Care of older people is becoming more complicated. GPs now play a crucial part in managing older patients with multiple comorbidities, addressing polypharmacy and tailoring management plans to the individual’s specific needs.
Managing expectations is essential in elderly care and may be the key to a successful outcome.
How GPs approach the assessment of the elderly patient depends on a number of factors, including the patient’s capacity to make a decision regarding a specific treatment, and whether the patient visits the surgery, is housebound or in a residential, nursing or elderly mental healthcare setting.
Challenges for GPs
Assessing elderly people in 10 to 12 minutes is challenging. There are generally numerous presenting problems, which may or may not interplay with each other.
There are also likely to be medical problems in the background, which may be relevant. They may involve one system or multiple systems.
A number of specialties may be involved in the patient’s care, and co-ordination of information may be vital to achieve a desired plan.
Polypharmacy is an increasing problem and may be the root cause of the symptoms presented to you.
A relative or friend of the patient could be raising concerns, so a third party history may be crucial.
The presence of advance decisions to refuse treatment, emergency healthcare plans and do not resuscitate orders may also directly influence the patient’s management.
Increasingly, GPs see elderly patients at home. House calls can prove invaluable when observing how patients are functioning in their environment, but it can prove tricky to examine the patient and co-ordinate investigations. Much depends on the resources available in your community.
Making an assessment
GPs may face a range of difficulties in assessing the older patient. For example, the history can be vague. Patients may not recollect how long symptoms have been present and if they have been investigated.
It may not be clear to the GP which specialties are involved in the patient’s care and delays in letters from secondary/tertiary care can make it difficult to know how to proceed. Incomplete coding may lead to an inaccurate history.
Physical symptoms, such as weight loss, thinning skin or dry mouth, may be normal symptoms for the patient’s age. Signs such as chest crackles, bruising or skin changes may be misinterpreted.
It may be difficult to interpret the relevance of laboratory results and their abnormalities, for example, slightly elevated ALT levels, vitamin D insufficiency, slightly elevated ESR or reduced Hb.
There may be discrepancies in the history from the patient and their relatives. Relatives may be far more concerned than the patient and this can lead to over- or under-investigation of symptoms.
GPs should not assume that the patient understands the outcome of the consultation. The Mental Capacity Act teaches us to assume capacity, but elderly patients may function very well day to day while lacking capacity to make a specific decision about therapy. This may only become apparent when the clinician investigates further.
The patient’s social situation needs to be explored, to discover if it warrants an increase in social care, rather than medical input.
At the surgery
When assessing an elderly patient at the surgery, there are certain key things that GPs should be alert to, by asking specific questions.
Begin by establishing a problem list and gaining some awareness of any previous investigations.
Look at the patient’s medication list and symptoms that could be attributable to these, such as statins and myalgia, calcium-channel blockers and swollen ankles, antihypertensive agents and falls, metformin and GI side-effects.
Find out how the patient receives their medications. Do they use a dosette box or blister packs?
Are other specialties involved in the patient’s care? Notes from the past few consultations or letters will help to clarify this.
Are other team members involved, such as the community matron, social worker, district nurse and safeguarding team?
Investigate whether the patient has any background of cognitive impairment.
Do they have family and/or live alone? Assess their independence – for example, do they still drive? Are there any carers involved?
Discuss with the patient what expectations they have of the
symptoms they present with. Find out if they have made an advance decision to refuse treatment.
|Table: Common drug side effects|
|Drug class||Common side effects|
|Antiplatelet agents||Bleeding, bruising and upper GI problems|
|Antihypertensives||Pre-syncopal symptoms and thus increased falls risk Electrolyte imbalances|
|Analgesics||Sedation, dry mouth, blurred vision, constipation, nausea|
|Bisphosphonates||Upper GI problems such as oesophagitis|
|Calcium channel blockers||Swollen ankles|
|Proton pump inhibitors||Diarrhoea|
NB: Drugs that could cause acute kidney injury can be remembered as those `DAMN drugs’ (diuretics, ACE inhibitors, metformin and NSAIDs)
At the patient’s home
When assessing elderly patients at home, the key questions to consider are:
- Are they permanently or temporarily housebound?
- What is their problem list?
- Who is at home with them?
- Is any carer stress evident?
- What sort of house is it?
- Do they have any external carers? If so, are there any handheld notes?
- Is there any evidence of hoarding medication?
- Are other health or social care professionals involved, such as social workers, district nurses, secondary care, meals on wheels and/or a pharmacist?
- Is there an emergency healthcare plan?
- Is a do not resuscitate order in place?
- Can the problem be managed at home, or will additional social support, or hospital admission, be needed?
At the care home
When assessing a patient in a care home, key things to be alert to, and questions to ask, include:
- Their level of function
- Their level of capacity
- Their resuscitation status
- Is there a next of kin?
- Is there an emergency healthcare plan?
- Is a deprivation of liberty safeguard in place?
- Their past medical history
- Their medication history
Case study: Use of an advocate
An 84-year-old woman with carers once daily was noted to have iron deficiency anaemia following a blood test performed for IHD. She denied any significant symptoms.
The patient had no known next of kin. She mobilised with a Zimmer frame and attended Age UK once a week. She had mild cognitive impairment and known diverticulosis, and had lower GI investigations in 2005. She had an MI 20 years ago. She took senna, clopidogrel and lansoprazole using a weekly dosette box.
After discussion, the patient declined further investigations. It was felt at this consultation that she did not have capacity to make this decision, although she functioned well at home.
The case was discussed at the weekly practice meeting. It was felt appropriate to contact an advocate on behalf of the patient. The patient was informed and a further consultation occurred with the advocate present. The outcome was referral to the iron deficiency clinic. The carer was informed, so the patient’s post could be monitored, and this was documented in the carer’s handheld notes.
The patient underwent a gastroscopy and sigmoidoscopy two weeks later. She was found to have duodenitis and an extension of her diverticular disease and commenced on iron supplements for three months. This was added to her dosette box.
Gastroscopy was disscussed with advocate
Independent advocates should be used to help patients make decisions if capacity for that decision is felt to be a problem. In this case, it allowed greater clarity over how to manage the patient’s iron deficiency and establish a cause. Her lack of capacity to make this decision was documented in the notes.
Case study: Enabling death at home
An 80-year-old woman with Alzheimer’s disease was found to have a malignant pleural effusion and possible oesophageal primary cancer.
She lacked capacity to make any decisions and her daughter had power of attorney. The patient lived at home with her daughter, son-in-law and husband, who also had progressive dementia.
A decision was made that further investigation was not in the patient’s best interests, but the daughter wanted her mother to be able to die at home. The patient was discharged from hospital and was asymptomatic.
The GP visited, following the weekly meeting identifying high-risk discharges. A do not resuscitate order was discussed and agreed on, and an emergency healthcare plan was put in place. The
out-of-hours GP service was informed. The family were happy with the discussions. The patient had a catheter placed, so the district nurses were also involved.
The case highlights the importance of capacity and ensuring plans are in place for end-of-life care when patients choose to die at home. Resuscitation must be discussed and emergency healthcare plans should be in place to ensure everyone knows when an admission would be appropriate.
Plans must be in place for end-of-life care
Discussions included management of infections, hydration status, symptomatic dyspnoea from the effusion, nutrition and fractures. Ensuring the out-of-hours GP service is aware of these conversations is crucial for a smooth patient journey as they approach the end of life.
Dr Singh is a GP in Northumberland