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Community Care of Older People

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... Liverpool has a substantial Somali population with deficiency identified in around 80% of individuals. 3 Our experience is that to ensure compliance with treatment in our Somali population we need to give a high loading dose of vitamin D over a short period of time. There is also no high-dose licensed liquid preparation for children. ...
... They are referenced in our book. 3 In addition Beswick in 2008, a much more recent metaanalysis than that cited by Iliffe, 4 has made a thorough appraisal of nearly all the research work done in this field. From 89 studies he showed that interventions reduced the risk of not living at home, of nursing-home and hospital admissions and falls. ...
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In Liverpool we are auditing vitamin D testing and prescribing in primary care, following guidelines issued to GPs in early 2012 to encourage evidenced based testing and prescribing.1 Our data indicates that some GPs are testing in an increasingly non-targeted way. GPs in Liverpool ordered over £100 000 worth of vitamin D tests in 2012, over 10 times the amount spent in 2007. Though more people were identified as deficient, the proportion of deficient results identified decreased significantly. We feel guidance from NICE is needed for detection and treatment of vitamin D deficiency in primary care. We also feel it is high time for universal vitamin D supplementation of pregnant and postnatal women and young children as recommended by Chief Medical Officers.2 With our increasingly diverse population in the UK we are very aware that currently some groups are missing out on prevention, and Healthy Start vitamin uptake is very low. In Liverpool we are rolling out universal supplementation out this spring. This should lead to a decrease in vitamin D deficiency, decrease in rickets and decrease in need for testing and high dose prescribing. Thirdly and very importantly the authors wonder why the use of licensed preparations is so low in primary care. This is because there are no high-dose licensed preparations available for us to prescribe. I have been working with vitamin D deficient patients for the past 10 years. My experience, as well as that of GP colleagues up and down the country, is that compliance is a big problem with low dose preparations particularly in certain population groups at risk of deficiency. Liverpool has a substantial Somali population with deficiency identified in around 80% of individuals.3 Our experience is that to ensure compliance with treatment in our Somali population we need to give a high loading dose of vitamin D over a short period of time. There is also no high-dose licensed liquid preparation for children. I note the authors appear to have had some connections with various pharmaceutical companies involved in vitamin D manufacture. It would be excellent to see some high dose preparations licensed for use in the UK.
... 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. ...
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In the December issue Iliffe1 assured us that our article ‘anticipatory care of older patients represented the triumph of hope over experience’.2 We find this a bewildering claim in view of the extensive research evidence to the contrary. No less than six controlled trials between 1979 and 1993 showed that a programme of care, tailored to the special needs of those in advanced old age, reduced the time spent in institutional care (hospitals and nursing homes). They …
... 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. ...
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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 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 …
... 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. ...
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Full-text available
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 …
... 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. ...
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