Older persons' health

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Instructions

This section provides a summary of the area of practice for this unit and highlights the importance of this topic to general practice and the role of the GP.

Australia’s population is ageing. In 2017, 15% of Australia’s population (3.8 million) was aged 65 years and over. By 2057, the proportion of this group is expected to rise to 22% (8.8 million).1,2 More than one in three general practice encounters are with people aged 65 years and over,3 with people aged 85 years and over increasingly presenting to general practice compared to other age groups.1 Older Australians are a diverse group, coming from a range of socioeconomic backgrounds and life experiences, and having a variety of healthcare needs.1

People are generally referred to as ‘older’ when they are aged 65 years and over. However, due to health inequity and the impact of social and cultural determinants, ageing-related conditions affect Aboriginal and Torres Strait Islander peoples at a younger age than non-Indigenous Australians. The age range of 50 years and over is therefore used when talking about ‘older’ Aboriginal and Torres Strait Islanders.1

The healthcare needs of older people can be complex, with one in two people aged 65 years and older experiencing multiple chronic conditions.3,4 The leading causes of the burden of disease in older Australians are cardiovascular disease, cancer, neurological conditions, musculoskeletal conditions and respiratory conditions.1 Older people may experience abuse, with an estimated 2–14% experiencing elder abuse,5 with the incidence predicted to increase with the ageing population.6

General practitioners (GPs) may care for older people in the community or in residential aged care facilities (RACFs). GPs are well placed to support older patients to stay in their homes longer through the promotion of wellbeing and independence. This may include assisting older patients to access government support through home support and home care programs.7 GPs are also well placed to provide advice to older people and their families and assist them when considering moving into an RACF.8

To meet the complex needs of older Australians, GPs need to take a patient-centred, whole-person care approach that considers multimorbidity.3 GPs also need to collaborate with the patient’s broader multidisciplinary healthcare team to meet the patient’s individual needs. This can include collaborating with other non-GP specialist medical practitioners, nurses, carers and other allied health professionals.8 GPs also need to work in partnership with families to ensure that the patient’s physical and mental health is optimised.3,8

Three in 10 older people in Australia were born overseas.1 GPs therefore need to consider and incorporate the socio-cultural needs of people from culturally and linguistically diverse backgrounds into their approach. Provision of culturally safe care and awareness of the specific healthcare needs of older Aboriginal and Torres Strait Islander peoples is also vital to minimise barriers to healthcare and help to close the gap in terms of health and life expectancy.9

The provision of care to older people also requires GPs to be aware of their jurisdictive medico-legal requirements. These include the patient’s rights under the Charter of Aged Care Rights,10 requirements for assessing fitness to drive,11 advance care directives, substitute decision-makers and end-of-life legislation such as assisted dying.12,13

References
  1. Australian Institute of Health and Welfare. Older Australia at a glance. Canberra: AIHW, 2018 [Accessed 30 November 2021].
  2. Australian Bureau of Statistics. Australian historical population statistics, 2014. ABS cat. no. 3105.0.65.001. Canberra: ABS, 2014.
  3. The Royal Australian College of General Practitioners. Aged care clinical guide (Silver book) - Part A: Common clinical conditions in aged care. East Melbourne: RACGP, 2019 [Accessed 30 November 2021].
  4. Australian Institute of Health and Welfare. Fact sheet: Experiences of people with multimorbidity. Canberra: AIHW, 2021 [Accessed 30 November 2021].
  5. Dow, B & Brijnath, B. Australia’s welfare 2019 data insights. Elder abuse context, concepts and challenges. AIHW, 2019 [Accessed 30 November 2021].
  6. World Health Organisation. Elder Abuse. Geneva: WHO, 2021 [Accessed 1 Aug 2021].
  7. Department of Health. What is aged care? Canberra: Australian Government, 2020 [Accessed 14 October 2021].
  8. The Royal Australian College of General Practitioners. Aged care clinical guide (Silver book) - Part B: General approaches to aged care. East Melbourne: RACGP, 2020 [Accessed 30 November 2021].
  9. Australian Government. National agreement on closing the gap. Canberra: Australian Government, 2020 [Accessed 14 October 2021].
  10. Australian Government, Aged Care Quality and Safety Commission. Charter of Aged Care Rights. Canberra: Australian Government, 2019 [Accessed 1 Aug 2021].
  11. Austroads. Assessing Fitness to Drive 2016. Sydney: AustRoads, 2017 [Accessed 30 November 2021].
  12. Australian Government Department of Health. Advance Care Directive. Canberra: Department of Health, 2019 [Accessed 1 August 2021].
  13. The Royal Australian College of General Practitioners. Voluntary assisted dying legislation – Position Statement – June 2019 [Accessed 1 August 2021].

