Domain – Older persons’ health (cases)

George is an 85-year-old man who comes into your clinic with his daughter, Sharon. Sharon made the appointment because she is concerned that George is becoming more ‘forgetful’ and ‘unsteady on his feet’. George lives alone and has a history of ischaemic heart disease, chronic obstructive pulmonary disease and osteoporosis. He is on a ‘long list’ of medications.

Communication and consultation skills
How might you manage the consultation to ensure that both George and his daughter are heard?
If George had thought this appointment was for a check-up and Sharon had rung in advance to voice her concerns, how might this affect the conversation?
How might you adjust your communication for a patient who might have a memory impairment? Or a hearing impairment?  

Ensuring Both George and Sharon Are Heard

1. Introduce Yourself and the Consultation’s Purpose:
   • Start by greeting George and Sharon warmly.
   • Explain the purpose of the consultation and that you will be addressing both George’s health concerns and Sharon’s observations.
2. Set the Agenda Together:
   • Ask George what he expects from the visit and if there are specific issues he wants to discuss.
   • Invite Sharon to share her concerns about George’s forgetfulness and unsteadiness.
3. Active Listening:
   • Listen attentively to both George and Sharon without interrupting.
   • Acknowledge their concerns and show empathy.
4. Encourage Open Communication:
   • Use open-ended questions to encourage George to express his thoughts and feelings.
   • Ask Sharon to elaborate on the changes she has noticed and provide specific examples.
5. Clarify and Summarize:
   • Repeat back key points to ensure understanding.
   • Summarize the discussion periodically to confirm that both George and Sharon feel their concerns are being addressed.

Managing the Consultation with Pre-appointment Information from Sharon

1. Start by addressing George directly to establish him as the primary focus of the consultation. This respects his autonomy and emphasizes that he is the patient.
2. Explaining the Purpose:Begin by gently clarifying the purpose of the visit. You might say something like:
   • “George, I understand that you thought this was a routine check-up, but your daughter Sharon mentioned she has some concerns about your health that she’d like to discuss. Is it alright if we talk about that today?”
3. Consent for Sharon’s Presence:
   • Ask George for his consent to have Sharon in the room for the discussion: “George, would you feel comfortable having Sharon stay with us while we talk about your health today?”

Conducting the Consultation:

1. Assessing George’s Wishes and Capacity:
   • If George agrees to have Sharon present, proceed with both of them in the room.
   • If George prefers to speak privately, respect his wishes and ask Sharon to wait outside for the initial part of the consultation.
2. Gathering Information:
   • Start with George, asking about how he’s been feeling and any concerns he might have. This can help gauge his insight into his health and cognitive status.
   • After speaking with George, incorporate Sharon’s observations and concerns to get a fuller picture.
3. Performing Assessments:
   • Conduct appropriate assessments for memory and balance issues.
   • Review his medication list and discuss any potential side effects or interactions that could contribute to his symptoms.

Legal and Ethical Approach:

1. Respecting Autonomy:
   • Throughout the consultation, ensure that George’s autonomy is respected by involving him in the discussion and decision-making process as much as possible.
2. Confidentiality and Consent:
   • If Sharon shared information beforehand, clarify with George that this information will be part of the discussion. Ensure he is comfortable with this and understands the context.
   • Document any consent given by George regarding the sharing of information and Sharon’s involvement.
3. Capacity and Best Interests:
   • If there are significant concerns about George’s cognitive capacity, consider a formal assessment of his decision-making capacity.
   • If George lacks the capacity to make informed decisions, involve Sharon appropriately in the discussion and decision-making process, always considering George’s best interests and previously expressed wishes.
4. Documentation:
   • Document all aspects of the consultation, including George’s consent for Sharon’s presence, any concerns raised by Sharon, and your clinical findings and recommendations.

Clinical information gathering and interpretation
What additional information do you need to know when a relative raises concerns about a patient?
Who may be able to assist you with the assessment of George’s cognition and safety at home?

Additional Information Needed

1. Specific Concerns and Examples:
   • Ask Sharon to provide specific examples of George’s forgetfulness and unsteadiness. How often do these issues occur? Are there any patterns or triggers?
2. Onset and Duration:
   • Determine when Sharon first noticed these changes in George’s behavior and how they have progressed over time.
3. Impact on Daily Life:
   • Understand how these issues are affecting George’s ability to perform activities of daily living (ADLs), such as cooking, cleaning, personal hygiene, and managing medications.
4. Safety Concerns:
   • Inquire about any incidents of falls, wandering, or accidents that may have occurred. Assess if George’s home environment is safe and if there are any immediate risks.
5. Medical History and Medications:
   • Review George’s medical history, including any recent changes in medications, as these can contribute to cognitive and balance issues.
6. Social and Support Network:
   • Gather information about George’s social support network. Does he have regular visitors or someone checking on him? How does he spend his days?
7. Mental Health:
   • Assess George’s mood and any signs of depression or anxiety, which can also affect memory and stability.
8. Cognitive Function:
   • Perform an initial cognitive assessment to gauge George’s memory, orientation, and executive function.

Who Can Assist with the Assessment

1. Geriatrician:
   • A geriatrician can provide a comprehensive assessment of George’s cognitive function, overall health, and medication management.
2. Neurologist:
   • If cognitive impairment is suspected, a neurologist can perform specialized tests and imaging to diagnose conditions like dementia.
3. Occupational Therapist:
   • An occupational therapist can assess George’s ability to perform ADLs safely and recommend modifications to his home environment to reduce fall risk.
4. Physiotherapist:
   • A physiotherapist can evaluate George’s balance and mobility and develop a plan to improve his strength and coordination.
5. Social Worker:
   • A social worker can help evaluate George’s social support network and connect him with community resources and services to support his independence.
6. Community Nurse:
   • A community nurse can regularly visit George at home to monitor his health, assist with medication management, and provide ongoing support.
7. Psychologist or Psychiatrist:
   • If there are concerns about George’s mental health, a psychologist or psychiatrist can assess and provide treatment for any mood disorders or anxiety.

