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The Role of Family Physicians in Older People Care

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This book provides family doctors with a wealth of evidence-based indications and tips regarding geriatric medicine and approaches for the management of older patients, to be applied in daily practice.

After discussing old and new features of healthy ageing and the approaches required in Family Medicine Consultation, the text introduces key elements of geriatric medicine such as frailty, sarcopenia, and the comprehensive geriatric assessment (CGA), before describing a range of characteristics unique to older patients in different contexts, with a dedicated section on Palliative Care. The role of polypharmacy and the importance of quaternary prevention and deprescribing are also addressed.

Finally, the book emphasizes both the importance of a humanistic approach in caring and the approach of research and meta-research in geriatrics. Though many texts explore the role of primary care professionals in geriatric medicine, the role of family doctors in older people care has not yet been clearly addressed, despite the growing burden of ageing, which has been dubbed the “silver tsunami.” 
Family physicians care for individuals in the context of their family, community, and culture, respecting the autonomy of their patients. In negotiating management plans with their patients, family doctors integrate physical, psychological, social, cultural and existential factors, utilizing the knowledge and trust engendered by repeated visits. They do so by promoting health, preventing disease, providing cures, care, or palliation and promoting patient empowerment and self-management.
This will likely become all the more important, since we are witnessing a global demographic shift and family doctors will be responsible for and involved in caring for a growing population of older patients.

This book is intended for family medicine trainees and professionals, but can also be a useful tool for geriatricians, helping them to better understand some features of primary care and to more fruitfully interact with family doctors.

Author(s): Jacopo Demurtas, Nicola Veronese
Series: Practical Issues in Geriatrics
Publisher: Springer
Year: 2021

Language: English
Pages: 464
City: Cham

Foreword
Preface
Contents
1: Family Doctors and the Silver Tsunami: Team up to Survive the Storm
1.1 Introduction
1.2 The Silver Tsunami
1.3 Peculiarities of Geriatric Care
1.3.1 Characteristics of Aging Population and Families
1.4 Dealing with the Silver Tsunami
1.4.1 Task Shifting
1.4.2 Comprehensive Care and Teamwork for Aging Societies: A Leadership Revolution
1.4.3 Intersection among Clinical and Social Issues Affecting Health Status of Older People
1.4.4 System’s Accountability and Sustainability in Older People Care
1.4.5 Multimorbidity, Goal-Oriented Care, and Equity
1.4.6 The Role of Family Physicians within the Team
1.5 Conclusions
References
Part I: Healthy Ageing
2: The Consultation with Older Patients in Primary Care: Communication Management and Clinical Reasoning
