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The RACGP Curriculum for Australian General Practice 2016

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Curriculum coverThe complete 2016 Curriculum consists of a number of units in addition to contextual units. All units will be available for download as a PDF shortly.

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Aged Care

Definition

Aged care in general practice is the management and care of the health of the elderly.

Although aging is associated with increasing levels of disability, most older people have a positive view of their own health with the majority of Australians aged 65 years or older (66%) rating their health as either good, very good or excellent, while 34% report their health as being fair or poor.1

The term 'frail aged' is used to describe aged people in need of substantial level of care and support.

The definition of older varies between individuals, communities and cultures. For example, Aboriginal and Torres Strait Islander people have a lower life expectancy than the non-indigenous population and are therefore likely to need aged care services earlier.

The gap in life expectancy between Indigenous and non-Indigenous Australians is smaller at older ages. For example, life expectancy at age 65 years is estimated to be 10.7 years for indigenous males and 12.0 years for indigenous females, around 6 years less for men and 8 years less for women than for non-Indigenous Australian males and females.1

Because of this life expectancy difference between Indigenous and non-Indigenous Australians, and the low proportion of Aboriginal and Torres Strait Islander people aged 65 years and over, the terms 'older indigenous person' or 'older Aboriginal/Torres Strait Islander person' is generally considered to include all those who are aged 50 years and over. In 2006, 11% of Indigenous Australians were aged 50 years and over. Women made up 53% of Indigenous Australians aged 50 years and over, and 55% of those aged 65 years and over.1

Curriculum in practice

A typical presentation that illustrates how the aged care curriculum applies to general practice is:

  • Walter, 92 years of age, is a veteran who moved to your area when his wife died 3 years ago. He lives in a converted garage behind his son's house and rarely socialises as he is reliant on others for transport. He has a history of degenerative joint disease, particularly affecting the lower back and right knee, for which he takes regular paracetamol, and hypertension for which he is taking a diuretic. He drinks a stubby of beer each evening, but has never been a heavy drinker. He used to smoke during the war, but hasn't for many years now. He wakes several times each night to use the toilet, which wakes the entire family when he enters the house. Despite this, his bed is often wet in the morning due to nocturnal enuresis. His daughter-in-law is at her wits-end and requests sleeping tablets for Walter. Walter is usually a well dressed man, but on this occasion you notice he is not cleanly shaven and his cardigan has food stains over it. He is vague and forgets your questions. He also appears under-nourished.

Rationale and general practice context

Australia has an aging population. In 2010, 13.5% of the Australian population was aged 65 years and over compared to 12.4% in 2000.2

Around 34% of general practice patient encounters are with adults aged 65 years and over, and general practitioners are seeing an increasing proportion of older patients, particularly those aged 75 years or over.3 This presents significant challenges for clinical care, population health and economics of healthcare.

The underlying pathologies among the elderly are the same as among the whole population, but at higher rates. However, there are specific features in the diagnosis and management and the functional and social ability of elderly patients, for example:

  • symptoms with no clearly identifiable aetiology
  • altered patient presentations
  • impact of aging on people with pre-existing conditions, particularly intellectual impairment, mental illness or physical disabilities
  • difficulties in cognition and communication
  • multiple pathologies
  • multisystem disease that often involves chronic disease management
  • problems of polypharmacy
  • decreased reserves in elderly people (physiological, psychological, financial)
  • the importance of functional assessment and support
  • sensory deficits such as impaired vision, hearing and balance
  • nutrition, physical activity, continence and pain
  • the need to relate to carers, relatives and other health professionals
  • the need to be aware of community resources
  • the importance of continuity of care.

A knowledge of the physiology and epidemiology of aging helps manage conditions that have special significance in the elderly, such as dementia and atherosclerosis.

Quality aged care in general practice requires:

  • positive attitudes toward empowering elderly patients to take an active part in maintaining their health
  • the ability to deal with and prioritise the numerous problems that the aged may present with, including associated diagnostic and management dilemmas
  • feeling comfortable when working with the aged, their families, carers and friends
  • working within multidisciplinary healthcare teams
  • recognising the special issues (including discrimination) facing older people from diverse backgrounds, including issues of gender differences, ethnicity, poverty and issues of sexuality including sexual preferenc
  • assessment of carer stress to allow early intervention including the possible need for respite care.