Conducting the Assessment

1. Cognitive Assessment Tools:
   • Use tools such as the Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), or Addenbrooke’s Cognitive Examination (ACE-III) to evaluate cognitive function.
2. Home Safety Evaluation:
   • Arrange for an occupational therapist to conduct a home safety evaluation to identify potential hazards and recommend modifications.
3. Balance and Mobility Assessment:
   • Perform tests such as the Timed Up and Go (TUG) test, Berg Balance Scale, or Functional Reach Test to assess George’s risk of falls.
4. Medication Review:
   • Conduct a thorough review of George’s medications to identify any that might contribute to cognitive impairment or balance issues, and consult with a pharmacist if needed.

Making a diagnosis, decision making and reasoning
How might you involve your practice team in assessing George?
What are the issues for George? Write a problem list (including the differentials and other issues that are important to consider).

Involving Your Practice Team in Assessing George

Practice Team Members

1. General Practitioner (GP):
   • Conducts the initial assessment, coordinates the care plan, and monitors ongoing health issues.
2. Practice Nurse:
   • Assists with assessments, conducts follow-up visits, and provides education and support for George and Sharon.
3. Allied Health Professionals:
   • Occupational Therapist: Assesses ADLs and home safety.
   • Physiotherapist: Evaluates and manages balance and mobility issues.
   • Social Worker: Addresses psychosocial concerns and connects George with community resources.
4. Pharmacist:
   • Reviews medications for potential side effects or interactions that could affect cognition and mobility.

Tools for Assessment in General Practice

1. Cognitive Assessment Tools:
   • Mini-Mental State Examination (MMSE)
   • Montreal Cognitive Assessment (MoCA)
   • Addenbrooke’s Cognitive Examination (ACE-III)
2. Functional and Mobility Assessments:
   • Timed Up and Go (TUG) Test
   • Berg Balance Scale
   • Functional Reach Test
3. Screening Tools for Depression and Anxiety:
   • Geriatric Depression Scale (GDS)
   • Hospital Anxiety and Depression Scale (HADS)
4. Home Safety Assessment:
   • Conducted by an occupational therapist to identify hazards and recommend modifications.
5. Medication Review:
   • Comprehensive review by a GP or pharmacist to identify medications that may contribute to cognitive impairment or falls.

Issues for George: Problem List

Medical Issues

1. Cognitive Impairment: Differential: Dementia, delirium, depression-related cognitive dysfunction.
2. Unsteadiness and Risk of Falls: Differential: Parkinson’s disease, vestibular dysfunction, medication side effects, muscle weakness, orthostatic hypotension.
3. Chronic Conditions:Ischaemic heart disease, Chronic obstructive pulmonary disease (COPD), Osteoporosis
4. Polypharmacy: Potential interactions and side effects contributing to cognitive and mobility issues.

Psychosocial Issues

1. Loss of Independence: Increasing reliance on others for ADLs and safety.
2. Social Isolation: Living alone may contribute to feelings of loneliness and affect mental health.
3. Caregiver Concerns: Sharon’s stress and anxiety about George’s health and safety.
4. Mood Disorders: Potential depression or anxiety impacting cognitive function and overall well-being.

Biopsychosocial Model Considerations

1. Biological Factors: Age-related changes, chronic diseases, medication side effects.
2. Psychological Factors: Cognitive impairment, mood disorders, fear of falling, anxiety about health decline.
3. Social Factors: Living alone, social isolation, support network availability, Sharon’s involvement and concern.

Management Plan

1. Medical Management:
   • Conduct a thorough medical review and adjust medications as needed.
   • Monitor and manage chronic conditions (heart disease, COPD, osteoporosis).
2. Cognitive and Functional Assessment:
   • Perform cognitive assessments (e.g., MoCA).
   • Evaluate balance and mobility (e.g., TUG test).
   • Arrange for occupational therapy assessment for home safety.
3. Psychosocial Support:
   • Address mood disorders with appropriate therapy or medications.
   • Involve social worker to connect George with community resources and support groups.
   • Provide caregiver support for Sharon, including counseling and respite care options.
4. Preventative Measures:
   • Implement fall prevention strategies (e.g., home modifications, strength and balance exercises).
   • Educate George and Sharon on managing chronic conditions and maintaining independence.
5. Follow-up and Monitoring:
   • Regular follow-up appointments to monitor progress and adjust the care plan as needed.
   • Encourage ongoing communication between George, Sharon, and the practice team.

Clinical management and therapeutic reasoning
What are the evidence-based interventions for preventing falls?

1. Exercise Programs

• Balance and Strength Training: Programs such as Tai Chi and other balance-focused exercises have been shown to reduce fall risk.
• Aerobic Exercise: Incorporating moderate aerobic exercises can improve overall health and reduce fall risk.

2. Medication Management

• Medication Review: Regularly review medications to identify those that increase fall risk, such as sedatives, antidepressants, and antihypertensives. Adjust or discontinue as appropriate.
• Vitamin D Supplementation: Supplementation may be beneficial, particularly in those with low levels or at risk of deficiency.

3. Vision and Hearing Correction

• Regular Vision Checks: Ensure corrective lenses are up to date and conditions such as cataracts are treated.
• Hearing Aids: Address hearing impairments to improve spatial awareness.

4. Home Safety Modifications

• Environmental Adjustments: Remove tripping hazards, install grab bars and handrails, improve lighting, and consider non-slip mats in bathrooms.
• Assistive Devices: Use of walkers or canes as needed for stability.

5. Medical Management

• Chronic Condition Management: Optimal management of conditions like arthritis, diabetes, and cardiovascular diseases to reduce their impact on balance and mobility.
• Postural Hypotension: Evaluate and manage postural hypotension, which can lead to dizziness and falls.

