Practice points

Conduct a comprehensive search of the patient’s electronic medical records to identify if they have multimorbidity

Opportunistically screen for multimorbidity during consultations using tools such as The Instrument for Patient Capacity Assessment (ICAN)

Use validated tools to:

• measure the increased risk of hospital admission
• assess frailty

Establish disease and treatment burden using a framework for identifying multimorbidity burden

Initiate advance care planning early when patients have capacity to express their wishes and directives for care if they become too ill or cognitively impaired to make decisions

General practitioners (GPs) can use a proactive, systematic approach to anticipate and provide person-centred care to the end of life and a ‘good death’ by:

• initiating advance care planning early to document patient wishes and directives
• anticipating and assessing escalating palliative care needs early along the illness trajectory
• establishing clinical care goals and treatment decisions with the patient/medical decision maker
• reviewing clinical care plans frequently to address symptoms and physical, psychosocial and spiritual/existential issues
• coordinating and participating in the provision of team-based end-of-life care.

Early identification, assessment and management of escalating palliative care needs are important to relieve symptoms, avoid suffering, reduce need for hospital care, and improve quality of remaining life and the death experience

Recognise escalating palliative care needs at major transition points along the illness trajectory to initiate timely:

• palliative approach
• end-of-life care
• terminal care, including after-death and bereavement support

Indicators such as the ‘surprise question’ and the Supportive and Palliative Care Indicators Tool (SPICT) can help identify patients early when considering whether a person may benefit from a palliative approach

Consider using symptom assessment tools, which can be valuable in identifying symptoms, scoring their severity and monitoring the effectiveness of treatments

Deprescribing should be undertaken with the assistance of a multidisciplinary care team, and appropriately communicated to all members of the care team

Establish a written tapering plan, especially for classes of medication that require slow tapering (eg  opioids, benzodiazepines), to avoid a return of disease symptoms or withdrawal symptoms

Explain to the patient that deprescribing is a positive intervention aimed at improving quality of life, and ensuring they do not receive unnecessary medicines with unlikely benefit or potential for harm

Review and reconcile medicines with other medicine lists, including those from a Home Medicines Review (HMR) or Residential Medication Management Review (RMMR), patient medicine list or discharge summary, with your current medicine list in your record

Assess medicine-related benefits and risk of harm, and discuss options with patient, resident, family and advocate

Discuss, prioritise and plan any changes with patient and family and advocate to decide and agree on specific medicines to change, generally one at a time, slowly over weeks or months, in a stepwise approach

Assess a patient’s risk of adverse medication events and drug interactions, particularly if polypharmacy includes over-the-counter medications or complementary and alternative medicines

Review all prescription medication following changes in comorbidity and progression of disease

Consider pre-planning medications when required for anticipated events from specific conditions (eg allergic reaction, angina, asthma, chronic obstructive pulmonary disease,constipation,diabetes, diarrhoea, dry eyes, nausea, pain, skin rashes)

Dose forms and devices for administration of medicines may be of assistance to patients

Consider the patient’s requirements for end-of-life care

Wherever possible, use non-drug treatments either alone or as an adjunct to medication

Use the lowest effective maintenance dose when starting the patient on a new medication

Consider the changing pharmacokinetics in older people that can affect drug absorption, distribution, metabolism and excretion, and adjust doses as appropriate

Only use medicines associated with strong evidence of benefit when indicated,and cease those with questionable or no evidence of efficacy

Identify inappropriate prescribing in older people using the Beers Criteria, with varying levels of evidence for different patient groups

All prescribing criteria have limitations and do not substitute for good clinical decision making; however, they are prompts for potentially inappropriate prescribing

Review the medication of all older people (ie prescribed, over-thecounter,complementary and alternative medicines) and attempt to deprescribe, particularly for those who are vulnerable to the adverse effects of medication

Consider indications, therapeutic aims, dose, efficacy, safety and ability to use devices as part of the patient’s medication review

Calculate renal function and consider hepatic impairment for all patients, especially those with polypharmacy

Check for drug interactions, side effects and adverse drug reactions

Medicines (including complementary and alternative medicines)must be written on the patient’s medication chart, even if the medicines are being self-administered

Use the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, (DSM-V) to assist with the diagnostic criteria of dementia

Apply a cognitive function test and exclude depression, physical disorders and possible effects of medications before making a diagnosis of dementia

Conduct pathology tests to exclude a medical cause of the patient’s cognitive decline

Conduct imaging to exclude brain tumour or other rare physical brain pathology (eg chronic subdural haematoma)

Assess for depression as it may mimic dementia (ie pseudodementia), and it may also accompany dementia

Undertake a full and comprehensive medication review to exclude medications that may be affecting brain function

Conduct a functional assessment as a dementia diagnosis cannot be made unless there is interference with function

Regularly review a patient’s functional capacity

Communicate the diagnosis of dementia using a gradual and individualised approach.

