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

We have been discussing frailty and improving the care of older people in general practice in this series of articles. Dementia is increasing in people of all ages across Australia. This month we help you recognise that the link between “frail body and frail mind” exists and while there is still no cure, more timely diagnosis can slow the inevitable progression if lifestyle changes are made. And yes, these changes can make a significant difference! Dementia care in general practice is so much more than prescribing cholinesterase inhibitors. The benefits of improving muscle mass, protein intake and mood as a result of detecting “frailty of the body”, all flow on to improving quality of life for people with dementia.

 

Dementia affects all ages

 

Dementia is a condition, which mostly affects older people, but there are an increasing number of people aged less than 65 who have a younger onset dementia. The 2014 film “Still Alice” featuring Oscar winning actor Julianne Moore highlights the issues of a working age person struggling with dementia.

About 10% of people at age 75, and 30% at age 85 will have some degree of dementia, mild, moderate or severe. Assess your own general practice’s level of detection and coding by searching your 75+ age group practice population list of chronic conditions, which includes dementia and chronic kidney disease. Finding this group using your software extraction tools can really make a difference.

 

Dementia is a journey

 

For the majority of people, it is a progressive condition, which means it becomes worse, slowly over time. A wonderful Australian film which describes the journey of 3 families with a loved one with dementia is http://thelonggoodbye.com.au.Knowing the journey through the patient’s eyes is important as everyone in the family is affected by the impact of dementia.

 

Screening tests for cognition changes- remember your audience!

 

You may want to try incorporating the RUDAS tool into your general practice health assessment template if many of your practice population does not have English as a first language. For this group, the usual tools such as MMSE are not sensitive or inappropriate. (RUDAS is the Rowland University Dementia Assessment Scale)

 

What can be done?

 

Currently there is no effective “cure” for any type of dementia. However, an early, or more accurately, a “timely diagnosis” can slow the progression, and allow a better quality of life. Implementing a “Mediterranean diet” plus a body and mind exercise program has evidence for slowing the disease.

Also quitting smoking, and improving blood pressure can slow the disease in the early stages.

 

Do medications have a role in dementia?

 

Medications are controversial for the treatment of dementia. The cholinesterase inhibitors (donepezil, galantamine and rivastigmine) and another type of medication, memantine, are approved for use in Alzheimer’s disease. These medications have been used to help people with early dementia to slow the progression of the disease, but it is important to remember they are not a cure. These medications make NO difference if prescribed late.

Some commonly prescribed medications may make the symptoms of dementia worse, or trigger a dementia like response. They have what is known as an “anticholinergic effect”, and reduce the amount of brain chemical (acetylcholine, a neurotransmitter) which helps messages pass between brain cells.

The following should be avoided in people with any degree of dementia:

  • Most antidepressants
  • Antihistamines
  • Opioid analgesics (including codeine and tramadol)
  • Bladder continence medications
  • Anti-diarrhoea and anti-vomiting medications
  • Statins
  • Diuretics

 

Deprescribing in older people

 

“Deprescribing” in older people can make a big impact on their cognitive and their physical performance. The wonderful thing about general practice is we can reduce medication doses slowly and regularly review the impact with our long term older patients rather than send them to hospital for this type of assistance. However, it is not always easy to know where to start! Being on “too many medicines” does worry older people. 50% of older people in Australia aged 75+ are currently taking 8+ medications every day. As an older person’s function changes, the need for some medications reduces. A guide to deprescribing can be found at: http://www.cpsedu.com.au/uploads/Documents/Deprescribing/Quick%20Reference%20Guide%201115%20V3.pdf

 

Activity can slow progression of dementia!

 

Exercise and physical activity improves muscle strength, mobility, mood, and blood flow to the brain, all key components of wellness in older people with, or at risk of both frailty and dementia. While more evidence is needed, it appears the best effect comes from multimodal exercise programs, incorporating a range of activities such as walking, lifting weights, circuits and interval training. https://www.dementia.org.au/files/NATIONAL/documents/Alzheimers-Australia-Numbered-Publication-36.pdf

 

The carer needs support

 

For more information, contact Alzheimer’s Australia, an organization dedicated to supporting people and their families with dementia. The National Dementia Helpline 1800 100 500 can help with services and supports for people with or worried about dementia. The web site https://fightdementia.org.au has invaluable information, and specific links to each state.

 

Are your General Practice resources older people friendly?

 

The main goal for older people is to stay independent for as long as possible, and physical activity is seen as key to achieving this. Overall people are clearly engaged in the concept of physical activity but the challenge appears to be to make sure they understand how much they need to do. Older persons aged over 70 years often have an overly positive perception of their state of health in general and in particular their risk of falls.

