The role of the GP in the care of older adults
As a GP, your role is to:
- diagnose, investigate and manage older adults, taking into account theories of ageing, differences in epidemiology and risk factors of disease in the older population and considering the physical, psychological and social changes that may occur with age
- communicate appropriately with patients, their families and carers, recognising potential challenges in communicating with older patients. When necessary, balance confidentiality with the need for information sharing and shared decision-making
- coordinate with other organisations and professionals (such as community nurses, social services, rehabilitation, care homes and the voluntary sector) while taking an advocacy position for the patient or family when needed, including for palliative and end-of-life care planning
- review medications and repeat prescriptions effectively, potentially working with pharmacists. Consider the factors associated with drug treatment in the older adult (such as changes to the physiology of absorption, metabolism and excretion of drugs and the hazards posed by polypharmacy, non-compliance and iatrogenic disease)
- offer advice and support patients, relatives and carers regarding prevention, monitoring and self-management. Ensure care is personalised and promotes patients’ sense of identity, independence and personal dignity and that the patient is not discriminated against as a result of their age.
Emerging issues in the care of older adults
- Availability of resources in the community has a direct impact on the provision of preventative services, so when care is required, it might become urgent and unplanned.
- There are increasing numbers of older people who are carers1 and this may impact on their own health and wellbeing.
Knowledge and skills guide
For each problem or disease, consider the following areas within the general context of primary care:
- the natural history of the condition, including whether acute or chronic
- the incidence and prevalence, including in different demographic groups
- typical and atypical presentations
- recognition of normal variations throughout life
- risk factors, including lifestyle, socio-economic and genetic factors
- diagnostic features and differential diagnosis
- recognition of ‘alarm’ or ‘red flag’ features
- appropriate and relevant investigations
- interpretation of test results
- management, including initial and continuing care, chronic disease monitoring and emergency care
- patient and carer information and education, including self-care
- prognosis.
Symptoms and signs
Consider the normal physical and psychological changes that can occur with age and relate them to the adaptations older adults make and to the breakdown of these adaptations (such as when hearing, vision or cognitive function continue to worsen).
Common and important conditions
- Cancer: recognise the common, early, ‘red flag’ symptoms and signs of malignancy, many of which may be non-specific if taken in isolation. Many cancers are more prevalent in the elderly population and may be insidious
- Cardiovascular: atrial fibrillation (AF), heart failure, hypertension, hypotension, ischaemic heart disease, risks for stroke and dementia
- Musculoskeletal: falls, fractures, gait disorders, osteoporosis, osteoarthritis
- Neurological: Parkinson’s disease, stroke, confusion
- Psychiatric: anxiety and depression, delirium, dementia
- Renal: chronic kidney disease (CKD), dehydration
- Respiratory: chronic obstructive pulmonary disease (COPD), lung cancer
- Skin: ulcers, skin malignancies, benign lesions associated with ageing
- Urogenital: infections, incontinence, lower urinary tract symptoms (LUTS), benign prostatic hypertrophy
Examinations and procedures
- Consider any adjustments that may be needed to examine appropriately and the normal variation in biometrics
- Informed consent and assessment of capacity
- Accurate measurements, such as dementia screening, frailty risk scoring and assessing for arrhythmias
- Indication and administration of vaccinations (seasonal flu, pneumococcal, shingles, Covid).
Investigations
- Changes in the normal range of laboratory values that are found in older people
- Interpretation of electrocardiogram (ECG), such as diagnosing AF
- Blood pressure (for example, risk of hypertension, postural hypotension)
Service issues
- The care of older people may be a significant proportion of general practice workload
- Increasing use of tools on frailty to identify populations that need increased support and management
- Increasing use of community teams and services to support and treat patients at home and avoid admissions to hospital, including hospital services at home
- Inequalities in healthcare provision can be particularly significant in older people (for example, learning, physical disabilities, access to care)
- Access to social services, rehabilitation, nursing homes, residential homes and various statutory and voluntary organisations to support older people in the community (for example, podiatry, visual and hearing aids, immobility and walking aids, meals on wheels, home care services). Note that there may be preconceived ideas of what ‘support’ can mean and some people may not identify themselves as needing support
- Differences when working with care homes, including continuity, medicines management and the use of care home advocacy
- Advance care planning and advance directives, including ‘Do not attempt resuscitation’ (DNAR) forms. Patient-held records can support appropriate decision-making in the context of long-term condition management and end-of-life care
- Ensure the appropriate use of screening and case-finding programmes. Note the potential challenges, such as auditing the quality of care in varying forms of residential accommodation
Additional important content
- Comorbidity and physical factors – particularly diet, exercise, ambient temperature and sleep – disproportionately affect the health of older people and will influence the management of existing disease
- Legal and ethical issues may arise (such as confidentiality, the Mental Health Act, the Mental Capacity Act, power of attorney, court of protection applications, guardianship, living wills, death certification and cremation)
- Issues related to carers, in particular the positive and negative impact of being a carer on their own health
- Safeguarding issues, including neglect and abuse (emotional, mental and physical)
- The impact of the Covid pandemic on the ageing population, including prolonged social isolation, inactivity and deconditioning, delayed diagnosis and post-Covid health issues, particularly in those with comorbidities
Case discussion
Ashok Patel, an 80-year-old man, attends the surgery in winter after having been discharged from hospital following treatment of a femoral fracture. He has severe back pain and a raised prostate-specific antigen (PSA) level. He has vascular dementia and was being cared for at home by his wife although she is finding it hard to cope. They have family overseas but no local support network.
