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Preventive care programmes keep people active and independent for longer



We contest D’Souza and Guptha’s claim that “no convincing evidence exists that increases in the provision of community services reduce the length of stay for frail older people.”1 There are two commonly used markers of the effectiveness of such programmes in older patients—the number of institutional referrals and time spent in institutional care. The ultimate objective of care in this field is to keep these vulnerable old people active and independent for as long as possible. Thus, the effectiveness of these measures is best reflected by reductions in the number of bed days of institutional care rather than the number of institutional referrals. The authors …
The projected doubling of the >75-year-old
population in the next 20 years presents
a major challenge.
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.
De Maeseneer, argued
that ‘practices integrate individual and
population-based care, blending the clinical
skills of practitioners with epidemiology,
preventive medicine and health promotion’.
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
enabling them to lead the best life
possible and to remain fit and active for
reducing the time they spend in hospital
and institutional care; and
dying with as much dignity and as little
suffering as possible.
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+
and by Age UK in Waltham
Forest. The categories are:
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
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.
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.
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.
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.
et al
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.’
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.
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.
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.
In Cirencester
trained volunteers were introduced after
the community health visitor and nurse
had assessed the patient as disabled and
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.
In 1956 the Rutherglen Experiment
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
in 2008 reported
unacceptably low levels of investigation and
treatment in many clinical areas in patients
aged 50 years.
The first randomised controlled trial of
geriatric screening and surveillance
by Tulloch and Moore
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,
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
et al
in 2008
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
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
However, we can only trace four doctors
or practices who have attempted to develop
a programme of anticipatory care in the
past 40 years.
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
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.
We thank Jan De Maeseneer and Steve Iliffe for
their helpful comments.
Freely submitted; not externally peer reviewed.
DOI: 10.3399/bjgp13X673892
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General lifestyle
London: ONS, 2009.
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David Beales
Hampshire Hunt Cottage, Ropley, SO24 0EG, UK.
“The management of complexity and comorbidity
become an essential part of core primary care.”
550 British Journal of General Practice, October 2013
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![][1] Today we face an important demographic and epidemiological transition, confronting us with the challenge of non-communicable diseases (NCDs), which occur more and more in the context of multimorbidity. In the next decade, multimorbidity will become the rule, no longer the exception: 50% of the those aged ≥65 years have at least three chronic conditions, whereas 20% of the ≥65-year group have at least five chronic conditions.1 In the case of COPD, for example, more than half of the patients have at least one comorbid disease.2 In recent years, not only Western countries, but also developing countries started with ‘chronic disease management-programmes’ to improve care. The design of those programmes include most frequently: strategies for case-finding, protocols describing what should be done and by whom, the importance of information and empowerment of the patient, and the definition of process- and outcome-indicators that may contribute to the monitoring of care. Wagner has described the different components of the Chronic Care Model (CCM) as developed in the context of primary health care.3 The CCM has inspired policy makers and providers all over the world and is widely accepted in the US and Canada, Europe, and Australia. Taking into account the epidemiological transition, we are faced with the question: ‘How will this approach work in a situation of multimorbidity’? Let us illustrate this with a patient from our general practice, we call her ‘Jennifer’ (Box 1). #### Box 1. Jennifer Jennifer is 75 years old. Fifteen years ago she lost her husband. She has been a patient at the practice for 15 years now. During these 15 years she has been through a difficult medical history: hip replacement surgery for osteoarthritis, hypertension, type 2 diabetes, and COPD. She lives independently at home, with some help from her youngest daughter, Elisabeth. I visit her regularly … [1]: /embed/graphic-1.gif
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To assess the receipt of effective healthcare interventions in England by adults aged 50 or more with serious health conditions. National structured survey questionnaire with face to face interviews covering medical panel endorsed quality of care indicators for both publicly and privately provided care. Private households across England. 8688 participants in the English longitudinal study of ageing, of whom 4417 reported diagnoses of one or more of 13 conditions. Percentage of indicated interventions received by eligible participants for 32 clinical indicators and seven questions on patient centred care, and aggregate scores. Participants were eligible for 19 082 items of indicated care. Receipt of indicated care varied substantially by condition. The percentage of indicated care received by eligible participants was highest for ischaemic heart disease (83%, 95% confidence interval 80% to 86%), followed by hearing problems (79%, 77% to 81%), pain management (78%, 73% to 83%), diabetes (74%, 72% to 76%), smoking cessation (74%, 71% to 76%), hypertension (72%, 69% to 76%), stroke (65%, 54% to 76%), depression (64%, 57% to 70%), patient centred care (58%, 57% to 60%), poor vision (58%, 54% to 63%), osteoporosis (53%, 49% to 57%), urinary incontinence (51%, 47% to 54%), falls management (44%, 37% to 51%), osteoarthritis (29%, 26% to 32%), and overall (62%, 62% to 63%). Substantially more indicated care was received for general medical (74%, 73% to 76%) than for geriatric conditions (57%, 55% to 58%), and for conditions included in the general practice pay for performance contract (75%, 73% to 76%) than excluded from it (58%, 56% to 59%). Shortfalls in receipt of basic recommended care by adults aged 50 or more with common health conditions in England were most noticeable in areas associated with disability and frailty, but few areas were exempt. Efforts to improve care have substantial scope to achieve better health outcomes and particularly need to include chronic conditions that affect quality of life of older people.