Factors affecting general practice aged care management

Familiarity with government policies and programs that have an impact on the aged4 and knowledge of the increased burden of disease in the elderly helps plan general practice aged care. These policies aim to promote health and to prevent and reduce the loss of function from illness, injury and disability. Examples of such policies and programs include rational prescribing practices, such as the Quality use of medicines guidelines,5 which consider the cost and benefits of prescribing medications to individual patients, helps incorporate public health initiatives into daily clinical practice, and health promotion and preventive care in the elderly.

Costs of different care options, such as home support versus institutional care, may influence general practice management options. Patients may need to be treated outside of the general practice setting, eg. at home, at hospital or in an aged care facility.

Cultural and linguistic diversity, socioeconomic status, gender, family and community supports, and geographical location may affect the needs, acceptance and availability of services and activities for the aged.

Cultural differences, perceptions and expectations of aging may affect levels of carer responsibility and involvement.

General practitioners need to be aware of the special services available to help meet the needs of Aboriginal and Torres Strait Islander people.

General practitioners need to be aware of how age related discrimination can affect the management of older patients.

Informed consent may be impaired in the elderly and the care of aged patients may involve carers, issues of power of attorney and regulatory administrative bodies such as guardianship boards. This includes discussing, formulating and documenting advanced care plans and decisions concerning the end-of-life.

Older patients may require assessment for fitness to drive and laws may affect their licence eligibility. Other legal requirements which may require general practice involvement, include pension eligibility, taxi concessions, and death and cremation certificates including coronial obligations. Clinicians need a knowledge of legislative reporting obligations to state public health units that may involve older patients.

Older patients are especially at risk of adverse patient safety outcomes, especially in relation to the inappropriate use of physical or medication induced restraint, missed diagnoses due to failure to evaluate vague or unclearly expressed symptoms, and failure to understand management instructions.

General practitioners identifying elder abuse have legal reporting responsibilities.

Multidisciplinary aged care and general practice

The rise of multidisciplinary teams in primary care (eg. aged care assessment teams) is changing the face of the care of older people. General practitioners need to ensure that the appropriate continuity of care and coordination of management are provided to maintain older people in an optimal state of health in the best possible setting.

General practitioners working as part of a multidisciplinary team need to understand the roles, knowledge and skills of each member of the aged care team including allied health professionals, support agencies and specialist aged care teams.

General practitioners need to be aware that comprehensive care plans can result in complex referrals, service overlaps and gaps requiring accurate written health summaries for patients and carers to avoid confusion during continuity of care.

Related curriculum areas

Most other curriculum areas have implications for aged care, including:

Training Outcome of the five domains of general practice

1. Communication skills and the patient-doctor relationship

AGET1.1

Promote comfortable discussion with aged people and accommodate patients with failing sight, hearing, mental capacities and physical limitations.

AGET1.2

Incorporate cultural and linguistic issues into patient-doctor communication, including aged patients who do not speak English as their first language.

AGET1.3

Use sensitivity when communicating with next-of-kin or carers, particularly in circumstances where the patient lacks the capacity to make an informed decision, or where there is a question of consent for treatment.

AGET1.4

Provide clear direction and patient care instructions to family, caregivers and residential aged care facility staff.

2. Applied professional knowledge and skills

AGET2.1

Adapt knowledge of all areas of medicine to the care of the aged, while recognising where this may differ in the aged and that the context and goals of diagnosis, management and prognosis may differ.

AGET2.2

Know how diagnosis, management and prognosis in older people may be affected by the presence of altered presentations, comorbidities (and their treatments), and socioeconomic and cultural factors.

AGET2.3

Understand the biological and psychosocial processes of aging, and how this affects the interpretation of investigations and the metabolism of drugs.

AGET2.4

Consider and evaluate the role of screening, prevention and health promotion in aged patients.

AGET2.5

Diagnose and treat classic geriatric presentations such as confusion, falls, leg ulcers and incontinence.

AGET2.6

Know the general practice implications of multiple pathological processes occurring simultaneously.

AGET2.7

Manage distressing symptoms, even in the absence of demonstrable pathology (eg. dizziness, isolation, constipation and dry skin).

AGET2.8

Be aware of the concepts of care versus cure and the impact on quality of life.

AGET2.9

Consider the goal of maintaining functional status.

AGET2.10

Manage the wide range of conditions seen mainly in the aged (eg. dementia, congestive heart failure, Parkinson disease).