He has multiple other medical problems including type 2 diabetes and hypertension. His prostate cancer was thought to be in remission. They live in a two-storey property with an upstairs toilet; he is the registered owner of the house. He is now unable to climb the stairs.
Ashok’s wife, another patient of yours, has a right cataract impairing her vision and has previously made some minor errors when administering his medications. She also has poor mobility and is due to have a left hip replacement for osteoarthritis. She has been receiving Carer’s Allowance and wants to continue to care for her husband at home.
You make a home visit after Ashok’s hospital discharge to find him unkempt and in soiled bedding in a cold house. There has been inadequate discharge planning and little assessment of his home situation to help him or his wife cope with his new immobility.
Questions
These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case discussion with your educational supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.
| Core capabilities | Questions |
|---|---|
Fitness to practise This is about professionalism and the actions expected to protect people from harm. This includes the awareness of when an individual’s performance, conduct or health, or that of others, might put patients, themselves or their colleagues at risk. | What are the personal challenges I face in my working life when caring for my older patients? How do my personal attitudes and biases towards older adults and to the processes of growing old, becoming frail and to dying affect my practice? How would I manage this complex scenario during the working day while also maintaining my performance elsewhere? |
An ethical approach This is about practising ethically with integrity and a respect for equality and diversity. | How might I address concerns about the inadequate discharge planning? How can my patients retain autonomy in this situation? What is my role in safeguarding the needs of the man with dementia while also respecting his wife’s wishes? |
Communicating and consulting This is about communication with patients, the use of recognised consultation techniques, establishing and maintaining patient partnerships, managing challenging consultations, third-party consulting, the use of interpreters and consulting modalities across the range of in person and remote methods. | What problems might I face in communicating with this couple? In the scenario described, who is my patient? How might I respond to apparently dated social and health beliefs and cultural traditions? |
Data gathering and interpretation This is about the gathering, interpretation and use of data for clinical judgement, including information gathered from the history, clinical records, examination and investigations. | Where can I access information on the management of vascular dementia? How do I balance the use of intensive or invasive tests and treatments and the use of limited healthcare resources in the care of older adults? What other information about the family would be useful? |
Clinical examination and procedural skills This is about clinical examination and procedural skills. By the end of training, the GP registrar must have demonstrated competence in general and systemic examinations of all the clinical curriculum areas, including the five mandatory examinations and a range of skills relevant to general practice. | Can I perform an accurate assessment of cognitive function using formal tools? |
Decision-making and diagnosis This is about having a conscious, organised approach to making diagnosis and decisions that are tailored to the particular circumstances in which they are required. | What are the most appropriate options for managing a situation where there is no clear clinical need for hospital admission? How much should Ashok’s wife influence this? How could the consultation encourage a shared decision-making process? |
Clinical management This is about the recognition and a generalist’s management of patients’ problems. | What are the immediate medical and social problems that I need to manage? What is the treatment of choice for Ashok’s hypertension? How can I ensure my personal biases regarding the management of risk factors in older adults (such as the cardiovascular risk factors of smoking, obesity, exercise, alcohol, age and race) do not influence management decisions? |
Medical complexity This is about aspects of care beyond the acute problem, including the management of comorbidity, uncertainty, risk and health promotion. | How might I describe the complexity of this episode of healthcare provision? How would I make a risk assessment of this couple’s situation? What are the possible supportive organisations and potential referral routes in this case? |
Team working This is about working effectively with others to ensure good patient care and includes sharing information with colleagues and using the skills of a multiprofessional team. | What arrangements would I make to improve continuity of care? If I was concerned there was a safeguarding issue in this case, how would I manage this? Who else might be able to help me? What processes are important for continuity of care in the out-of-hours setting? |
