Beyond traditional medical intervention: improving the health and wellbeing of older patients

As a GP with a specialist interest in geriatric medicine, I have reflected on the additional complexities that the pandemic has brought to managing our older patient population.

The central issue has been that of balancing the risk that COVID-19 poses to these individuals, with that of the risks posed by prolonged periods of social isolation and inactivity during the extended periods of restrictions. One in three older people have less energy than before the pandemic, one in four older people are not able to walk as far as before, and one in five older people agree that they are finding it harder to remember things post-lockdown.¹

Throughout the pandemic I have advised patients that, if they are able to do so, they should leave their homes on a daily basis to engage in physical exercise and social interaction in whatever form is achievable for them. As we face another winter, this simple advice is important to reiterate to all of our older patients, many of whom have found new routines that no longer require them to leave the home daily.

FRAILTY

Not all patients are able to leave their home, in which case it is important that we suggest simple and safe interventions in the home.

Prolonged inactivity in older patients can quickly lead to physical deconditioning and loss of confidence, which can subsequently put patients at risk of frailty and falls. Frailty defines the group of patients who have less physical resilience and potential to overcome an illness, and are at highest risk of falls, disability, admission to hospital, or the need for long-term care. While frailty is reversible, prevention is better than cure, and moderate and severe frailty are not an inevitability of old age.

The physiological process of ageing does not need to be detrimental to us until we are in our nineties, as long as we remain physically and mentally active. Sir David Attenborough and the Queen are examples of nonagenarians who have remained in good health and have remained physically and socially active in their later years.

When looking at interventions aimed at preventing falls, frailty, and illness, and extending life expectancy, there are two that have proven high efficacy and low cost. These are physical exercise and social interaction.

DAILY EXERCISE AND REGULAR SOCIAL INTERACTION

Regular exercise can prevent dementia, type 2 diabetes, some cancers, depression, heart disease, and other common serious conditions, reducing the risk of each by at least 30%.² A meta-analysis reviewing 308 809 individuals has shown that an individual with adequate social interactions has a 50% greater chance of survival than those without; this effect is comparable to quitting smoking.³

These interventions are as effective as many medications that we prescribe. Many of these medications result in adverse side effects and are costly to the NHS, particularly if prescribed and never taken. It is in the best interest of patients to reduce their medication burden where possible, as polypharmacy is also linked to adverse outcomes for patients. There are very few adverse effects from encouraging daily exercise appropriate to the individual, or regular social interaction.

Social interaction is innately human, and according to research is optimal in the form of interaction with friends and family versus strangers.³ Encouraging patients to reach out to their family and friends on a weekly basis may feel more achievable and motivating to them than other health interventions we suggest.

If people were aware of the importance of maintaining regular contact with their older relatives and friends, amidst busy lives and ongoing concerns about COVID-19, they may help to further embed these important routines in the lives of their loved ones.

Our practice recently set up a walking group for mild and moderately frail and socially isolated patients. We have established this in partnership with Open Age (www.openage.org.uk), who have agreed to manage and insure the event on a weekly basis. Our hope is that patients who might otherwise find such an experience overwhelming will be encouraged to attend if it is recommended and overseen by their own GP practice.

TAKING PERSONAL OWNERSHIP OF HEALTH

In the era of COVID-19, an illness that has impacted our older population more than any other group, it has never been more important to suggest to these patients steps that they can take to improve their mental and physical health.

Patients should be encouraged to take ownership of their health, and this will feel more achievable if we suggest attainable goals that have proven efficacy. It is in the interest of both patients and the medical profession to reduce the burden of frailty on the healthcare system by encouraging patients to make meaningful and sustainable changes to their lifestyles.