2.1 Consultation as a Complex and Effective Medical Procedure
2.2 Organization of the Service and Opening Phase
2.3 Subjectivity
2.4 Examination
2.5 Evaluation
2.5.1 Evaluation: The Clinical Task
2.5.1.1 Prioritization
2.5.1.2 Risk and Uncertainty
2.5.1.3 Analytic and “Fast and Frugal” Clinical Reasoning, Values
2.5.2 Evaluation: The Management Task
2.6 Design
2.7 Shared Choice
2.7.1 The Three Objectives
2.7.1.1 How to Communicate?
2.7.1.2 Who to Inform?
2.7.2 Communication in the Two-Scenario Framework
2.7.3 Unpredictability
2.8 Summary and Take-Home Messages
2.8.1 Managing the Older Patient
2.8.2 Subjectivity of the Patient
2.8.3 Examination
2.8.4 Overall Clinical Judgement
2.8.5 Choice
2.8.6 Shared Decision-Making
References
3: Dealing with Older Patients: Health and Disease in Old Age
3.1 Introduction and Aims
3.2 Health and Sickness in Old Age (Table 3.1 Everlasting I. Fraizer)
3.2.1 What Dying Means to the Older People
3.3 Knowing the Patient, their Relations and Environment
3.4 Care Paths and Social Dimension
3.5 Anecdotes as a Guide to Therapy
3.6 Basic Knowledge and Advanced Knowledge
3.7 To Negotiate the Meaning of Life
3.8 Teaching Tools for Medical Students, for Post-Grads in General Practice, for Doctors Who Work in the Field
3.9 Conclusions
References
4: Nutritional Issues of Older People in Primary Care
4.1 Introduction
4.2 Malnutrition in Older People
4.2.1 Identification of Malnutrition
4.2.2 Screening for Nutritional Status in Older People
4.2.3 Malnutrition and Weight Loss in Older People: From Diagnosis to Management
4.2.3.1 Inadequate Dietary Intake
4.2.3.2 Physiologic Factors
4.2.3.3 Evaluation of Weight Loss
4.2.3.4 Tips for Weight Loss Diagnosis
4.2.3.5 Treatment of Weight Loss in Older People
4.2.4 Obesity in Older People
4.2.5 What’s the Role of General Practitioner in Nutritional Issues in Older People?
4.3 Conclusions
References
5: The Role of Physical Activity in Healthy Ageing: An Overview for the Family Physician
5.1 Defining and Conceptualising Physical Activity
5.2 Physical Activity and Health
5.3 Physical Activity Recommendations
5.4 Levels of Physical Activity
5.5 Interventions to Promote Physical Activity in Older Adults
5.6 What’s the Role of Family Physicians in the Promotion of Physical Activity for Healthy Ageing
5.7 Summary
References
6: Sexual Health in Older People
6.1 Definition
6.2 Levels and Patterns of Sexual Activity in Older Adults
6.3 Physical Health Benefits of Sexual Activity in Older Adults
6.4 Mental Health Benefits of Sexual Activity in Older Adults
6.5 Sexual Orientation and Sexual Activity in Older Adults
6.6 Mechanisms Linking Sexual Activity to Healthy Ageing
6.7 Sexual Dysfunction in Older Adults
6.8 What’s the Role of Family Physician’s in the Promotion of Sexual Health in Older People
6.9 Conclusion
References
7: Immunizations in Older Adults
7.1 Background
7.2 Prevention Strategies in Older Adults
7.3 Factors Influencing Vaccine Uptake
7.4 The Role of General Practitioners
7.5 Tetanus, Pertussis, and Diphtheria Vaccine (Tdap)
7.6 Influenza Vaccine
7.7 Pneumococcal Vaccine
7.8 Herpes Zoster Vaccine
7.9 Other Vaccines
7.10 Conclusions
References
8: Digital Health in an Ageing World
8.1 Introduction: The Potential of Digital Health Use by Older Persons
8.2 Examples and Uses of Digital Tools in Older Persons
8.2.1 Digital Applications and Telemedicine
8.2.2 Wearables
8.2.3 Ambient Assisted Living
8.2.4 Digital Coaching/Teaching
8.2.5 A Synergistic Technological Focus
8.3 Concerns and Limitations
8.4 Partnering with Older Persons to Develop Patient-Centred Digital Solutions
8.5 New Opportunities and the Way Forward
8.6 The Role of the Family Physician
References
Part II: Tools and Scores for Geriatric Assessment (with Tables and Synopsis)
