Editor’s view—political interference, assisted dying and multicomponent interventions

The past month has been dominated by worldwide turmoil in the wake of Donald Trump’s administration’s actions since taking office. Our journal’s Editorial Executive Committee was appalled to hear that employees of the Centre for Disease Control were ordered to retract or withdraw any articles recently submitted to medical or scientific journals that included any ‘forbidden terms’ such as gender, transgender or transsexual. The order covered articles under consideration and those already accepted but not yet published. Decisions on publication and retraction should only be made according to the highest standards of publication ethics and scientific integrity rather than authoritarian dictats. Age and Ageing will not condone any attempt to retract manuscripts or remove authors affected by the Trump administration’s ideological censorship.

Long-term care policy

If you want a practical example of how government policies can have profound effects on our practice and the lives of our older patients, our February issue includes a study by MacNeil Vroomen and colleagues showing the consequences of abrupt long-term care reforms in the Netherlands https://doi.org/10.1093/ageing/afaf018 [1]. The Netherlands is interesting in having the highest spend on publicly financed long term care of any country in the world. In January 2015 the Dutch government introduced reforms to try to ensure only those needing ‘full-time, continuous care supervision’ had publicly funded places in nursing homes. This was designed to lower spiralling social care costs but also to promote ageing in place. Did it work? The short answer is yes. Nursing home admissions fell by 20% over the next three years. They found a statistically significant rise in mortality, suggesting people were being admitted to nursing homes later in their life journey but mean survival times from admission dropped by only two weeks from 622 days before the reform to 608 days afterwards (P < .01). However, the authors report the reform’s abruptness brought considerable disruption and unnecessary transitional costs. They strongly recommend that initiatives to promote ageing in place should be implemented more gradually, with continuous systematic assessment, and that the rest of the world can learn from the experience in the Netherlands.

Assisted dying

Another issue that has become contentious and somewhat politicised in the United Kingdom is that of legalising assisted dying. We published a commentary highlighting the official British Geriatrics Society (BGS) position on the issue in our January issue https://doi.org/10.1093/ageing/afae290 [2]. A survey of BGS members showed the majority oppose legalising it, although there was a spread of opinion. It may be worth pointing out that, although Age and Ageing is the official journal of the BGS, the journal’s board maintains editorial independence. In the latest issue we publish two further thoughtful commentary articles on the debate. Our former editor-in-chief Rowan Harwood presents an impassioned plea in favour of legalising assisted dying; arguing respect for personal autonomy should be paramount https://doi.org/10.1093/ageing/afaf029 [3]. He points out that it is possible to build safeguards against abuse and that many other places have successfully legalised assisted dying without the undue problems that are usually given as reasons to oppose it. Ultimately he argues it is wrong to impose beliefs on those that do not share them, provided safeguards are in place. Meanwhile, Hopkins and colleagues explain why an older person with frailty requesting assisted dying may present a special challenge under current proposals for legislation https://doi.org/10.1093/ageing/afaf028 [4]. They argue that prognosis may be uncertain and decision-making and autonomy is often relational rather than limited to a single individual. They feel these issues need clarification in any proposed legislation and want to see evidence of the wider effects of legalising assisted dying on older people with frailty.

Trials show multi-component interventions are better

If most conditions in geriatric medicine are multifactorial in aetiology, it makes perfect sense that effective treatments may well need to be multi-component, too. This is well illustrated in our latest issue, which includes results from four randomised controlled trials. Firstly, Chang and colleagues https://doi.org/10.1093/ageing/afaf017 [5] showed that a multi-component intervention in older (aged over 50 years) community-dwelling people in rural Taiwan improved measures of intrinsic capacity even when offered to a relatively unselected population. The intervention looked for and addressed polypharmacy, sarcopenia and osteoporosis, as well as providing nutritional support and exercise training. Compared to the usual care arm and a third arm that received only usual care plus osteoporosis management, the intervention arm was happier and had higher intrinsic capacity scores at one-year follow-up. Secondly, Liu and colleagues https://doi.org/10.1093/ageing/afaf010 [6] found that combining nutritional supplementation with exercise training was significantly superior to exercise training alone in treating osteoarthritis of the knee. The supplement included glucosamine, chondroitin and rhizome drynariae. Thirdly, a trial of inter-sectoral case management of 400 older people with cognitive impairment during and after their hospitalisation failed to show significant improvements in physical function and activities of daily living https://doi.org/10.1093/ageing/afaf011 [7]. However, significant improvements in hospitalisation rates, health-related quality of life and mental health prompt the authors to conclude the intervention could yet prove very successful if better targeted according to patient need or in people with specific diagnoses. Lastly, we present a post-hoc analysis of a large Finnish trial of a multicomponent intervention involving diet, exercise, cognitive training and vascular risk monitoring https://doi.org/10.1093/ageing/afaf041 [8]. This showed the intervention was effective at improving cognitive performance in all individuals regardless of their baseline frailty status, but the pre-frail group benefitted the most. The authors suggest this is the group at which this intervention should be targeted.

Housing adaptations

An interesting analysis of the English Longitudinal Study of Ageing suggests housing adaptations slow down the development of disability in people who had good health to begin with https://doi.org/10.1093/ageing/afaf023 [9]. This contrasts with some other studies that found the most benefit in those with the poorest health. Some caution is required in interpreting the findings as causation cannot be inferred in this type of observational study, and cost-effectiveness remains unknown.

Variation in goals of care

How much better would healthcare be if doctors placed as much or greater importance to establishing our patient’s goals of care as we do to recording presenting complaints or past medical history. On behalf of the European Geriatric Medicine Society Special Interest Group in Palliative Care, Piers and colleagues surveyed goals of care and treatment limitation decisions in 23 acute geriatrics units across several European countries https://doi.org/10.1093/ageing/afaf026 [10]. They found a high degree of unwarranted variation in case-mix, goals of care discussions and treatment escalation decisions. They found statistically significant differences across European regions, though I suspect such differences would even be found within countries. Our patients deserve to have a greater say in their own care and eliminating such unwarranted variation should be a focus for cost-effective improvement work.

Declaration of Funding:

None declared.

Editor-in-Chief

References