More than one in 10 people in Ireland are aged over 65 and this figure is expected to double to more than one million people by 2035, with the greatest proportional increase occurring in the 85-plus age group.¹

People are living longer due at least in part to advances in medical science and technology, but with this welcome development comes a growing complexity of healthcare needs for an ageing population. While the majority of older people can continue to live at home with HSE or family support, approximately 21,000² reside in the country’s 450 or so registered nursing homes.  

The long-term care of older people in residential and nursing homes places major demands on GPs. 

Approximately 70% of residents are classified as ‘high/maximum dependency’ and more than six in 10 have dementia, Dr Brian Meade, Dublin GP told a recent ICGP Care of the Elderly Symposium. A high percentage of patients in nursing homes have multiple chronic morbidities requiring complex medication regimens to treat each condition, which can present numerous challenges for the medical practitioner, and also places this group at increased risk of experiencing an adverse drug reaction.

“This work is more challenging than mainstream general practice and without the availability of agreed guidelines or treatment protocols to guide GPs in caring for patients in nursing homes and long-stay residential care. Where chronic disease management guidelines do exist they can be difficult to apply in frail elderly patients with a limited life expectancy,” Dr Meade told Forum.

Two full-day symposia organised by the College in Mullingar and Dublin examined clinical and logistical issues facing GPs with nursing home patients. 

Dr Meade highlighted the need for more formal structures surrounding GP nursing home visits.

“For a lot of GPs, calls to nursing homes are often done at lunchtime or at the end of the surgery when they are tired or under time pressure. The temptation to prescribe an antibiotic or sedative drug is strong. Dealing with elderly patients in nursing homes can be time consuming. If possible, it is better for a GP to focus on a small number of nursing homes and organise regular visits at which all issues can be dealt with in an organised fashion. This cuts down on frequent unscheduled visits, out-of-hours visits, and telephone consultations from nursing homes,” he said.

This call to regulate patient/doctor visits in nursing homes, which could ultimately pre-empt potential medical complications and avoid hospital transfers, was echoed in a presentation another Dublin GP, Dr Liam Lacey. With more than three decades of experience as a GP, and the past eight years as CEO of four nursing homes in the greater Dublin area, Dr Lacey has approached these treatment and management challenges from both sides of the fence. The key, he says, is to replace ‘fire-fighting’ with advanced care planning.

“It’s not a secret that people are more ill and dependent when they go into nursing homes, so our first priority is to develop the expertise of the medical people coming in to care for these patients so that we do not have occasion to transfer people to hospital as much as normally.

“In our nursing homes, we have organised ward rounds during which the GP will visit each patient, accompanied by the clinical nurse manager or the assistant director of nursing. We have also formulated a pre-visit programme so that, prior to the doctor’s visit, the nurse on duty will have recorded information such as pulse, blood pressure, temperature, urinalysis and glucose stick. These rounds take place up to three times a week; patients are monitored very closely so that we can catch any complications early and avoid hospital transfer,” explained Dr Lacey.

Routine ward rounds are coupled with quarterly health checks on individual patients. In addition, a drugs and therapeutics committee conducts a full review of medication on a three-monthly basis.

Epidemiological data from Europe indicates that people aged 65 and older take 2.3 times more medication than younger counterparts,³ which can prove problematic on several levels, including a greater potential for ADRs and drug interactions, as well as an increased risk of inappropriate prescribing. Also, age-related pharmacokinetic changes can alter drug absorption, distribution, metabolism and excretion. For example, many elderly patients have renal impairment, which affects drug absorption and excretion and can alter blood drug levels.

Potential inappropriate prescribing is a major area of concern and has been implicated as a substantial burden to health services internationally. A study in older residents in nursing homes found that almost three quarters (73%) of residents in Ireland had at least one potentially inappropriate medication identified by STOPP criteria and more than half (54.3%) had at least one identified by the Beers’ criteria.⁴

Dr Siobhan Kennelly, consultant geriatrician in Connolly Hospital, Blanchardstown, offered guidance through this potential medication minefield. She highlighted issues that should be considered when prescribing and reviewing medication for older patients, such as: life expectancy; the right therapeutic approach in patients with poor prognosis; ability to swallow; and medication selection with the most favourable risk/benefit ratio. For example, the use of warfarin in older patients requires special consideration because of concerns over increased risk for major bleeding as a result of falls, as well as potential distress regarding INR monitoring. 

Not all confusion in elderly patients is dementia; delirium should always be considered. “Any drug can potentially cause confusion. Take a careful history of any new drug started or any old drug stopped recently,” she suggested. Other risk factors for the development of delirium include dementia, pre-existing cognitive decline, dehydration, severe illness, vision impairment, pain, faecal impaction, urinary retention, and alcohol intoxication or withdrawal.

