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Care of the elderly involves all the primary care team

Jill E Thistlethwaite
BSc MMEd MB BS MRCGP DRCOG ILTM
Senior Lecturer in Community-Based Teaching
Academic Unit of Primary Care University of Leeds
Leeds

General practitioners are expected to offer health checks to their patients over the age of 75. A suitably trained practice or district nurse usually carries these out (Table 1). Particular attention should be paid to asking about and checking three of the most modifiable risk factors for morbidity and mortality in this age group: smoking, body mass index and exercise patterns.(2) Advice on how to modify these risk factors may lead not only to an increase in lifespan but also to a healthier old age. Elderly patients should also be offered influenza vaccination at the appropriate time.

[[NIP07_table1_36]]

Patients should be encouraged to be physically active. Brisk walking is beneficial, as are gardening, dancing and bowling.(3) People with poor mobility may be assessed by a physiotherapist or occupational therapist to see if walking aids would help improve mobility. Podiatrists are also a useful resource in advising on foot care and suitable shoes, as well as tackling foot problems and nail care.

Common conditions requiring intervention
Ageing itself leads to certain conditions for which patients may need help and advice. Common conditions and possible interventions are shown in Table 2. The healthcare professional needs to be able to distinguish those conditions that are amenable to treatment, and perhaps therefore cure, from those related to age that require intervention to increase quality of life and/or prevent further problems.

[[NIP07_table2_38]]

For example, urinary incontinence is a common symptom, with about 32% of women over 80 years being affected. It may have a serious impact on the physical and mental wellbeing of patients, with fear of embarrassment leading to decreased activity and lack of socialisation. The treatment of causes such as urinary tract infection or atrophic vaginitis is relatively simple, while incontinence aids and pads for those with intractable problems can help restore dignity. A specialised incontinence nurse practitioner is invaluable in providing advice about such issues, with follow-up by district nurses, who should have a range of incontinence aids for helping patients. Some patients require indwelling catheters, a variety of which are available that need tailoring to the individual patient.

As about 1.5% of the British population now suffer from some form of dementia, deterioration in cognitive ability may be picked up by healthcare professionals or may be reported by concerned relatives. Memory loss is a common presenting complaint, and while it is a symptom of the dementing process, a certain amount of memory loss is also attributable to ageing. Diagnosis and management of dementia are best tackled by using a multidisciplinary team approach.

The Mini Mental State Examination (MMSE) has been commonly used to test cognitive function, though it may be influenced by verbal fluency, age, education and social class. Its length (30 questions) does have its drawbacks. Shortened forms may be used in primary care settings with only a small reduction in specificity.(4) The four items of the MMSE that are predictors of dementia are: orientation to day, spell WORLD backwards, recall three words and write a sentence. The patient should also be asked about how they are coping with routine tasks such as managing medication, using the telephone, dealing with money matters and using public transport. A combination of these questions and tests should help distinguish those patients with dementia.

It is important to remember that carers' needs and concerns are often neglected yet these carers are commonly elderly themselves.

Home visits
While a decrease in frequency of home visiting is a feature of modern general practice, visits to housebound or immobile elderly patients will always be necessary. These may be carried out by district nurses, who are in a prime position to monitor the health of such patients and to check the home for risks that could lead to injury, such as loose rugs, steep stairs and poor lighting. Home visits identify a large number of unmet medical and social needs(5) and can reduce mortality and admission to long-term institutional care.(6) The privacy of patients should be respected, however, as not all elderly people want or need to have a home assessment.

Falls
About one-third of people over the age of 65 living at home will have at least one fall a year.(7) While the many processes involved in staying upright do deteriorate to varying degrees with age, falling is often one of the first indicators of medical problems, though diagnosis is not always easy.(8) A district nurse-run programme of muscle strengthening and balance retaining has been shown to reduce the number of falls by patients over 80.(9)

Aids in the home
Care of an elderly disabled person living at home can be eased by various aids such as stair lifts, showers with seating, tap grips and ejector seats. Nurses may liaise with occupational therapists in order to assess patients' needs for such aids. Pharmacists can dispense a weekly supply of medication in Dosette boxes for ease of administration.

Conclusion
It should be remembered that the majority of the over-65s are in good health.(10) There is tremendous scope for health promotion and both primary and secondary prevention in this age group. Elderly patients should be involved in decisions about their care, with doctors and nurses respecting their wishes and treating them like their younger patients. Government policy is that older people should remain in their own homes as long as possible, and once patients do become frail and/or disabled they should be assessed for help with daily activities.

References

  1. Andrews GR. Promoting health and function in an ageing population. BMJ 2001;322:728-9.
  2. Vita AJ, et al. Ageing, health risks and cumulative disability. N Engl J Med 1998;338:1035-41.
  3. McMurdo MET. Exercise in old age: time to unwrap the cotton wool.Br J Sports Med 1999;33:295-6.
  4. Eccles M, Clarke J, Livingstone M,et al. North of England evidence based guidelines development project: guideline for the primary care management of dementia. BMJ 1998;317:802-8.
  5. Tulloch AJ, Moore V. A randomised controlled trial of geriatric screening and surveillance in general practice.J R Coll Gen Pract 1979;29:733-42.
  6. Elkan R, Kendrick D, Dewey M, et al. Effectiveness of home based support for older people: systematic review and meta-analysis. BMJ 2001;323:719-25.
  7. Campbell AJ, et al. Falls in old age: a study of frequency and related clinical factors. Age Ageing 1981;10:262-70.
  8. Swift CG. Falls in later life and their consequences: implementing effective services. BMJ 2001;322:855-7.
  9. Robertson MC, et al. Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. I. Randomised controlled trial. BMJ 2001;322:697-701.
  10. Office of Population Censuses and Surveys. General Household Survey. London: HMSO; 1982.

Resources
Age Concern
T:020 8765 7200
E:infodep@ace.org.uk
W:www.ageconcern.org.uk
British Geriatric Society
T:020 7608 1369
E:info@bgs.org.uk
W:www.bgs.org.uk
Independent Living Company- for advice and purchase of aids for the elderly, including mobility and housekeeping
T:020 8931 6000
E:sales@independent-living.co.uk
W:www.independent-living.co.uk
Manfred Sauer Limited - for continence products and advice
T:01604 588090
F:01604 588091
E:helpline@manfred-sauer.co.uk W:www.manfred-sauer.co.uk