6. Education and Behavioral Strategies

• Fall Prevention Education: Educate patients and caregivers on strategies to avoid falls, including proper footwear and the importance of physical activity.
• Behavioral Strategies: Teach safe transfer techniques and the importance of avoiding risky behaviors.

7. Multifactorial Interventions

• Comprehensive Assessment: Conduct a thorough assessment of individual risk factors and tailor interventions accordingly.
• Interdisciplinary Approach: Involvement of physiotherapists, occupational therapists, pharmacists, and other healthcare professionals to address the multifaceted nature of fall risk.

8. Community-Based Programs

• Community Resources: Utilize community-based fall prevention programs and support groups to reinforce safety practices and provide social support.

Evidence Supporting These Interventions:

1. Exercise Programs: Randomized controlled trials (RCTs) have shown that balance and strength training reduce fall rates by up to 30% .
2. Medication Review: Systematic reviews highlight that polypharmacy management and targeted medication adjustments significantly reduce fall risk .
3. Vitamin D Supplementation: Meta-analyses indicate that vitamin D reduces fall risk, particularly in those with low baseline levels .
4. Home Modifications: Studies show that environmental adjustments can reduce falls by approximately 20-30% .
5. Multifactorial Interventions: Comprehensive approaches tailored to individual risk factors are supported by strong evidence, showing a significant reduction in fall rates .

References:

1. Sherrington, C., et al. (2019). “Exercise for preventing falls in older people living in the community.” Cochrane Database of Systematic Reviews.
2. Gillespie, L. D., et al. (2012). “Interventions for preventing falls in older people living in the community.” Cochrane Database of Systematic Reviews.
3. Vieira, E. R., et al. (2016). “Falls in older people: Risk factors and prevention strategies.” Rehabilitation Research and Practice.
4. Bolland, M. J., et al. (2014). “Vitamin D supplementation and falls: a trial sequential meta-analysis.” The Lancet Diabetes & Endocrinology.
5. Clemson, L., et al. (2008). “Environmental interventions to prevent falls in community-dwelling older people: a meta-analysis of randomized trials.” Journal of Aging and Health.
6. Hopewell, S., et al. (2018). “Multifactorial interventions for preventing falls in older people living in the community.” Cochrane Database of Systematic Reviews.

Specific Advice Based on Risk Factors

1. Home Safety Tips:
   • Remove any loose rugs or clutter that could be a tripping hazard.
   • Use non-slip mats in the bathroom and secure handrails on both sides of the stairs.
   • Make sure home is well-lit, especially in areas like the hallway and bathroom.
2. Proper Footwear:
   • wear shoes that fit well and have non-slip soles, even when you’re indoors.
   • Avoid walking in socks or slippers that don’t provide good grip
3. For Patients with Chronic Conditions:
   • Emphasize the importance of managing chronic conditions like arthritis, diabetes, and cardiovascular diseases.
   • Suggest physical therapy or occupational therapy if the patient has mobility or balance issues.
4. For Patients on Multiple Medications:
   • Discuss the importance of a medication review to reduce polypharmacy and minimize drugs that contribute to falls.
5. For Patients with Postural Hypotension:
   • Advise standing up slowly from sitting or lying positions.
   • Suggest drinking plenty of fluids and avoiding alcohol, which can exacerbate hypotension
6. Awareness and Prevention:
   • Educate the patient on recognizing early signs of dizziness or balance issues and taking appropriate action.
     • includes feeling dizzy when you stand up
     • experiencing weakness in your legs
     • having difficulty with balance
   • Encourage them to ask for help with tasks that may pose a risk of falling, such as reaching for high shelves or carrying heavy items.
7. Behavioral Strategies:
   • Teach safe transfer techniques, such as getting in and out of bed or chairs.
   • Discuss the importance of pacing activities and not rushing, especially when moving from sitting to standing.
8. Emergency Plan:
   • In case you do fall, it’s important to have a plan
   • Keep a phone within reach at all times, and consider wearing a medical alert device that you can use to call for help if needed

How would you approach the management of multiple medical conditions?
What are some of the reversible causes of ‘confusion’?
Elderly patients often have multiple doctors prescribing their medication. How would you find out what medications a patient is taking?
When is a medication review helpful?
When would you discuss advance care planning? How would you introduce the topic?

Management of Multiple Medical Conditions

1. Comprehensive Assessment:
   • Detailed History: Collect a complete medical history, including current and past illnesses, treatments, and surgeries.
   • Physical Examination: Conduct a thorough physical exam to identify any current issues.
2. Prioritization:
   • Severity and Impact: Focus on the most severe conditions that have the greatest impact on health and quality of life.
   • Patient Preferences: Incorporate the patient’s values, goals, and preferences into the care plan.
3. Coordination of Care:
   • Interdisciplinary Team: Engage a team of healthcare professionals, including specialists, nurses, pharmacists, and allied health professionals.
   • Communication: Ensure clear and consistent communication among all team members and with the patient.
4. Medication Management:
   • Medication Reconciliation: Regularly review and reconcile all medications to avoid polypharmacy and interactions.
   • Deprescribing: Discontinue unnecessary medications and simplify the regimen.
5. Chronic Disease Management:
   • Guideline-Based Treatment: Follow evidence-based guidelines for managing each condition.
   • Monitoring and Follow-Up: Schedule regular follow-ups to monitor the effectiveness and adjust treatments as necessary.
6. Patient Education:
   • Self-Management Support: Educate the patient on managing their conditions, recognizing symptoms, and adhering to treatment plans.
   • Health Literacy: Ensure the patient understands their conditions and treatments.

