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Common care home problems

In the second part of our new series, BUPA medical director Dr Clive Bowman and GP trainee Dr Emma Bowman look at dementia, falls, chronic disease management and medication issues for patients in care homes

In the second part of our new series, BUPA medical director Dr Clive Bowman and GP trainee Dr Emma Bowman look at dementia, falls, chronic disease management and medication issues for patients in care homes

Dementia

Although ‘brain failure' and loss of mental capacity are the principal reasons for people to need long-term care home admission, it is disappointing how often a clear diagnosis is lacking. Receiving doctors should satisfy themselves a firm diagnosis has been made and that remediable conditions have been considered, as case one demonstrates.

41239661Dementia is generally progressive, and is accompanied by a range of behavioural challenges that can lead to inappropriate long-term antipsychotic medication. Care homes have been repeatedly criticised for sedating patients with dementia. Although homes do not prescribe medication, some staff may overtly or inadvertently encourage doctors to prescribe.

Importantly, more than half of antipsychotic prescriptions to care home residents are initiated before admission, either in NHS hospitals or in the community. In hospitals, these drugs may be started to maintain the safety of the individual and those around them. In the community, prescription may be an attempt to help a family cope.

Whatever the initial driver for the prescription, a well-run dementia care unit should attempt to reduce medication use. Starting antipsychotic medication in care homes needs careful reflection: is it being considered because the patient is displaying delirium or because the home is unable to cope? Is this a reflection of inadequate commissioning or inadequate care by inadequately trained staff? The course of dementia means that a once-good placement may need critical review, as case two (below) illustrates.

41239662The prevalence of dementia is due to increase in the next four decades in the UK from 750,000 to about 1.5 million, at a time when the number of younger people (and probably care staff) is likely to fall. Any improvements in independent living, care and support in the community are unlikely to have a major impact on the probable increase in demand for residential care places. There is a pressing need to develop care and invest in this predictable demand.

Falls

A care home with no falls is either operating a no-risk approach to care or failing to record falls! The medical response to a fall in practice is generally an assessment of the injury and the need for further action. But falls are a symptom, a final common pathway, not a diagnosis. Referral and intensive investigation are only justified after a bedside review. The GP has a unique opportunity to take on this assessment, which almost certainly will take less time than writing a referral.

Key points to consider include:

• the circumstances of the fall

• whether it was caused by poor footwear or poorly supervised ambulation

• the patient's usual mobility and stability status

• whether the patient's pulse is normal and whether blood pressure is maintained when upright

• an iatrogenic cause

• the patient's current mobility – assuming they are not seriously injured

• whether the care is sufficient for the resident's needs.

A common presentation involves a serious fracture following a fall in late-stage Alzheimer's disease.

Although this is technically remediable, the stress, distress, limited potential health gain and high complication rate of orthopaedic treatment for some such patients should make clinicians think carefully about whether a conservative palliative approach would be more appropriate, recognising the fracture as a pre-terminal event.

Such decision-making often needs careful discussion with care staff and family, and should be fully informed by the patient's past medical history. Simply referring the patient to hospital will often lead to intervention with receiving teams not unreasonably taking the view that, as the patient has been referred, treatment is being sought.

Medication and chronic disease management

On average, care home residents are prescribed more than seven items each. Whether these regimes are helpful or harmful will vary – but most patients are likely to benefit from a critical review of their pharmaceutical burden.

Specific targets might include:

Antihypertensives: nursing care homes can provide records of blood pressure and a significant number of patients taking antihypertensives will remain normotensive. It is probably more useful to check standing blood pressure or, if the patient is frail, sitting. This simple check is likely to identify many patients who can be weaned off medication. Blood pressure can then be monitored and the care home told to report readings that exceed a specified limit.

Heart failure: diuretics are often more of a problem than acute deterioration of cardiovascular disease. Patients may present hugely congested, having multiple unresponsive chest infections – basically left ventricular failure – but more commonly, they are dehydrated. For many patients with chronic disease, moderate weight loss and reduced activity may diminish the problems associated with heart failure and allow reduction of diuretic dosage.

Lipid lowerers: use of these in aged frail care-home residents is beyond the traditional evidence base. As these interfere with metabolism and nutrition, and the original purpose may have been overtaken by events, they could be stopped.

Parkinson's disease: it is common for medication to become increasingly complex in an attempt to allow patients with Parkinson's to continue living at home. But this increases the risk of hallucinations. Having been admitted to care, it is likely that simplification of a regime will bring a clearer mind with a manageable increase in physical dependency. Certainly, dosing schedules can often be rationalised.

Polypharmacy: complex dosing regimens are a major risk to care home residents and a challenge to manage. Often, the rationale for various therapies has long been lost and review is likely to be helpful.

Dr Clive Bowman is medical director of BUPA Care Services, Leeds

Dr Emma Bowman is a trainee in general practice in Cardiff

This an extract from Managing older people in primary care, a practical guide for clinicians involved in the day-to-day care of older people in the community. With most chapters co-authored by a specialist and a GP, it provides an indispensable resource, including tips on differential diagnosis and summaries of the existing evidence base, and guidelines on treatment.

For more information and to order your copy at a 20% discount visit: www.oup.com/uk/isbn/9780199546589 and quote the promotion code PULSE.

Case one Case two Common care home problems

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