AGET2.11

Manage the problems of polypharmacy and the systematic recording and review of medications

AGET2.12

Discuss sensitively and assist formulating and documenting advanced care plans and decisions concerning the end-of-life.

AGET2.13

Making appropriate arrangements for care of the dying and for the bereaved is an important skill in the care of the aged.

AGET2.14

Perform or refer patients for appropriate practical procedures, which are often used in the management of conditions common in the elderly.

3. Population health and the context of general practice

AGET3.1

Understand how to use government policies that impact on aged care, such as specific Medicare aged care payments.

AGET3.2

Use comprehensive care plans funded under government chronic disease plans and other aged care initiatives.

AGET3.3

Understand how knowledge of the increased burden of disease in the elderly helps plan general practice aged care.

AGET3.4

Understand how aged care policies and programs that aim to promote health, prevent and reduce the loss of function from illness, injury and disability work and how these policy changes may have implications for general practice aged care.

AGET3.5

Use rational prescribing practices that consider the cost and benefits of prescribing medications to individual patients.

AGET3.6

Incorporate health promotion and prevention into aged care.

AGET3.7

Understand how the issues involved in the cost of different care options, such as home support versus institutional care, may influence general practice management options.

AGET3.8

Understand how cultural and linguistic diversity, socioeconomic status, gender, family and community supports, and geographical location may affect the needs, acceptance and availability of services and activities for the aged.

AGET3.9

Understand how cultural differences, perceptions and expectations of aging may affect levels of carer responsibility and involvement.

AGET3.10

Be aware of the special services available to help meet the needs of Aboriginal and Torres Strait Islander people.

AGET3.11

Assessment of carer stress allows early intervention including the possible need for respite care.

4. Professional and ethical role

AGET4.1

Adopt appropriate professional attitudes including awareness of how age discrimination can affect the management of older patients.

AGET4.2

Do not deny useful treatment purely on the basis of age when evaluating the benefits and risks of proposed treatments.

AGET4.3

Work effectively as part of a multidisciplinary team and understand the role, knowledge and skills of each member of the aged care team.

AGET4.4

Understand the ethics of how informed consent may be impaired in the elderly and the care of aged patients may involve carers, issues of power of attorney and regulatory administrative bodies such as guardianship boards.

AGET4.5

Practise ethical principles regarding informed consent in the discussion, formulation and documentation of advanced care plans and decisions concerning the end-of-life.

AGET4.6

Identify elder abuse (including physical, psychological, social, financial, sexual abuse and neglect) and understand professional legal reporting responsibilities.

AGET4.7

Pay close attention to patient safety risks in the aged, especially in relation to inappropriate use of physical restraint, missed diagnoses due to failure to evaluate vague or unclearly expressed symptoms and ensuring that patient information is as clear as possible.

5. Organisational and legal dimensions

AGET5.1

When providing aged care services work in conjunction with government and nongovernment agencies and specialist aged care assessment teams. This includes working with the Aged Care GP Panels Initiative, aged care assessment teams and many other community services.

AGET5.2

Identify and work with complex referrals, service overlaps and gaps, as well as differing criteria for service eligibility.

AGET5.3

Where appropriate, treat patients outside of the general practice setting, eg. at home, hospital or in an aged care facility.

AGET5.4

Accurately document appropriate health summaries for patients and carers to assist continuity of care, including care plans that include the systematic recording of medications to help manage polypharmacy.

AGET5.5

Assess, as appropriate, older patients for fitness to drive and understand the laws affecting licence eligibility in the aged.

AGET5.6

Assist with legal requirements where appropriate, including pension eligibility, taxi concessions, death and cremation certificates.

AGET5.7

Know legislative reporting obligations to state public health units that may involve older patients.

Learning objectives across the GP professional life

Medical student

1. Communication skills and patient-doctor relationship

AGELM1.1

Describe the impact of sensory impairment on effective patient-doctor communication and measures to address these barriers.

AGELM1.2

Describe the cultural and social barriers to patient-doctor communication with older people.

2. Applied professional knowledge and skills

AGELM2.1

Discuss theories of the physiology of aging.

AGELM2.2

Summarise the health promotion in the elderly including nutrition and exercise.

AGELM2.3

Describe how physical and psychosocial changes of aging affect lifestyle, including how people cope and situations in which they can no longer cope.

