Medical care of older persons in residential aged care facilities


The Silver Book
Medical assesment of residents
☰ Table of contents


Comprehensive health assessment


Comprehensive health assessment is the cornerstone of quality care of older people. It leads to improved identification and management of health care needs. Clinical studies have shown that older people with multiple health and functional problems benefit from comprehensive health assessment, through:23

  • reduced medication useimproved functioning or reduction in functional decline
  • improved quality of life and mental health
  • improved client/carer satisfaction and a reduction in carer burden
  • reduced use of hospital services
  • reduced need for residential care
  • decreased annual health care costs
  • prolonged survival.

The multidimensional assessment incorporates physical, psychological and social function as well as medical health, and so a multidisciplinary approach is often helpful. Assessment is generally undertaken using standardised tools, structured or semistructured proformas, and checklists24 (see Tools).

Residential aged care facilities are required to assess needs and produce care plans for all residents. These plans have a strong focus on personal and nursing care. Medicare rebates have been introduced to support GPs' participation in multidisciplinary assessment and care through doing comprehensive medical assessments and contributing to residents' care plans (see Organisational aspects of medical care).

General practitioners have reported that comprehensive medical assessment of residents is useful for giving structure to the admission process, helps to formally introduce advance care planning and to clarify who can give consent for care. However, its use needs to be flexible and appropriate to the resident's personal situation, so that it can focus on each individual's needs and contribute to multidisciplinary health assessment and care planning.25

Comprehensive medical assessment at the time of admission would include review of background information and recent investigations. Additional information can be collected from direct questioning of residents or other informants (eg. relative/carer, RACF staff), direct observation by trained health professionals, and medical records. Each information source has inherent limitations, so it is valuable to combine information from residents, RACF staff, relatives/carers and medical documents (eg. ACAS report, resident care plan, advance care plan, hospital discharge, or medical correspondence). The accuracy of information from direct questioning of older people can be limited by acute illness, impaired cognition, impaired hearing, impaired communication (dysarthria, dysphasia), depression, limited proficiency in English, fear of significant change to lifestyle, and denial of problems. Most people admitted to residential care have some cognitive impairment, therefore it is advisable to seek collateral information as a matter of course from relatives/carers and RACF staff. Use direct observation and assessment from other health professionals and geriatric assessment services for patients with very complex problems or unstable conditions. For example, physiotherapists assess gait and balance, occupational therapists assess activities of daily living, speech pathologists assess swallowing, pharmacists perform medication reviews, and nurses assess continence.

When conducting a comprehensive medical assessment, it is desirable to see residents earlier in the day when less tired, sitting out of bed facing you at a similar level in a quiet well lit environment. Endeavour to ensure that any needed spectacles are readily available (and clean) and that hearing aids, if needed, are functioning. Complete the assessment over several visits if necessary. Ask what they consider the main problem is and their goals for care. Seek permission to gain further information from relatives/carers and other sources, and to share health information with other relevant service providers.26 It is important to respect patient autonomy by fostering understanding, avoiding coercion, and recognising the right of residents to reject advice or refuse the communication of personal information to others.27

Ethnic groups differ widely in their approach to decision making (ie. involvement of family and carers), disclosure of medical information (eg. cancer diagnosis), and end of life care (eg. advance care planning and resuscitation preferences).28 Also, wide differences appear among individuals within ethnic groups, therefore, in caring for patients of any ethnicity:29

  • use the patient's preferred terminology for their cultural identity in conversation and health records
  • determine whether interpreter services are needed; if possible use a professional interpreter rather than a family member
  • recognise that patients may not conceive of illness in western terms
  • determine whether the patient is a refugee or survivor of violence or genocide
  • explore early on patient preferences for disclosure of serious clinical findings and confirm at intervals
  • ask if the patient prefers to involve or defer to others in the decision making process
  • follow patient preferences regarding gender roles.

Particular attention should be paid to assessing residents with impaired communication skills, eg. due to dementia, stroke, visual or hearing difficulties.30 Consider cognitive impairment or depression in residents appearing 'flat', not making good eye contact or responding to questions. For residents with hearing impairment (who can not hear normal spoken conversation from 1 m away in a quiet room), check ears for wax and that any hearing aid is working, then speak slowly and loudly so they can see your mouth. 31 Establish whether the resident has a written advance care plan, and if they have appointed a representative to make health care decisions for them in the event that they are incapable of doing so themselves.


Diagnostic evaluation


Accurate diagnosis of disease and geriatric conditions is essential to formulate a list of medical problems and goals of care. Diagnostic evaluation involves obtaining a detailed history, examining the resident and ordering appropriate investigations. A detailed history includes: identifying the current main medical problems, past medical history, systems review, medication review, smoking and alcohol, nutritional status, oral health, immunisation status (influenza, tetanus, pneumococcus), and advance care planning.

