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