Care Plans for Seniors in Belconnen: Comprehensive Healthcare for Older Adults

Unique Healthcare Needs of Older Adults

As we get older, we are blessed with wisdom, perspective and time for what is important. It also presents certain health concerns unique to older adults.

Aged persons tend to suffer from several illnesses at once. A 40-year-old may have one or two health problems, while a 75-year-old may have five or more. This complexity demands attention and care that cannot be achieved with the treatment of single conditions.

Senior health care is more than just treatment. It’s about living independently, maintaining quality of life, coping with the physical changes of aging, and dealing with the social and emotional aspects that affect people’s health.

A complete care plan for seniors takes into account the entire person – their medical issues, living arrangements, family support, medication management, nutrition, mental health and the desire of the person involved for what they hope to do in the last years of life.

An Aged Care Assessment will be performed.There will be a comprehensive Aged Care Assessment.

The first step in effective senior care involves a comprehensive evaluation which extends beyond blood pressure and cholesterol.

Your GP will consider:

• Physical health factors: any medical conditions (current), medical prescriptions (current), allergies (current), past surgeries, past hospital stays. This will provide a full picture of your medical complexity.
• Functional ability: Be able to dress, cook, care for personal hygiene and be independent? Knowing what you can and cannot do, assists you in planning for support.
• Cognitive function: Memory, orientation, decision making and daily functioning. Cognitive changes can be identified early, and thus intervention can be implemented.
• Social situation: The situation of the social family, the availability of social support, financial resources, and social networks. Social isolation significantly impacts older adults’ health.
• Nutrition is affected by nutritional status, including weight changes, shopping and cooking tasks, dental health, swallowing issues and dietary restrictions.
• Mobility and balance: Falls is an important risk factor for older people. Evaluation of gait, balance and muscle strength to determine fall risk.
• Medications: Ensure that all medications are kept and doses are right and there are no problematic drug interactions.
• Mental health: Depression, anxiety and cognitive decline are prevalent but often unrecognized in seniors.

This is a thorough evaluation that takes time, and is the basis for planning for appropriate care.

Multiple Medication Management and Deprescribing

Most seniors use several drugs, some of them five, ten or even more! Medications that are needed are lifesaving, but too many medications cause problems.

The elderly may be more susceptible to side effects. Some medications may interact with each other. Certain drugs that were prescribed sometime in the past might not be needed anymore. It can be difficult to keep track of several medicines.

Deprescribing is the process of slowly decreasing or discontinuing medications that are no longer helping. No, this is not about cutting back on needed treatment, but rather asking the question, “Is each medication still needed?”

Your GP might stop or reduce medications if:

• You’ve achieved the target (e.g., blood pressure is now controlled)
• You are having some concerning side effects
• The medication’s benefit is outweighed by risks in someone your age
• You’re taking duplicate medications
• You have a new life expectancy or health goal.

Having medicines reviewed regularly (preferably more than once a year) will make sure your medicine cabinet fits the way you are feeling now and not after decades of medicines.

Fall Prevention and Safety

Falls are among the biggest health risks for older people. The results of a fall include broken bones, dependency, hospitalization, and changes in lifestyle.

Multiple factors need to be considered when it comes to fall prevention:

• Home safety: Clear away trip hazards, increase lighting in home, install grab bars in bathrooms, make sure stairs are safe. Many falls can be avoided with simple changes.
• Medication review: Certain medications can make you dizzier or more confused which can increase fall risk. Your GP may be able to adjust these if they are playing a role in causing falls.
• Vision correction: They reduce the risk of falling due to their poor vision. Regular eye examinations and glasses prevent falls.
• Balance and spatial awareness: Hearing loss affects balance and spatial awareness. Appropriate hearing correction helps prevent falls.
• Strength and balance training: Exercises are directed to maintain muscle strength and balance which are important fall prevention strategies.
• Footwear – The right footwear with good grip and support is important. Do not wear slippers or high heels which have a higher risk of falling.
• Sudden drop in blood pressure on standing up causing dizziness and falls. This can be prevented with good management.

Your GP may refer you to physiotherapists and/or occupational therapists trained in fall prevention.

Identifying cognitive dysfunction or dementia.Identification of cognitive dysfunction or dementia.