The systems review helps to identify conditions commonly associated with ageing that may otherwise be unrecognised. Ask about:32

  • loss of appetite
  • weight loss or gain (amount, time period)
  • oral health (mouth, teeth, gums, presence of dentures)
  • fatigue
  • poor exercise tolerance
  • pain (location, character, intensity)
  • dizziness (postural, vertigo, dysequilibrium)
  • falls (number in past 6 months, location, time of day, mechanism: slip/trip, overbalancing, legs giving way, dizziness or syncope)
  • cardio-respiratory symptoms (including chest pain, palpitations, shortness of breath)
  • musculoskeletal symptoms (including arthritis, stiffness, weakness)
  • neurological symptoms (including loss of sensation or power)
  • hearing (including availability and use of aids)
  • vision (including availability, use and type of spectacles, when vision last tested)
  • feet and usual footwear
  • swallowing (solids and liquids)
  • communication (speech, handwriting)
  • sleep habits (including pattern, duration, use of hypnotic medication)
  • elimination (including usual pattern of bladder and bowel function, continence, use of aids)
  • sexual function (including libido, symptoms of dysfunction).

Consider referral for a residential medication management review on admission and annually (see Medication management, and Organisational aspects)



Functional assessment


Any illness in older residents may be associated with loss of independence in self care and mobility, which may in turn increase dependence on family and community services. People are admitted to a RACF because they have lost their independence in self care and mobility, and their needs can no longer be adequately met by their families, friends or community services.

The World Health Organisation has described functional consequences of disease in terms of 'abnormality of body structure and function', 'activity limitation' and 'participation restriction'. 33 Abnormalities of body structure and function can be thought of entirely within the skin. They can result from any cause (eg. hemiplegia from cerebral infarction, or hip fracture from trauma). Activity limitations reflect the consequences of abnormalities of body structure and function in terms of functional performance and activity by the individual (eg. inability to walk following hemiplegia from stroke). Activity limitations can be conceptualised as reflecting problems at the level of the person. Participation restrictions are concerned with the disadvantages experienced by the individual as a result of impairments and disabilities (eg. inability to use public transport due to inability to walk following hemiplegia from stroke or hip fracture from trauma). Participation restrictions reflect interaction with the person's surroundings. Participation restrictions can be thought of as the inability to fulfil roles that are normal for people given their age, gender and position in society. Using this classification framework, all residents will have diseases, abnormalities of body structure and function, activity limitations and personal care participation restrictions at the time of their admission to a RACF.

Accommodation in the facility and the admission assessment ensure that the personal care needs have been met and that there are no participation restrictions. Further functional assessments provide the means to consider whether there are activity limitations, and abnormalities of body structure and function that need to be addressed to prevent and/or reverse decline in a resident's physical, psychological and social function.



Physical function


The Barthel Index (see Tools) is widely used to assess changes in self care and mobility activities of daily living. However, for older people in RACFs, the Barthel Index may give only a broad brush picture, as its ability to reflect change in function is limited by a floor effect and by lack of sensitivity to change. The floor effect occurs because many residents score in the lowest categories in most items in the Barthel Index, and in the event of deterioration there is no possibility to score their function any lower. The sensitivity to change is limited, as important improvements do not necessarily result in a change in score.34

When asking an older person about their physical function, it is important to recognise the distinction between their 'capacity' (which can be established by asking 'Can you..?') and their 'performance' (which can be established by asking 'Do you..?'). Older people in RACFs may perform below their capacity due to lack of support, feeling unwell or afraid (especially of falling), or the lack of suitable aids or environmental modifications.35 Relatives/carers and RACF staff are well placed to provide information concerning the physical function of residents. However, sometimes they may underestimate capacity or may not have had sufficient contact to be able to provide up-to-date information. Direct observation by trained health professionals is likely to provide more accurate measurement of functional capacity than either self or informant reports which tend to reflect actual performance.



Psychological function


Early recognition of cognitive impairment is a particularly important aspect of assessment, as it may have a significant impact upon how assessment information is obtained and from whom. It is important to distinguish between delirium (acute) and dementia (chronic) (see Table 5 and Dementia). The incidence of delirium is greater in those with pre-existing cognitive impairment (see Delirium). Depression is a common problem that can have a negative impact if not recognised and treated (see Depression). Loss and grief for older residents and their families are key features of both entering and living in residential aged care. Changes in physical and mental functioning may lead to changes in role, status, and relationships with relatives and others. There may be a loss of valued skills and attributes, companionship and intimacy, identity and autonomy, possessions and surroundings, and expectations for the future.36,37 The sense of loss may be difficult to acknowledge because the older person is still alive and the journey may be protracted, with no definite starting or end point.38 Grief may be accompanied by guilt, anxiety and confusion.



Social function


Assessment includes type of residential living arrangements (single or shared room), living environment and services, social support, financial circumstances, elder abuse or neglect and family issues. Social support includes the availability and adequacy of social input and emotional support from relatives/carers, RACF residents/staff/volunteers, and others. Elder abuse may be physical, psychological, financial or social, and may include neglect as well as actual harm. Carer issues also need to be considered. These may include the burden that the care role places on them; the provision of adequate support; and their own health status, needs and expectations.



Assessment of capacity


General practitioners are increasingly required to assess residents' capacity to make decisions such as granting a power of attorney, making an advance care plan, or choosing a health care investigation or treatment.