Messages that promote health and independence may be more effective than specifically discussing falls prevention according to research released by Carolyn Loton from Juntos marketing http://fallsnetwork.neura.edu.au/wp-content/uploads/2011/03/Communicating-healthy-ageing-messages-to-older-Australians-16-to-9-Carolyn-Loton-and-Claire-Dyson.pdf

Based on the findings of the research, it is recommended to use terminology such as staying active and stable, or staying socially connected. In terms of effective engagement with an older audience, the term ‘fall prevention’ should be used with caution, as should the words ‘old’ and ‘senior’.

Participants in the study responded well to; relevant printed materials, the concept of group activities (delivered by trusted health professionals), and interventions that could be tailored to individual needs. It also helps if materials are endorsed by a credible source. Professional design people favouring larger print, colour contrast with a predominantly white background and well-spaced content works well.

 

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.

This QI activity attracts 40 category 1 points from the RACGP and it involves:

  1. Identifying 10 community dwelling patients aged 75 years or older from your general practice who have been admitted to hospital or attended a hospital ED in the last 12 months.
  2. Reviewing the circumstances pre/post the admission or ED attendance and reflecting on what could have been done differently to avoid the admission or ED attendance. Sometimes this is not immediately obvious, so it is worthwhile considering if there were factors in the preceding 6 months which could have impacted the outcome.
  3. Checking if a 75+ Health Assessment had been performed in the previous 2 years, and if this assessment included:
  • The goals of the older person
  • Cognition screening
  • Nutrition screening
  • Mood assessment
  • Fitness to drive (if applicable)
  • Comprehensive social history (communicated in all referral letters and care plans)
  • Mobility function assessment, including a record of the mobility deficits that were observed
  • The number of times body weight was recorded for the person in the previous 18 months, and if there was a trend of unplanned weight loss, what action had occurred?
  • An annual Kidney Health Check comprising Creatinine, eGFR, Blood pressure and urinary Albumin/Creatinine Ratio (ACR) and checking for any renally-cleared medications
  • The number of medicines taken by the older person and a request for a Home Medicine Review
  • Documented legal documents to support the older person’s choices in the event they lose capacity (e.g. Advance Directives).

This QI activity is great for team-building as it can be done with a group of GPs and nurses discussing improvements in the “process of care” in your practice.

 

What assistance can the Staying Well at Home team provide?

 

The Staying Well at Home team can assist your practice with this QI activity by demonstrating how to identify at-risk patients with extraction tools, please contact the ‘Staying Well at Home’ team. Kim Sherman k.sherman@cesphn.com.au or Jason Phillips j.phillips@cesphn.com.au.

 

We have been discussing frailty and improving the care of older people in general practice in this series of articles. Dementia is increasing in people of all ages across Australia. This month we help you recognise that the link between “frail body and frail mind” exists and while there is still no cure, more timely diagnosis can slow the inevitable progression if lifestyle changes are made. And yes, these changes can make a significant difference! Dementia care in general practice is so much more than prescribing cholinesterase inhibitors. The benefits of improving muscle mass, protein intake and mood as a result of detecting “frailty of the body”, all flow on to improving quality of life for people with dementia.

Dementia affects all ages
Dementia is a condition, which mostly affects older people, but there are an increasing number of people aged less than 65 who have a younger onset dementia. The 2014 film “Still Alice” featuring Oscar winning actor Julianne Moore highlights the issues of a working age person struggling with dementia.
About 10% of people at age 75, and 30% at age 85 will have some degree of dementia, mild, moderate or severe. Assess your own general practice’s level of detection and coding by searching your 75+ age group practice population list of chronic conditions, which includes dementia and chronic kidney disease. Finding this group using your software extraction tools can really make a difference.

Dementia is a journey
For the majority of people, it is a progressive condition, which means it becomes worse, slowly over time. A wonderful Australian film which describes the journey of 3 families with a loved one with dementia is http://thelonggoodbye.com.au .Knowing the journey through the patient’s eyes is important as everyone in the family is affected by the impact of dementia.

Screening tests for cognition changes- remember your audience!
You may want to try incorporating the RUDAS tool into your general practice health assessment template if many of your practice population does not have English as a first language. For this group, the usual tools such as MMSE are not sensitive or inappropriate. (RUDAS is the Rowland University Dementia Assessment Scale https://www.dementia.org.au/sites/default/files/20110311_2011RUDASAdminScoringGuide.pdf )

What can be done?

Currently there is no effective “cure” for any type of dementia. However, an early, or more accurately, a “timely diagnosis” can slow the progression, and allow a better quality of life. Implementing a “Mediterranean diet” plus a body and mind exercise program has evidence for slowing the disease.
Also quitting smoking, and improving blood pressure can slow the disease in the early stages.