Consider a supported approach for more complex decision-making

Three acetylcholinesterase inhibitors are recommended as options for managing the symptoms of mild-to-severe Alzheimer’s disease, Parkinson’s disease dementia, Lewy body dementia, vascular dementia or mixed dementia:

• donepezil
• rivastigmine
• galantamine.

Be aware of adverse reactions, side effects and interactions between medications

Conduct a comprehensive work-up of patients presenting with behavioural and psychological symptoms of dementia (BPSD), including the family and carers

Document the patient’s triggers, describe the behaviours, frequency and timing with the assistance of family members and carers by using scoring tools

Review the patient’s medication to exclude drug-induced delirium as a cause for the BPSD

Conduct an assessment to understand the social, cultural and religious norms of the patient

Consider changes to the patient’s environment, routine and tasks that may help to reduce distress in day-to-day activities

Seek advice from carers and residential aged care facility (RACF) staff on what they have tried and what has worked in the past

The first-line management of BPSD includes a person-centred, multidisciplinary management plan of non-pharmacological approach

Prescription of antipsychotic medication can be effective, particularly for behaviours and distress that have been precipitated by hallucinations and delusions, but must be carefully considered

Consider the use of antipsychotics (risperidone has the strongest evidence) in those with BPSD who cause ‘significant distress to themselves or others’; treatment must be reviewed every one to three months

Conventional antipsychotic agents (eg haloperidol) are not recommended because of a lack of evidence of effectiveness, common extrapyramidal side effects and sedative anticholinergic side effects

Consider the  risks and benefits of using medication to manage BPSD before prescribing

Assess the fracture risk of all older people using risk calculators that have been validated

Consider vertebral fracture and X-ray if the patient has a clinical kyphosis or historical height loss of ≥3 cm

Consider calcium and vitamin D as preventive strategies and prior to medical treatment

Recommend exercise, healthy eating, ceasing smoking and low alcohol intake as part of a healthy life, and contribution to good bone health

Oral bisphosphonates and denosumab are effective options for the management of osteoporosis

Consider assessment of pain on admission to the residential aged care facility, after a change in medical or physical condition, and as symptoms arise

Ask about present pain (rather than in the past) as this is a reliable method of assessment for patients whose communication skills are compromised

Consider using the Abbey Pain Scale for patients with dementia who cannot verbalise their pain; it may also be useful for cognitively intact patients who are unable to verbalise, are not willing or cannot talk about their pain

Consider using the Modified Resident’s Verbal Brief Pain Inventory for residents who are able to verbalise their pain

Establish treatment goals with the patient and/or representative, taking into account their culture, beliefs and preferences

Non-pharmacological and complementary therapies may be used as standalone therapies, or in conjunction with pharmacological treatments

Choose pain medication based on pain severity by beginning with a mild analgesic (eg paracetamol) and build up stepwise to opioids for unrelieved pain only after first-line, non-pharmacological management fails

Paracetamol is the preferred analgesic for older people, and is effective for musculoskeletal pain and mild forms of neuropathic pain

Nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase-2 (COX-2) inhibitors should only be used at the lowest possible dose and for a short period (ie five to seven days), as the risk of side effects is high in the older person

Codeine has a short half-life, and is suitable for incident pain or predictable mild-to-moderate, short-lasting pain

Opioids should not be withheld if pain is moderate to severe, and if the pain is unresponsive to other interventions

Morphine is suitable for the treatment of severe pain in older people, and is available in forms for most routes of administration

Transdermal fentanyl can be used for ongoing severe pain; however, it is potent and long-acting, and the risk for delirium and respiratory depression is high

Use tools that may be beneficial in determining the effect of dermatological issues on the quality of life

Grade the severity of specific illnesses to determine the intensity of treatments needed and the progress to recovery

Reconsider the use of anticoagulants, nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin, as these worsen the bruising in older people

Obtain a good history of past occupation and recreation that may point to long-term or ongoing exposure to environmental factors

Consider that itch can be caused by medication or a sign of a systemic condition

Use of moisturisers and symptom relief with cold compresses supplemented by antihistamines and treating underlying conditions are the mainstay of treatment of pruritus

Thorough skin examination is the mainstay of the early prevention and detection of skin cancers, depending on the individual’s sun exposure history and previous skin cancers

Repair tears using the patient’s own skin flap as a ‘graft’ where possible

Always consider the need for biopsy of the wound edge and wound swab for microbiology if the wound or ulcer is clinically infected using the Levine technique

Use of barrier creams and ointments associated with reduction in causative factors are effective in the prevention of wounds and ulcers

Use of pressure stockings and elevation of limbs can be effective in control, prevention and assist in healing varicose ulcers

Use of emollients (moisturisers) are paramount and need to be applied frequently if allergen penetrates the dermis

Always consider scabies when diagnosing and managing itch in older people, especially in residential aged care facilities

Access to clinical and non-clinical services can help support older people with their mental health

Tailor activities and programs that aim to address social isolation to individual patients

Management of loss and grief may help to prevent older people from developing depression, or worsening their condition

Diagnose depression using validated screening and assessment tests

Manage depression and anxiety disorders using an individualised approach that is tailored to the patient’s needs

