Caring for the older person
- New Zealand has a rapidly ageing society, witnessing a faster increase in the proportion of older MÄori, Pacific and Asian populations compared to older Europeans
- Ageing and frailty
- normal ageing encompasses physiological changes in all organ systems, resulting in alterations in metabolism and a decline in physiological reserve
- frailty is a multidimensional geriatric syndrome characterised by a decline in cognitive and physical reserves, with associated vulnerability to stress or illness
- many different concepts of frailty exist, with key models being Friedâs phenotype model and Rockwoodâs accumulated deficits model
- frailty is not an inevitable part of ageing, but its prevalence increases with age. MÄori experience frailty earlier than other ethnic groups
- although frailty itself is seldom a direct cause of death, severe frailty should be considered a terminal illness
- Key aspects to consider when caring for an older person
- the GERIATRIC 5M Tool is a clinical framework that can be used to integrate key geriatric-specific principles into the care of older adults to maximise their quality of life
- Multicomplexity
- many older adults live with multimorbidity and complex psychosocial needs, necessitating a âwhole-personâ approach to care
- coordination and integration of care across various disciplines and healthcare settings may be required
- Mind
- regularly evaluate cognition and psychiatric health
- examine for the presence of early cognitive impairment, which can be easily overlooked and may impair an individualâs understanding of their situation and prognosis, as well as their ability to make complex decisions
- address modifiable risk factors for delirium, including avoiding psychotropics and medications with anticholinergic activity if possible
- be vigilant for hypoactive delirium, which can be easily missed
- address mental health conditions such as depression and anxiety
(See respective chapters on Dementia, Delirium, and Depression for information on assessment and management).
- Mobility
- regularly assess and optimise physical function, strength, and balance in order to maintain independence and reduce the risk of falls with potentially catastrophic consequences
- assess falls risk factors and initiate targeted interventions which may include a combination of
- improving continence
- providing a mobility aid
- advising on appropriate footwear
- implementing strength and balance training
- conducting home hazard assessment and modification
- medication review â medications most likely to increase falls risk include antidepressants including SSRIs and tricyclics, antipsychotics, benzodiazepines, and beta-blockers
- Medications
- Polypharmacy and inappropriate prescribing are prevalent, contributing to symptom burden, frailty, falls, and functional and cognitive decline
- âstart low and go slow,â and âkeep goingâ until adequate symptom control is achieved
- consider using tools and technology, such as pill boxes, blister packs, medication alarms and reminders, to improve adherence
- do not assume correct medication adherence and routinely reconcile medications with the patient and caregiver
- regularly review medications, deprescribing those that are poorly tolerated, ineffective, duplicated, or inappropriate. Medication optimisation tools developed specifically for older adults like STOPP/START can assist in the process
- consider medication adverse effects as explanations for development of symptoms requiring palliative intervention
- minimise anticholinergic burden, recognising that older individuals are more susceptible to its adverse effects which may add to the symptom burden. Elevated anticholinergic burden is also associated with an increased risk of delirium and falls
- Matters most
- uncover the individualâs personal values, goals, and preferences to guide the care provided
- advance care planning is particularly relevant for frail older adults given their vulnerability, and those with dementia, who may gradually lose the ability to make informed decisions over time
- use healthcare crises, and hospital admissions, or admissions to long-term care facilities as opportunities for advance care planning discussions