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Clinical guidelines

Guidelines for preventive activities in general practice 9th edition

5. Preventive activities in older age

Older people are at increased risk of multiple chronic conditions that may impair their function and quality of life. Those living alone, with difficulties accessing healthcare, with poor mobility and with limited financial support are particularly vulnerable.1 Their health problems may be exacerbated by poor nutrition, poor oral health,2 lack of physical activity,3 taking multiple medications4,5 and lack of sun exposure,6 all of which can be addressed in preventive activities.

Older people may rely on the help and support of carers and family. Carers, particularly carers for people with dementia or depression, are at risk of depression, anxiety, emotional distress, loneliness and isolation, but their healthcare needs are often overlooked.7–11 Their need for support should be assessed when possible (C) and appropriate referral instituted.12 Carer support resources are helpful for carer wellbeing and may delay the need for the older person who is receiving care to be relocated to a residential facility.7,13–15

People should be advised to plan as much as possible for their care as they get older to prevent family disruption in episodes of illness as well as unpleasant and undesired acute care interventions. This includes organising wills, financial enduring power of attorney, and the equivalent documentation for health and care (called enduring guardianship in some jurisdictions), and an advance care plan.16

The Royal Australian College of General Practitioners’ (RACGP) position statement on the incorporation of advance care planning into routine general practice is available here

Medication-related problems may cause unnecessary hospital admissions, adverse drug reactions and other adverse outcomes for older people living in the community.17 General practitioners (GPs) should review medications in older people, particularly for vulnerable groups. Vulnerability factors include:

  • recent discharge from hospital or other facility
  • significant changes made to medication treatment regimen in the past three months
  • high-risk drug groups (eg those with a narrow therapeutic index and those that cause xerostomia)
  • confusion/cognitive impairment or dementia
  • other causes of difficulty managing medications including literacy, language issues, dexterity problems, sight impairment
  • inability to manage therapeutic devices
  • history of falls
  • currently taking five or more regular medications
  • taking >12 doses of medication per day
  • patients attending multiple doctors including GPs and specialists
  • disease states where medication management is an important process of care (chronic kidney disease, congestive cardiac failure)18
  • multiple chronic medical problems
  • regular use of alcohol
  • previous adverse drug reaction
  • anticholinergic load.

GPs may consider a medication review, in particular focusing on reducing medications and anticholinergic load. The most successful interventions were delivered by small numbers of pharmacists working in close liaison with primary care doctors (III, C).19 The review should include consideration of the need for each medication; issues around patient compliance and understanding of the medication; screening for side effects, particularly falls and cognitive impairment; and consideration of the use of aids such as dosette boxes and Webster packaging. A review of the combined anticholinergic and sedative loads of the medications may also be done, as anticholinergic and sedative loads increase the rate of confusion and other adverse side effects.20–23 This process is often referred to as ‘deprescribing’.24

References

    1. Elwan A. Poverty and disability: A survey of the literature. Washington, DC: World Bank, 1999. Available at http://siteresources.worldbank.org/INTPOVERTY/Resources/WDR/Background/elwan.pdf [Accessed 16 December 2015].
    2. Petersen PE, Yamamoto T. Improving the oral health of older people: The approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol 2005;33(2):81–92.
    3. Warburton DE, Nicol CW, Bredin SS. Health benefits of physical activity: The evidence. CMAJ 2006;174(6):801–09.
    4. Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. Am J Geriatr Pharmacother 2007;5(4):345–51.
    5. Kharicha K, Iliffe S, Harari D, Swift C, Gillmann G, Stuck AE. Health risk appraisal in older people 1: Are older people living alone an ‘at-risk’ group? Br J Gen Pract 2007;57(537):271–76.
    6. Holick MF. Sunlight and vitamin D for bone health and prevention of autoimmune diseases, cancers, and cardiovascular disease. Am J Clin Nutr 2004;80(6 Suppl):1678s–88s.
    7. Department of Health and Ageing. The carer experience: An essential guide for carers of people with dementia. Canberra: DoHA, 2002.
    8. Argimon J, Limon E, Vila J, Cabezas C. Health-related quality of life in carers of patients with dementia. Fam Prac 2004;21(4):454–57.
    9. Hare P. Keeping carers healthy: The role of community nurses and colleagues. Br J Community Nurs 2004;9(4):155–59.
    10. Mafullul Y. Burden of informal carers of mentally infirm elderly in Lancashire. East African Med J 2002;79(6):291–98.
    11. Smith L, Norrie J, Kerr SM, Lawrence IM. Impact and influence on caregiver outcomes at one year post-stroke. Cerebrovasc Dis 2004;18(2):145–53.
    12. Bruce D, Paley G, Underwood PJ, Roberts D. Communication problems between dementia carers and general practitioners: Effect on access to community support services. Med J Aust 2002;177(4):186–88.
    13. Australian Bureau of Statistics. Disability, ageing and carers, Australia: Summary of findings. Canberra: ABS, 2012. Available at www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/4430.0Main+Features12012?OpenDocument [Accessed 15 December 2015].
    14. Droes R, Breebaart E, Meiland FJM, van Tilburg W. Effect of meeting centres support program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health 2004;8(3):2001–11.
    15. Marriott A, Donaldson C, Tarrier N, Burns A. Effectiveness of cognitive-behavioural family intervention in reducing the burden of care in carers of patients with Alzheimer’s disease. Br J Psychiatry 2000;176:557–62.
    16. Fried TR, Bullock K, Iannone L, O’Leary JR. Understanding advance care planning as a process of health behavior change. J Am Geriatr Soc 2009;57(9):1547–55.
    17. Jano E, Aparasu RR. Healthcare outcomes associated with beers’ criteria: A systematic review. Ann Pharmacother 2007;41(3):438–47.
    18. Easton K, Morgan T, Williamson M. Medication safety in the community: A review of the literature. Sydney: National Prescribing Service, 2009.
    19. Holland R, Smith R, Harvey I. Where now for pharmacist led medication review? J Epidemiol Community Health 2006;60(2):92–93.
    20. Lechevallier-Michel N, Molimard M, Dartigues JF, Fabrigoule C, Fourrier-Reglat A. Drugs with anticholinergic properties and cognitive performance in the elderly: Results from the PAQUID Study. Br J Clin Pharmacol 2005;59(2):143–51.
    21. Gray SL, Anderson ML, Dublin S, et al. Cumulative use of strong anticholinergics and incident dementia: A prospective cohort study. JAMA Intern Med 2015;175(3):401–07.
    22. Kalisch Ellett LM, Pratt NL, Ramsay EN, Barratt JD, Roughead EE. Multiple anticholinergic medication use and risk of hospital admission for confusion or dementia. J Am Geriatr Soc 2014;62(10):1916–22.
    23. Salahudeen MS, Hilmer SN, Nishtala PS. Comparison of anticholinergic risk scales and associations with adverse health outcomes in older people. J Am Geriatr Soc 2015;63(1):85–90.
    24. Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: The process of deprescribing. JAMA Intern Med 2015;175(5):827–34.
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