REFREC008

GERIATRIC MEDICINE REFERRAL RECOMMENDATIONS

Diagnosis / Symptomatology / Evaluation / Management Options / Referral Guidelines
Geriatric Medicine is a broad-based specialty covering a wide range of practice for the client group (see definition).
Those with complex medical problems associated with impairments in function or one or more of the list below benefit from Geriatrician consultation:
  • Multiple pathology
  • Polypharmacy
  • Impaired cognitive function
  • Chronic or declining physical disability
  • Falls and mobility problems
  • Problems with continence
  • Anorexia and weight loss
  • Social situation of continuing concern.
  • Resident in a Hostel or nursing home.
These Referral Recommendations are organised under the following problem groups:
  • Aged Care Assessment Teams
  • Geriatric Clinic
  • Incontinence
  • Memory clinics and dementia care
  • Mobility/falls clinics
  • Parkinson’s disease in the elderly
/ A geriatric assessment is intended to be comprehensive with attention paid to the patients’ medical, psychological, functional and social problems. Thus it is useful to provide information on the following:
  • History of functional decline or cognitive impairment.
  • Existing social supports eg involvement of other agencies.
  • Social/Carer history.
  • Goals/expectations for patient and carers.
  • Past medical history (often lengthy).
  • Other recent sub-specialty involvement.
  • Any relevant legal history eg. Enduring Power of Attorney.
  • Appropriate baseline investigations that may be considered by the referrer prior to referral.
/ Specific treatments depend on the specific problem identified and often include rehabilitation.
Most cases require the involvement of several disciplines (social work, rehabilitationists).
Most cases require an assessment of caregiver knowledge and ability to support the patient. / Geriatricians generally work with teams including community nurses, social workers, physiotherapists and occupational therapists. It is useful for the GP to state what he/she expects of the referral. Cases are generally discussed at multidisciplinary team meetings and further assessments by other team members may be recommended.
Investigation results should always be provided with a referral where possible.
Patients with long term mental health problem may be more appropriately referred to the Mental Health Service.
Although geriatric medicine is generally involved with elderly patients, there is no specific age barrier for selected younger patients.
Diagnosis / Symptomatology / Evaluation / Management Options / Referral Guidelines
Aged Care Assessment Teams (ACATs)
Assessment for commonwealth support schemes for frail elderly patients – specifically for community care packages or residential care (permanent or respite). In Perth ACAT staff are sited within all the geriatric departments and the referral system is identical to the other services. / An ACAT assessment is essentially for providing community support services including residential care. Staff are also experienced in case-finding for comprehensive geriatric assessment and rehabilitation and generally feed-back to multidisciplinary teams.
  • Details of medical conditions.
  • Assessment of ADL and disability.
  • Caregiver burden and stress.
/
  • Residential care – high or low care.
  • Community care packages.
  • Respite care.
  • Liaison with other community support services.
  • Liaison with other geriatric and rehabilitation services.
  • Liaison with other supports eg Alzheimers Association.
  • Carer education and support.
/ Refer to local geriatric departments – Category 3.
Diagnosis / Symptomatology / Evaluation / Management Options / Referral Guidelines
Geriatric clinic
  • Any general medical problem that is complex or associated with functional problems.
  • Frailty
  • Malnutrition, anorexia etc
  • Mental state problems, dementia or depression
  • Cardiac/respiratory disease
  • Old stroke
  • Arthritis
  • Osteoporosis
  • Palliation in elderly patients
/
  • Impact of symptoms on ability to function
  • Complete drug history
  • Full physical examination
  • Assessment of mental state
  • Assessment of function
  • Rehabilitation potential
  • Need for social supports
Investigations:
  • Consider basic haematology, biochemistry, thyroid function, calcium metabolism, vitamin deficiencies (D, folate, B12)
  • MSU
  • Appropriate radiology.
/
  • Diagnose cause of change in function or new symptom.
  • Optimise medical management.
  • Exclude drug toxicity and reduce polypharmacy.
  • Consider rehabilitation for functional deficits.
  • Consider further assessment of cognitive or continence problems.
  • Introduce appropriate social supports.
  • Educate and support caregivers.
/ Generally Category 3 for outpatient clinics.
Home (or residential care) visiting for heavily disabled or demented patients is often useful (Category 3).
Most services offer more urgent review either in clinics or at home and a phone call to the service is the best way to access this service (Category 2).