Instructions

This section lists the knowledge, skills and attitudes that are expected of a GP for this contextual unit. These are expressed as measurable learning outcomes, listed in the left column. These learning outcomes align to the core competency outcomes of the seven core units, which are listed in the column on the right.

Communication and the patient–doctor relationship
Learning outcomes Related core competency outcomes
The GP is able to:   
  • use effective strategies to overcome barriers when communicating with older patients, including when not able to physically attend the patient (eg telephone/telehealth)
1.1.1, 1.1.5, 1.1.6, AH1.3.1, 1.2.1, RH1.1.1
  • discuss declining health and end of life with sensitivity and in an individually and culturally appropriate manner
1.1.2, AH1.3.1, 1.2.1, 1.3.1, 1.3.2
  • collaborate in a manner of shared decision-making with patients, their families, carers and other health professionals when establishing management plans
1.1.3, 1.4.3, 1.4.5, AH1.4.1, RH1.4.1
Applied knowledge and skills
Learning outcomes Related core competency outcomes
The GP is able to:   
  • develop treatment plans that address the interactions and complications of multisystem disease and the use of multiple medications
2.1.3, 2.1.7, 2.1.9, AH2.1.2, 2.2.2, 2.3.1
  • assess an older person’s functional needs and support them to maintain independence and safety
2.1.1, 2.1.3, 2.1.6, RH2.3.1
  • manage acute medical presentations and emergencies commonly encountered in older people
2.1.3, 2.3.3
  • continue to provide care for long-term patients after they move into a RACF, recognising the differences in workflow structure between clinic and RACF settings
2.1.3, 2.1.9, 2.1.10, 2.3.1, AH2.3.1, AH2.3.2
  • describe the psychological and social changes that occur with ageing and how these changes may impact on health, for example, disability, loneliness, grief
2.1.1, 2.1.4, 2.3.2, AH2.1.2, AH2.3.1
  • acknowledge clinical uncertainty and respond appropriately to it as patients age and treatment goals change
2.1.10
Population health and the context of general practice
Learning outcomes Related core competency outcomes
The GP is able to:   
  • provide age-appropriate preventive care and health promotion to older patients
3.1.1, 3.1.4, 3.2.3
  • engage in activities that address health inequality and access to appropriate services for older people
3.2.1, 3.2.2, 3.2.4, AH3.2.1, AH3.2.2, RH3.2.1
Professional and ethical role
Learning outcomes Related core competency outcomes
The GP is able to:   
  • reflect on attitudes, values and behaviours related to ageing and older people and how these impact on patient interactions
3.1.1, 3.1.4, 3.2.3
  • respect dignity and autonomy in older patients to support them to maintain independence in a safe manner
3.2.1, 3.2.2, 3.2.4, AH3.2.1, AH3.2.2, RH3.2.1
Organisational and legal dimensions
Learning outcomes Related core competency outcomes
The GP is able to:   
  • assess and act appropriately in situations involving potential abuse of older people
5.1.2, 5.2.1, 5.2.3
  • observe and keep up to date with state laws and statutory obligations affecting older people
5.2.3, 5.2.4
  • assess, advise and report fitness to drive based on current defined standards and state legislative requirements
5.2.1, 5.2.3
  • implement safe and effective use of GP and RACF practice management and record systems to provide quality care to older patients
5.1.1, AH5.1.1, AH5.1.2, AH5.1.3
  • recognise the importance of the role of enduring power of attorney and how this fits within the decision-making process
5.2.2, 5.2.3
  • be aware of, and facilitate discussions about, enduring power of attorney, guardianship and advance care planning where relevant
5.2.2, 5.2.3

Instructions

This section includes tips related to this unit from experienced GPs. This list is in no way exhaustive but gives you tips to consider applying to your practice.