Reversible Causes of Confusion

1. Medication Effects:
   • Adverse effects from new medications, polypharmacy, drug interactions.
2. Infections:
   • Urinary tract infections (UTIs), pneumonia, sepsis.
3. Metabolic Imbalances:
   • Electrolyte disturbances (e.g., hyponatremia), dehydration, hypoglycemia, hypercalcemia.
4. Nutritional Deficiencies:
   • Vitamin B12 deficiency, thiamine deficiency.
5. Hypoxia:
   • Due to cardiac or respiratory conditions.
6. Pain:
   • Uncontrolled or poorly managed pain.
7. Sensory Impairments:
   • Poor vision or hearing leading to sensory deprivation.
8. Acute Stress or Trauma:
   • Physical or emotional stress.

Finding Out What Medications a Patient is Taking

1. Patient and Caregiver Interview:
   • Ask the patient and caregiver to bring all medications, including over-the-counter drugs, supplements, and herbal remedies.
2. Pharmacy Records:
   • Contact the patient’s pharmacies for a list of dispensed medications.
3. Medical Records:
   • Review electronic health records and previous discharge summaries.
4. Medication Reconciliation:
   • Compare the patient’s medication list from different sources (e.g., hospital, primary care, specialists).

When is a Medication Review Helpful?

1. Polypharmacy: When the patient is taking multiple medications or has a complex medication regimen.
2. Adverse Drug Reactions : If the patient is experiencing potential side effects or drug interactions.
3. Transitions of Care : Following hospital discharge, transfer between care settings, or after seeing multiple specialists.
4. Changes in Health Status : New diagnoses, worsening of chronic conditions, or changes in weight or organ function.
5. Patient Concerns: When patients or caregivers have concerns about medications or their effectiveness.

Domiciliary Medication Management Review (DMMR), also known as a Home Medicines. Review (HMR)

Eligibility Criteria for DMMR/HMR

1. Referral by a GP:
   • The review must be initiated by a General Practitioner (GP) who determines that the patient would benefit from the service.
   • The GP must prepare a referral that includes relevant clinical information about the patient.
2. Patient Eligibility:
   • Patients living in the community (i.e., not in a residential aged care facility).
   • Patients who have a chronic medical condition or are taking multiple medications.
   • Patients with recent significant changes to their medication regimen.
   • Patients who have been discharged from hospital recently.
   • Patients who are at risk of medication misadventure due to cognitive impairment, confusion, or other factors.
   • Patients who have difficulty managing their medications independently.

Process of DMMR/HMR

1. GP Referral:
   • The GP identifies the need for a medication review and refers the patient to an accredited pharmacist.
2. Pharmacist Home Visit:
   • An accredited pharmacist visits the patient’s home to conduct a comprehensive review of their medications.
   • The pharmacist assesses the patient’s understanding of their medications, adherence to the prescribed regimen, and any potential issues.
3. Medication Review Report:
   • The pharmacist prepares a detailed report based on their findings and recommendations.
   • This report is sent back to the referring GP.
4. GP Follow-Up:
   • The GP reviews the pharmacist’s report and discusses the findings and recommendations with the patient.
   • Any necessary changes to the medication regimen are made in consultation with the patient and the pharmacist.
5. Implementation and Monitoring:
   • The patient is supported in implementing any changes to their medication regimen.
   • Ongoing monitoring is conducted to ensure the effectiveness of the new regimen and to address any further issues.

MBS Item Numbers and Billing

• MBS Item Number 900:
  • This item number is used for the GP’s initial referral and assessment for the DMMR/HMR.
  • It covers the time spent by the GP in assessing the patient, preparing the referral, and reviewing the pharmacist’s report.
• Accredited Pharmacist:
  • The pharmacist conducting the HMR is reimbursed separately, often through arrangements with the patient’s pharmacy or other professional fees.

Key Points to Note

• Patient-Centered Approach:
  • The HMR is tailored to address the specific needs and circumstances of the patient, ensuring a personalized approach to medication management.
• Collaboration:
  • Effective communication and collaboration between the GP, pharmacist, and patient are essential for the success of the HMR.
• Documentation:
  • Detailed documentation of the referral, pharmacist’s report, and follow-up actions is required for compliance with MBS requirements.

Benefits of DMMR/HMR

• Improved medication safety and adherence.
• Reduction in medication-related hospital admissions.
• Enhanced understanding of medications by patients and caregivers.
• Identification and resolution of medication-related issues.
• Optimization of therapeutic outcomes.

By following the MBS criteria and process for DMMR/HMR, healthcare providers can help ensure that patients manage their medications safely and effectively, ultimately improving health outcomes and quality of life.

Discussing Advance Care Planning

When to Discuss:

1. Routine Visits:
   • During regular check-ups, especially for patients with chronic illnesses or advanced age.
2. Significant Health Changes:
   • New diagnosis of a serious illness, hospitalization, or significant change in health status.
3. Annual Wellness Visits:
   • As part of preventive care and long-term health planning.

How to Introduce the Topic:

1. Empathy and Sensitivity:
   • “I want to make sure we respect your wishes and provide the best care possible, so I’d like to talk about what’s important to you as we plan for the future.”
2. Normalize the Conversation:
   • “Many of my patients find it helpful to discuss their preferences for future care in case something unexpected happens.”
3. Open-Ended Questions:
   • “Have you thought about what kind of medical care you would want if you were unable to make decisions for yourself?”
4. Involve Family Members:
   • Encourage involving family members in the discussion for support and clarity.

Tools and Resources:

1. Advance Care Directive Forms:
   • Provide and explain forms specific to your region.
2. Decision Aids:
   • Use tools and guides to help patients understand and articulate their wishes.
3. Referral to Specialists:
   • Refer to palliative care or legal advisors if needed for detailed planning.

Preventive and population health
How would your approach be different if George lived in a remote area?
What support is available in the community for older people?
Are there different support options for Aboriginal and Torres Strait Islander patients? What about other cultural groups?

