Although many strides have been made in recognising that older people are the key adult client group of our health services, many redoubts of tenacious ageism persist in the system.
Rarely arising from malice, the underlying gerontological illiteracy is nonetheless inexcusable among clinical programmes and healthcare managers, given what we now know about the complexity of care needed in the later stages of life.
A classic example, much bruited about in these challenging times, is that of “step-down” beds for older people in hospitals: few phrases are as likely to send a shiver up the spine of a geriatrician.
A key element of illnesses that bring older people to hospital is that they often present with, or are accompanied by, a loss of function, such as a reduced ability to walk, be continent, swallow efficiently or think straight.
In addition, the combination of illness, immobility and hospitalisation means that 30-40 per cent of older people will have a further loss of function in hospital.
These changes in function are caused by very well-recognised biological syndromes such as delirium, critical care myopathy and sarcopaenia (forms of muscle wasting), and also the effects of medications.
In former days medicine ignored these aspects, or tried to export them elsewhere in what has sometimes been described as the adversarial patient management system, one that had difficulty in dealing with patients who did not get better quickly or die quickly.
Classic novel
In the 1970s, this approach was immortalised in a classic novel about life in hospitals,
The House of God
. Here a frail older person with dementia and immobility was classified as a Gomer: Get Out of My Emergency Room. It is not hard to perceive elements of this sentiment in current discourse of older people in hospitals: GOMHs?
For what is needed for most older people who have loss of function associated with their illness is timely diagnosis and rehabilitation. If you, or an older relative, find you cannot walk as well, think as clearly, or be continent as you could prior to the illness that precipitated the hospital admission, you should clarify with the medical or surgical team as to how this is to be provided.
It may be provided in the hospital through co-ordinated multidisciplinary teamwork, in specific rehabilitation units such as those in Peamount, St Mary’s and the Royal Hospitals in Dublin, geriatric medicine day hospitals or, if co-ordinated teams exist in the community, by community rehabilitation.
It is important that such services are clearly specified as rehabilitation, as there is a specific need for clear medical leadership, and the appropriate complement of staff: physiotherapy, occupational therapy, clinical nutrition, speech and language therapists and social workers.
What is worrying about the phrase “step-down” is that it appears to be a mealy-mouthed way of avoiding the provision of the appropriate structure and staffing needed for rehabilitation: indeed, given the depredations on therapist staff in many general hospitals, off-site rehabilitation is likely to represent a “step-up”.
My own anxiety about this systematic dilettantism about rehabilitation is fuelled by the number of private nursing homes which, while providing an excellent residential service, seem to think that the provision of a few sessions of physiotherapy allows them to consider that they are providing a “rehabilitation service”.
Acid test
The acid test of any such “step-down” service is whether hospitals would send younger people – for example, young trauma victims in orthopaedic services – to them: this is highly unlikely.
This also applies to “transitional care” beds, for a tiny minority of people for whom, after appropriate rehabilitation, there is a delay awaiting home renovation or a nursing home place. The danger is the temptation for stretched hospital services to send people to these beds who actually require rehabilitation. I and other geriatricians have encountered this often.
There is a significant shortage of appropriately resourced and staffed geriatric rehabilitation units in the country, well short of the modest targets outlined in the now almost historic 1988 blueprint for healthcare for older people, The Years Ahead, and reiterated in the HSE's own Acute Model of Care Document from the National Clinical Programme for Older People launched in July 2012 by Minister of State with responsibility for older people, Kathleen Lynch.
A key priority in resolving the current bed crisis is the urgent development of such units to support general hospitals, with appropriate complements of suitably qualified staff. The private sector has not distinguished itself to date in this type of service, and it is likely that public and voluntary services are the appropriate setting for any new initiatives.
Desmond O’Neill is a consultant physician in geriatric and stroke medicine and professor of medical gerontology at Trinity Centre for Health Sciences, Tallaght hospital.