Extension exercise: Speak to your study group or colleagues to see if they have further tips to add to the list.

  1. Make sure your goals adapt and align with the changing wishes and priorities of your patients as they age.
  2. Prioritise advance care planning: so much is gained by having the conversation with the person and their family.
  3. Consider what pursuing a diagnosis will change for the patient. We often overestimate the benefits of treatment and underestimate the harms – this is especially so in our frail elderly patients. Balance the risk and benefits and be mindful of both over and undertreatment.
  4. Much can be done to improve quality of life. How is the patient managing day-to-day? Look for ways to improve care. Take the opportunity to undertake a home visit: so much can be gained from seeing a patient in their home environment.
  5. Family and friends can provide invaluable information that can help in your management of an older person.

Instructions

  1. Read this example of a common case consultation for this unit in general practice.
  2. Thinking about the case example, reflect on and answer the questions in the table below.

You can do this either on your own or with a study partner or supervisor.

The questions in the table below are ordered according to the RACGP clinical exam assessment areas and domains, to prompt you to think about different aspects of the case example.

Note that these are examples only of questions that may be asked in your assessments.

Extension exercise: Create your own questions or develop a new case to further your learning.

Older persons' health

George is an 85-year-old man who comes into your clinic with his daughter, Sharon. Sharon made the appointment because she is concerned that George is becoming more ‘forgetful’ and ‘unsteady on his feet’. George lives alone and has a history of ischaemic heart disease, chronic obstructive pulmonary disease and osteoporosis. He is on a ‘long list’ of medications.

Questions for you to consider Clinical exam assessment area Domains

How might you manage the consultation to ensure that both George and his daughter are heard?

If George had thought this appointment was for a check-up and Sharon had rung in advance to voice her concerns, how might this affect the conversation?

How might you adjust your communication for a patient who might have a memory impairment? Or a hearing impairment?  

  1. Communication and consultation skills
1,2,5

What additional information do you need to know when a relative raises concerns about a patient?

Who may be able to assist you with the assessment of George’s cognition and safety at home?

  1. Clinical information gathering and interpretation
2   

How might you involve your practice team in assessing George?

What are the issues for George? Write a problem list (including the differentials and other issues that are important to consider).

  1. Making a diagnosis, decision making and reasoning
2

What are the evidence-based interventions for preventing falls?

How would you approach the management of multiple medical conditions?

What are some of the reversible causes of ‘confusion’?

Elderly patients often have multiple doctors prescribing their medication. How would you find out what medications a patient is taking?

When is a medication review helpful?

When would you discuss advance care planning? How would you introduce the topic?

  1. Clinical management and therapeutic reasoning
2   

How would your approach be different if George lived in a remote area?

What support is available in the community for older people?

Are there different support options for Aboriginal and Torres Strait Islander patients? What about other cultural groups?

  1. Preventive and population health 
1,2,3

What would you do if George didn’t attend his scheduled follow-up appointment?

Many older patients transition from living in the community to a residential aged care facility. How can the GP help this process?

What is the role of the GP in residential aged care facilities?

  1. Professionalism
4   

What legal aspects do you need to consider for George?

How would you assess George’s capacity to consent/make informed decisions?

How will you arrange follow-up appointments? What MBS services (item numbers) could you consider using as part of your management plan?

How would you assess if an elderly patient meets the medical standards to drive?

What is the role of a substitute decision-maker? 

  1. General practice systems and regulatory requirement
5   

How would you do a cognitive assessment in the clinic?

How would your assessment be different if your patient were hearing impaired? Or vision impaired? What if English was their second language?

  1. Procedural skills
2   

How would you communicate the differential diagnoses to George and Sharon?

If George is diagnosed with dementia, how would you answer a question from Sharon about his prognosis?

  1. Managing uncertainty
2   

How would you approach the consultation if George appeared acutely confused and irritable? 