9: Scales and Scores for Comprehensive Geriatric Assessment in Primary Care
9.1 The Comprehensive Geriatric Assessment: More than Numbers
9.2 The Unreplaceable Meaning of the Patient-GP-Specialist Triad
9.3 Through the Jungle of Scales, Scores, Screenings and Assessments: What’s What
9.3.1 Geriatric Screenings: Little Expenditure of Time but Also Not Specific
9.3.2 A Single Geriatric Syndrome Approach: Specific but Not Comprehensive
9.3.3 The CGA: The Problem of Gaining Comprehensive Information in a Timely Frame
9.4 Conclusions
References
Part III: Older Patients with Geriatric Syndromes: The Role of Family Doctors
10: Frailty and Sarcopenia in Primary Care: Current Issues
10.1 Frailty
10.2 Sarcopenia
10.3 Physical Frailty and Sarcopenia (PF&S): A New Conceptual Model
10.4 The Role of the General Practitioner in Managing Frailty and Sarcopenia
10.5 To Sum up
References
11: Approach the Older Patients with Cognitive Impairment in Primary Care
11.1 Anamnesis
11.2 Laboratory and Imaging
11.3 Screening Tests
11.4 Management
References
12: The Older Patient with Psychiatric Illness
12.1 Epidemiology of Major Psychiatric Disorders in the Older People
12.2 Major Psychiatric Disorders in Older People
12.2.1 Depressive Disorder in the Older People
12.3 Anxiety Disorder
12.3.1 Hypochondriasis in the Older People
12.3.2 Alcohol Use Disorder in the Older People
12.3.3 Bipolar Disorders in the Older People
12.4 Psychosis in the Older People
12.5 Delirium
12.5.1 The Role of Family Physician
12.6 Conclusion
References
13: Managing Urinary Incontinence
13.1 Introduction
13.2 Anatomy and Physiology
13.3 Changes in the Lower Urinary System with Age
13.4 Epidemiology of Urinary Incontinence
13.5 Quality of Life in UI
13.6 Etiology of Urinary Incontinence
13.7 Acute and Transient Causes of Urinary Incontinence
13.8 Chronic and Persistent Causes of Urinary Incontinence
13.9 Evaluation of Urinary Incontinence in Older People
13.9.1 Targets
13.9.2 What Should Be Considered in the Anamnesis?
13.9.3 What Should Be Considered in Physical Examination [8, 29–31, 34, 37]?
13.9.4 Which Tests Should Be Performed [6, 31, 38]?
13.9.5 Which Cases Should Be Referred to a Urologist or Urogynecologist?
13.10 Treatment of Chronic Urinary Incontinence
13.10.1 Urge Incontinence Treatment
13.10.2 Stress Incontinence
13.10.3 Overflow Incontinence
13.10.4 Functional Incontinence
13.10.5 The Role of the General Practitioner in Managing Urinary Incontinence
13.11 Conclusion
References
14: Red Flags in Geriatric Medicine: Assessing Risk and Managing It in Primary Care
14.1 Introduction
14.1.1 What Do We Mean by Red Flags?
14.2 Chest Pain and Dyspnea
14.3 Trauma
14.4 Altered State of Consciousness
14.5 Oligoanuria
14.6 Fever
14.7 Abdominal Pain
14.7.1 Inflammatory Pain
14.7.2 Obstructive Pain
14.7.3 Vascular Pain
References
Part IV: The Older Patient in His Context
15: The Older Patient at Home
15.1 Introduction
15.2 First Part: A Public Health Perspective of Home-Based Primary Care
15.2.1 How Should Home Care Be Defined?
15.2.2 The Past, Present and Future of Home Visits: Current Trends in Home Visits
15.2.3 Clinical Outcomes and Cost-Effectiveness of Home Care
15.2.4 How Is Home Care Organized?
15.2.5 What Physicians and Patient Think About Home Care?
15.3 Second Part: Performing a House Call
15.3.1 Who Is Eligible for a House Call?
15.3.2 How Should I Plan a House Call? What Should I Bring with Me During a House Call?
15.3.3 What Should I Look at to Perform a Comprehensive Home-Assessment?
References
16: The Older Person in Nursing Home and in the Intermediate Care Structures: What’s the Role of the GPs?
