Download The changing face of care of the elderly

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The changing
face of care
of the elderly
The vital work GPs do in providing
care for older people living in
nursing homes may require more
advanced care planning and less
‘fire fighting’. Eimear Vize reports
More than one in 10 people in Ireland are aged over 65
and this figure is expected to double to more than one million people by 2035, with the greatest proportional increase
occurring in the 85-plus age group.1
People are living longer due at least in part to advances
in medical science and technology, but with this welcome
development comes a growing complexity of healthcare
needs for an ageing population. While the majority of older
people can continue to live at home with HSE or family support, approximately 21,0002 reside in the country’s 450 or
so registered nursing homes.
The long-term care of older people in residential and
nursing homes places major demands on GPs.
Approximately 70% of residents are classified as ‘high/
maximum dependency’ and more than six in 10 have
dementia, Dr Brian Meade, Dublin GP told a recent
ICGP Care of the Elderly Symposium. A high percentage
of patients in nursing homes have multiple chronic morbidities requiring complex medication regimens to treat
each condition, which can present numerous challenges
for the medical practitioner, and also places this group at
increased risk of experiencing an adverse drug reaction.
“This work is more challenging than mainstream general
practice and without the availability of agreed guidelines
or treatment protocols to guide GPs in caring for patients
in nursing homes and long-stay residential care. Where
chronic disease management guidelines do exist they can
be difficult to apply in frail elderly patients with a limited
life expectancy,” Dr Meade told Forum.
Two full-day symposia organised by the College in Mullingar and Dublin examined clinical and logistical issues
facing GPs with nursing home patients.
Dr Meade highlighted the need for more formal structures
surrounding GP nursing home visits.
“For a lot of GPs, calls to nursing homes are often done at
lunchtime or at the end of the surgery when they are tired or
under time pressure. The temptation to prescribe an antibiotic or sedative drug is strong. Dealing with elderly patients
in nursing homes can be time consuming. If possible, it
is better for a GP to focus on a small number of nursing
12 FORUM May 2013
homes and organise regular visits at which all issues can
be dealt with in an organised fashion. This cuts down on
frequent unscheduled visits, out-of-hours visits, and telephone consultations from nursing homes,” he said.
This call to regulate patient/doctor visits in nursing
homes, which could ultimately pre-empt potential medical
complications and avoid hospital transfers, was echoed in a
presentation another Dublin GP, Dr Liam Lacey. With more
than three decades of experience as a GP, and the past
eight years as CEO of four nursing homes in the greater
Dublin area, Dr Lacey has approached these treatment and
management challenges from both sides of the fence. The
key, he says, is to replace ‘fire-fighting’ with advanced care
planning.
“It’s not a secret that people are more ill and dependent
when they go into nursing homes, so our first priority is to
develop the expertise of the medical people coming in to
care for these patients so that we do not have occasion to
transfer people to hospital as much as normally.
“In our nursing homes, we have organised ward rounds
during which the GP will visit each patient, accompanied
by the clinical nurse manager or the assistant director of
nursing. We have also formulated a pre-visit programme so
that, prior to the doctor’s visit, the nurse on duty will have
recorded information such as pulse, blood pressure, temperature, urinalysis and glucose stick. These rounds take
place up to three times a week; patients are monitored very
closely so that we can catch any complications early and
avoid hospital transfer,” explained Dr Lacey.
Routine ward rounds are coupled with quarterly health
checks on individual patients. In addition, a drugs and therapeutics committee conducts a full review of medication on
a three-monthly basis.
Epidemiological data from Europe indicates that people
aged 65 and older take 2.3 times more medication than
younger counterparts,3 which can prove problematic on
several levels, including a greater potential for ADRs and
drug interactions, as well as an increased risk of inappropriate prescribing. Also, age-related pharmacokinetic changes
can alter drug absorption, distribution, metabolism and
excretion. For example, many elderly patients have renal
impairment, which affects drug absorption and excretion
and can alter blood drug levels.
Potential inappropriate prescribing is a major area of concern and has been implicated as a substantial burden to
health services internationally. A study in older residents
in nursing homes found that almost three quarters (73%)
of residents in Ireland had at least one potentially inappropriate medication identified by STOPP criteria and more
than half (54.3%) had at least one identified by the Beers’
criteria.4
Dr Siobhan Kennelly, consultant geriatrician in Connolly
Hospital, Blanchardstown, offered guidance through this
potential medication minefield. She highlighted issues
that should be considered when prescribing and reviewing
medication for older patients, such as: life expectancy; the
right therapeutic approach in patients with poor prognosis; ability to swallow; and medication selection with the
most favourable risk/benefit ratio. For example, the use of
warfarin in older patients requires special consideration
because of concerns over increased risk for major bleeding
as a result of falls, as well as potential distress regarding
INR monitoring.