Capacity and the lack of capacity are legal concepts. Capacity is determined by whether a person can understand and appreciate information about the context and decision, not the actual outcomes of choices made, and not whether they can perform tasks. For instance, illness can temporarily impair capacity, and chronic conditions such as schizophrenia or Alzheimer disease do not automatically mean incapacity. A declaration of incapacity is serious as it implies a need to assume responsibility for the incapable person's wellbeing. Valid assessments of capacity are necessary to honour the ethical principles of respect for individuals, beneficence and justice.

Capacity can be divided into a number of broad domains which include capacity to make a will or grant a power of attorney, make an advance care plan, manage finances or property, choose medical treatment, and manage personal care. Decision making in various domains involves a mixture of cognitive and functional abilities, and a person can be incapable in one domain and capable in another. A capable person:

  • knows the context of the decision at hand
  • knows the choices available
  • appreciates the consequences of specific choices
  • does not base choices on delusional constructs.

It is easy to judge the capacity of someone who is clearly capable or incapable. When a person has partial understanding and their capacity is borderline, the GP may undertake a more systematic assessment or refer to a psychologist or geriatrician. Table 1 shows a six step assessment process developed to help judge capacity. Decisional aids are available to assess capacity in specific domains (step 5).40


Table 1. The six step capacity assessment process 41

  1. Ensure that assessment of decision making capacity is done only when a valid trigger is present (situations that place the allegedly incapable person or others at risk, and on the face of it appear to be due to lack of capacity)
  2. Engage the person being assessed in the process
  3. Gather information to describe the context, choices and their consequences
  4. Educate the person about the context, choices and their consequences
  5. Assess capacity
  6. Take action based on results of the assessment

 


Medical management and review


Problems identified from the comprehensive medical assessment and the resident's situation and wishes at the time will determine the goals for current management and what emphasis is placed on;

  • prevention
  • treatment of disease
  • rehabilitation and restoration of function
  • symptom control and palliative care.

Goals should also be discussed for future care (see Advance care planning). The comprehensive medical assessment, active problem list and goals of care can be incorporated into the resident's care plan and reviewed regularly. Chronic conditions such as diabetes, and cardiovascular and respiratory diseases may be assessed and managed according to existing disease specific guidelines. However, goals of care will vary depending on the stage of illness, comorbidities and wishes of the resident. The GP can then monitor the resident's management and health status and adjust management as necessary at scheduled visits.

Scheduled RACF visit checklist:42

  1. Evaluate patient for interval functional change
  2. Check vital signs, weight, laboratory tests, consultant reports since last visit
  3. Review medications (correlate to active diagnoses)
  4. Sign orders
  5. Address RACF staff concerns
  6. Write SOAP notes in resident record (SOAP: subjective data, objective data, assessment, plan)
  7. Revise problem list as needed
  8. Update advance care plan at least yearly
  9. Update resident: update family member(s) as needed.

Education and involvement of relatives/carers in a resident's care can improve clinical outcomes, reduce feelings of loss and captivity, and increase satisfaction with care.43 General practitioners play a significant role in supporting residents and relatives/carers with plain language information about the condition, management and likely course. This includes sensitivity to the different cultural needs of families and how they care for their older relatives, responding to any feelings or concerns, and referring for counselling and support if required (see Contacts).44,45