What are the possible causes of delirium? How would you investigate and manage this?

What would you do if you were concerned about George’s safety at home?

  1. Identifying and managing the significantly ill patient
2

Instructions

This section has some suggestions for how you can learn this unit. These learning suggestions will help you apply your knowledge to your clinical practice and build your skills and confidence in all of the broader competencies required of a GP.

There are suggestions for activities to do:

  • on your own
  • with a supervisor or other colleague
  • in a small group
  • with a non-medical person, such as a friend or family member.

Within each learning strategy is a hint about how to self-evaluate your learning in this core unit.

On your own

Identify resources for reviewing medications and deprescribing for elderly patients (see an example in the learning resources section). 

  • Are they appropriate for Australian practice?
  • Does frailty influence recommendations?  

Review how the national Assessing Fitness to Drive Standards relate to older people.

  • In what situations would a patient not meet the criteria for driving?
  • What are your legal responsibilities as a GP?

Which immunisations would you recommend to people over the age of 65? 

Have you seen a patient recently who may benefit from further discussion about the following legal processes: advance care directives and substitute decision-making?

  • Were you able to ask them about advance care directives or substitute decision-making?
  • What were the barriers to this conversation? How could they be overcome?
With a supervisor

Review the notes of a patient aged over 75 years (select a patient at random).

  • What are the goals of care for this patient? Are these goals of care documented?
  • Does the patient have an advance care directive in place?
  • Have they had a health assessment?
  • Would they benefit from a medication review? Would deprescribing be appropriate in this situation? How could you approach this?

Discuss a patient who you suspect may have undiagnosed cognitive impairment. 

  • How would you raise this with the patient? What additional information may be helpful? What investigations would you consider?
  • Ask your supervisor how they manage this situation.

Visit a registered aged care facility (RACF) with a GP who provides regular services. Review the care structure and clinical handover processes.

  • Is there an opportunity for you to get experience working in an RACF?  
  • What are the differences when working in an RACF compared to a GP clinic? What are the challenges?
  • How does your supervisor overcome or manage these challenges?
In a small group

Role-play the case consultation example given above, with an emphasis on sensitively exploring George’s home situation. Consider the potential for abuse from a family member who may benefit from the patient moving out of their home.

  • What strategies did you use to explore the home situation? How did you involve George and his daughter in the consultation?
  • Ask for feedback from the group about what worked well and what might be done differently. 

Discuss intimate relationships and sexuality in older people.

  • What are the impacts of a change in a person’s living situation? What does the literature say in this area? Is this something you have considered in your consultations before? How could you incorporate this into your future practice?

Present a challenging case with multiple comorbidities in an older person. Consider the disease-specific guidelines. 

  • Are the guidelines helpful? What are their limitations?
  • How could you measure quality when managing multimorbidity in an older person?
  • How might the goals of care and management change with age?

Discuss the following scenario as a group. You receive a call from the registered nurse at the local RACF who is concerned that Mrs Rossi ‘is more confused’ and has punched another resident. They request your urgent review. 

  • How can you respond to this request? What more would you like to know about the situation? Could this be delirium? What is your diagnostic approach?
  • What advice do you give the RACF staff about managing Mrs Rossi? If you’re not able to attend in person, what advice do you give?
With a friend or family member

Talk to a family member or friend who is or has been a carer for an older person and ask them about their experience. 

  • What barriers to care have they encountered? What improvements would they suggest? What support have they found helpful?

Discuss advance care planning and the resources available. 

  • What resources are available for older people and their families?

Ask an older person about their experiences of finding and receiving healthcare.

  • What would they change? What tips do they have for you, as a GP?

Instructions

These are examples of topic areas for this unit that can be used to help guide your study.

Note that this is not a complete or exhaustive list, but rather a starting point for your learning.