Performance, learning and teaching This is about maintaining the performance and effective CPD of oneself and others. The evidence for these activities should be shared in a timely manner within the portfolio. | What do I know about residential and care homes in my practice area? What can be identified as areas of personal educational need? What areas could be explored further for potential improvement for colleagues managing similar cases? |
Organisation, management and leadership This is about understanding how primary care is organised within the NHS, how teams are managed and the development of clinical leadership skills. | How can I retain patient confidentiality when recording information about this couple in the notes? What information would I normally expect to receive following a hospital admission? What can my practice do to improve the support for similar patients? |
Holistic practice, health promotion and safeguarding This is about the ability of the doctor to operate in physical, psychological, socio-economic and cultural dimensions. The doctor is able to take into account the patient’s feelings and opinions. The doctor encourages health improvement, self-management, preventative medicine and shared care planning with patients and their carers. The doctor has the skills and knowledge to consider and take appropriate safeguarding actions. | Considering Ashok’s wife, what might be the consequences for her if her husband goes into a care home? What sort of discussion should I be having with his couple regarding long-term care and placement? How can I manage this couple’s ideas, concerns and expectations? How might the practice team have anticipated the problems identified in this scenario? Which problems, if any, do I think might have been prevented? What other services may be available to carers in my practice? |
Community health and environmental sustainability This is about the management of the health and social care of the practice population and local community. It incorporates an understanding of the interconnectedness of health of populations and the planet. | How common is this type of problem in my practice population? How would I try to find out? What voluntary support services are available to my patients? What support can be offered by the primary care team and/or hospital outreach services? |
How to learn this area of practice
Work-based learning
In general practice you will have the opportunity to care for many older patients with physical and mental conditions who live at home or in a residential care home. As a GP registrar you should be encouraged to look after some of the practice’s older patients throughout your placement. As you follow them along their journey you will gain a better understanding of their problems and of the social and medical care they receive. Case conferences and multiprofessional assessments of your older patients will give you a better understanding of disease processes and their functional consequences.
A placement in a care of the elderly medicine (geriatric) department offers you the opportunity to learn how to manage complex comorbidity, interact with interprofessional teams, experience inter-agency work and work closely with the voluntary sector. You may also encounter hospital services provided in the home environment. You should also take the chance to expand your knowledge and skills in end-of-life care and advance directives. Take the opportunity also to attend day hospital and clinics, as well as to accompany your consultant on any domiciliary visits.
Self-directed learning
Older patients often have many complex psychological, social and physical problems that provide rich subjects for tutorials and case-based learning.
Learning with other healthcare professionals
The discipline of care for older adults involves huge numbers of professionals, each with their particular areas of expertise. These include community nurses, physiotherapists, occupational therapists, speech therapists, opticians, audiologists, palliative care nurses, physicians and social workers, to name but a few. You should endeavour to spend some time with these colleagues to ensure you understand the breadth and frequency of input that can be provided to the older adult, the effectiveness of such input and the appropriateness of referral to these agencies. You should also take the opportunity to visit patients at their homes with other members of the primary healthcare team and to accompany the occasional patient to hospital clinics to gain a better understanding of the ‘patient journey’.
Examples of how this area of practice may be tested in the MRCGP
Applied Knowledge Test (AKT)
- Diagnosis of frequent falls
- Tools for assessing cognitive impairment
- Differential diagnosis of immobility
Simulated Consultation Assessment (SCA)
- An older man requests more analgesia for advanced hip osteoarthritis. He has declined a hip replacement because he is the sole carer for his disabled wife
- A woman with heart failure is dyspnoeic but cannot cope with the incontinence when she takes her diuretic medication
- Phone call: an adult son is concerned that his elderly father is no longer coping safely with living alone
Workplace-based Assessment (WPBA)
- Log entry about attending a multidisciplinary team meeting planning the hospital discharge of an older woman with dementia
- Log entry about completing a care plan for a nursing home resident whose daughter has unrealistic expectations
- Data gathering in a consultation with a garrulous patient giving an inconsistent and vague history
- Mini mental state examination (MMSE)