Primary Care and Care for the Older Persons - Framework

Primary Care and Care for the Older Persons - framework

Introduction½ - 1 page

In many populations the number of the old people is increasing. For Europe the proportion of people aged 65 years and older is projected to grow from just under 15% (in 2000) to 23.5% by 2030, while the proportion of those aged 80 years and over is expected to more than double (from 3% in 2000 to 6.4% in 2030) (Kinsella and Philips, 2005) However, the pace of aging in Europe differs considerably between countries. Turkey and Ireland have the lowest proportion of people over 65 years of age (respectively 6 and 11 %), Germany and Italy have the highest proportion (approximately 20 %) [1]. In all countries these percentages are higher for females than for males and they are increasing. Partially, that is the result of increasing longevity : currently, at the age of 65, females have a life expectancy of 15 (Turkey) to 22 (Spain) years. For males these figures are respectively 13 (SlovakRepublic and Hungary[P1]) and 18 (Switzerland) years.

Because of changing demographics we will undeniably be caring for an increasing number of older persons in the highest age-groups, with other physiology and pathophysiology. This provokes a series of challenges that require effective policy and practice.

In many European countries hopes are on Primary Care for the delivery of health services to the older persons[2]. While in Europe convergence takes place of role and functions of Primary Care, the organisation, structure and funding base varies widely between countries. Also, some countries have developed a strong and coherent Primary Care system whereas others are less oriented towards the community and more to hospitals[P2]. No country however can claim to have a Primary Care system that is sufficiently robust to adequately address all the challenges it meets – including the adequate provision of care for the older persons. Primary Care reform is ongoing in many countries. It is the diversity and reform of Primary Care that makes international studies and comparison rewarding.

In order to show examples of reform and the benefits of Primary Care and as an inspiration to policy makers, practitioners and researchers across Europe, this Position Paper provides an overview of the needs of older people and the responses of Primary Care services. Good policies and practices as well as innovations are highlighted. This Position Paper does not claim encyclopaedic completeness, it rather aims to show variety and diversity. Because each approach is highly dependent on context, the organizational examples often provide little understanding about the critical factors for success or failure in a specific setting. The differing contexts in which people work require that solutions be tailored to national circumstances.

This Position Paper has been developed in 2010 through a Medline search and[P3] an expert consultation process which has been designed by the European Forum for Primary Care[3]. It is one of a series of Position Papers that is being published since 2005.

Definition of terms½ - 1 page

Primary Care

In this Paper, we make no distinction between Primary Care and Primary Health Care (PHC). PHC is not a fixed organisational structure or level of care, that can be easily and unambiguously identified. Instead, it is considered as a combination of essential characteristics on the basis ofthe core values of equity, solidarity and social justice, that are promoted by the PHC movement since more than 30 years:

• Care that is easily accessible – in the community, without financial or physical (distance) barriers.
• Long term personal relationship and continuity of care – person oriented care and not disease or organ oriented care. This implies attention for functioning and independent living of people.
• Comprehensive and quality care, implying evidence based generalist care for all common health problems. It includes a collaboration with specialist services where generalist services are insufficient.
• Responsibility for the health of people in their community, which implies attention for determinants of ill-health and social aspects.
• People are partners in managing their own health.

PHC does not emerge spontaneously, it requires a constant effort and well planned design to ensure performing PHC. According to the World Health Report of 2008[4] most countries would benefit from four major reforms:

1. Universal coverage reforms, to improve health equity;
2. Service delivery reforms, to make health systems people-centred and of high medical quality.
3. Leadership reforms, to ensure the development of coherent health systems;
4. Public policy reforms, to promote the collaboration between public health and primary care, addressing the health of communities as well as individuals.

The older persons – beyond the stigma

Ageing is a very individual process, that varies a lot according many factors as genes and life history.The United Nations decided in 1963 tu use “third age” for people 60-74 and “fourth age” for people 75 and over. As people are now living longer and in better health in the developed countries, this definition should be moved to “third age” 70-84, and “fourth age” 85 and more.