  1. Flicker L. Clinical issues in aged care, managing the interface between acute, sub-acute, community and residential care. Aust Health Rev 2002;25:136-9.
  2. Lewis G, Pegram R. Residential aged care and general practice. Workforce demographic trends 1984-2001. Med J Aust 2002;177:84-6.
  3. Gray L, Woodward M, Scholes R, Fonda D, Busby W. Geriatric medicine: a pocket book for doctors, nurses, other health professionals and students. 2nd ed. Melbourne: Ausmed Publications, 2000.
  4. Aged Care Association Australia (ANHECA). Aged care Australia: the future challenges. Canberra: ANHECA, 2004.
  5. Aged Care Standards Agency (ACSA). Accreditation guide for residential aged care services. Canberra: ACSA Ltd., 2001.
  6. Australian Institute of Health and Welfare (AIHW). Residential aged care services in Australia 2000-1. A statistical overview. Canberra: AIHW, 2002.
  7. Carers Australia. Submission to the House of Representatives Standing Committee on Ageing: inquiry into long term strategies to address the ageing of the Australian population, 2004.  [Accessed 19 April 2005].
  8. Johnson N, Iddon P, Pierce G. Outside looking in: a resource kit on carer friendly practices in aged care facilities. Carers Victoria, 2003.
  9. Flicker L, op. cit.
  10. National Aged Care Alliance (NACA). NACA issues paper. The aged care - health care interface, 2003. [Accessed 19 April 2005].
  11. Saliba D, Solomon D, Rubenstein L, Young R, Schnelle J, Roth C, Wegner N. Quality indicators for the management of medical conditions in nursing home residents. J Am Med Dir Assoc 2004;5:297-309.
  12. Australian Nursing and Midwifery Council (ANMC). ANMC national competency standards for the enrolled nurse. [Accessed 01 August 2005].
  13. Healy J, Richardson S. Who cares for the elders? What we can and can't know from existing data. Adelaide: National Institute of Labour Studies, Flinders University, 2003.
  14. Australian Pharmaceutical Advisory Council (APAC). Guidelines for medication management in residential aged care facilities. 3rd ed. Canberra: APAC, Commonwealth of Australia, 2002.
  15. Health Professional Council of Australia. Membership and member organisations, 2005.  [Accessed 23 May 2005].
  16. Whitehead C, Penhall R. Australian Society for Geriatric Medicine. Position statement no. 8. Geriatric Assessment and Community Practice, 2000.  [Accessed 19 April 2005].
  17. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op. cit.
  18. Care Australia. A guide to palliative care service development: a population based approach, 2005.  [Accessed 19 April 2005].
  19. Ruth D, Wong R, Haesler E. General Practice in residential aged care, partnerships for 'round the clock' medical care. Melbourne: North West Melbourne Division of General Practice, 2004.  [Accessed 22 April 2005].
  20. Ibid.
  21. The Royal Australian College of General Practitioners (RACGP). Standards for general practices. 2nd ed. Melbourne: RACGP, 2000.
  22. RACGP and Committee of Presidents of Medical Colleges. Handbook for the management of health information in private medical practice, 2002. [Accessed 19 April 2005].
  23. Dorevitch M, Davis S, Andrews G. Guide for assessing older people in hospitals. Prepared for the Care of Older Australians Working Group and Department of Health and aged Care, May 2005 (in press).
  24. Gray LC, Newbury JW. Health assessment of elderly patients. Aust Fam Physician 2004;33:795-7.
  25. Siggins Miller Consultants and School of Population Health, University of Queensland. Executive summary. In: A report to the Brisbane North Division of General Practice (BNDGP). The residential care project. Queensland: BNDGP, 2002. [Accessed 26 April 2005]
  26. Dorevitch M, Davis S, Andrews G, op. cit.
  27. National Health Medical Research Council (NHMRC). Communicating with patients: advice for medical practitioners. Canberra: Commonwealth of Australia, NHMRC, 2004.
  28. Reuban DB, Herr KA, Pacala JT, et al. Geriatrics at your fingertips: 2005, 7th ed. New York: The American Geriatrics Society, 2005. [Accessed 17 June 2005].
  29. Ibid.
  30. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op. cit.
  31. Dorevitch M, Davis S, Andrews G, op. cit.
  32. Ibid.
  33. World Health Organisation (WHO). International classification of functioning, disability and health. Geneva: WHO, 2001.
  34. Mahoney FI, Bethel D. Functional evaluation: the Bethel Index. Maryland State Med Journal 1965;14:56-61.
  35. Dorevitch M, Davis S, Andrews G, op. cit.
  36. Pierce G, Nankervis J. Putting carers in the picture: Improving the focus on carer needs in aged care assessment. Melbourne: Carers Association Victoria, 1998.
  37. Doka DJ. Grief, loss and care giving. In: Doka KJ, Davidson JD, editors. Caregiving and loss. Washington, DC: Hospice Foundation of America, 2001;215-30.
  38. Boss P. Ambiguous loss: learning to live with unresolved grief. London: Harvard University Press, 2000.
  39. Darzins P, Molloy DW, Strang D, editors. Who can decide? The six step capacity assessment process. Adelaide: Memory Australia Press, 2000.
  40. Ibid.
  41. Ibid.
  42. Reuban DB, Herr KA, Pacala JT, et al, op. cit.
