Teaching Aged Care for general practice – getting perspective
How do we appropriately prepare doctors for care of the ageing, particularly in general practice? What is the relevant curricular content (what do GPs see or what do they need) and how is it best taught?
Let’s start with the caveats. Not all practices are the same and not all doctors are the same. Despite statistical observations about average patient populations there are some doctors who see scores of nursing home patients and some who see none. There are GPs who focus on kids or women’s health or travel medicine. Some sub-specialise in palliative care, sports medicine or skin procedures. The list goes on and, certainly, newly Fellowshipped doctors are more likely to see (on average) a younger patient load in their early years.
A lot of the fuss about aged care is because it often seems complex but it is also at the forefront of discussion because it is high on the government agenda. Policy makers of course are concerned about anything that is a significant cost to the health system and this includes hospital admissions and residential care, in which areas older patients are well represented.
Demographics and “Aged Care”
Our population is undeniably ageing, chronic disease is increasing, the cost of dementia and residential aged care is increasing and the cost of the final year of life is disproportionately high. These are the issues that make headlines and influence policy and funding. Unsurprisingly, therefore, I have noticed that when Aged Care is mentioned these days it often refers only to those in Residential Aged Care Facilities (RACF) as if this were the most important area of caring for the ageing patient. In fact, the proportion of those over 65 in residential care has actually declined over recent decades. However, given the increasing proportion of older people overall, the absolute numbers are still increasing. Of the 85 + age group a quarter are in RACF whereas in the 65-74 years age group it is only 2%.
The median length of stay in RACF is five months (the average is higher owing to some with very long lengths of stay) and half die within 6 months of nursing home admission. Today, over half of people die in hospitals and around thirty percent in residential care.
Care for those in RACF is becoming rather separated from usual GP care, partly because there is often a change of doctor as patients are obliged to move to a different geographical area. Instead of following a patient’s care to the nursing home a GP often takes on multiple patients in one location, which is a different style of practice. Residents are also older and sicker than they were decades ago. Recruiting doctors to work in RACF is problematic (for many reasons) but we also know that those who care for nursing home patients as a registrar are subsequently more likely to do this once fellowed so, despite the low numbers, it would seem to be useful to address this area in teaching.
What is not celebrated
Along with the decreased proportion of older patients living in RACF, it should be noted that not only are Australians living longer but most of those additional years are free of disability. Nevertheless, there are often years at the end of life where multiple services are required. Despite a tendency toward greater use of health services with age, someone over 85 with no chronic diseases is less likely to need services than someone under 85 with several chronic diseases. The problem is not just age.
The implications for general practice
The average GP has 20 patients die each year in GP practice in the UK (with higher patient loads) and if we can extrapolate to Australian practice, a full time GP might have between one and two per cent of their regular patients die each year – which leaves some hundreds of older patients requiring other sorts of care.
Topics taught in aged care courses generally include diseases such as Parkinson’s, dementia, stroke and so forth and yet these are a minority of the problems presented by older patients in primary care. Nevertheless, if you are looking after nursing home patients the proportion with these conditions is very much higher.
In terms of population proportions, the 15-64 year old age group has remained stable whereas the under 15s have decreased and those over 65 have increased, with the over 85s growing at a faster rate than other segments of the population. But they are still only at 2%. Over 65s are a similar proportion to under 15s. This will be reflected in general practice but, as older people tend to have more conditions, more medications and more illness, the GP will be seeing them much more often.
The “average” (but with incredible variation) GP probably only has a couple more nursing home patients than they might have had in the 1990s. For every 1000 patients in a practice there may now be 20 who are over 85 of which 5 might be in RACF but there will be 15 in the community – with all that this implies about complex care needs. There might also now be 130 between 65 and 84 – the age group where chronic diseases are increasing but where appropriate preventive activities may still make a substantive difference. Basically, this is where the changes are most apparent in general practice and this indicates the skills that are needed.
The majority of GP patients are not in nursing homes, nor in the final year of their lives or requiring palliative care. In addition we are not dealing just with patients who have been judged to have entered the geriatric paradigm although it is useful to be aware of the concepts of geriatric syndromes and functional status etc. However, GPs care for patients transitioning through some of these stages.
GPs, in the community, hopefully see patients over a period of time – continuity of care. We manage their acute illnesses (despite the spin being that these days GPs see only chronic disease) as well as their injuries. We listen to their problems and we try to implement appropriate preventive interventions. Somewhere along this journey they likely acquire some chronic diseases and the ongoing management becomes a little more complex. Crucially we need to recognise impending frailty or acute deterioration. All this constitutes caring for ageing patients.
So what should we be teaching GPs?
First, we should still start (and finish) with being patient/person-centred and we need to convey this in a system which is becoming more of a challenge to continuity and patient-centredness. The doctor/patient relationship still matters. We often need to be advocates for elderly patients in an increasingly impersonal system. Second, the skill of clinical judgment is more important than ever. GPs need to identify when it is appropriate to apply differing paradigms for management (such as prevention, geriatric principles, palliative care approach, teamwork etc). In addition to all this, of course, are the skills of prescribing, managing polypharmacy and multimorbidity which are most appropriately utilised in the general practice context. For the majority of ageing patients the GP is crucial in terms of delaying progression of disease and functional decline. It is a challenge to enthuse learners about prevention when outcomes are hard to measure and not obvious.
This still misses a couple of things. One is the necessity of knowledge about other services and the requirement for teamwork. This is quite a challenge in our fragmented system and mentors, role models and supervisors are invaluable. The practice placement makes such a difference. The next crucial factor to consider is the carer. People are staying in the community and being cared for by others often with their own health needs. This adds an extra dimension to the health care and moves appropriately into the ethical, professional, legal and organisational domains of curricula.
So, if we are keen to teach what is relevant in terms of GP clinical exposure and workload we need to keep the realities of practice in mind. Certainly teach about palliative care and focus on the specific skills for the increasingly differentiated processes of care in RACF (there are some useful AFP articles such as http://www.racgp.org.au/afp/2015/april/models-of-general-practitioner-services-in-residential-aged-care-facilities/ ) and ensure experience in this area. However, the useful long term outcome is to have fewer patients requiring this sort of care so don’t forget about the continuum of ageing care and the large number of relatively healthy, ageing patients and what can be done for them – which may then influence the development of dependence and frailty and quality of life at the end of life.
In terms of how it is done, the suggestions would be similar to those in the post on Multimorbidity. Although lectures can be useful for becoming acquainted with important concepts (frailty, functional status, geriatric syndromes, recognising delirium), case studies and case discussion give learners the opportunity to practice the complexity of diagnosis and management in this group of patients. However, many of these skills are honed in practice as one’s patients age. It is a very relevant topic for ongoing CPD.
Some interesting references with figures on the population, ageing, chronic disease and service use etc if interested