Aging can be associated with rising levels of multimorbidity and dependency. Despite the fact that some authors state that healthy ageing is lagging behind, with older people spending more and more of their years in ill health,(references) there is some evidence supporting the “compression of morbidity” thesis (Fries,1983) which suggests that, as populations adopt healthier lifestyles and therapeutic advances continue, the period of illness that individuals experience before death is compressed (Parker and Thorslund, 2007, Freedman 2002).Very frail people aged 80 years and over are major users of informal care and health and social services (Audit commission 2000, Hellstrom and Hallberg 2001). Yet the older persons are a heterogeneous group with heterogeneous needs which creates important challenges to healthcare providers (Byles,2000) and health systems.Our perspective is not that of a doom scenario, with unlimited populations of inactive, dependent and ill elderly. Aging of our societies should be considered as progress and as a success and older people can be seen as a resource to society rather than as a cost. A general remark is here that “age” and “disease” are two different things. Many times mixed up, what is not correct, and this finding was already described by Cicero (44BC). You can be very ill in youth and you can be very fit in very old age. A pessimistic approach to ageing and older patients might lead to unfair access to services. Decisions about access to treatment and care should be made on the basis of each individual’s health needs and not their age. For example, even very complex treatments, if used appropriately, can benefit older people and should never be denied on the basis of age (NHS national service framework for older people). A pessimistic approach to ageing might lead to premature admission in hospitals of residential care settings. All older people who need hospital care should receive it.

BLACK BOX. PATIENT AUTONOMY/PATIENT EMPOWERMENT

Patient autonomy should be central in every approach in care. [P4]Patient empowerment

Enable patients to make informed decisions through proper information about care across different care sectors. Empower patients towards self management. Opportunities Challenges of providing such support to patients with multiple conditions or those with different ethnic or socio economic background.

Specific needs of older persons 2-3 page

In the following paragraphs we try to offer a wide view on the needs and challenges to care for older persons.

Maintenance of good health – prevention – away from pessimism (they are old anyway).

A pessimistic approach to ageing and older patients might lead to impeding the promotion of health and active life in older age. Health promotion interventions in later life require a different focus than those at youngerages, with an emphasis on reducing age-associated morbidity and disability and the effectsof cumulative disease co-morbidities.Even a small reduction of disability may translate into large health care savings and improvements in the physical, emotional and social health of older persons. According to the UK’s National Health Service, there is a growing body of evidence to suggest that the modification of risk factors for disease even late in life can have health benefits for the individual; longer life, increased of maintained levels of functional ability, disease prevention and an improved sense of well being. However, a narrative literature review on health promotion measures and interventions on long term care conducted by M Hasseler indicated a lack of findings on effective health promotion measurements and interventions for elderly. However, countries invest many resources in programs and activities for older people, often without knowing if they are effective and usefull[P5].

-It is important to note the differences in morbidity patterns among various regions (within and between countries). For example different life styles (caloric intake, exercise, ...) But at what age to intervene?

-Life long vaccination[P6]...

BLACK BOX. LIFE LONG VACCINATION

-Prevention of falls is a domain that borders primary care and has gained wide interest because it has shown to be effective[P7].

BLACK BOX. PREVENTION OF FALLS

Clinical needs

Primary Care meets with a range of health problems of older persons. The likelihood of developing a potentially disabling condition rises with increasing age and older people often suffer from multiple chronic diseases with impending disability and loss of independence. Many chronic diseases have now disappeared: blindness disappeared with the lens-implant, the hip and knee replacements restore mobility, angina pectoris disappeared with stenting,... However the prevalence of chronic diseases such as depression, dementia, Parkinson’s disease, cardiovascular disease, COPD, stroke,... is rising. Some diseases are more or less typical for older people such as dementia (...% of all cases above age ...), malignancies (6/7 above age 50 and 3/7 above age 70), Parkinson (...% of cases above age ...). Other diseases tend to start earlier, but prevalences rise sharply with age (diabetes, COPD). Clinical practice guidelines are being developed to improve quality of health care[P8]. Being disease specific in set up, they overlook the reality of multimorbidity (Boyd CM 2005)(Van Weel and Schellevis 2006).(Marengoni et al) (Anderson 2002). For example obtaining exercise to promote health in diabetes or COPD may be complicated by pain by osteoartritis or lack of motivation caused by depression. Theoretically, individuals with multiple conditions face polypharmacia, fragmentation of care, competing or conflicting guidelines, and inattention to their own preferences and concerns (Ritchie 2007, Boyd CM 2005). Therefore, in daily practice guidelines are questioned and modified based on the context of the patient. Comorbid diseases, patient preferences, functional status, quality of life, life expectancy and environmental factors will be of influence. It is clear that managing multimorbidity, is much more than simply the sum of separate guidelines (Van Weel and Schellevis 2006).There is a need to develop strategies for the inclusion of the clinical and practical aspects of multimorbidity in clinical practice guidelines. PHC needs it own and adapted tools to take important clinical decisions[P9].