Establish those at the highest risk of suicide in the immediate future who have the intention to end their life, a specific plan, the means to carry out the plan and a time frame

Consider adjunct psychological treatments for bipolar disorders along with pharmacological treatments

Antipsychotic medication is the first-line treatment in schizophrenia; cognitive behavioural therapy has been found to aid in the management of patients with persistent auditory hallucinations

Prevention of infections via prophylactic vaccination is recommended, including pneumococcus vaccine and annual influenza vaccination

Ensure appropriate reminder systems are in place for regular, specific prophylaxis

Within an enclosed healthcare facility, general practitioners have an important role in endorsing infection control procedures and promulgating the herd immunity concept

Use the correct antibiotic for the correct indication; use the correct dose for the correct time

If the use of an antibiotic is deemed urgent, it may be appropriate to commence an antibiotic reflecting a previous documented system-specific infection, and known sensitivities, while waiting for the microbiology result

Consider a broad range of other differential diagnoses when making an assessment for infection and sepsis

Depending on the individual context, patients with high-risk criteria for sepsis must be urgently assessed with a view to immediate transfer to hospital

Depending on the clinical scenario, when dealing with sepsis:

• swabs should be taken
• results reviewed when available
• antibiotics prescribed for the shortest possible duration and given by the most appropriate dosing regimen

A mid-stream urine is recommended prior to commencing treatment for urinary tract infections (UTIs)

Treating any underlying structural abnormalities and/or removal of indwelling catheter will reduce UTI frequency

In the context of tissue infection, persistent localised pain is a red flag

Treatment of gastrointestinal infections is via rehydration principles, and symptomatic support as required

A physiotherapist may be able to determine falls risk and provide important diagnostic information by undertaking a thorough gait and balance assessment, including activities such as Tai Chi, and balance and functional exercise programs

Consider specific neurological conditions, cardiovascular diseases and vestibular diseases when investigating falls

Consider pharmacological and non-pharmacological strategies for the prevention of falls and reduction of injury in the event of a fall

Conduct a post-fall assessment after an older person has experienced a fall to identify any injuries, understand what may have caused the fall and importantly prevent or reduce the risk of further falls

Consider assessing frailty annually using one of two broad models – frailty phenotype model and frailty index

Avoid iatrogenic harm by having early discussion about end-of-life goals and appropriate limitation of invasive therapies

Be vigilant and recognise complications of acute illness that are common in frailty

Consider pharmacological and non-pharmacological strategies for the prevention of frailty and reduction of injury in the event of frailty

Vitamin D supplements to maintain normal levels may be helpful for older people found to be deficient in vitamin D

All patients admitted to a residential aged care facility should be screened for risk of malnutrition and, if at risk, referred to a dietitian

Step 1. Evaluation
Evaluate the patient’s lower urinary tract and general medical, unctional and cognitive status

Step 1. Evaluation
Identify and treat transient, potentially reversible causes of incontinence using the DIPPERS mnemonic

Step 2. Take detailed history

Step 3. Review medication
Review medications that may cause or aggravate urinary incontinence

Step 4. Focused examination
Use validated, evidence-based frailty screening tool

Step 4. Focused examination
Consider the effect of physical disability and possible cognitive impairment

Step 4. Focused examination
Conduct abdominal, gynaecological, rectal, perineal skin and lower-limb neurological examinations

Step 5. Basic investigations
Consider including urinalysis +/– microscopy and culture as part of the basic investigation

Step 5. Basic investigations
Consider including bladder chart over three days as part of the basic investigation

Step 5. Basic investigations
Consider including portable bladder scan for measurement of post-void residual urine as part of the basic investigation

Establish goals of care for urinary incontinence by taking into consideration patient factors, personal preference and the capabilities of care providers

Consider altering lifestyle and behavioural measures; however, it may not be practical to implement many of these lifestyle and behavioural measures for older people who have significant cognitive impairment and/or physical disability

Consider medications, bladder drainage options and surgical treatment options in some patients

Consider referral to specialist care based on indications for referral, availability, patient transport and patient preference

Assess the type of incontinence using an objective grading system (eg Bristol Stool Chart)

Include a seven-day bowel chart to provide information about frequency, timing, episodes of incontinence and stool consistency during history-taking

Examination should include a digital rectal examination,assessment of skin integrity and primary neurological conditions

Establish a regular bowel pattern by encouraging (and assisting if necessary) the patient to open their bowels soon after a meal, at the same time each day

Establish a regular bowel pattern by encouraging (and assisting if necessary) the patient to open their bowels soon after a meal, at the same time each day

Promote easy access to toilet or provide a commode next to the bed

Advise regular exercise within the context of the patient’s comorbidities and physical abilities

Regularly review the use of laxatives, as overuse can lead to diarrhoea and faecal incontinence

Consider that transanal irrigation may be suitable for those with intact cognition and high motivation levels to comply with treatment

The mainstay of treatment of faecal incontinence is often containment strategies (eg pads, bed protection)