  43. Maas ML, Reed D, Myonghwa P, et al. Outcomes of family involvement in care intervention for caregivers of individuals with dementia nursing research. Nurs Res 2004;53:76-86.
  44. O'Shea M. An unrecognised grief: loss and grief issues for carers - a workers guide. Melbourne: Carers Association Victoria, 2001.
  45. Payda C, Draper B, Luscombe G, Erlich F, Maharja J. Stress in carers of the elderly - a controlled study of patients attending a Sydney medical practice. Aust Fam Physician 1999;28:233-7.
  46. Steinberg MA, Cartwright CM, Najman JM, MacDonald SM, Williams GM. Healthy ageing, health dying: community and health professional perspectives on end of life decision making: report to the Research and Development Grant Advisory Committee (RADGAC) of the Department of Human Services and Health. University of Queensland Department of Social and Preventive Medicine, February 1996.
  47. Cartwright CM, Parker MH. Advance care planning and end of life decision making. Aust Fam Physician 2004;33:815-9.
  48. Australian Medical Association (AMA) Committee on Care of Older People. Making decisions for later life: the medical profession's role. Working paper. AMA 2002.
  49. Ruth D, Wong R, Haesler E. General Practice in residential aged care: clinical information sheet: Advance care planning to improve end of life care, in Residential Aged Care Kit. Melbourne: North West Melbourne Division of General Practice, 2004. [Accessed 19 April 2005].
  50. Cartwright CM, Parker MH, op. cit.
  51. 51. World Health Organisation (WHO). National cancer control programmes: policies and managerial guidelines, 2nd ed. Geneva: WHO, 2002.
  52. Australian Government Department of Health and Ageing. Guidelines for a palliative approach in residential aged care. Canberra: Rural Health and Palliative Care Branch, Australian Government Department of Health and Ageing, 2004.  [Accessed 10 May 2005].
  53. WHO. National cancer control programmes: policies and managerial guidelines, op. cit.
  54. Rousseau P. Spirituality and the dying patient. J Clin Oncol 2003;21(9 Suppl):54-6.
  55. Murray SA, Kendall M, Boyd K, Sheikh, A. Illness trajectories and palliative care. BMJ 2005;330:1007-11.
  56. Australian Government Department of Health and Ageing 2004. Guidelines for a Palliative Approach in Residential Aged Care, op. cit.
  57. Taylor A, Box M. Palliative Care Australia: multicultural palliative care guidelines, 1999. Accessed 31 May 2005].
  58. Writing Group for Therapeutic Guidelines: Palliative Care. Therapeutic Guidelines: Palliative Care, version 1. Melbourne: Therapeutic Guidelines Ltd, 2001.
  59. Jones J, Willis D. In search of a good death: what is a good death? BMJ 2003;327:224.
  60. Age Health and Care Study Group. The future of health and care of older people: the best is yet to come. London: Age Concern, 1999.
  61. Ellershaw J, Wilkinson S, editors. Care of the dying - a pathway to excellence. New York: Oxford University Press, 2003.
  62. Ibid.
  63. Liverpool Care Pathway, 2005. [Accessed 10 May 2005].
  64. The RACGP. Clinical audit: what is a clinical audit? 2002. [Accessed 10 May 2005].
  65. ACSA, op. cit.
  66. Liverpool Care Pathway project. Beacon resource pack September 2002 - August 2003. [Accessed 10 May 2005].
  67. Australian Pharmaceutical Advisory Council (APAC), op. cit.
  68. Australian Medicines Handbook. Australian Medicines Handbook: medication choice companion: aged care. Adelaide: Australian Medicine Handbook, 2003.
  69. Ibid.
  70. Wagerty D, Brickley R. American Medical Directors Association and American Society of Consultant Pharmacists joint position statement on the Beers List of Potentially Inappropriate Medications in Older Adults, 2005.  [Accessed 26 April 2005].
  71. Australian Medicines Handbook, op. cit.
  72. Swagerty D, Brickley R, op. cit.
  73. APAC. APAC national guidelines to achieve the continuum of quality use of medicines between hospital and community. Canberra: APAC, Commonwealth of Australia, 1998.
  74. Pharmaceutical Society of Australia (PSA). Professional practice standards. Pharmacy services to residential care facilities, in Australia Pharmaceutical Formulary and Handbook. 19th ed. Canberra: PSA, 2004.
  75. Brown TM, Boyle MF. Clinical review ABC of psychological medicine: delirium. BMJ 2002;325:644-7.
  76. Writing Group for Therapeutic Guidelines: Psychotropic. Therapeutic Guidelines: Psychotropic, version 5. Melbourne: Therapeutic Guidelines Limited, 2003.
  77. Ibid.
  78. Australian Medicines Handbook, op. cit.
  79. Innouye SK, Charpentier PA. Precipitating factors for delirium in hospitalised elderly persons: predictive model and interrelationship with baseline vulnerability. JAMA 1996;275:852-7.
  80. Ibid.
  81. Writing Group for Therapeutic Guidelines: Psychotropic, op. cit.
  82. Ibid.
  83. Australian Medicines Handbook, op. cit.
  84. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op cit.
  85. Brodaty H, Draper BM, Low LF. Behavioural and psychological symptoms of dementia: a seven tiered model of service delivery. Med J Aust 2003;178:231-4. [Accessed 29 April 2005].