BLACK BOX. PRIORITY SETTING based on stEP ASSESSMENT (Ulrike Junius Walker)

Multimorbidity is supposed to be associated with poor quality of life, physical disability, high healthcare utilization and mortality and this association has been proved by Gijsen et al[5]. Moreover the authors described less preventive care, lower intensity of treatment for certain conditions, less attention to psychiatric comorbidity, greater numbers of hospitalization and outpatient visits and overall higher healthcare costst.(Gijsen 2001). On the contrary, there are some findings[P10] indicating that the assessment of quality of life if multimorbid elderly is not necessarily poor. Growing morbidity does not always imply concurrent disability, since diagnostic and therapeutic strategies have improved (Christensen 2009). Multimorbidity is a complex phenomenon with an almost endless number of possible disease combinations with unclear implications. To manage multimorbidity in the future we have to assess the impact of the problem in detail to be able to focus strategies in clinical management and health care organization to the patient’s individual needs. To define measures of the quality of care needed by patients with multimorbidity we should cross the borders of individual diseases. We need a comprehensive approach, beyond traditional biomedical parameters (outcomes for single diseases), with the focus on generic outcome measures such as functional status and quality of life. The eventual purpose is to adapt delivered health care to the individual’s specific needs and goals. This perspective is in line with the paradigm shift from problem oriented to goal oriented care (Mold 1991). An important challenge is the variability in needs of the complex patient. There is need for research on more generic and patient centred outcome measures[P11]. In this very old patients the classical outcome measure of five-years survival percentage is simply ridiculous, and has to be changed in other outcome measures as degree of autonomy (related to degree of disability, diminished functionality) and quality of life. Qualitative research at this point is important. For instance qualitative research on mobility from the perspective of elderly indicates they have a different meaning of mobility compared to health professionals. It encompasses eq autonomy, independence and other factors ) (ref via M hasseler) [P12].

BLACK BOX. DISEASE SPECIFIC GUIDELINES/POLICIES

In France, we have le plan Alzheimer and le plan cancer, two national disease specific initiatives which encourage the development of services and research on these topics. Some part of these two plans have been implemented. I can describe it if you want.

Pharmaceutical care[P13]

The use of medications in the care for elderly is important for several reasons.

a. It is a complex process (prescription, delivery, intake, adverse effects, patient safety). What is good for oneproblem, may be bad for another problem. E.g.cortocoids may be good for COPD but bad for diabetes. The relevant research on these topics is scarce.An important problem is that drugs are tested in clinical trials with people with a mean age of 55 years, while the real patients taking the medicines have a mean age of 80 years...So, in older persons all physicians are prescribing out of label..., which is a real ethical problem.

b. Causing quite some iatrogenic problems

c. And therefore generating an important cost

A review of the literature showed that there are no good data or results of good research concerning the strategies to create a ‘seamless care’concerning drug use in the elderly (Spinewine & Mallet, 2003; Spinewine et al., 2005; Spinewine et al., 2007; Spinewine, 2006). Only recently the issue gets more scientific interest but is by far not clear what procedures are most effective (Gallagher, Ryan, Byrne, Kennedy, & O'mahony, 2008;O'Mahony & et alli, 2010; Lewis, 2005).Medication review is an important multidisciplinary activity (Krska & Onvolledig, 2001; Lewis, 2005;Spinewine, Dumont, Mallet, & Swine, 2006; Lenaghan, Holland, & Brooks,2007; Kaboli, Hoth, McClimon, & Schnipper, 2006).New methods have tobe looked for in order to overcome these problems (Spinewine et al.,2010).