Approach for Managing George’s Health in a Remote Area

1. Telehealth Services:
   • Utilize telehealth consultations to conduct regular check-ups, follow-ups, and consultations with specialists, including geriatricians and pharmacists.
   • Ensure George and Sharon are comfortable using telehealth technology and have access to necessary equipment and internet connectivity.
2. Local Healthcare Providers:
   • Collaborate with local healthcare providers such as community nurses, rural health clinics, and general practitioners in the area.
   • Utilize services offered by Royal Flying Doctor Service (RFDS) for more specialized care and emergency support.
3. Community Outreach Programs:
   • Engage community outreach programs that provide health services to remote areas, including mobile clinics and visiting healthcare professionals.
4. Medication Management:
   • Ensure George has a consistent supply of medications, possibly through mail-order pharmacies or local dispensaries.
   • Arrange for regular medication reviews via telehealth or during visits from healthcare professionals.
5. Home Modifications and Safety:
   • Coordinate with local agencies to assess and modify George’s home for safety, using remote guidance if necessary.
6. Social Support:
   • Encourage involvement in local community groups or remote social support networks to reduce isolation.
   • Utilize technology to connect George with family and social networks.

Community Support Available for Older People

1. Aged Care Services:
   • Home care packages that provide assistance with daily living activities.
   • Respite care services to give caregivers a break.
2. Health and Wellness Programs:
   • Community centers offering fitness classes, social activities, and wellness programs.
   • Chronic disease management programs and support groups.
3. Transportation Services:
   • Community transport services for medical appointments and social activities.
4. Meals and Nutrition:
   • Meal delivery services like Meals on Wheels.
5. In-Home Support:
   • Personal care assistants and home health aides for daily living assistance.

Support Options for Aboriginal and Torres Strait Islander Patients

1. Culturally Appropriate Healthcare:
   • Aboriginal Community Controlled Health Services (ACCHS) that provide culturally sensitive healthcare services.
   • Aboriginal Health Workers who act as liaisons between patients and healthcare providers.
2. Tailored Health Programs:
   • Programs addressing specific health issues prevalent in Aboriginal and Torres Strait Islander communities, such as diabetes, cardiovascular disease, and mental health.
3. Social and Emotional Wellbeing Services:
   • Culturally specific mental health and counseling services.
   • Community support groups that address social and emotional wellbeing.
4. Community Elders and Leaders:
   • Involvement of community elders and leaders in health promotion and decision-making processes.

Support for Other Cultural Groups

1. Multicultural Health Services:
   • Health services that provide interpreters and culturally appropriate care.
   • Multicultural health workers who support patients in navigating the healthcare system.
2. Community Organizations:
   • Community groups and organizations that offer support and services tailored to specific cultural groups.
   • Social and support networks that provide cultural activities and peer support.
3. Cultural Competence Training for Healthcare Providers:
   • Training programs to ensure healthcare providers understand and respect the cultural needs and preferences of diverse patient populations.

Addressing George’s Needs in a Remote Area

If George lived in a remote area, your approach would need to be flexible and resourceful, leveraging technology and local resources to ensure comprehensive care. Key elements would include:

• Utilizing telehealth for regular consultations and medication reviews.
• Collaborating with local healthcare providers and services like RFDS.
• Ensuring consistent medication supply and monitoring.
• Engaging community support services to reduce isolation and maintain social connections.
• Tailoring care to address any cultural needs, particularly if George belongs to a specific cultural group.

Professionalism
What would you do if George didn’t attend his scheduled follow-up appointment?
Many older patients transition from living in the community to a residential aged care facility. How can the GP help this process?
What is the role of the GP in residential aged care facilities?

Managing Missed Follow-Up Appointments for George

1. Immediate Follow-Up:
   • Contact George and Sharon by phone to understand the reason for the missed appointment and reschedule it as soon as possible.
   • If unable to reach by phone, send a reminder via mail or email.
2. Identify Barriers:
   • Discuss with George and Sharon any potential barriers to attending appointments, such as transportation issues, forgetfulness, or health concerns, and address them accordingly.
   • Arrange for transportation services if needed or consider home visits if George is unable to travel.
3. Telehealth Option:
   • Offer a telehealth consultation as an alternative if attending in person is challenging.
4. Care Plan Review:
   • Reassess George’s care plan to ensure it is manageable and consider any additional support he may need to adhere to follow-up appointments.
5. Community Resources:
   • Engage community health workers or local support services to check on George and provide reminders for upcoming appointments.

Assisting the Transition to a Residential Aged Care Facility

1. Early Discussions:
   • Begin conversations about the possibility of moving to a residential aged care facility early, ensuring that George and his family are involved in decision-making.
   • Provide information on the types of care available, costs, and what to expect.
2. Assessment and Planning:
   • Conduct a comprehensive assessment of George’s health and care needs to determine the appropriate level of care.
   • Help the family complete necessary paperwork and applications for aged care assessment (ACAT/ACAS assessment).
3. Support and Guidance:
   • Offer emotional support and counseling to George and his family during the transition period.
   • Discuss advance care planning and ensure George’s wishes are documented.
4. Coordination with Facility:
   • Communicate with the aged care facility to provide a detailed medical history, current medications, and care requirements.
   • Ensure a smooth handover by coordinating with the facility’s healthcare team.
5. Follow-Up:
   • Arrange for a follow-up visit shortly after George’s move to address any immediate concerns and adjust the care plan if necessary.