  86. Alzheimer's Australia and Access Economics. Dementia estimates and projections: Australian states and territories. Report by Access Economics for Alzheimer's Australia, 2005.  [Accessed 29 April 2005].
  87. Scherer S. Getting ACROSS Dementia: A dementia management resource for general practice. Melbourne: Southcity GP Services and Alzheimer's Association Victoria, 2003.
  88. Bridges-Webb C, Wolk J. Care of patients with dementia in general practice guidelines. Sydney: The Royal Australian College of General Practitioners and NSW Health, 2003.  [Accessed 29 April 2005].
  89. Ibid.
  90. Pond D, Brodaty H. Diagnosis and management of dementia in general practice. Aust Fam Physician 2004;33:789-93.
  91. Folstein MF, Folstein S, McHugh PR. Mini-Mental State a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-98.
  92. Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing 1972;1:233-8.
  93. Dorevitch M, Davis S, Andrews G, op. cit.
  94. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op. cit
  95. Australian Medicines Handbook, op. cit.
  96. Scott E, Pesiah C, Hickie I, Ricci C, Davenport T. A depression management program for older patients and their general practitioners. Melbourne: SPHERE: A national mental health project, 1995. 
  97. Scott E, Pesiah C, Hickie I, Ricci C, Davenport T, op. cit.
  98. Juby A, Tench S, Baker V. The value of clock drawing in identifying executive cognitive dysfunction in people with a normal Mini-Mental State Examination score. CMAJ 2002;167:859-64.
  99. Bridges-Webb C, Wolk J, op. cit.
  100. Ibid.
  101. Scherer S, op. cit.
  102. Bridges-Webb C, Wolk J, op. cit.
  103. Kane RL, Ouslander JG, Abrass IB. Essentials of clinical geriatrics. 4th ed. New York: McGraw-Hill, 1999.
  104. Maas ML, Reed D, Myonghwa P, et al, op. cit.
  105. Rosen J, Mittal V, Mulsant BH, Degenholsz H, Castle N, Fox D. Educating the families of nursing home residents: a pilot study using a computer-based system. J Am Med Dir Assoc 2003;4:128-34.
  106. Scherer S, op. cit.
  107. Van Doorn C, Gruber-Baldini AL, Zimmerman S, et al. Dementia as a risk factor for falls and fall injuries among nursing home residents. J Am Geriatr Soc 2003;51:1213-8.
  108. Ouslander JG, Simmons S, Schnelle J, Uman G, Fingold S. Effects of prompted voiding on fecal continence among nursing home residents. J Am Geriatr Soc 1996;44:424-8.
  109. Ostaszkiewicz J, Johnston L, Roe B. Timed voiding for the management of urinary incontinence in adults (Cochrane Review). In: The Cochrane Library, Issue 1, 2004. Chichester: Wiley.
  110. Scherer S, op. cit.
  111. Brodaty H, Draper BM, Low LF, op. cit.
  112. National Dementia Behaviour Advisory Service (Alzheimer's Australia). ReBOC: reducing behaviours of concern: a hands on guide. Canberra: Australian Government Department of Health and Ageing, 2003.
  113. Popplewell P, Phillips P. Is it dementia? Which one? Aust Fam Physician 2002;31:319-21.
  114. National Prescribing Service. Galantamine (Reminyl) prolonged release capsules for dementia in Alzheimer's disease. NPS RADAR Review, December 2004. [Accessed 16 May 2005].
  115. Neal M, Briggs M. Validation therapy for dementia (Cochrane Review). In: The Cochrane Library, Issue 3, 2003. Chichester: Wiley.
  116. Australian Government Department of Health and Ageing. Decision making tool: responding to issues of restraint in aged care. Canberra: Australian Government Department of Health and Ageing, 2004.  [Accessed 10 May 2005].
  117. Writing Group for Therapeutic Guidelines: Psychotropic, op. cit.
  118. Scott E, Pesiah C, Hickie I, Ricci C, Davenport T, op. cit.
  119. National Prescribing Service. Galantamine (Reminyl) prolonged release capsules for dementia in Alzheimer's disease, op. cit.
  120. Writing Group for Therapeutic Guidelines: Psychotropic, op. cit.
  121. Scott E, Pesiah C, Hickie I, Ricci C, Davenport T, op. cit.
  122. Australian Medicines Handbook, op. cit, 5-8.
  123. Writing Group for Therapeutic Guidelines: Psychotropic, op. cit.
  124. Ibid.
  125. Brodaty H, Draper BM, Low LF, op. cit.
  126. Australian Medicines Handbook, op. cit, 5-8.
  127. Scherer S, op. cit.
  128. Writing Group for Therapeutic Guidelines: Psychotropic, op. cit.
  129. Australian Medicines Handbook, op. cit, p.5-8.
  130. Writing Group for Therapeutic Guidelines: Psychotropic, op. cit.
  131. National Prescribing Service. Resperidone (Risperdal) for behavioural disturbances in dementia. NPS RADAR Review, April 2005.   [Accessed 16 May 2005].
  132. Ibid.
  133. Australian Medicines Handbook, op. cit, 5-8.
  134. Ibid.
  135. Katona CLE, Livingstone G. Functional psychiatric illness in old age. In: Tallis RC, Fillit HM, editors. Brocklehurst''s Textbook of Geriatric Medicine and Gerontology, 6th ed. London: Churchill Livingstone, 2002.
  136. Teresi J, Holmes D, Ramirez M, Eimicke J. Prevalence of depression and depression recognition in nursing homes. Soc Psychiatry, Psychiatr Epidemiol 2001;36:613-20.
  137. Fleming R, editor. Challenge depression: a manual to help staff identify and reduce depression in aged care facilities. Sydney: The Hammond Care Group, 2001.
