Multimorbidity
- Define multimorbidity and identify associated issues, including:
- quality of life
- use of healthcare services
- hospitalisations
- treatment burden
- multiple medicines
- mortality.
- Recognise the limitations of disease-specific guidelines in the context of multimorbidity:
- chronic obstructive pulmonary disease
- osteoporosis
- cardiovascular disease
- cerebrovascular disease
- chronic kidney disease
- diabetes
- osteoarthritis
- cancer.
- Clarify goals of care with patients.
Health assessment and preventive care
- Conduct a thorough health assessment and manage preventive care, including:
- hearing
- vision
- continence – bowel and bladder
- constipation
- falls risk
- chronic pain
- wound care and prevention of pressure injuries
- nutrition
- oral health
- mental health, including risk assessment and management
- sexuality
- alcohol and other drugs.
- Define frailty and be familiar with validated assessment tools.
- Consider neglect and abuse.
- Conduct assessments of functional, cognitive, decision-making and driving capacity.
- Screen for cancer, and recognise the diminishing value of some screening activities in older patients, including for the following cancers:
- cervical
- breast
- bowel.
- Recommend and administer immunisations (age appropriate).
- Screen for and manage osteoporosis.
- Enquire about and assess safety in the home, identify concerns and act appropriately.
Acute conditions
- Recognise symptoms of infectious diseases early and manage appropriately.
- Manage patients with infectious diseases in a registered aged care facility (RACF), including isolation, testing, quarantine and infection control.
- Understand that emergencies, such as cardiac conditions, cerebrovascular accidents, trauma, delirium, etc, may present differently in older people and require different treatment goals.
Behavioural and psychological presentations
- Understand the importance of prompt recognition, assessment and treatment of:
- delirium
- dementia
- depression
- anxiety
- insomnia.
- Be aware of the communication difficulties that may occur with cognitive decline in patients who do not speak English as their first language.
Recognise the importance of non-pharmacological treatment in the management of conditions commonly encountered in older people –> link
Palliative and end-of-life care
- Initiate conversations about advance care planning and support patients.
- Manage symptoms – be aware of symptoms encountered and management options.
- Provide psychological support for patients, families and carers.
- Communicate with interdisciplinary team members.
- Communicate with friends/family.
- Understand and incorporate substitute decision-making into patient care.
- Be aware of end-of-life law.
Medication management
- Identify patients who would benefit from a medication review.
- Understand the role of the pharmacist and work collaboratively to refer and incorporate feedback into patient management.
- Prioritise deprescribing.
- Manage short-term pharmacotherapy of severe behavioural and psychological symptoms, and understand and adhere to the ethical, legal and reporting requirements.
Legal and ethical
- Fitness to drive.
- Wills and testamentary capacity.
- Abuse of older people – reporting.
- Advance care planning.
- Enduring power of attorney.
- Guardianship.
- Voluntary assisted dying.
Healthcare system
- Effectively communicate across practice and RACF systems.
- Provide team-based care.
- Engage in case conferencing.
- Facilitate family meetings.
- Be aware of community services and resources.