Many older adults experience cognitive changes. Losing your keys is a normal part of aging. Not forgetting the members of your family is not.

Knowing that your loved one is cognitively declining early can help you begin treatment early, make long-term plans, and access therapies that can help slow cognitive decline.

At regular GP appointments you are screened for any cognitive issues using simple tests. If problems do arise, thorough evaluation by specialists may determine if it is part of the normal aging process or if something is wrong, such as Alzheimer’s disease.

If cognitive decline is at an early stage, it could be possible to restore the decline through treatment for underlying conditions such as:

• Depression (which can resemble dementia)
• Thyroid problems
• Vitamin B12 deficiency
• Medication side effects
• Sleep disorders

Diagnosis and treatment can improve cognitive abilities. When dementia occurs, the earlier it is diagnosed, the more time there is to plan as the person with the dementia is still able to make decisions about their future.

Make Mental Health one of your Senior Projects!

Depression and anxiety frequently occur in older people, but may not be recognized. Seniors might dismiss their symptoms or chalk them up to “just getting old.

Unfortunately, depression in older adults manifests differently from depression in younger people. Rather than sadness, older adults might experience:

• Losing interest in their activities which they used to enjoy
• Constant tiredness for no reason, even after a good night’s rest.
• Difficulty concentrating
• Weight loss or gain, or decrease in appetite.
• Unexplained physical complaints
• Thoughts about death or wanting to die

Senior anxiety may be related to health issues, finances or the ability to be independent.

Mental health issues are linked to physical health. Depression has a negative impact on the outcome of chronic disease. Anxiety has an impact on life quality. However, both are very treatable with counseling, therapy and sometimes medication.

In a preventative visit to the GP, they look for mental health problems. It is important to build trustful relationships where seniors feel comfortable sharing about emotional challenges in order to recognize and address these issues.

Frailty Assessment

Frailty is more than just a person’s age. A weak person can easily be affected by bad health factors, such as getting sick or changing medicines.

Frailty involves:

• Muscle weakness
• Slow walking speed
• Unintentional weight loss
• Fatigue, lack of energy
• Reduced physical activity

The identification of frailty is crucial as this underlies a need for care which is different from that required by robust older people of the same age.

Sometimes, frailty can be enhanced by nutrition, exercise and treatment of underlying factors. Even if frailty is not reversible, the recognition of frailty alters medical decision making.

The difference between Frailty and Aging

Not all older adults are frail. Some 85-year-old people are strong and agile while others 65-years-old are weak. Frailty refers to a specific vulnerability and not to the age.

Your GP determines frailty through strength, the rate of movement, physical activity and any recent changes in weight. Frailty can be detected from simple tests such as grip strength or walking speed.

Knowing if you’re frail helps make medical choices. A strong, fit 80-year-old may be able to endure a treatment for a problem. If the person is older (around 65 years or more), he may want to receive more comforting measures rather than stronger ones.

Prevention and improvement of frailty

There is a degree of frailty which comes with very old age but there is much that can be prevented or improved. Resistance exercise helps keep muscles strong. If protein and nutrition is adequate, muscle loss does not occur. Chronic diseases are responsible for the disability that leads to frailty, which can be avoided through management.

Your GP may refer you to physiotherapists or exercise specialists who develop programmes tailored to preventing and/or improving frailty. These programs can often have a significant benefit on the quality of life.

Discussions about advance care planning and death.Conversations about advance care planning and end of life.

Advance care planning involves planning for future care decisions, in case you are ever unable to make decisions for yourself.

These conversations, though uncomfortable, are so important. They answer such questions as:

• Which is more important in your life, quality of life or quantity of life?
• If you were really sick, would you want life support?
• Would you like to die at home or in hospital?
• If you don’t, then who should?
• Are there medications you can’t stand or can’t live without?

Talking to your GP and family about these things while you are well allows your values to be taken into account in your care if you are not able to communicate later.

An advance care plan could contain:

• An advance directive (a document with your wishes)
• EPOA (appointment of an enduring power of attorney – someone acting if you are not able to)
• Data regarding places of death desired.
• Family’s information on preferred level of medical intervention
• Organ donation preferences

It’s important to have these talks because they take away the stress that is created if your wishes aren’t heard or taken into account.

