A little bit about care for an older person

You find an excellent policy giving you lots of information (see link below)

https://www.england.nhs.uk/ourwork/clinical-policy/older-people/improving-care-for-older-people/

How do we define an older person? How old is an older person? Asking a cohort of nursing delegates the answer ranged from 60 (I was quite offended…lol) to 80 years old.

NHS England had the same difficulty. It is not easy to apply a strict definition because people can biologically age at different rates so, for example, someone aged 75 may be healthier than someone aged 60.  Look at the 95 year old in the picture below.

In their policies, the NHS have made the decision that assessing ‘frailty’ not just age, has a bigger impact on peoples likelihood to require care and support.

NHS England (2022) have produced guidance for Health and Social care professionals (this includes us) to help people age well and help recognise and reduce frailty.

Another document you may find useful is a toolkit for assessing frailty in General Practice (you will find the link in the materials section).

The electronic frailty index is one tool to use to identify individuals aged over 65 years who are living with frailty, it can also tell us the degree of their condition (mild, moderate, severe).

Considerations when examining older patients

  • A thorough assessment may have to be split into more than one session or deferred, initial prioritisation of the most relevant issues is important.

  • Older patients with limitations of mobility, exertion or posture may require an adaptive approach to the usual sequence of examination.

  • Accept less than ideal conditions, e.g. a kyphosis or severe heart failure may limit the ability to lie flat for examination.

  • Patients with dementia, delirium, or psychiatric illness may not give consent or participate in
    examination.

  • Whether the patient has capacity to agree or refuse examination and, if not, assessment performed
    bearing in mind the best interests of the patient using provisions of mental capacity legislation.

  • Sensory loss – this may be a problem with communication.

  • Poor foot care can cause poor balance and function – therefore the person is at more risk of falls.

  • Check Gait and balance.

  • Lying and standing blood pressure (this can provide clues about fluid status, medication effects and causes of dizziness or falls).

  • Cognition and mood.

  • A full functional assessment is generally done by specialist occupational therapists, but you may pick up evidence of difficulties with personal care (hygiene,choice of attire) whilst visiting.

  • Pain/joints – many older patients will deny pain or be unable to express it. Observation during movement or change in posture may yield clues that mobility or function may be limited by pain.

  • Weight and nutrition – check and record weight consistently. Other evidence of weight loss such as poorly fitting clothes or loose skin should be noted.

  • General condition of hair and nails can yield clues about nutrition, and an observation of oral health
    (including checking of dentures) is useful.

  • PR and genitalia- Constipation is often missed and can cause chronic reduction in appetite or recurrent abdominal pain as well as acute deterioration, nausea and overflow diarrhoea.

  • Non-pathological changes are increasingly common in older adults. Skin changes such as wrinkling/thinning.

  • Medication review – older patients with multiple comorbidities can often be taking multiple medications, some of which may be based on sound, relevant evidence, but others may do more harm than good, particularly in combination.