Do medications have a role in dementia?
Medications are controversial for the treatment of dementia. The cholinesterase inhibitors (donepezil, galantamine and rivastigmine) and another type of medication, memantine, are approved for use in Alzheimer’s disease. These medications have been used to help people with early dementia to slow the progression of the disease, but it is important to remember they are not a cure. These medications make NO difference if prescribed late.
Some commonly prescribed medications may make the symptoms of dementia worse, or trigger a dementia like response. They have what is known as an “anticholinergic effect”, and reduce the amount of brain chemical (acetylcholine, a neurotransmitter) which helps messages pass between brain cells.
The following should be avoided in people with any degree of dementia:
• Most antidepressants
• Antihistamines
• Opioid analgesics (including codeine and tramadol)
• Bladder continence medications
• Anti-diarrhoea and anti-vomiting medications
• Statins
• Diuretics
Deprescribing in older people
“Deprescribing” in older people can make a big impact on their cognitive and their physical performance. The wonderful thing about general practice is we can reduce medication doses slowly and regularly review the impact with our long term older patients rather than send them to hospital for this type of assistance. However, it is not always easy to know where to start! Being on “too many medicines” does worry older people. 50% of older people in Australia aged 75+ are currently taking 8+ medications every day. As an older person’s function changes, the need for some medications reduces. A guide to deprescribing can be found at: http://www.cpsedu.com.au/uploads/Documents/Deprescribing/Quick%20Reference%20Guide%201115%20V3.pdf

Activity can slow progression of dementia!
Exercise and physical activity improves muscle strength, mobility, mood, and blood flow to the brain, all key components of wellness in older people with, or at risk of both frailty and dementia. While more evidence is needed, it appears the best effect comes from multimodal exercise programs, incorporating a range of activities such as walking, lifting weights, circuits and interval training. https://www.dementia.org.au/files/NATIONAL/documents/Alzheimers-Australia-Numbered-Publication-36.pdf

The carer needs support
For more information, contact Alzheimer’s Australia, an organization dedicated to supporting people and their families with dementia. The National Dementia Helpline 1800 100 500 can help with services and supports for people with or worried about dementia. The web site https://fightdementia.org.au has invaluable information, and specific links to each state.

Are your General Practice resources older people friendly?
The main goal for older people is to stay independent for as long as possible, and physical activity is seen as key to achieving this. Overall people are clearly engaged in the concept of physical activity but the challenge appears to be to make sure they understand how much they need to do. Older persons aged over 70 years often have an overly positive perception of their state of health in general and in particular their risk of falls.
Messages that promote health and independence may be more effective than specifically discussing falls prevention according to research released by Carolyn Loton from Juntos marketing http://fallsnetwork.neura.edu.au/wp-content/uploads/2011/03/Communicating-healthy-ageing-messages-to-older-Australians-16-to-9-Carolyn-Loton-and-Claire-Dyson.pdf
Based on the findings of the research, it is recommended to use terminology such as staying active and stable, or staying socially connected. In terms of effective engagement with an older audience, the term ‘fall prevention’ should be used with caution, as should the words ‘old’ and ‘senior’.
Participants in the study responded well to; relevant printed materials, the concept of group activities (delivered by trusted health professionals), and interventions that could be tailored to individual needs. It also helps if materials are endorsed by a credible source. Professional design people favouring larger print, colour contrast with a predominantly white background and well-spaced content works well.

Is there room for improvement in your practices’ 75+ Health Assessment?
CESPHN has developed a Clinical Audit “Self-assessment 75+ Health check” 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.
Please link to RACGP accredited 40 point QI activity materials: ’40 point QI Guideline’ and ‘Reflection question template’
This QI activity attracts 40 category 1 points from the RACGP and it involves:

1. Identifying 10 community dwelling patients aged 75 years or older from your general practice who have been admitted to hospital or attended a hospital ED in the last 12 months.
2. Reviewing the circumstances pre/post the admission or ED attendance and reflecting on what could have been done differently to avoid the admission or ED attendance. Sometimes this is not immediately obvious, so it is worthwhile considering if there were factors in the preceding 6 months which could have impacted the outcome.
3. Checking if a 75+ Health Assessment had been performed in the previous 2 years, and if this assessment included:
a) The goals of the older person
b) Cognition screening
c) Nutrition screening
d) Mood assessment
e) Fitness to drive (if applicable)
f) Comprehensive social history (communicated in all referral letters and care plans)
g) Mobility function assessment, including a record of the mobility deficits that were observed
h) The number of times body weight was recorded for the person in the previous 18 months, and if there was a trend of unplanned weight loss, what action had occurred?
i) An annual Kidney Health Check comprising Creatinine, eGFR, Blood pressure and urinary Albumin/Creatinine Ratio (ACR) and checking for any renally-cleared medications
j) The number of medicines taken by the older person and a request for a Home Medicine Review
k) Documented legal documents to support the older person’s choices in the event they lose capacity (e.g. Advance Directives).
This QI activity is great for team-building as it can be done with a group of GPs and nurses discussing improvements in the “process of care” in your practice.

What assistance can the Staying Well at Home team provide?
The Staying Well at Home team can assist your practice with this QI activity by demonstrating how to identify at-risk patients with extraction tools, please contact the ‘Staying Well at Home’ team. Kim Sherman k.sherman@cesphn.com.au or Jason Phillips j.phillips@cesphn.com.au