16.1 Introduction and Definition of Nursing Home and Intermediate Care
16.2 Nursing Home Setting
16.2.1 The Relationship with the Guest
16.2.2 Communication Problems
16.2.3 Problems Due to Cognitive Impairment or Psychiatric Disorders
16.2.4 Dysphagia Problems
16.2.5 Problems Related to Wrong Beliefs
16.2.6 End of Life and Nutritional Support Measures
16.2.7 The Relationship with Family Members
16.2.8 Multi-professional Team Case Management
16.3 Intermediate Care Setting
16.3.1 A General Perspective
16.3.2 Intermediate Care Unit Aims
16.3.3 What’s the Role of the GP in Intermediate Care Units?
16.4 Conclusion
References
17: The Role of Caregivers in the Care of Older People
17.1 Introduction
17.2 Care Process
17.3 Multiple Roles of Caregivers
17.3.1 Assisting with Daily Living Activities (ADL)
17.3.2 Emotional and Social Support
17.3.3 Health and Medical Care
17.3.4 Care Coordination
17.3.5 Decision-Making
17.4 Caregiver Burden
17.4.1 What’s the Role of Family Physicians
References
18: Elder Abuse and Neglect
18.1 Introduction
18.2 Definition and Subtypes
18.2.1 Elder Abuse and Neglect Definitions
18.2.2 Subtypes
18.3 Epidemiology
18.3.1 Prevalence of EAN
18.3.2 Prevalence of EAN in Residential Settings
18.4 Aetiology and Risk Factors
18.4.1 Social-Ecological Model
18.4.2 Risk Factors at Individual Level: Victim
18.4.3 Risk Factors at Individual Level: Perpetrator
18.4.4 Risk Factors at Relationship Level
18.4.5 Community Level
18.4.6 Risk Factors at Societal Level
18.5 Consequences of EAN
18.5.1 Health Costs: Physical
18.5.2 Health Costs: Mental Health
18.5.3 Financial Costs
18.5.4 Indirect Costs
18.6 Identification and Management of EAN
18.6.1 Suspect
18.6.2 Evaluate Cognition, Competence and Functional Ability
18.6.3 Obtain Biopsychosocial History
18.6.4 Physical Examination
18.6.5 Laboratory and Imaging
18.6.6 Primary Management
18.6.7 Consulting and Reporting
18.6.8 Follow-Up
18.7 Prevention of EAN
18.7.1 Types of Prevention and Their Aim
18.7.2 Screening as a Prevention Tool
18.7.2.1 Screening Effectiveness and Employment
18.7.2.2 Screening Tools
18.7.3 Prevention: The State of the Art
18.8 What’s the Role of Family Physicians in Elder Abuse and Neglect?
References
Part V: Quaternary Prevention
19: Polypharmacy, Overdiagnosis and Overtreatment
19.1 Polypharmacy
19.1.1 Definition of Polypharmacy
19.1.2 Prevalence of Polypharmacy
19.1.3 List of Potentially Inappropriate Medications
19.1.4 Tools for Identifying Potentially Inappropriate Medications (PIMs)
19.1.5 Consequences of Polypharmacy
19.1.6 Determinants of Polypharmacy
19.1.7 How to Address the Problem?
19.1.7.1 Medication Review
19.1.7.2 Benefits of Medication Reviews
19.1.8 Role of Primary Care in Addressing Polypharmacy
19.2 Overdiagnosis and Overtreatment
19.3 Overdiagnosis
19.3.1 Definition of Overdiagnosis
19.3.2 Causes of Overdiagnosis
19.3.2.1 Drivers of Overdiagnosis
19.3.2.2 Defensive Medicine
19.3.2.3 Fears of Patients
19.3.2.4 What It Isn’t
19.3.2.5 Overtesting
19.3.2.6 Consequences of Overdiagnosis
19.3.2.7 Example of Not Effectiveness
19.4 Overtreatment
19.4.1 Definition of Overtreatment
19.4.1.1 Consequences of Overtreatment
19.4.1.2 Overdiagnosis, Overtreatment, and Therapeutic Nihilism
19.4.1.3 Research on Overdiagnosis and Overtreatment
19.4.1.4 Research Opportunities on Overdiagnosis: Role of the Qualitative Studies
19.4.2 Awareness of the Problem in Primary Care
19.4.2.1 What’s the Role of Family Physicians in Polypharmacy?
References
Part VI: Palliative and Supportive Care for Older Patients
20: Supportive and Palliative Approach to the Older Persons
20.1 Introduction
20.2 Factors Related to the Medical and Health World
20.3 Early Identification
20.4 Trajectories of Illness and the Dynamic “Four-Dimensional” Pattern of Needs
20.4.1 Rapid Functional Decline (Fig. 20.1)
20.4.2 Intermittent Decline (Fig. 20.2)
20.4.3 Gradual Decline (Fig. 20.3)
20.5 Pro Re Nata
20.6 Potential Issues and Barriers to Palliative Care
