Consultation skills - Consulting with elderly patients

It is vital that GPs feel confident when dealing with this group of patients, explains Dr Anna Cumisky.

In dementia cases, written plans to take home can be helpful (Photograph: SPL)
In dementia cases, written plans to take home can be helpful (Photograph: SPL)

It is predicted that by 2033, those aged 65 years and over will account for almost one quarter of the total population, with more than a fifth of this group aged over 85 years.

In general practice, those over 85 years have an average of four times more consultations per year than all other age groups.1 It is therefore vital for all GPs to feel confident when dealing with this group of patients despite some potential challenges. For instance, the elderly are more likely to have mobility, communication and memory difficulties and response to medication is less predictable with age.

Mobility difficulties
Many elderly patients use sticks or other walking aids. GPs can help with simple steps such as minimising the distance between waiting room and consultation room wherever possible, offering a supportive arm, ensuring chairs in the consultation and waiting rooms are sufficiently high seated and by having handrails positioned in key sites.

Medication concerns
It has been estimated that almost half of all prescribed medications are for patients older than 65 years and that more than a third of all patients aged 75 years or more take four or more prescribed drugs.2

It is not uncommon to have a patient taking 10 or more tablets each day so it is hardly surprising that, according to research, up to half of all patients do not take their medications correctly.

Some patients report difficulty in reading and understanding the instructions on the packaging, some forget to take all of their medications or become confused with the timings and rules for each prescription.

Others are more consciously non-concordant with medication, and say they dislike feeling dependent on so many tablets, they find side-effects unacceptable or do not understand the need for a medication when they feel well.

In modern general practice, there is a drive for compliance regarding medication and all medications should be fully discussed with patients. The discussion should be clearly documented and include the reasons for taking each medication, any potential alternatives, the perceived benefits and any likely side-effects.

Preparation type should be considered and liquid or dissolvable oral medication, transdermal and topical formulations should be used if necessary.

Discussion can be enhanced by providing a written summary and by offering a consultation with a relative present if there are memory concerns. Regular medication review is important as it helps ensure unnecessary medications are stopped and offers a regular point of contact to discuss any concerns.

A face-to-face appointment is especially useful following any suggested medication changes, for instance after discharge from hospital or specialist appointment. A patient should be encouraged to attend with their medications in order to identify and confirm the ones that are no longer required and to ensure that additions or substitutions are made safely.

When there are suspicions that patients may be struggling with medication, a home visit can be invaluable. Administration aids such as dosette boxes should be considered and discussed with anyone who has persistent difficulty in taking their medications.

Pharmacological effects
Drug absorption, distribution, metabolism and excretion (pharmacokinetics) and the effect on a target organ (pharmacodynamics) are altered with increasing age.

There is likely to be decreased renal and hepatic function, a relative increase in body fat with a consequential increase in lipid solubility and a reduction in the sensitivity of a target tissue.

Such changes are not uniform and individual variation makes it much more difficult to predict how an elderly patient will react to a new medication.3 As a result, it is advisable to start many new medications at a lower dose and titrate cautiously.

Reduced cognitive function
The incidence of dementia increases with age and can be worrying for both patients and their families. Complex medication schedules can be tricky to follow and should be streamlined wherever possible.

Patients with memory problems pose a unique challenge to GPs. Such patients can present well and may appear cognitively intact during a consultation but retain little of what is discussed.

To help, some elderly patients may prefer to attend with a relative but many would rather come alone, preferring to keep their health concerns private. In this case, written plans to take home and refer to later can be helpful and a follow-up telephone call could be considered.

For patients with dementia it is important to set aside time during the early stages of illness to have a full and frank discussion about the disease.

Discussion should cover the nature and expected course of the illness. The important issue of mental capacity should be raised to determine whether a patient has any strong beliefs regarding future medical care. The Mental Capacity Act toolkit4 is a useful resource to help direct this discussion.

Patients with early dementia often feel anxious and are concerned about the potential impact on their independence. The GP is in an excellent position to listen, help them with their concerns and to educate.

  • Dr Cumisky is a locum GP in Bath, Somerset
Learning points - Helping the elderly

1. Discussion about medication can be enhanced by providing written information.

2. As pharmacological effects change with increasing age, start new medications at a lower dose and titrate cautiously.

3. A frank discussion with the patient in the early stages of dementia is vital to identify the patient's wishes for future care.

References
1. NHS Information Centre.

2. Social care institute for excellence (SCIE)

3. Mangoni AA, Jackson SHD. Age-related changes in pharmacodynamics and pharmacokinetics: basic principles and practical applications. Br J Clin Pharmacol 2004; 57: 10-4.

4. BMA Mental Capacity Act toolkit.

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