Making Your Advance Directive

An advance directive is a document that expresses your wishes about treatment. It is relevant if you become unable to make decisions because of dementia, a stroke or other factors.

The following should be included in your advance directive:

• If your heart has stopped, will you want CPR?
• If breathing ceases, do you wish for mechanical assistance?
• If you are unable to eat, do you wish to have a feeding tube?
• First, if you have an infection, do you need antibiotics?
• Your overall objective if you fall seriously ill (comfort, trying to get better or something else)?
• Religious or spiritual beliefs that impact on your care

Your GP can assist you to consider these questions and record your preferences. If you talk to your family about these things, they will know your values and will be able to speak on your behalf if necessary.

Choosing Your Healthcare Power of Attorney

The person you designate as your enduring power of attorney is the one to make health care decisions for you if you are unable to. This person is supposed to be well acquainted with your values and stand up for what you want even when it is not what he/she thinks is best.

This is an important decision. The person you select should:

• Know yourself and what’s important to you
• Openly discuss challenging matters.Be prepared to talk about difficult things.
• Stay cool, collected and on track when things are difficult
• Reside relatively near the community
• Be prepared to be involved in medical conversations

Discuss with the person and then formally appoint. They must be made aware of the responsibilities that they take on.

Successful co-ordination of Aged Care Services

As seniors’ needs increase, coordination between healthcare providers becomes crucial.

When your GP refers you to an aged care service – such as home care support, day programs or residential aged care – sharing information means everyone knows about your health.

You still have your GP as your main health care professional even if you are receiving aged care support. If your GP keeps in touch with aged care providers, this means:

• Changes of medication are conveyed
• New health issues are discovered
• You have an up-to-date careplan.You have an ‘up to date’ careplan.
• Complications are identified early and prevented

This coordination will need your consent and collaboration.

Home Safety Assessment

It is important to take home safety into consideration for seniors who wish to stay living at home without assistance.

An OT can evaluate your home and suggest you:

• Install grab bars in bathrooms.
• Addressing foundation sinkage and other trip hazards.
• Improved lighting
• To make ramps or stairs more accessible.To modify stairs or ramping.
• Making adjustments to the kitchen if they have limited mobility.Making adjustments to kitchen if they have limited mobility.
• Bedroom safety changes
• Bathroom modifications

Educational interventions to prevent falls and injuries are often simple, and low cost, and enable older adults to age in place for as long as possible.

Use of mobility and independence management.

Mobility directly impacts independence. People who are unable to walk safely or move about freely become dependent on others for basic tasks.

Your care plan will include care for mobility, which means:

• Strength maintenance/exercises to improve strength in the body.
• Supportive equipment such as walker, cane and/or wheelchair as required
• Home modifications to safely get around.
• Pain that is treated to allow movement.Pain that is managed to allow movement.
• Workouts designed with your inabilities in mind.Workouts designed for your inabilities.
• Treatment of disorders of mobility

The aim is to maximise independence within sensible limits and with the help of the appropriate support.

Nutrition and swallowing problems.Nutrition and Swallowing problems.

Eating a balanced diet will help to keep older people healthy and strong. However, as we grow older, eating is becoming more and more difficult.

Problems include:

• Chewing problems because of missing teeth or dentures
• Difficulty swallowing (dysphagia)
• Inappetence as a result of medication.
• A decrease in the ability to taste or smell.
• Trouble buying and cooking food
• Medications and/or lack of activity that cause constipation.
• Dry mouth, if drinking is hard

If there are swallowing difficulties, your GP or speech pathologist will be able to evaluate your swallowing and suggest foods and eating techniques that are safe for you.

If an individual has a low appetite or limited intake of certain nutrients, nutritionists can help solve the problem.

Keeping a good diet through simple solutions, such as preparing meals that are delivered or family helps out with the cooking.

Avoid using a raised floor for the following reasons:Don’t use a raised floor for the following reasons:

The three areas that are important to quality of life and frequently seen as uncomfortable or a normal part of growing older.

Preserving vision

Regular visits to the eye doctor can help detect glaucoma, cataracts and age-related macular degeneration at an early stage. Wearing correct glasses or treatment, maintains independence and avoids falls.