Role of the GP in Residential Aged Care Facilities

1. Primary Healthcare Provider:
   • Continue to provide primary care, managing chronic conditions, acute illnesses, and preventive health measures.
   • Conduct regular health assessments and monitor ongoing health issues.
2. Medication Management:
   • Review and manage medications to avoid polypharmacy and adverse drug reactions.
   • Ensure appropriate prescribing and deprescribing practices.
3. Coordination of Care:
   • Coordinate with the facility’s healthcare team, including nurses, allied health professionals, and specialists, to ensure comprehensive care.
   • Facilitate communication between the resident, their family, and the healthcare team.
4. Advance Care Planning:
   • Discuss and document advance care plans and end-of-life wishes with residents and their families.
   • Ensure these plans are respected and followed by the care team.
5. Health Promotion and Disease Prevention:
   • Implement preventive health measures such as vaccinations, screenings, and lifestyle modifications.
   • Educate residents and staff on health maintenance and disease prevention.
6. Emergency Care:
   • Provide timely interventions for acute medical issues and arrange for hospital transfers if necessary.
7. Psychosocial Support:
   • Address mental health concerns such as depression, anxiety, and dementia.
   • Support the emotional well-being of residents through counseling and referrals to mental health services.
8. Palliative Care:
   • Provide palliative care and pain management for residents with terminal illnesses.
   • Ensure a dignified and comfortable end-of-life experience for residents.

General practice systems and regulatory requirement
What legal aspects do you need to consider for George?
How would you assess George’s capacity to consent/make informed decisions?
How will you arrange follow-up appointments? What MBS services (item numbers) could you consider using as part of your management plan?
How would you assess if an elderly patient meets the medical standards to drive?

What is the role of a substitute decision-maker? 

Legal Aspects to Consider for George

1. Capacity to Consent:
   • Assess George’s capacity to make informed decisions about his health care, treatment, and living arrangements.
2. Advance Care Directives:
   • Ensure George has an advance care directive or living will, outlining his preferences for future medical treatment.
3. Enduring Power of Attorney/Guardianship:
   • Confirm if George has designated an enduring power of attorney or guardian to make decisions on his behalf if he becomes incapacitated.
4. Documentation:
   • Properly document all assessments, discussions, and decisions made regarding George’s care to ensure legal compliance and continuity of care.
5. Confidentiality:
   • Maintain patient confidentiality while involving family members, ensuring any shared information is with George’s consent.

Assessing George’s Capacity to Consent/Make Informed Decisions

1. Mental Status Examination:
   • Conduct a comprehensive mental status examination to assess cognitive functions such as memory, attention, orientation, and executive functioning.
2. Cognitive Assessment Tools:
   • Use standardized tools like the Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), or Addenbrooke’s Cognitive Examination (ACE-III).
3. Understanding and Communication:
   • Evaluate George’s ability to understand information relevant to the decision, appreciate the consequences of the decision, and communicate his choices.
4. Context-Specific Evaluation:
   • Assess capacity for specific decisions rather than a global assessment. For example, understanding medication changes vs. complex medical procedures.
5. Involvement of Specialists:
   • If necessary, involve geriatricians, neurologists, or psychiatrists for a detailed capacity assessment.

Arranging Follow-Up Appointments and MBS Services

1. Scheduling Appointments:
   • Arrange regular follow-up appointments based on George’s health needs, either in-person or via telehealth.
   • Use reminder systems, such as phone calls, SMS, or email, to ensure George and Sharon remember the appointments.
2. MBS Item Numbers:
   • MBS Item 900: Domiciliary Medication Management Review (HMR).
   • MBS Item 10987: Follow-up service provided by a practice nurse or Aboriginal health worker.
   • MBS Item 721: Preparation of a General Practitioner Management Plan (GPMP).
   • MBS Item 732: Review of a GPMP.
   • MBS Item 731: Contribution to a multidisciplinary care plan prepared by another provider.

Assessing Medical Standards for Driving in Elderly Patients

1. Comprehensive Assessment:
   • Conduct a detailed medical examination focusing on vision, hearing, mobility, and cognitive function.
2. Specific Tests:
   • Use vision tests (Snellen chart), hearing tests (audiometry), and cognitive assessments (MoCA, MMSE).
3. Functional Ability:
   • Assess reaction time, coordination, and physical ability to operate a vehicle safely.
4. Review Medications:
   • Evaluate the impact of medications on driving ability, particularly those that may cause drowsiness or impair reaction time.
5. Referral to Occupational Therapist:
   • Consider a referral to an occupational therapist for an on-road driving assessment if needed.
6. Regulatory Standards:
   • Follow state or territory guidelines and medical standards for assessing fitness to drive, such as those outlined by Austroads.

substitute decision-makers

Substitute Decision-Maker	Role	Scope of Authority
Enduring Power of Attorney (EPOA)	Appointed by the individual to make decisions on their behalf.	Financial decisions: managing bank accounts, paying bills, handling property. Personal matters: decisions about daily living arrangements. Health care decisions: consent to medical treatments, decisions about health care.
Statutory Health Attorney	Automatically assigned in the absence of an EPOA.	Health care decisions only. Hierarchy: 1. Spouse or de facto partner. 2. Unpaid carer (currently or previously providing care). 3. Close friend or relative.
Guardian	Appointed by the Queensland Civil and Administrative Tribunal (QCAT).	Personal matters: decisions about living arrangements, lifestyle, and support services. Health care decisions: consent to medical treatments, decisions about health care.
Administrator	Appointed by QCAT.	Financial decisions: managing finances, property, and legal affairs.

Australia in general:

1. Enduring Power of Attorney (EPOA):
   • Allows an individual to appoint someone to make financial, personal, and health decisions on their behalf, which remains effective even if they lose capacity. Names and specific powers may vary by state.
2. Statutory Health Attorney(in QLD):
   • If no EPOA has been appointed, a statutory health attorney can make health care decisions. This is typically a spouse, unpaid carer, close friend, or relative. The hierarchy is prescribed by law.
3. Enduring Guardian:
   • A person appointed to make lifestyle, health, and medical decisions when the individual loses capacity. The appointment must be made while the individual still has capacity.
4. Guardian:
   • Appointed by a tribunal or court to make personal and health decisions when no EPOA or enduring guardian has been appointed or is available. Different states have specific tribunals for this purpose, such as the Guardianship Division of NCAT in New South Wales or SACAT in South Australia.
5. Tribunal-Appointed Decision-Maker:
   • In cases where there is no appointed substitute decision-maker, a state tribunal (such as QCAT in Queensland, VCAT in Victoria, or NCAT in New South Wales) can appoint a guardian or administrator to make necessary decisions.