  138. Fleming R, op. cit.
  139. Snowdon J. Late-life depression: what can be done? Aust Prescr 2001;24:65-7.
  140. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-IV). 4th ed. Washington DC: American Psychiatric Association Press, 1994.
  141. Scott E, Pesiah C, Hickie I, Ricci C, Davenport T, op. cit.
  142. Fleming R, op. cit.
  143. Writing Group for Therapeutic Guidelines: Antibiotic, op. cit.
  144. Scott E, Pesiah C, Hickie I, Ricci C, Davenport T, op. cit.
  145. Khan F. Poststroke depression. Aust Fam Physician 2004;33:831-4.
  146. Scott E, Pesiah C, Hickie I, Ricci C, Davenport T, op. cit.
  147. Khan F, op. cit.
  148. Fleming R, op. cit.
  149. Khan F, op. cit.
  150. Australian Medicines Handbook, op. cit.
  151. Writing Group for Therapeutic Guidelines: Psychotropic, op. cit.
  152. Snowdon J, op. cit.
  153. Scott E, Pesiah C, Hickie I, Ricci C, Davenport T, op. cit.
  154. Khan F, op. cit.
  155. Bird MJ, Parslow RA. Potential for community programs to prevent depression in older people. Med J Aust 2002;177:S107-110.
  156. Snowdon J, op. cit.
  157. Writing Group for Therapeutic Guidelines: Psychotropic, op. cit.
  158. Ibid.
  159. Australian Medicines Handbook, op. cit.
  160. Chan D, Phoon S, Yeoh E. Australian Society for Geriatric Medicine. Position statement no. 12. Dysphagia and aspiration in older people. Australas J Ageing 2004;23:198-202.  [Accessed 19 April 2005].
  161. Martino R, Pron G, Diamant N. Screening for oropharyngeal dysphagia in stroke: insufficient evidence for guidelines. Dysphagia 2000;15:19-30.
  162. Australian Medicines Handbook, op. cit.
  163. Chan D, Phoon S, Yeoh E, op. cit.
  164. Australian Medicines Handbook, op. cit.
  165. Jonsen AR, Siegler M, Winslade WJ. Clinical ethics: a practical approach to ethical decisions in clinical medicine, 5th ed. New York: McGraw-Hill, 2002.
  166. Scherer S, Jennings C, Smeaton M, Thompson P, Stein M. A multi-disciplinary practice guideline for hip fracture prevention. Australas J Ageing 2002 21:203-10.
  167. Australian Council for Safety and Quality in Health Care. Preventing falls and harm from falls. Best practice guidelines for Australian hospitals and residential aged care facilities. Canberra, ACT: Australian Government Department of Health and Ageing, 2005; in press.
  168. Ibid.
  169. Ibid.
  170. Ibid.
  171. Guideline for the prevention of falls in older persons. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. J Am Geriatr Soc 2001;49:664-72.
  172. Australian Council for Safety and Quality in Health Care, op. cit.
  173. Writing Group for Therapeutic Guidelines: Therapeutic Guidelines: endocrinology, version 4. Melbourne: Therapeutic Guidelines Limited, 2004.
  174. Australian Council for Safety and Quality in Health Care, op. cit.
  175. Fonda D. Improving management of urinary incontinence in geriatric centres and nursing homes. Victorian Geriatric Peer Review Group. Aust Clin Rev 1990;10:66-71.
  176. Gardner J. Promoting continence in nursing homes: a national project. Urol Nurs 1992;12(2):83.
  177. Reuban DB, Herr KA, Pacala JT, et al, op. cit.
  178. The RACGP (West Australian Research Unit). Managing incontinence in general practice. Clinical practice guidelines. Perth: RACGP, 2002.  [Accessed 6 June 2005].
  179. Australian Medicines Handbook, op. cit.
  180. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op. cit.
  181. Ibid.
  182. Australian Medicines Handbook, op. cit.
  183. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op. cit.
  184. Australian Medicines Handbook, op. cit.
  185. Ibid.
  186. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op. cit.
  187. Sapsford R. Physiotherapy for pelvic floor dysfunction in the aged care setting. In: Nitz JC, Hourigan SR, editors. Physiotherapy practice in residential aged care. Edinburgh: Butterworth Heinemann, 2004.
  188. The RACGP (West Australian Research Unit), op. cit.
  189. Kalantar JS, Howell S, Tally MJ. Prevalence of faecal incontinence and associated risk factors: an underdiagnosed problem in the Australian community? Med J Aust 2002;176:54-7.
  190. Reuban DB, Herr KA, Pacala JT, et al, op. cit.
  191. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op. cit.
  192. Australian Medicines Handbook, op. cit.
  193. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op. cit.
  194. Reuban DB, Herr KA, Pacala JT, et al, op. cit.
  195. Ibid.
  196. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op. cit.
  197. Kamm MA. Faecal incontinence: common and treatable Med J Aust 2002;176:47-8.
  198. The RACGP (West Australian Research Unit), op. cit.
  199. Australian Government Department of Health and Ageing. Infection control guidelines for the prevention of transmission of infectious diseases in the health care setting, 2004.  [Accessed 19 April 2005].
  200. Ibid.
  201. Writing Group for Therapeutic Guidelines: Antibiotic, op. cit.
  202. Australian Government Department of Health and Ageing. Infection control guidelines for the prevention of transmission of infectious diseases in the health care setting, op. cit.