Should be standard practice, according to a wealth of evidence Care of older people differs from care of middle aged adults. Older people often have more complex multisystem problems, are at increased risk for morbidity and mortality, and need comprehensive interventions that take into account the biopsychosocial components of health. Comprehensive geriatric assessment is an approach developed for this purpose. It is a process that determines an older person’s medical, psychosocial, functional, and environmental resources and problems, and it creates an overall plan for treatment and follow-up.1 It encompasses linkage of medical and social care around medical diagnoses and decision making under the leadership of a doctor trained in geriatric medicine. Older people admitted to hospital as emergencies are at especially high risk. In the linked systematic review (doi: 10.1136/bmj.d6553), Ellis and colleagues performed a meta-analysis of the comprehensive geriatric assessment of elderly people admitted to hospital.2 They found that patients in hospital who received such an assessment were significantly less likely to die or experience functional deterioration. As …
A randomized controlled trial of geriatric screening and surveillance was undertaken on a practice population of 295 patients aged 70 years or more over a two-year period. In the screened group (145 patients) many social problems were found and a total of 380 medical conditions were reported during the study period, 144 (38 per cent) of which were previously undetected. Conditions found most frequently involved the circulatory, musculoskeletal and nervous systems; 67 per cent of the conditions found were manageable, half being improved and the remainder resolved completely.The screening programme was found to increase the use of social and health services but it did also decrease the expected duration of stay in hospital.Independent assessment of patients in the study and control groups at the end of the two-year period showed that the screening programme had made no significant impact on the prevalence of socio-economic, functional, and medical disorders affecting health.We formed the firm impression that the study patients were made more comfortable (by control of pain) and less disabled, although there was no unequivocal objective evidence of this. They were, however, kept independent for longer.The findings are discussed and a model of geriatric care is suggested combining conventional management on demand with comprehensive screening to identify the high-risk patients on whom care might need to be focussed.
Health screening for old people who live at home has been the subject of debate for 30 years or so. It has come to the fore again in the UK with the new emphasis on annual assessments by general practitioners (GPs) of those aged 75 or more. Screening in the elderly has implications for manpower. How can it best be done? We describe here a randomised, controlled study of case finding and surveillance in patients aged 65 and over in a general practice in South Wales. Problem identification was by a postal questionnaire, focusing on function, that was sent at random to 369 eligible patients with subsequent verification and intervention by a specially appointed nurse. The 356 controls had no questionnaires and no contact with that nurse. The study lasted 3 years, and end-points included mortality, self-ratings of quality of life, and health status, and use of all services (GP contacts, hospital admission, home help, and so on). Mortality was significantly lower in the intervention group (18%) than in the controls (24%) (difference 6.0% [95% CI 0.1-11.9%], p less than 0.05). Total number of hospital admissions did not differ between intervention and control groups, but duration of hospital stay of patients aged 65 to 74 years was significantly shorter in the intervention group (difference 4.6 days [95% CI 1.6-7.6], p less than 0.01). An increase in visits to a GP was largely offset by a lower number of home visits by a GP. Quality-of-life measures revealed no between-group differences, but self-rated health status was superior in the intervention group. We conclude that the use of a postal screening questionnaire with selective follow-up and intervention can favourably influence outcome and use of health care resources by elderly people living at home.