Multimorbidity
  • Define multimorbidity and identify associated issues, including:
    • quality of life
    • use of healthcare services
    • hospitalisations
    • treatment burden
    • multiple medicines
    • mortality.
  • Recognise the limitations of disease-specific guidelines in the context of multimorbidity:
    • chronic obstructive pulmonary disease
    • osteoporosis
    • cardiovascular disease
    • cerebrovascular disease
    • chronic kidney disease
    • diabetes
    • osteoarthritis
    • cancer.
  • Clarify goals of care with patients.
Health assessment and preventive care
  • Conduct a thorough health assessment and manage preventive care, including:
    • hearing
    • vision
    • continence – bowel and bladder
    • constipation
    • falls risk
    • chronic pain
    • wound care and prevention of pressure injuries
    • nutrition
    • oral health
    • mental health, including risk assessment and management
    • sexuality
    • alcohol and other drugs.
  • Define frailty and be familiar with validated assessment tools.
  • Consider neglect and abuse.
  • Conduct assessments of functional, cognitive, decision-making and driving capacity.
  • Screen for cancer, and recognise the diminishing value of some screening activities in older patients, including for the following cancers:
    • cervical
    • breast
    • bowel.
  • Recommend and administer immunisations (age appropriate).
  • Screen for and manage osteoporosis.
  • Enquire about and assess safety in the home, identify concerns and act appropriately.
Acute conditions
  • Recognise symptoms of infectious diseases early and manage appropriately.
  • Manage patients with infectious diseases in a registered aged care facility (RACF), including isolation, testing, quarantine and infection control.
  • Understand that emergencies, such as cardiac conditions, cerebrovascular accidents, trauma, delirium, etc, may present differently in older people and require different treatment goals.
Behavioural and psychological presentations
  • Understand the importance of prompt recognition, assessment and treatment of:
    • delirium
    • dementia
    • depression
    • anxiety
    • insomnia.
  • Be aware of the communication difficulties that may occur with cognitive decline in patients who do not speak English as their first language.
Recognise the importance of non-pharmacological treatment in the management of conditions commonly encountered in older people
Palliative and end-of-life care
  • Initiate conversations about advance care planning and support patients.
  • Manage symptoms – be aware of symptoms encountered and management options.
  • Provide psychological support for patients, families and carers.
  • Communicate with interdisciplinary team members.
  • Communicate with friends/family.
  • Understand and incorporate substitute decision-making into patient care.
  • Be aware of end-of-life law.
Medication management
  • Identify patients who would benefit from a medication review.
  • Understand the role of the pharmacist and work collaboratively to refer and incorporate feedback into patient management.
  • Prioritise deprescribing.
  • Manage short-term pharmacotherapy of severe behavioural and psychological symptoms, and understand and adhere to the ethical, legal and reporting requirements.
Legal and ethical
  • Fitness to drive.
  • Wills and testamentary capacity.
  • Abuse of older people – reporting.
  • Advance care planning.
  • Enduring power of attorney.
  • Guardianship.
  • Voluntary assisted dying.
Healthcare system
  • Effectively communicate across practice and RACF systems.
  • Provide team-based care.
  • Engage in case conferencing.
  • Facilitate family meetings.
  • Be aware of community services and resources.

Instructions

The following list of resources is provided as a starting point to help guide your learning only and is not an exhaustive list of all resources. It is your responsibility as an independent learner to identify further resources suited to your learning needs, and to ensure that you refer to the most up-to-date guidelines on a particular topic area, noting that any assessments will utilise current guidelines.

Journal articles
Two good resources for deprescribing. How to assess for cognitive impairment.
Online resources
An invaluable resource to accompany any driving medical assessment. Available in hard copy and also online. Clinical guidelines/prescribing information. The Therapeutic Guidelines has many topic areas relevant to aged care. A useful deprescribing resource. Information about non-drug treatments.
Learning activities
Training and resources on advance care planning.  A training program that focuses on the law relating to end-of-life decision-making.
Other
A screening test for cognitive impairment. A screening tool for cognitive impairment. A validated cognitive screening tool for older Aboriginal and Torres Strait Islander peoples living in rural and remote areas. My Aged Care is the starting point for older Australians to access aged care support services.
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Printed from the RACGP website at https://www.racgp.org.au/education/education-providers/curriculum/curriculum-and-syllabus/units/older-person-s-health 4/07/2022