AGELM2.4

Describe common psychological and mental health issues in the elderly.

AGELM2.5

Describe methods of assessing patient mental health status and cognitive function.

AGELM2.6

Describe the impact of multiple health conditions on patient management.

AGELM2.7

Discuss pharmacology in older people, including altered drug metabolism.

3. Population health and the context of general practice

AGELM3.1

Describe the epidemiological patterns of common medical and psychological conditions that affect older people.

AGELM3.2

Discuss the social and behavioural impact of aging.

AGELM3.3

Discuss how ethnicity, socioeconomic status, gender, family and community supports and geographical location may affect aged care service needs, including acceptance and availability of services and activities.

4. Professional and ethical role

AGELM4.1

Describe how age discrimination has an impact on patient care and access to services.

AGELM4.2

Discuss issues of patient autonomy in older people.

AGELM4.3

Describe the principles behind power of attorney and advanced medical care plans and identify the legislative processes that implement them.

AGELM4.4

Outline the requirements for high quality multidisciplinary care in older people.

5. Organisational and legal dimensions

AGELM5.1

Summarise the social structure of aged care health services including structures in community, hospital and residential aged care settings.

AGELM5.2

Discuss the role of family and carers in providing aged care, including carer stress.

AGELM5.3

Describe how age discrimination laws may have an impact on elderly patients.

Prevocational doctor

1. Communication skills and patient-doctor relationship

AGELP1.1

Describe how consultation environmental factors such as privacy, background noise and location can affect communication with the elderly.

AGELP1.2

Describe how families and carers may affect patient communication.

AGELP1.3

Explain and discuss investigations and therapies of common diseases of the elderly to the patient and his/her carers and family.

2. Applied professional knowledge and skills

AGELP2.1

Demonstrate how to take a history and examination in order to elicit common diseases that affect the aged, involving carers when appropriate.

AGELP2.2

Investigate and refer appropriately for diseases affecting the aged.

AGELP2.3

Describe how the biological process of aging affects the interpretation of investigations and the metabolism of drugs.

AGELP2.4

Discuss the special issues of drug therapy in the aged, including changes in pharmacokinetics and the special risks of drug therapy including polypharmacy.

3. Population health and the context of general practice

AGELP3.1

Identify common medical and psychological conditions that affect older people.

AGELP3.2

Outline the care issues resulting from age discrimination.

AGELP3.3

Describe the stresses encountered by those who care for the aged.

4. Professional and ethical role

AGELP4.1

Identify how age discrimination has an impact on patient care and access to services.

AGELP4.2

Discuss the sensitive treatment of older patients, including issues relating to patient autonomy.

AGELP4.3

Describe legislation relating to power of attorney and advanced medical plans.

5. Organisational and legal dimensions

AGELP5.1

Describe effective discharge planning for the elderly including planning for continuity of care, assessment for safety and support services at home and future respite.

AGELP5.2

Describe the indications for and regulatory requirements of various levels of residential care.

AGELP5.3

Describe the effect systems of care may have on the health of the elderly.

Vocational registrar

1. Communication skills and patient-doctor relationship

AGELV1.1

Use strategies that promote comfortable discussion with the aged including patients with failing sight, hearing and mental capacities.

2. Applied professional knowledge and skills

AGELV2.1

Demonstrate the comprehensive assessment and management of patients who present with aged care problems including biological, psychological and social aspects.

AGELV2.2

Identify how diseases may present differently in the aged compared to younger people (eg. dementia, congestive cardiac failure, Parkinson disease).

AGELV2.3

Describe the problems of polypharmacy and the importance of systematic recording and review of medication.

AGELV2.4

Describe the changes in normal ranges of laboratory values in older people.

AGELV2.5

Manage distressing symptoms whether or not there is demonstrable pathology (eg. confusion, falls, dizziness, isolation, constipation, decreased morbidity, leg ulcers and disease masquerades).

3. Population health and the context of general practice

AGELV3.1

Outline the relevance of aged care to general practice.

AGELV3.2

Summarise the complexities of providing services and healthcare funding to the aged.

AGELV3.3

Identify the stresses encountered by those who care for the aged.

AGELV3.4

Describe strategies for addressing age discrimination in aged healthcare.

AGELV3.5

Describe the appropriate use of community services and resources for the aged and their carers (eg. nursing homes, hostels, community resources, respite care).

