asymptomatic patients with tight carotid artery stenosis, may also make an impact1.
2. Dementia medication
The latest draft NICE guidance4 for medication in Alzheimer's disease has found that the results are too varied, with significant and varied bias, and with an unacceptable cost per quality of life year gained to recommend their use in routine practice (typically between £37,000 and £63,000 depending on choice of drug, disease severity and method of calculation.)
A lot of weight has been placed on the AD2000 trial, which was felt to most closely resemble real-life practice, and which reportedly showed no difference in time to institutionalisation between medication and placebo arms.
The economic guidance is targeted towards the care home costs covered by the NHS and PSS budgets.
Further, increasing evidence supports the role for cholinesterase inhibitors in other forms of dementia, in particular Lewy body disease, where the underlying problem is more biochemical as compared with the structural problems of Alzheimer's and cerebrovascular disease.
3. Parkinson's disease
The race is on for the first drugs to show neuroprotective properties, and also to improve the evidence base for delay of dyskinesia onset after starting L-dopa therapy.
Currently the dopamine agonists are leading the way, with further research into entacapone2.
Further developments, such as deep brain stimulation, are unlikely to become a significant option for most older patients.
This is because side-effects are more likely and cognitive problems, a contraindication to the treatment, are often present at this stage in the disease.
There is likely to be an increased use of osteoblast stimulators, such as teriparatide (a synthetic parathyroid hormone analogue), currently limited by its expense and paucity of data.
The latest NICE guidance advocates its use in patients with severe osteoporosis and those unable to tolerate a bisphosphonate. There is ongoing debate about the frequency and duration of bisphosphonate therapy.
First, there is concern over their long-term safety, with fears that excessive inhibition of osteoclasts and subsequently reduced turnover of bone will produce brittle bones (probably not a problem).
Also, the frequency with which bisphosphonates need to be given is under review, with longer intervals between treatments potentially being possible3.
5. Intermediate care and rapid response
It is increasingly apparent that large district hospitals are not the best place to care for frail older people who are ill. Certainly, while many older people need to be in hospital at the time of illness (after an MI or GI bleed, for example), recovery is often best in other environments, such as a community hospital, purpose-built recovery care unit, temporary care home placement or, best of all, in the patient's own home with increased support.
These intermediate care schemes will hopefully drive down hospital-induced morbidity rates (for example nosocomial infection, pressure sores, polypharmacy etc). As well as preventing admissions, there has also been a focus on avoiding a hospital admission when a crisis occurs in the form of 'rapid response' schemes. These offer intensive community-based rehabilitation and immediate provision of carers.
The important point, however, is to ensure that older people in these schemes still have access to appropriate expertise from geriatricians, specialist therapists and nurses.
Such teams should therefore include previously hospital-based health care professionals working in a new way.
6. Single assessment process
One of the biggest changes to impact on older people is the single assessment process currently being rolled out.
This requires a structured assessment along nationally determined (in England and Wales) guidelines of older people who appear to be vulnerable or who have evidence of impending frailty.
It also covers the sharing of information across agencies including general practice, and the NHS information strategy intends for electronic systems to be in place for this within three years (although doubt remains as to the feasibility of this).
Meanwhile, many changes to facilitate this are already happening, including the interim establishment of paper-based systems.
7. The mental capacity Bill
This is currently going through committee stage and is set to become law in England and Wales over the next year.
It will introduce three new principles:
1. The assumption of capacity and the need to use standardised methods to demonstrate incapacity.
2. The statutory establishment of advance directive or living wills. These will allow patients to determine in advance which treatments they want to refuse. It is still not clear in law after the recent judgment (Burke vs GMC) whether patients will be able to determine in advance treatments that they want to be given even if medical opinion thinks it inappropriate.
3. The ability for anyone to appoint someone to be their health attorney, who will be able to speak on matters of health for the patient or older person if they become incapable.
8. Chronic disease management
Teams dedicated to caring for the frailest older people in the community are a hot topic in the NHS.
Evidence from the US suggests such a process reduces repeated hospital admissions and other unplanned uses of health resources, as well as possibly reducing functional decline.
The pilot projects in the UK ('Evercare projects') are still in progress, though many areas are implementing schemes in advance of the results, as the theory is so compelling. The DoH of has proposed creating 'community matron' posts to facilitate this process.
9. Assisted dying Bill
A Bill going through its second reading in the House of Lords at the moment proposes the establishment in law of the concept of physician-assisted suicide.
While accepting the many safeguards in the Bill, the British Geriatrics Society remains opposed to the principle for older people because of the inherent difficulty of separating out the wants and needs of the older person, from the wants and needs (often subliminally expressed) of their families.
And on its way.... six things that the future holds
six things that the future holds
1Minimally invasive cardiac valve repair A relatively non-invasive approach would mean valvular surgery becomes an option for those currently considered unfit for open-heart operations.
2Anticoagulation without the drawbacks of monitoring warfarin The risk-benefit decisions regarding anticoagulation per se would remain complicated, but the difficulties with warfarin dosing and its interactions could be excluded from the debate. Ximelagatran, an orally active thrombin inhibitor, looks to be the most promising option at present5.
3Neuroprotection pre-stroke/dementia Some evidence of association of low folate levels predating dementia, though prospective longitudinal studies are needed. There will also be further interest in the role of statins.
4Different categorisation for Parkinsonism based on underlying protein pathology This approach could apply to the a-synuclein related disorders (eg idiopathic Parkinson's disease, Lewy body disease); Tau related diseases (frontal lobe dementia, progressive supranuclear palsy).
This also would reflect the different approaches to therapy. However, the issue is complicated by the variety of abnormal proteins and increasing number of gene abnormalities identified.
5New approach to osteoporosis
Current therapies work predominantly through bone mineralisation, though newer strategies may target collagen strengthening.
6Natriuretic peptides (BNP and ANP) Assays for these may become much more widespread as tools to aid in the diagnosis of heart failure and their analogues provide a further therapeutic option for the condition.
1 Halliday A et al. (MRC asymptomatic carotid surgery trial (ACST) collaborative group.) Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial.
Lancet. 2004 ;363(9420):1491-502
2 Clarke CE. Neuroprotection and pharmacotherapy for motor symptoms in Parkinson's disease. Lancet Neurol. 2004;3(8):466-74
3 Rodan G et al. Bone safety of long-term bisphosphonate treatment. Curr Med Res Opin. 2004 (8):1291-300
4 National Institute for Clinical Excellence. Appraisal consultation document: Alzheimer's disease donepezil, rivastigmine, galantamine and memantine.
March 2005. www.nice.org.uk
5Hirsh J et al.New anticoagulants.
Blood. 2005:105(2); 453-63
House of Commons select committee report on elder abuse www.publications.parliament.uk/pa/cm/cmhealth.htm
British Geriatric Society
Adam Harper, specialist registrar in geriatrics, Southampton University Hospitals NHS Trust
Gill Turner, consultant geriatrician, Princess Elizabeth Hospital, St Andrew, Guernsey; and honorary consultant physician, Southampton University Hospitals NHS Trust