Better care for older people from a GP perspective (Part 1 of 3 Part series)

Author: Dr Chris Bollen (MBBS MBA FRACGP FACHSM MAICD)

The Intergenerational Report released in 2015 highlighted that people are living longer, and many GPs would recognise the rapidly increasing numbers older people in our practice populations. The NSW population has 16 per cent of people aged 65 years and older, yet the care of community dwelling older patients comprises a larger proportion of the workload for GPs. For example, the BEACH study in 2013 showed patients aged 65 years or more accounted for 30 per cent of general practice encounters.

Older patients are a complex group. At least 50 per cent of people aged 75 years or older take eight or more medications, and 30 per cent having Chronic Kidney Disease stage 3a or worse (eGFR less than 60 mL/min). Consider the challenges of delivering safe and effective care to this group in your practice if CKD is not identified by your prescribing software!

 

A major issue for about 10-15 per cent of older people is the concept of “frailty”, a subset of functional decline, and reflects the inability to perform usual activities of daily living due to weakness, reduced muscle strength, and reduced exercise capacity.

What is frailty?

There are many definitions and tools – clinical, research, simple and complex, functional only or a combination of both functional and cognitive. Frailty can be defined as “Functional and/or Cognitive vulnerability”, and may have one or more of the following features:

  • Cognitive decline
  • Falls and low trauma fractures
  • Deteriorating gait
  • Chronic Urinary incontinence
  • Multiple medical problems (especially > 85)
  • Polypharmacy and medication side effects.

Frailty can also be seen as a multidimensional deterioration of function in cognitive, physical, and social domains. The chronic condition known as “Frailty” occurs due to a combination of deconditioning and acute illness on a background of existing functional decline and is often under recognised. Frailty and functional decline are core factors for attendance at Emergency Departments, admission to hospital and premature entry to residential aged care facilities after an acute illness.

A “wellness model” of primary care based rehabilitation and/or restoration for older people is possible when general practice and community aged care providers collaborate to improve outcomes for older people. The evidence now shows that such intervention results in:

  • Improved quality of life for older people
  • Reduced functional decline
  • Reduced cognitive decline
  • Reduced hospital admission

How do you recognise "frailty"?

Awareness of frailty and associated risks for adverse outcomes, and an understanding of its biological basis, can improve care for this vulnerable subset of patients. Although there is no gold standard for detecting frailty in older adults, several new evidence-based frailty screening tools have been developed. These tools assess deficits including diseases signs, symptoms, laboratory abnormalities, cognitive impairments, and disabilities in activities of daily living.

Best practice in the care of older people is well described in the excellent publication “Fit For Frailty”, which is a joint collaboration between the British Geriatric Society and the UK Royal College of General Practitioners. Two easy to implement practice-based tips which are worth adding to our consultations, care plans and/or health assessments for anyone over 75 are the FRAIL screen, and weighing older people at every consultation.

Remember the simple questions for the FRAIL screen from Professor John Morley (which requires a yes/no response).

Fatigue-are you feeling tired or fatigued? (yes-score 1)
Resistance- can you walk a flight of stairs? (overcoming the resistance of body weight against gravity) (no-score 1)
Ambulation- can you walk around the block? (no-score 1)
Illnesses- 5 or more chronic conditions? (yes-score 1)
Loss of weight of 5 per cent or more over past 6 months? (yes-score 1)

Scoring: If the older person scores 2, they are pre-frail, 3+ indicates they are frail and would benefit with immediate referral to community based restorative care program.

Is there room for improvement in your practices' 75+ Health Assessment?

CESPHN has developed a pdf Clinical Audit “Self-assessment 75+ Health check” (161 KB)  to help GPs and the practice team identify whether there is room for improvement in their general practice’s 75+ Health Assessment. This QI activity attracts 40 category 1 points from the RACGP. Designed by Dr Chris Bollen, this is a great team-building exercise, as it can be done with a group of GPs and nurses discussing improvements in the “process of care” in your practice.

What assisstance can the Staying Well at Home team provide

The Staying Well at Home team can assist your practice by demonstrating how to identify at-risk patients in your practice using extraction tools. For more information please contact the ‘Staying Well at Home’ team Kim Sherman k.sherman@cesphn.com.au or Jason Phillips j.phillips@cesphn.com.au

More information in next weeks e-news; Part 2: Who is at Risk of Frailty in my practice? and What can you do about Frailty?