Diagnosis / Symptomatology / Evaluation / Management Options / Referral Guidelines
Incontinence
Most geriatric services run continence clinics. These are usually run by nurse continence advisers with a variable medical input from either geriatricians or urologists.
Continence advisers are also skilled in assisting with the assessment and management of faecal incontinence. /
  • History and specific symptoms (urge versus stress incontinence)
  • Drug history
  • Associated conditions: mobility, infection, gynaecological history, cognition, constipation etc
  • Renal function
  • Neurology or diabetes
  • Abdominal examination
  • Rectal/vaginal examination
Investigations:
  • Urinalysis, post-void bladder volume, voiding diaries.
  • Referral for urodynamics
/
  • Exclude drug causes including alcohol and over-the-counter drugs.
  • Exclude faecal impaction.
  • Hydration.
  • Bladder diary.
  • Bladder drill, treatment of stress incontinence, treatment of vaginal atrophy.
  • Medication as appropriate.
  • Continence aids.
  • Patient education.
  • Caregiver education and support.
/ Refer to continence advisor (where available) – Category 3.
Refer to other specialty as indicated by evaluation eg. Urology, gynaecology – Category 3 (c.f. Gynaecology and Urology Referral Recommendations).
Diagnosis / Symptomatology / Evaluation / Management Options / Referral Guidelines
Memory clinics and dementia care
All metropolitan geriatric departments run memory clinics for the diagnosis of memory problems and management of early dementia (specifically anticholinesterase therapy).
General geriatric services (clinics, home visiting and ACATs) can be used to evaluate problems with established dementia:
  • Caregiver support
  • Community support
  • Residential care
  • Specific behaviour problems
  • Difficulty with finances
  • Driving ability
/
  • History of onset of disorder.
  • Cognitive assessment eg. MMSE or similar.
  • Behaviour problems associated with dementia.
  • Laboratory dementia screen.
  • Consider need for brain imaging.
  • Assess carer burden or stress.
  • Assess ability to drive or manage. finances or other legal requirements.
/
  • Accurate diagnosis of cognitive impairment.
  • Exclude drug toxicity.
  • Exclude depression.
  • Diagnose psychotic complications of Alzheimer’s disease.
  • Consider anticholinesterase therapy.
  • Consider rehabilitation for functional deficits.
  • Introduce social supports.
  • Educate and support caregivers.
/ Most referrals – Category 3.
Acute deterioration may need urgent attention – eg Category 2.
Note:
Major psychiatric or behaviour disorders associated with dementia are usually managed by psycho-geriatric service.
Diagnosis / Symptomatology / Evaluation / Management Options / Referral Guidelines
Mobility / Falls clinic
Mobility and falls clinics are available in all metropolitan health regions. Most include an assessment of bone health. Most are not equipped to assess syncope.
These are multidisciplinary and offer assessment and rehabilitation.
Many at-risk patients have other geriatric problems (dementia, incontinence) that need to be addressed /
  • Drug history.
  • Impact of falls/reduced mobility on lifestyle.
  • Primary neurology/cardiology. assessment, eg. Postural hypotension.
  • Occupational therapy eg aids and appliances.
  • Physiotherapy.
/
  • Consider the diagnosis and need for further investigations.
  • Optimise drugs.
  • Appropriate rehabilitation program (individual treatment, referral to group programs).
  • Consider confidence strategies given importance of “fear of falling”.
  • OT aids and personal alarms.
  • Caregiver education and support
  • Management of important co-morbidities.
  • Referral for bone mineral density.
/ Refer any older person with failing mobility and/or a problem with falls and fractures – Category 3.
Most clinics can offer advice on osteoporosis management but are not set up to investigate syncope.
Diagnosis / Symptomatology / Evaluation / Management Options / Referral Guidelines
Parkinson’s disease in the elderly
Multidisciplinary clinics for older patients with PD or PD patients with significant disability are available at Osborne Park and Fremantle geriatric services.
  • These clinics offer rehabilitation services and caregiver support as well as specialist assessment of disabling PD and related disorders
  • These services can complement (rather than replace) usual neurologist management
/
  • Motor symptoms including fluctuations.
  • Non-motor symptoms including neuropsychiatric evaluation.
  • Assessment of impairments and disability.
  • Caregiver burden and stress.
/
  • Optimal management of PD medications.
  • Management of important co-morbidities.
  • Assessment and management of motor fluctuations.
  • Management of neuropsychiatric problems (mood, cognition, hallucinations).
  • Multidisciplinary rehabilitation including nutrition and swallowing.
  • Patient and carer education and support.
/ Refer to Osborne Park and Fremantle geriatric departments – Category 3.

Last updated February 2006Page 1 of 7