Role of a Substitute Decision-Maker

1. Decision-Making Authority: A substitute decision-maker (SDM) makes decisions on behalf of a patient who lacks the capacity to make informed decisions themselves.
2. Types of Decisions: The SDM can make decisions related to medical treatment, personal care, and living arrangements, as specified in the enduring power of attorney or guardianship documents.
3. Best Interests: The SDM must act in the best interests of the patient, considering their previously expressed wishes, values, and beliefs.
4. Legal Authority: Ensure the SDM’s authority is legally recognized, with documentation such as an enduring power of attorney or guardianship order.
5. Collaboration with Healthcare Providers: The SDM collaborates with healthcare providers to make informed decisions, ensuring continuity of care and adherence to the patient’s wishes.

Procedural skills
How would you do a cognitive assessment in the clinic?
How would your assessment be different if your patient were hearing impaired? Or vision impaired? What if English was their second language?

Conducting a Cognitive Assessment in the Clinic

1. Structured Cognitive Tests:
   • Mini-Mental State Examination (MMSE)
   • Montreal Cognitive Assessment (MoCA)
   • Addenbrooke’s Cognitive Examination (ACE-III)
2. Functional Assessment:
   • Evaluate the patient’s ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs).
3. Collateral Information:
   • Speak with family members or caregivers to get additional insights into the patient’s cognitive function and daily behavior.
4. Physical Examination:
   • Conduct a thorough physical examination to rule out other medical conditions that might affect cognitive function.

Adjusting the Assessment for Specific Needs

Hearing Impaired Patients

1. Communication Adjustments:
   • Ensure a quiet environment to minimize background noise.
   • Speak clearly and at a moderate pace, facing the patient to allow for lip reading.
   • Use written instructions and questions if the patient can read.
2. Assistive Devices:
   • Encourage the use of hearing aids or other assistive listening devices if available.
3. Alternative Tools:
   • Consider using non-verbal cognitive tests or those with minimal verbal requirements.

Vision Impaired Patients

1. Verbal Instructions:
   • Provide clear, concise verbal instructions.
   • Avoid reliance on visual components of standard cognitive tests.
2. Modified Tools:
   • Use cognitive assessments designed for vision-impaired individuals, such as the verbal version of the MMSE.
3. Tactile and Auditory Aids:
   • Utilize tactile aids or auditory components to facilitate the assessment.

Non-English Speaking Patients

1. Use of Interpreters:
   • Engage professional medical interpreters to ensure clear and accurate communication.
   • Avoid using family members as interpreters to maintain confidentiality and accuracy.
2. Translated Tools:
   • Use cognitive assessment tools that have been validated in the patient’s primary language, if available.
3. Cultural Sensitivity:
   • Be aware of cultural differences that may affect the interpretation of cognitive assessments.
   • Take time to build rapport and explain the purpose of the assessment clearly.

Example Adjustments for Each Scenario

1. Hearing Impaired Patient:
   • Use written instructions and questions.
   • Modify verbal components of tests to written or visual formats.
   • Ensure the patient uses hearing aids and verify they are functioning correctly.
2. Vision Impaired Patient:
   • Conduct assessments verbally, using auditory cues and instructions.
   • Modify or replace visual components with tactile or auditory tasks.
   • Ensure a clear verbal explanation of each task.
3. Non-English Speaking Patient:
   • Use a certified medical interpreter for the assessment.
   • Utilize cognitive assessment tools in the patient’s primary language.
   • Be culturally sensitive and explain the importance of the assessment in a culturally appropriate manner.

Managing uncertainty
How would you communicate the differential diagnoses to George and Sharon?
If George is diagnosed with dementia, how would you answer a question from Sharon about his prognosis?

Communicating Differential Diagnoses to George and Sharon

1. Preparation:
   • Ensure a comfortable and private setting.
   • Allocate sufficient time for the discussion to avoid rushing.
2. Use Simple and Clear Language:
   • Avoid medical jargon. Use simple terms that George and Sharon can understand.
   • Example: “George, based on our assessment, there are a few possible reasons for your symptoms. These could be related to changes in your brain function, the effects of your medications, or other health issues.”
3. Explain Each Possibility:
   • Provide a brief, clear explanation of each differential diagnosis.
   • Example: “One possibility is that the forgetfulness might be due to Alzheimer’s disease, which affects memory and thinking. Another possibility is that it could be related to your medications, which sometimes have side effects that can cause confusion.”
4. Reassure and Provide Context:
   • Reassure them that further tests will help narrow down the diagnosis.
   • Example: “We will need to do some more tests to understand better what is causing these symptoms. This will help us decide the best way to help you.”
5. Encourage Questions:
   • Invite them to ask questions and express any concerns.
   • Example: “Do you have any questions about these possibilities? Is there anything that you’re particularly worried about?”
6. Summarize and Plan Next Steps:
   • Summarize the discussion and outline the next steps.
   • Example: “To get more clarity, we will do a few more tests and review your medications. We’ll meet again soon to discuss the results and decide on the best course of action.”