Not all confusion in elderly patients is dementia; delirium
should always be considered. “Any drug can potentially
cause confusion. Take a careful history of any new drug
started or any old drug stopped recently,” she suggested.
Other risk factors for the development of delirium include
dementia, pre-existing cognitive decline, dehydration,
severe illness, vision impairment, pain, faecal impaction,
urinary retention, and alcohol intoxication or withdrawal.
Dr Kennelly’s recommendation that due consideration
be given to non-pharmacological options was reiterated by
consultant psychiatrist Dr Greg Swanwick, who emphasised
that non-pharmacological measures are the cornerstone of
managing both delirium and behavioural and psychological
symptoms of dementia (BPSD).
Dr Swanwick, consultant in psychiatry of old age at Tallaght Hospital, stressed that information is the key. Before
even considering prescribing an antipsychotic, find out as
much as possible about the patient, including family structure, items for reminiscence, previous work and activities,
food likes and dislikes, personal interests, and details about
their current environment, for example, is it non-stressful
and are appropriate daytime activities provided?
A 2012 study in the UK found that psychotropic drugs,
such as antipsychotics, benzodiazepines and anticholinergic antihistamines, are prescribed much more frequently in
nursing homes than in the community.5 The drugs have the
potential to cause harmful side effects, which the researchers stated may also contribute to functional and cognitive
decline in a vulnerable group. “Where medication is indicated ‘go low and go slow’, remember to periodically review
and stop medication,” Dr Swanwick said.
Family issues
At times, dealing with patients’ families can also prove
challenging and, in some cases, family disputes can erupt
regarding treatment. “Sometimes families can have unrealistic expectations about the medical health of their loved
one and about the ability of the nursing home to provide
acute medical care,” said Dr Meade. “Family disputes are
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also not uncommon and GPs can find themselves drawn
into these.”
Stephen McGuinness,Hayes Solicitors said that while
family members are often called upon to give consent to
treatment for an incapacitated adult patient, there is actually
no legal basis for doing so. “Your duty is to the patient not
to the family. The same position applies even if there is no
family dispute as to the proposed treatment for the patient.”
Issues that should be considered when treating patients
who lack capacity, include:
• Which treatment option provides the best clinical benefit
• The patient’s past and present wishes, if known
• Whether the patient’s capacity is likely to increase
• The views of other people close to the patient
• The views of other healthcare professionals involved in
the patient’s care.
“The GP is not alone in the decision-making process. We
mustn’t forget that these patients have 24/7 cover; they
have qualified nurses, a director of nursing, assistant director of nursing, clinical nurse managers and their family.
Many of the issues that arise regarding when to switch from
active supportive therapy to palliative care do not have to
be problematic as long as the doctor addresses them in
advance by talking to the patients or their next of kin. If
you don’t talk about it then there will be no entry in the
care plan as to what the respective wishes might be,” said
Dr Lacey.
The National Clinical Programme for Older People
(NCPOP) is currently preparing a scoping document to
explore the main issues around GP involvement in nursing home care, with a view to developing a new model of
care. However, John Farrell from HIQA told the Mullingar
symposium that the nursing home provider, and not the GP,
is ultimately responsible for the healthcare and welfare of
the resident.
“As we pointed out to him at the meeting, that can’t be
done without the GP, it’s more of a team event,” said Dr
Lacey. “Increasingly, GPs are coming to terms with the
concept of primary care in a nursing home setting. Before
it was a drop-in/drop-out service and some nursing homes
had a service once a week or once a fortnight. But in order
to head trouble off at the pass you have to be much more
attentive, more proactive, and give a much more professional service. You have to be in there regularly to try to see
the changes happening.”
GPs were unified in the view that current remuneration
rates for care of patients in nursing homes does not reflect
the workload involved and inhibits the involvement of doctors in more preventative and anticipatory care.
“It leaves me at a loss as to why the Minister for Health
would cut payments by 50% for GPs who treat patients in
nursing homes and then consider taking a further 10% off
this year,” said Dr Lacey. “Yet still GPs around the country
continue to provide this vital service, so I wouldn’t think
money is high on the agenda for GPs in terms of being outspoken on the issue. But it’s a long road that has no turning,
and when it comes down to rolling out the increased management of chronic illnesses in the community, unless the
resources are made available that will never happen. And
that’s a fact the Minister is missing.”
References on request
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