20.6.1 Language (Denial, Palliphobia, Pallilalia, Palliactive) [28]
20.6.2 Cultural
20.7 Advocacy
20.8 Burnout Risk in GP Palliative Care
20.9 Conclusions
References
21: Dying at Home
21.1 Introduction
21.2 Better at Home?
21.3 Patient’s Choice
21.4 Discharge Planning
21.5 Bereavement and Grief
21.6 The Role of Primary Care Physicians
21.7 Conclusion
References
22: Integrating Spiritual Care in the Frame
22.1 Introduction
22.2 What Is Spirituality?
22.3 Assessing Spiritual Need
22.4 Know Your Patient: Know the Person
22.5 Spiritual History Tools
22.6 Responding to Spiritual Need
22.7 Spirituality in End-of-Life Care
22.8 Spirituality in Dementia
22.9 What Is the Role of General Practitioner in Spiritual Needs of the Patients?
22.10 Conclusion
Appendix: FICA Spiritual History Tool©™
F: Faith and Belief
I: Importance
C: Community
A: Address in Care
References
Part VII: Self-Determination, Dignity and Humanism
23: An Introduction to Dignity Therapy
23.1 Introduction
23.2 The Concept of Dignity
23.3 The Therapy of Dignity
23.4 The Therapist
23.5 The Protocol
23.6 The Generative Document
23.7 Acceptability and Satisfaction of the DT
23.7.1 PDQ (Patient Dignity Question)
23.8 Dignity Therapy Outside Palliative Care
References
24: The Role of the General Practitioner in the Last Developmental Task of the Elder People About Death, Identity, Narratives and Dignity
24.1 Introduction
24.2 Harm Reduction of Ageing
24.3 The Last Developmental Task and Suicide Among the Elder People
24.4 The Relational Dimensions of Dignity
24.5 Narratives of the Past for the Future to Improve the Last Developmental Task
24.6 Conclusions
References
25: Family Physicians’ Relationship with Older Patients Between Palliative Care and Advance Care Planning Management
25.1 Introduction
25.2 The Family Physician’s Role in the Management of Palliative Care and Advance Care Planning with Older People
25.3 General Practitioner Between Palliative Care and Anticipated Care Planning with Terminal Ill Patients
25.4 Nurses’ Collaboration with the Family Doctor for the Patient Engagement
25.5 A Bioethical Note
25.6 Conclusions
References
26: Educating Physicians for the Aging World: A Humanistic Approach in Doctoring
26.1 Technology and Humanism: Finding a New Balance
26.2 Regarding Suffering and Death: Are We Educating Doctors for Immortal Patients?
26.3 Palliative Care: A Humanistic Approach to Human Contingency
26.3.1 Family Doctors and Life Stories in Palliative Care: A Successful Educational Scenario
26.4 Meeting Patients’ Needs Through Empathy: An Educational Challenge
26.4.1 Teaching the Non-teachable Issues
26.5 Why We Need Humanities for Educating Patient-Centered Doctors?
26.5.1 Humanities in Medical Education: From Emotions to Ethical Attitudes
26.5.2 Narrative Medicine: Reloading a Millenary Resource for Caring
26.6 Teaching with Movies to Foster Reflective Practice
26.6.1 The Movie Clip Methodology: Using Wisely Short Time Teaching
References
Part VIII: Appendix
27: Hints for Meta-research on Ageing for Family Doctors
27.1 Introduction
27.2 What Is Meta-research?
27.3 Meta-research in Geriatric Medicine: Specific Issues
27.4 The Importance of Family Doctors in Meta-research Regarding Ageing
27.5 Hints for Meta-research on Ageing for Family Doctors
27.6 Conclusions
References
28: Beyond Quantitative Research: How Qualitative Research Could Affect Our Understanding of Older People Needs
28.1 What Is Qualitative Research, and Why Is It Important?
28.2 The Underpinnings of Qualitative Research
28.3 Qualitative Approaches and Methods
28.4 Examples of Qualitative Studies in the Area of Chronicity and Primary Care
28.5 Conclusion: Qualitative Research as Listening and Participation
References
29: COVID-19: Impact of Pandemic on Older People Health and Well-Being
29.1 Introduction
29.2 Frailty and Agism in COVID-19
29.3 Cognitive and Psychological Problems in Older People During COVID-19
29.4 The Role of Geriatrician and General Practitioner in COVID-19
29.5 Conclusions
References