Explaining Dementia Diagnosis and Prognosis to Sharon

1. Empathetic Communication:
   • Start with empathy and reassurance.
   • Example: “Sharon, I understand this is a difficult time for you and George. I want to make sure you have all the information you need to understand his condition.”
2. Explain the Diagnosis:
   • Provide a clear and straightforward explanation of dementia.
   • Example: “Dementia is a condition that affects the brain’s ability to function properly, impacting memory, thinking, and behavior. It is a progressive condition, meaning it gradually gets worse over time.”
3. Discuss Prognosis:
   • Offer a realistic yet compassionate explanation of the prognosis.
   • Example: “The progression of dementia varies from person to person. Some people may experience a slow decline over many years, while others may progress more quickly. It’s important to focus on maintaining George’s quality of life and managing symptoms as they arise.”
4. Outline Management and Support:
   • Discuss the management plan and available support.
   • Example: “There are treatments and strategies that can help manage symptoms and improve George’s quality of life. We will work together to create a care plan that includes medications, lifestyle changes, and support services.”
5. Provide Hope and Support:
   • Offer hope and emphasize the support available.
   • Example: “While there is no cure for dementia, there are many ways we can help George live well with the condition. You’re not alone in this; there are many resources and support groups for both of you.”
6. Encourage Ongoing Communication:
   • Emphasize the importance of ongoing communication and follow-up.
   • Example: “We will keep a close watch on George’s condition and adjust the care plan as needed. Please feel free to reach out if you have any concerns or questions at any time.”

Example Conversation with Sharon about Prognosis

Sharon: “What does this diagnosis mean for my dad’s future?”

Doctor: “Dementia is a progressive condition, which means it will gradually affect more of his memory and thinking skills over time. It’s difficult to predict exactly how quickly it will progress, as it varies from person to person. However, we can focus on making sure George has the best quality of life possible. We can manage many of the symptoms with medication and supportive therapies, and we will work together to adapt his care as his needs change.”

Sharon: “How long can he stay at home?”

Doctor: “Many people with dementia can live at home for many years with the right support. We will help you with resources and strategies to make the home environment safe and supportive. As the condition progresses, we can also discuss other care options if needed. The goal is to support both you and George in this journey.”

By using these approaches, you can effectively communicate complex medical information in a compassionate and understandable way, addressing the concerns and questions of both George and Sharon.

Identifying and managing the significantly ill patient
How would you approach the consultation if George appeared acutely confused and irritable? 
What are the possible causes of delirium? How would you investigate and manage this?
What would you do if you were concerned about George’s safety at home?

Approach to Consultation if George Appears Acutely Confused and Irritable

1. Ensure Immediate Safety:
   • Assess the immediate environment to ensure George’s safety and prevent injury.
   • Calmly and gently reorient George, reassuring him to reduce agitation.
2. Initial Assessment:
   • Conduct a rapid assessment of vital signs (temperature, blood pressure, heart rate, respiratory rate, oxygen saturation).
   • Evaluate George’s level of consciousness and orientation (person, place, time).
3. Gather History:
   • Obtain a brief history from George if possible and from Sharon or other caregivers regarding the onset, duration, and severity of symptoms.
   • Ask about recent changes in medications, infections, pain, or other stressors.
4. Focused Physical Examination:
   • Perform a focused examination looking for signs of infection, dehydration, hypoxia, or other acute medical conditions.
   • Assess for signs of trauma, neurological deficits, or cardiac abnormalities.
5. Communication:
   • Communicate clearly and calmly with George, using simple language and short sentences.
   • Involve Sharon in the discussion to provide additional context and support.

Possible Causes of Delirium and Investigation

Common Causes of Delirium (DELIRIUM mnemonic):

• D: Drugs (new medications, drug withdrawal, polypharmacy)
• E: Electrolyte imbalance (dehydration, renal failure, metabolic disturbances)
• L: Lack of drugs (withdrawal from alcohol or other substances)
• I: Infection (UTIs, pneumonia, sepsis)
• R: Reduced sensory input (vision or hearing impairment)
• I: Intracranial causes (stroke, subdural hematoma, meningitis)
• U: Urinary retention or fecal impaction
• M: Myocardial and respiratory (hypoxia, COPD exacerbation, heart failure)

Investigations:

1. Laboratory Tests:
   • Complete blood count (CBC)
   • Electrolytes, renal function tests (urea, creatinine)
   • Liver function tests
   • Blood glucose level
   • Urinalysis and urine culture
   • Thyroid function tests
   • Blood cultures if infection is suspected
2. Imaging:
   • Chest X-ray (if pneumonia or pulmonary issues are suspected)
   • CT scan or MRI of the head (if intracranial pathology is suspected)
3. Other Tests:
   • ECG (to check for cardiac issues)
   • Oxygen saturation (to assess for hypoxia)

Management of Delirium

1. Identify and Treat the Underlying Cause:
   • Correct electrolyte imbalances, treat infections, manage withdrawal symptoms, and address pain or sensory impairments.
2. Supportive Care:
   • Ensure a calm, well-lit environment with minimal stimulation.
   • Reorient George frequently, using clocks, calendars, and familiar objects.
   • Encourage hydration and proper nutrition.
3. Medication Management:
   • Review and adjust medications, stopping any non-essential drugs that might contribute to delirium.
   • Avoid sedatives and antipsychotics unless absolutely necessary and under close supervision.
4. Monitoring and Follow-Up:
   • Regularly monitor George’s mental status, vital signs, and overall condition.
   • Arrange for follow-up appointments to reassess and adjust the care plan as needed.

Addressing Concerns About George’s Safety at Home

1. Immediate Safety Measures:
   • Ensure that George is safe in the immediate environment.
   • Consider temporary measures such as having Sharon stay with George or arranging for home care services.
2. Comprehensive Assessment:
   • Conduct a thorough assessment of George’s ability to perform daily activities and manage his health safely.
   • Involve occupational therapy for a home safety assessment and recommendations.
3. Support Services:
   • Arrange for home health services, including nursing visits and personal care assistance.
   • Provide information on community resources, such as Meals on Wheels, transport services, and senior centers.
4. Medical and Social Support:
   • Consider engaging a social worker to assist with accessing services and support.
   • Coordinate with community health services to ensure ongoing monitoring and support.
5. Long-Term Planning:
   • Discuss long-term care options with Sharon and George, including potential respite care or residential care facilities if home safety cannot be ensured.
6. Legal and Ethical Considerations:
   • If George lacks capacity and is at significant risk, consider involving adult protective services or applying for guardianship to ensure his safety.