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  • Health care system is going to change soon... so maybe this lecture will be wrong.
  • A large proportion of health care is provided in the community
    • 25% of over 75s are admitted to hospital in a year
  • Geriatricians cover people in hospital, community or age care facility

Assessment

  • GP
  • ACAT—Aged Care Assessment team
    • This is about determining who goes into certain services - for allocating resources. They fill in a form called an ACCR to allow that person to get their services
    • Don't need ACAT assessment for meals on wheels - they'll also do an assessment.
  • All community services
  • geriatricians
    • Looks at the medical problems, but ALSO the home/social problems

Components of geriatric assessment

  • Medical
    • Just because someone has had a problem for a long time doesn't mean it doesn't need assessment.
  • Nursing (Personal care/wounds/continence)
    • LACK OF CARERS is the main reason for having to go into an aged care facility (irrespective of medical condition)
  • Functional (Occupational therapy)
  • Social (accommodation/carers/financial)
  • Medications
    • They take a lot of medications, causing side effects and drug interactions. A lot of their problems can come from medications.
  • Cognition
    • Mini mental is a good starting point
    • Assessment is difficult

An assessment for you

  • He babbles incoherently and incessantly
  • He walks poorly
  • He falls a lot
  • He is incontinent of urine and faeces
  • He sleeps poorly
  • Does he need to be placed in a nursing home?

--

  • He's actually a baby
  • Point = you need all the information (info about carers etc)

Balancing care and needs (the see saw)

  • Patient’s wishes (independence/own home)
  • Family’s /carer’s wishes
  • RISK
  • PATIENT’S NEEDS = CARE from FAMILY/CARERS + CARE FROM COMMUNITY
    • Most important person to talk to is the patient themselves: their expectations etc
    • If the patient wants to go home - just let them! Tell them the risks etc, but if they're willing to take that risk, that's what you should do.
    • Mainstay of care = family member
    • If the patient can be safe, then they can stay home. There is no evidence that a mini mental stops you being at home. Check out their function, check out their environment, do a full assessment.
    • All they need to do if living alone is go bed-->chair, bed-->kitchen, bed --> toilet.

Keeping people at home

  • FAMILY/CARERS
  • COMMUNITY
  • NEED TO COVER:
    • Mobility
    • Transport
    • Meals
    • Shopping
    • Housework
    • medications
      • e.g. Webster packs - have the day of the week with all your medicines in it, making it easy

Services

  • Government/non‐profit/profit: Community nurses (depends on amount of money you've got)
    • meals on wheels
    • day care
    • Home care
    • community transport
    • community packages(CACP/EACH)
    • transitional care packages (for getting people out of hospital and getting back home). Elderly people are deconditioned when they leave hospital.
    • dementia services
    • Respite services
    • continence services
    • community rehabilitation
    • Chronic care teams
    • community pharmacy
    • Public trustee
    • Guardianship board

Aged care facilities

  • Independent units
  • Low level mainstream (hostel) - can find their way around
  • High level mainstream (nursing home) - can't remember where things are etc
  • Low level dementia (hostel - people who are mobile)
  • High level dementia
  • Ageing in place
  • Cultural clusters (prefer a particular culture or religion)
  • Medical clusters (e.g. youngsters with motor neurone disease - so young people are not with a whole lot of old people; they do have different needs. Not good for them)
  • Residents with special needs (young/Multiple sclerosis)

==High and low level facilities==

  • Duration of stay: a) Respite (short term) b) Permanent
  • Financial: a) Concessional (if no assets, can go in on 85% of pension) b) Non-concessional (if they have assets, can use them to pay for nursing)

Hostel/low level

  • Toilet self
  • Mobilise to dining room
  • No significant substantial behavioural problems

Nursing homes (high level)