4. Professional and ethical role

AGELV4.1

Evaluate specialist treatment recommended for aged patients by discussing the benefits and risks of suggested treatment, and ensure that patients are not denied useful treatment purely on the basis of age.

AGELV4.2

Describe how to advocate for the elderly in accessing aged care and other resources.

AGELV4.3

Discuss ethical issues related to the aged regarding autonomy, power of attorney, legal and medical plans, including guardianship board, principles of informed consent, and euthanasia.

AGELV4.4

Discuss the physical, psychological and financial forms of elder abuse.

AGELV4.5

Demonstrate the ability to provide multidisciplinary aged care.

5. Organisational and legal dimensions

AGELV5.1

Describe the importance of respite care for the wellbeing of patients and their carers.

AGELV5.2

Describe the role of each member of the aged care multidisciplinary team.

AGELV5.3

Access resources and aids, which assist the elderly (eg. visual and hearing aids, dosette boxes, mobility aids, home care services).

AGELV5.4

Demonstrate how to use medical records systems and care plans to document the care of older people.

AGELV5.5

Outline methods for providing adequate services to meet the needs of patients who are unable to attend the doctor's surgery.

AGELV5.6

Describe practice processes to facilitate communication with hospitals and other facilities in relation to discharge planning.

AGELV5.7

Arrange and provide appropriate care for the dying and the bereaved.

AGELV5.8

Comply with the legal requirements for certificates of sickness, eligibility for pension, taxi concessions, certification of death and cremation.

Continuing professional development

1. Communication skills and patient-doctor relationship

AGELC1.1

Demonstrate maintenance of skill level in communicating with the elderly.

2. Applied professional knowledge and skills

AGELC2.1

Demonstrate up-to-date management of conditions in the elderly.

AGELC2.2

Demonstrate up-to-date knowledge of prescribing issues in the elderly.

AGELC2.3

Incorporate evidence based advances into the care of the elderly.

AGELC2.4

Consider the need for more specialised training in aged care by those practitioners with a high caseload or interest in aged care.

3. Population health and the context of general practice

AGELC3.1

Identify the impact of local demography of older patients on the general practice.

AGELC3.2

Keep up-to-date with changes in aged care policies.

AGELC3.3

Identify the impact of changes and initiatives in government aged care policy on general practice.

AGELC3.4

Identify the expectations and the diversity of views presented by culturally and linguistically different patient populations and the impact of these on general practice aged care.

4. Professional and ethical role

AGELC4.1

Identify own gaps in knowledge and skills in relation to aged care.

AGELC4.2

Consider involvement in residential care facility or nursing home care.

AGELC4.3

Incorporate professional development needs for the general practice care of older people into ongoing quality assurance activities.

5. Organisational and legal dimensions

AGELC5.1

Seek information and training in the use of government funded programs such as the Aged Care GP Panels Initiative, other aged care initiatives and community services to assist in improving the quality of aged care.

AGELC5.2

Consider the use of up-to-date specific assessment tools in managing the elderly.

AGELC5.3

Consider the use of computerised medical records when managing elderly patients, especially those with multiple comorbidities.

AGELC5.4

Review practice processes to facilitate communication with hospitals and other facilities in relation to discharge planning.

AGELC5.5

Identify local aged care facilities and resources.

AGELC5.6

Maintain a list of locally available aged care resources including community care services (eg. meals on wheels).

References

  1. Australian Institute of Health and Welfare. Older Australia at a glance. 4th edn. Canberra: AIHW; 2007. Available at www.aihw.gov.au/publication-detail/?id=6442468045.
  2. Australian Bureau of Statistics. 4101.0 – Australian Social trends; 2011. Available at www.abs.gov.au/ausstats/abs@.nsf/mf/4102.0.
  3. Britt H, Miller GC, Charles J, et al. General practice activity in Australia 2000–01 to 2009–10: 10 year data tables. Canberra: AIHW; 2010. Available at www.aihw.gov.au/publication-detail/?id=6442472440.
  4. Department of Health and Ageing. Aged care. Canberra: Australian Government; 2011. Available at www.health.gov.au/internet/main/publishing.nsf/Content/ageing-whatnew.htm-copy2.
  5. Department of Health and Ageing. Quality use of medicines. Canberra: Australian Government; 2011. Available at www.health.gov.au/internet/main/publishing.nsf/content/nmp-quality.htm.

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