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A CHALLENGE TO PRIMARY CARE
The projected doubling of the >75-year-old
population in the next 20 years presents
a major challenge.
1
While standards of
care in general practice have risen steadily
over the past 30 years, for vulnerable
older people the picture is different. The
term ‘vulnerable’ covers multimorbidity,
functional incapacity, and socioeconomic
and psychological problems severe enough
to put the patients at significantly increased
risk of hospital and institutional admission.
Routine GP surgery sessions alone are
inadequate to assess complex comorbidity,
polypharmacy, and adherence, in addition
to reviewing disabilities and carer pressure.
At the age of 75 years, patients will have, on
average, three medical disorders. At least
one-quarter will have a significant level of
functional disability, rising exponentially with
increasing age, and they will often have
socioeconomic and psychological problems
which loom larger in advanced old age. It is
vital that all these problems are addressed if
the patient’s needs are to be adequately met.
We challenge primary care to develop
cost-effective ways to integrate population
scanning of the older population,
most logically for those over the age of
75 years, leading to risk stratification and a
coordinated primary care and community
response. Community programmes,
working with primary care, are also
needed to reduce behavioural risks such
as smoking cessation as well as encourage
exercise and give dietary advice. In our own
practices we valued cooperative work with
trained volunteers.
2
De Maeseneer, argued
that ‘practices integrate individual and
population-based care, blending the clinical
skills of practitioners with epidemiology,
preventive medicine and health promotion’.
3.
THE NEED FOR A CHANGE IN PRIMARY
CARE
The first requirement may be to change the
mindset, from student level into practice,
of some GPs in their management of
vulnerable older people; recognising that
they require a different programme of care
geared to their particular needs.
The present system, usually relying on
demand-led care, and used successfully
for younger people, is not appropriate to the
needs of vulnerable older patients. The key
to success is to define the objectives very
clearly. These are as follows:
• minimising suffering;
• promoting and maintaining health,
function, integration in society, and
independence;
• enabling them to lead the best life
possible and to remain fit and active for
longer;
• reducing the time they spend in hospital
and institutional care; and
• dying with as much dignity and as little
suffering as possible.
RISK ASSESSMENT
The first requirement is a register of all
patients aged 75 years, where most of the
multimorbidity lies. Annual postal birthday
questionnaires place patients in four risk
categories according to the severity of
their chronic diseases, disabilities, and
socioeconomic problems. The Cardiff
Newport Questionnaire is used for this
purpose in Cirencester’s Stay Well 75+
program
4
and by Age UK in Waltham
Forest. The categories are:
1.
Relatively low risk:
patients in fairly
good health for their age, with medical
disorders which are neither serious nor
progressive: disability is limited and
they can cope with their non-medical
problems.
2.
Medium risk:
patients have chronic
disease and/or disability which affect
their day-to-day life to some degree
while their non-medical problems need
identification. Careful management and
prevention of falls is vital.
3.
High risk:
more serious disease, disability
and non-medical problems which
together have a significant effect on day-
to-day life and put patients at greater risk
of institutional admission.
4.
Very high risk:
very frail or severely
disabled subjects, often with significant
or high levels of medical or non-medical
problems, at imminent risk of need for
institutional care.
COMPREHENSIVE GERIATRIC
ASSESSMENT
We suggest careful data collection
preferably using questionnaires of health,
disability and relevant socioeconomic
problems leading to assessment of risk.
A community nurse-led comprehensive
review with protected time follows for the
25% identified as entering frailty (categories
3 and 4) and a full comprehensive geriatric
assessment (CGA) at a clinic for those with
clinical and complex needs (category 4)
when time is not at a premium.
Stuck
et al
5
concluded that ‘CGA
programmes linking geriatric evaluation
with strong long-term management are
effective for improving survival and function
in older people’. Huss
et al
in 2009, with
another meta-analysis of randomised
controlled trials, reported that:
‘... preventative home visits have the potential
to reduce disability burden among older
adults when based on multidimensional
assessment with clinical examination.’
6
We think it is important for one doctor
with a special interest in elderly care to
take the lead in coordinating and directing
such a programme in a group practice,
and lead the organisational audit of
elderly care services. This doctor may
also assess those with complex problems
in a clinic for comprehensive geriatric
review. Coordinated practice-based risk
stratification approaches work well with
a healthy ageing strategy, in combination
with voluntary organisations such as Age
UK and the Expert Patients Programme.