  • Dementia/behavioural problems
  • Continence(faecal)
  • Functional(mobility/falls)
  • Needs:
    • Medical (can be significant)
    • Nursing(RN/AIN)‐medical treatment, pressure care/continence/feeding - teeth are a big deal
    • Nutrition
    • Mobility - walk with them to prevent falls

Medical issues

  • Behavioural symptoms of dementia (also delirium)
  • Chronic pain (45‐80%)
  • Depression (40%)
  • Incontinence (50‐80%)
  • Hip fracture risk (10X increase)
  • Sensory loss (Eyes/ears)
  • Ulcers
  • Neurological conditions(stroke/Parkinsons)
  • Chronic disease(heart/lung/diabetes/arthritis)
  • Sub‐acute‐hospital discharged patients
  • Palliative care

Residential aged care population 2007

  • 50% of dementia sufferers
  • 28% of hostel 60% of nursing home have dementia
    • So the people who are more well are heading to hostels
  • All require personal care assistance (54% in 1990)
    • Hence we're sending a lot more people home, living in the community with services coming in

Psychological issues

  • Depression (loss of home/independence)
  • Cultural issues
  • Living in close proximity with others (used to be several people in one room. Now single or double).
  • Boredom
  • Isolation

End of life decisions

  • Prior to loss of capacity
    • If someone's got to the point of being fed up with life and they ask not to be resuscitated etc, making the end of their life comfortable is your duty. Don't try to save them for no reason.
  • Power of attorney (financial) - not looking after accommodation/health issues
  • Enduring guardianship (accommodation/medical)
    • This person should be decided at some stage while they're 100% cognitively functional, so they're well-looked-after
  • Will (after life)
  • Advanced care planning

Quality of life

  • Who is best to assess?
    • (a)The patient/client/resident (answer)
    • (b)The family (terrible at assessing)
    • (c)Doctors (bad)
    • (d)Nurses (a bit better than doctors)
  • Avoid your own:
    • Cultural
    • Social
    • Experiential beliefs
  • life does not equal quality of life
  • Look at their culture/religion, you need to ask the patient.

Active or palliative care?

  • Bedridden
  • Fully dependent
  • Dementia
  • Poor oral intake

Advanced care planning

  • Capacity is required
  • ISSUES
    • Any resuscitation
    • Any treatment
    • Transfer to hospital
    • feeding
    • Different treatments for different conditions

Issues

  • People can change minds
  • Circumstances change
  • Cultural aspects
  • Religious aspects

End of life issues

  • Feeding –swallowing/aspiration
  • Pain
  • depression

Confronting advanced care planning

  • Encouragement to make plans (on entry to aged care facility)
  • Family conferences
    • Resident/family‐carer/nursing staff/GP/other nursing‐medical‐allied staff/religious minister

Dos and don'ts

  • Be empathic
  • Understand the resident and the background
  • Allow everyone to state case
  • Discuss quality of life
  • Ask decision makers to put themselves in the patient’s situation
  • Give time
  • Discuss in satisfactory place
  • Reduce guilt
  • Do not abandon patient
  • Do not say “nothing more can be done”
  • Do not get aggressive
  • Do not show superiority
  • Do not ask person or decision maker “do you want CPR?”

Advanced care directives

  • Legal document
  • Provide direction
  • Should not be overuled
  • Need to be in accessible place
  • Need to be communicated to others

Resolving disagreement

  • Time
  • Repeat discussion
  • Second opinion
  • Time‐limited trial of treatment
  • Mediation
  • Clinical Ethics committees
  • Guardianship
  • courts

feeding

  • Food:biological/social/religious/
    • ?lack causes discomfort
  • feeding‐
    • Altered diet(speech therapist):
    • Time to feed/type of feed/posture
    • Take the risk?
    • NG tube
    • PEG tube
    • S/C fluids
    • Regular mouth care
    • Other comfort measures(Positioning/analgesia/relaxants

PEG feeding

  • Patients still aspirate
  • Aspiration may be worse
  • Infection
  • Blockage of tubes