  203. Writing Group for Therapeutic Guidelines: Antibiotic, op. cit.
  204. Australian Medicines Handbook, op. cit.
  205. National Health and Medical Research Council. The Australian immunisation handbook. 8th ed. Canberra: Commonwealth of Australia, 2003.
  206. Ruth D, Wong R, Haesler E. General practice in residential aged care: clinical information sheet: Urinary tract infections. In: Residential Aged Care Kit. Melbourne: North West Melbourne Division of General Practice, 2004. [Accessed 19 April 2005]
  207. Ibid.
  208. Australian Government Department of Health and Ageing. Guidelines for a palliative approach in residential aged care, op. cit.
  209. Ruth D, Wong R, Haesler E, op. cit.
  210. Mater Hospital (Oncology and Palliative Care Wards). Authorised opioid conversion chart. Brisbane: Mater Hospital, 2005.
  211. Writing Group for Therapeutic Guidelines: Analgesic: Therapeutic Guidelines: Analgesic, version 4. Melbourne: Therapeutic Guidelines Limited, 2002.
  212. Ibid.
  213. Joanna Briggs Institute. Pressure sores - part 1: prevention of pressure related damage. Best Practice 1997;1:1-6.  [Accessed 6 June 2005].
  214. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op. cit.
  215. Stacey MC. Preventing pressure ulcers [editorial]. Med J Aust 2004;180:316.
  216. Prentice JL, Stacey MC. Pressure ulcers: the case for improving prevention and management in Australian health care settings. Primary Intention 2001;9:111-20.
  217. Australian Wound Management Association. Clinical practice guidelines for prediction and prevention of pressure ulcers. Perth: Cambridge Media, 2001.
  218. Queensland Health. Pressure ulcer prevention and management resource guidelines. Brisbane: Queensland Health, 2004.  [Accessed 6 June 2005].
  219. Ibid.
  220. Stacey MC, op. cit.
  221. Norton D, Exton-Smith AN, McLaren R. An investigation of geriatric nursing problems in hospitals. London: Churchill Livingstone. National Corporation for Care of Old People, 1975.
  222. Bergstrom N. A clinical trial of the Braden Scale for predicting pressure score risk. Nurs Clin North Am 1987;22:417-28.
  223. Waterlow J. Pressure sores: a risk assessment card. Nurs Times 1985;81:49-55.
  224. Joanna Briggs Institute. Pressure sores - part 1: prevention of pressure related damage. Best Practice 1997;1:1-6. [Accessed 6 June 2005].
  225. Dorevitch M, Davis S, Andrews G, op. cit.
  226. Norton D, Exton-Smith AN, McLaren R, op. cit.
  227. Queensland Health, op. cit
  228. Australian Wound Management Association, op. cit.
  229. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op. cit.
  230. Ibid.
  231. Reuban DB, Herr KA, Pacala JT, et al, op. cit.
  232. Queensland Health, op. cit.
  233. Ibid.
  234. Ibid.
  235. Guy RJ, Di Natale R, Kelly HA, et al. Influenza outbreaks in aged-care facilities: staff vaccination and the emerging use of antiviral therapy. Med J Aust 2004;180:640-2.
  236. Australian Medicines Handbook, op. cit.
  237. Writing Group for Therapeutic Guidelines: Antibiotic, op. cit.
  238. Guy RJ et al., op. cit.
  239. Australian Medicines Handbook, op. cit.
  240. Ibid.
  241. National Health and Medical Research Council, op. cit.
  242. Writing Group for Therapeutic Guidelines: Antibiotic, op. cit.
  243. Ibid.
  244. Australian Medicines Handbook, op. cit.
  245. Ruth D, Wong R, Haesler E. General practice in residential aged care: clinical information sheet: Urinary Tract Infections, op. cit.
  246. Australian Medicines Handbook, op. cit, 5-8.
  247. Ruth D, Wong R, Haesler E. General practice in residential aged care: clinical information sheet: Urinary tract infections, op. cit.
  248. Ibid.
  249. Australian Medicines Handbook, op. cit, 5-8.
  250. Ruth D, Wong R, Haesler E. General practice in residential aged care: clinical information sheet: Urinary tract infections, op. cit.
  251. Australian Medicines Handbook, op. cit, 5-8.
  252. Writing Group for Therapeutic Guidelines: Antibiotic, op. cit.
  253. Australian Medicines Handbook, op. cit, 5-8.
  254. Ruth D, Wong R, Haesler E. General practice in residential aged care: clinical information sheet: Urinary tract infections, op. cit.
  255. Ibid.
  256. Writing Group for Therapeutic Guidelines: Antibiotic, op. cit.
  257. Australian Medicines Handbook, op. cit, 5-8.
  258. Ruth D, Wong R, Haesler E. General Practice in residential aged care, partnerships for 'round the clock' medical care, op. cit.
  259. Australian Government Department of Health and Ageing. Medicare Benefits Schedule, 2005. Available atwww7.health.gov.au/pubs/mbs/index.htm [Accessed 10 May 2005].
  260. Aged Care Standards Agency. Continuous improvement for residential aged care: an education package, 2001.  [Accessed 10 May 2005].
  261. NSW Health Department. Easy guide to clinical practice improvement. A guide for health care professionals, 2002. [Accessed 10 May 2005].
  262. Dorevitch M, Davis S, Andrews G, op. cit.
  263. Flicker l, Loguidice D, Carlin JB, Ames D. The predictive value of dementia screening in clinical populations. Int J Geriatric Psychiatry 1997;12:203-9.
  264. Dorevitch M, Davis S, Andrews G, op. cit.