In this Toolkit - Challenges, Definitions and Solutions

Resources for the Comprehensive Geriatric Assessment based

Proactive and Personalised Primary Care of the Elderly

Challenges, definitions and solutions

along a pathway of excellence

Geriatrics is a relatively young discipline

Modern History

Yet, the number of people aged 60 and over is growing larger in both developed and developing countries worldwide.

This means that the care of older people will continue to make up an increasingly higher proportion of the workload of the general practitioner

Older people

often experience

multiple health problems

which, in recent decades,

have been approached

in a problem-based,

disease oriented fashion

Now, there are 2 universally recognised realities which undermine optimum outcomes

in this traditional problem-based, disease oriented model of care, particularly as it is applied to the care of the elderly

The first reality is that, particularly in the elderly, one disease and its management often influences the prevention, the diagnosis, the impact and the treatment of another diseases

For example :

Diabetes control

may influence the sequelae of PVD

which mat reduce the need for diuretics and antithrombotics

which may influence cardiac medication

and may reduce the risk and incidence of falls

which may reduce the need for analgesics

which may improve liver function

This means that care of the elderly needs to shift from the old problem-based and disease-oriented model towards a more goal-oriented and integrated care delivery ...

a delivery of care which aims to achieve more than simply improving outcomes per disease

but aims instead at more global health outcomes such as

- learning new skills

- changes in behaviour

- access to community support

- and more appropriate, unconflicting medication and treatment plans

It has been irrefutably demonstrated that the successful achievement of these more desirable outcomes,

and patient compliance with the required treatment plans

is demonstrably higher in people

who are actively personally engaged in their healthcare

This personal engagement,

particularly in the care of the elderly, strives towards

- informed agreement of treatment goals

- the identification of support needs

- the consequent targeted development and implementation of action plans

- and the monitoring of progress

with a continuous process of reassessment and adjustment of the plans to meet the unique personal needs and circumstances of every individual

So, the first characteristic

of optimum healthcare delivery

to the elderly

is that the care is personalised

The GP is often the very first health-carer to suspect the presence of physical, functional, mental or social problems

The second reality that cannot be ignored in the delivery of optimum healthcare to the elderly is that prevention is always better than cure.

For example :

Peter has always presented himself immaculately dressed and always perfectly groomed,

He was widowed 3 months ago,

and he now presents with long untidy hair

and a soiled jersey

This raises the question, is Peter :

- struggling with daily chores

- depressed

- or non-compliant with his diabetes medication and diet

Another example is Mary :

She has always been

impeccably on time and compliant,

but she has missed her last 2 appointments.

Is Mary :

- becoming more frail

- less socially supported

- or is she now struggling to cope with the care of her invalid husband.

If ignored, these detected red flags will inevitably lead to new health problems and poor health outcomes for both Peter and Mary.

Optimum healthcare for both would include the investigation and treatment of the underlying problems before they escalate or multiply.

So, the second universally recognised requirement for delivery of optimum healthcare to the elderly is that it has to be not only personalised but also proactive.

Proactive care is preventative and aims to identify the individual's physical health, mental health and social care needs by means of simple and effective screening and targeted testing.

The benefits of more proactive and personalised care are extensively documented in the professional literature

Proactive Personalised Care

Helps reduce the burden on Emergency Departments
Helps reduce Hospital admissions and Nursing Home admissions
Helps effectively identify, monitor and manage frailty
and Helps improve and prolong quality of life both at home and in residential care

Worldwide, the successful delivery of healthcare is recognised as dependent on the crucial role of the GP providing quality primary care to the elderly,

There is a recognised need to empower GP's, local staff and patients

to develop a more preventative care mentality, take more proactive care decisions,

and engage in management plans of acute and chronic health conditions

that are at once personalised, systematic, and effective,

optimally tapping into the local multidisciplinary resources available.

CGA Toolkit Plus is a web-based resource aimed at empowering and assisting GPs and allied primary carers to understand and successfully provide more proactive and personalised care of the elderly.

It is structured around the Comprehensive Geriatric Assessment as the optimum framework on which the GP can create and execute protocols and systems of proactive and personalised care which are logistically and financially viable given that GP's unique practice location and resources.

In other words, it is a systematic assessment of all aspects of the elderly person's health,

not just the physical but also the psychological and social.

From this assessment flows a formulated plan of action for the elderly person and carers to improve and monitor and maintain optimal health and function.

CGA Toolkit Plus is a centralised depository of resources required by GPs for the development and implementation of a Comprehensive Geriatric Assessment based approach to care of the elderly.

That approach sees many of the tasks devolve to practice nurses and staff, and frees the GP to concentrate on clinical assessment and decision making.

The approach fosters a GP led team approach to care, in a manner which is highly adaptable to the GP's unique local circumstances and resources, be they urban or rural based.