Dr Kennelly’s recommendation that due consideration be given to non-pharmacological options was reiterated by consultant psychiatrist Dr Greg Swanwick, who emphasised that non-pharmacological measures are the cornerstone of managing both delirium and behavioural and psychological symptoms of dementia (BPSD). 

Dr Swanwick, consultant in psychiatry of old age at Tallaght Hospital, stressed that information is the key. Before even considering prescribing an antipsychotic, find out as much as possible about the patient, including family structure, items for reminiscence, previous work and activities, food likes and dislikes, personal interests, and details about their current environment, for example, is it non-stressful and are appropriate daytime activities provided?

A 2012 study in the UK found that psychotropic drugs, such as antipsychotics, benzodiazepines and anticholinergic antihistamines, are prescribed much more frequently in nursing homes than in the community.⁵ The drugs have the potential to cause harmful side effects, which the researchers stated may also contribute to functional and cognitive decline in a vulnerable group. “Where medication is indicated ‘go low and go slow’, remember to periodically review and stop medication,” Dr Swanwick said. 

Family issues

At times, dealing with patients’ families can also prove challenging and, in some cases, family disputes can erupt regarding treatment. “Sometimes families can have unrealistic expectations about the medical health of their loved one and about the ability of the nursing home to provide acute medical care,” said Dr Meade. “Family disputes are also not uncommon and GPs can find themselves drawn into these.”

Stephen McGuinness,Hayes Solicitors said that while family members are often called upon to give consent to treatment for an incapacitated adult patient, there is actually no legal basis for doing so. “Your duty is to the patient not to the family. The same position applies even if there is no family dispute as to the proposed treatment for the patient.”

Issues that should be considered when treating patients who lack capacity, include: 

• Which treatment option provides the best clinical benefit
• The patient’s past and present wishes, if known
• Whether the patient’s capacity is likely to increase
• The views of other people close to the patient
• The views of other healthcare professionals involved in the patient’s care.

“The GP is not alone in the decision-making process. We mustn’t forget that these patients have 24/7 cover; they have qualified nurses, a director of nursing, assistant director of nursing, clinical nurse managers and their family. Many of the issues that arise regarding when to switch from active supportive therapy to palliative care do not have to be problematic as long as the doctor addresses them in advance by talking to the patients or their next of kin. If you don’t talk about it then there will be no entry in the care plan as to what the respective wishes might be,” said Dr Lacey.

The National Clinical Programme for Older People (NCPOP) is currently preparing a scoping document to explore the main issues around GP involvement in nursing home care, with a view to developing a new model of care. However, John Farrell from HIQA told the Mullingar symposium that the nursing home provider, and not the GP, is ultimately responsible for the healthcare and welfare of the resident.

“As we pointed out to him at the meeting, that can’t be done without the GP, it’s more of a team event,” said Dr Lacey. “Increasingly, GPs are coming to terms with the concept of primary care in a nursing home setting. Before it was a drop-in/drop-out service and some nursing homes had a service once a week or once a fortnight. But in order to head trouble off at the pass you have to be much more attentive, more proactive, and give a much more professional service. You have to be in there regularly to try to see the changes happening.”

GPs were unified in the view that current remuneration rates for care of patients in nursing homes does not reflect the workload involved and inhibits the involvement of doctors in more preventative and anticipatory care.

“It leaves me at a loss as to why the Minister for Health would cut payments by 50% for GPs who treat patients in nursing homes and then consider taking a further 10% off this year,” said Dr Lacey. “Yet still GPs around the country continue to provide this vital service, so I wouldn’t think money is high on the agenda for GPs in terms of being outspoken on the issue. But it’s a long road that has no turning, and when it comes down to rolling out the increased management of chronic illnesses in the community, unless the resources are made available that will never happen. And that’s a fact the Minister is missing.” 

References

1. Department of Health. Health in Ireland Key Trends 2012. Available at www.doh.ie/publications/key_trends_2012.html
2. Central Statistics Office. Census 2011 Results Interactive Tables. Available at www.cso.ie 
3. Barry PJ et al. Inappropriate prescribing in the elderly: a comparison of the Beers criteria and the improved prescribing in the elderly tool (IPET) in acutely ill elderly hospitalized patients. J Clin Pharm Ther 2006; 31(6): 617-626
4. Byrne S, O’Mahony D, Hughes C et al. An evaluation of the inappropriate prescribing in older residents in long term care facilities in the greater Cork and Northern Ireland regions using the STOPP and Beers’ criteria. Centre for Ageing Research and Development in Ireland (CARDI) Report, 2011
5. Shah SM, Carey IM, Harris T et al. Quality of prescribing in care homes and the community in England and Wales. Br J Gen Pract 2012; 62(598): e329-336