WORKLOAD
In a notional ’list’ of 2000 patients, 7.9% will
be >75 years of age, totalling 158. Higher risk
patients in risk categories 3 and 4 represent
about 40 patients for comprehensive review
at home by community nurses or in a
practice clinic. Doctor-led CGA for category
4 patients leads to a clinic of 4 patients
per 2000 once a month. Each practice will
Community care of vulnerable older people:
cause for concern
“The present system is not appropriate to the needs
of vulnerable older patients. The key to success is to
define the objectives very clearly.”
Debate & Analysis
British Journal of General Practice, October 2013 549
decide how many patients they can fit into
their normal workload, adding the small
number of longer appointments, depending
on their demography and working with
departments of geriatric medicine.
VOLUNTEER SUPPORT
From an early stage we both recognised the
need to recruit volunteer visitors. In Bicester,
trained volunteers visited the over 75s at
home to give health education and to brief
them about benefits and entitlements, as
well as helping them to complete the health
and social questionnaire.
7
In Cirencester
trained volunteers were introduced after
the community health visitor and nurse
had assessed the patient as disabled and
vulnerable.
8
They follow-up these patients
with a 3-monthly assessment using the
Winchester Questionnaire, which stratified
disability into low, medium, and high. A
change of score band led to an earlier
complete comprehensive geriatric review.
UNMET NEED
In 1956 the Rutherglen Experiment
9
in
Glasgow drew attention to a significant
level of undiagnosed disease among older
people, who tended to assume that their
health problems were simply the price
of ageing. The conditions most likely to
be overlooked were sensory impairment,
depression, dementia, urinary tract
disorders, anaemia, foot, and locomotor
disorders. Steel
et al
10
in 2008 reported
unacceptably low levels of investigation and
treatment in many clinical areas in patients
aged ≥50 years.
REDUCED INSTITUTIONAL CARE
The first randomised controlled trial of
geriatric screening and surveillance
by Tulloch and Moore
7
produced two
important findings. Study group patients
spent significantly less time in institutional
care, that is, they were kept more active for
longer in the community. Health was not
significantly improved. The MRC study,
11
reporting in 2004, did not use time spent in
institutional care as an indicator of outcome.
Instead it used hospital admissions, and not
bed days, as an outcome measure and
these were reduced but not significantly.
The number of bed days of institutional
care was also explored but the data were
inconclusive. In a large systematic review
Beswick
et al
in 2008
12
concluded that:
‘… complex interventions can help elderly
people living at home, largely through
prevention of the need for nursing home
care, and can help to reduce the rate of
falls — evidence suggested that all elderly
people may benefit from assessment and
appropriate health and social interventions
’.
BENEFITS FROM ACHIEVABLE
PROGRAMMES
Patients are kept active for longer and
spend less time in institutional care. The
reduction in institutional care represents a
considerable saving when on average, 50%
of those in nursing and residential care are
paid for by the state. Hospital bed days are
reduced.
However, we can only trace four doctors
or practices who have attempted to develop
a programme of anticipatory care in the
past 40 years.
2
We believe that the reason
for this is that doctors are not taught, at
student or postgraduate level, to organise
and deliver care to older people in a manner
fundamentally different from that in the
young and middle-aged. Beswick
12
pointed
out in 2008 that programmes of this sort
were under way in Germany, Italy, France,
the Netherlands, and Denmark. What
is needed is a requirement by the NHS
Commissioning Board for an organisation
audit of community care of older people
with recommended standards and inclusion
within the Quality Outcomes Framework.
Commissioners, aware that 10% of the
population consume 70% of NHS and social
care costs, will need to include protected
clinical time for anticipatory care planning
and assessment for those at risk. The
management of complexity and comorbidity
become an essential part of core primary
care. Commissioners need to create the
right multidisciplinary teams to support
primary care.
David L Beales,
Medical Advisor, Centre for Nutrition and Lifestyle
Management, Wokingham.
Alistair J Tulloch,
Retired GP, Bicester.
Acknowledgements
We thank Jan De Maeseneer and Steve Iliffe for
their helpful comments.
Provenance
Freely submitted; not externally peer reviewed.
DOI: 10.3399/bjgp13X673892
REFERENCES
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General lifestyle
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Community
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Medical Press, 1998.
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Multidimensional preventive home visit
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ADDRESS FOR CORRESPONDENCE
David Beales
Hampshire Hunt Cottage, Ropley, SO24 0EG, UK.
E-mail: dbeales@heartsandminds.fsnet.co.uk
“The management of complexity and comorbidity
become an essential part of core primary care.”
550 British Journal of General Practice, October 2013