Possibly : BLACK BOX. PHARMACIST AS AN EXPERT IN A MULTIDISCIPLINARY TEAM APPROACH (Pilootproject COOP apotheken Belgium : pharmaceutical care in rusthuizen

Functional decline and loss of independence.

Notwithstanding that most older people retain high levels of independence (we find now more and more very active and completely autonomous persons of 90 and older.) and make substantial contributions to society, there are clear age related support needs. Australian figures indicate that while only one in 20 of those aged 65-69 require assistance with self care activities, this rises to one in three among those aged 80 years and over. (Australian Institute of Health and Welfare). Serbic figures out of Belgrade indicate that among those aged over 80, 85,1% reports to need assistance from other persons in various activities of daily living (Sevo et al. Needs assessment of the oldest old citizens of Belgrade[JPB14]) What and how much health and social care a person needs is entirely determined by their health, physical, cognitive and social function. Almost always it is a deterioration in health that leads to a decline in a person’s abilities. In turn, ability, personality, mental health and the extent to which a person has friends and family available to help them determines how much and what sort of formal care services they need (ref). Living with another person often provides much ongoing volunteer or family support that helps people remain as independent as possible for as long as possible. However, the burden on the family could be too much. Maintainance of independence could be at the cost of independence of members of the family. Feminist studies for instance have shown that women caregivers give up their lives to care for their dependents. Strong social and community support should add family and volunteer support. Many older people use community services to help them remain independent. Community based services are needed to help older adults manage chronic illness while maintaining independence, remain connected while getting assistance and maximize their self care abilities. Frail older adults usually have multiple impairments and function best in environments they know. Since each move to a new setting may cause physical decline and depression we should guard it unacceptable that patients must give up their independence, to receive services they need, to remain as active as possible. (Rantz et al, ref 103)

Little is known regarding the proportion of the population at risk for functional decline. Health indicators based on selected chronic conditions or risk factors are difficult to interpret because multiple combinations of degenerative diseases result in considerable heterogeneity in the risk for functional loss and health care needs. Frailty is likely to be a precursor of disability.

Frailty : beyond the disease specific approach

Frailty provides a conceptual basis for moving away from organ and disease based medical approaches toward a health based integrative approach. Frailty is a state of increased vulnerability to adverse outcomes. It is a syndrome that results from a multisystem reduction in reserve capacity to the extent that a number of physiological systems approach or cross the threshold of symptomatic clinical failure. The frail older patient has a declining reserve capacity for dealing with stressors.As frailty leads to recurrent hospitalization (Fried, 2001), institutionalization (Bandeen Roche 2006) and death (Fried, 2001, Bandeen roche 2006, Fugate Woods, 2005, Ensrud, 2007; Ensrud 2008; Cawthon 2007), prevention and where possible treatment of frailty should be high on the medical agenda. Because frailty appears to be a dynamic and also potentially reversible process, early recognition of frailty and early interventions should be important issues for family medicine. On the basis of US studies it appears that frailty affects about 7% of people aged 65 years or older and about 25-40% of those aged 80 or older (Fried 2001 uit ref 32 PB). A meta-analysis from Santos-Eggiman et al (2009) estimated that in ten European countries frailty affects about 17 % of patients older than 65 with higher proportions in Southern than in northern Europe. Although demographic characteristics did not explain international differences in frailty they found a strong relationship between education and frailty and an attenuation of country effects after adjusting for this factor. This illustrates the need of a biopsychosocial approach which integrates nonmedical factors. Because we are still organ and disease focused both frailty as a syndrome and the vulnerability that underpins it can be easily overlooked. Frailty does not fit into an organ- or disease focused understanding of patients because there is almost never a chief complaint and the features of frailty occur in combination. Frailty fits the biopsychosocial model of generalism very well.