Hearing

Hearing loss leads to social isolation, depression and brain damage. Contemporary hearing devices are very quiet, effective and greatly improve quality of life.

Incontinence

Many older people have the embarrassment of being incontinent of urine or stool, and it can be treated. Your GP may be able to find out what is causing your symptoms – it could be because of a side effect of the medicine you are taking, a urinary infection or constipation – and suggest treatment.

Solving these problems is no vanity – it affects the way you communicate with other people and enjoy your independence.

Prevention of social connections and isolation.Prevention of social connections/iso-lation.

Social isolation is as harmful to health as smoking. It raises depression, cognitive impairment and death.

The following should be included in your care plan:

• Opportunities for social involvement
• Children will be taken to social events.
• Technology to connect with family
• Volunteer opportunities
• Community groups/classes
• Religious or spiritual community groups
• Pet companionship
• Transportation to and from services where mobility is restricted

Loneliness is not a natural part of growing older, it can be avoided through intentional connection.

Palliative Care Planning

Palliative care is comfortable and dignified care with a emphasis on quality of life when cure is not possible. This can be cancer treatment, advanced dementia care, heart failure or anything that gives the person suffering.

Palliative care is not about giving up, it is about being realistic about prognosis and maximising comfort and meaning.

Your GP may talk to you about palliative care if it’s appropriate and make sure your treatment is aimed at comfort rather than cure.

Parenting Support and Family Involvement

Older adults get important support from their families. Incorporating them into care planning is a recognition of this and it means everyone knows how the care approach is going to be taken.

However, it’s important that:

• The older adult’s voice is still in the foreground.
• Decisions are based on older adult’s values and not family preferences.
• Caregivers are supported in an appropriate way
• Medical information is confidential, unless the older adult consents.

You and your family should have discussions with each other about your healthcare with your GP helping you.

Move to aged care facilities

Residential aged care is an option to provide the support needed if it is not safe or possible to continue living at home.

Your GP assists by:

• Giving medical information to the aged care facility.
• Checking your medication list with facility
• Maintaining continuity of care,
• Being on call for continuous healthcare services
• Talking about any concerns relating to the transition

The aim is to have your move go as safely and smoothly as possible without interrupting your care.

Identifying, assessing, and creating a Living Care Plan.

A good senior care plan is not one that’s set and forgotten. It is a work in continuous evolution as your health, situation and preferences change.

Your care plan is a collection of:

• All of your health issues and medications.
• The ways you do and don’t function or are limited.
• The type of home and help you have
• People who are connected to you and your emotional wellness.The individuals you know and your emotional wellbeing.

Your values and preferences:

• What you want to achieve in the remaining years of life.What you want to do in the years left to live.
• Specific actions to respond to identified needs
• At regular intervals, review for updating the plan

By visiting your GP regularly with your plan (ideally every 3-6 months), your plan stays up-to-date with your health changes.

The Goal: Healthy, Independent, Dignified Aging

Senior healthcare is not the same as keeping a person alive for as long as possible. It’s about having as healthy and independent and meaningful of the rest of your life as you can.

This is achieved by a comprehensive care plan that identifies you and values your health issues, your strengths, your values and your aims.

We offer comprehensive GP care to your senior parent or loved one with special plans designed for their needs, so they can enjoy optimal care from our best GP in Belconnen. We will remain dedicated to helping older adults remain independent, enjoy their life and have dignity throughout the years.

1: At what age should we start thinking about a comprehensive care plan for my aging parent?

Covers:

• Age guidelines (65-70)
• Early vs. reactive planning
• Why start early
• Conversation starters
• What to discuss initially

 

2: How do we manage my parent’s multiple medications safely? They’re on over 10 different drugs.

Covers:

• Common problems
• Medication reviews
• Deprescribing
• Simplified schedules
• Webster packs
• Pharmacy consultation
• Red flags

 

3: My parent wants to stay home but is having balance problems and falls. What can we do?

Covers:

• Medical assessment
• Home modifications
• Grab bars
• Lighting
• Stair safety
• Assistive devices
• Exercise
• Medication review

 

 4: How do we approach conversations about end-of-life care without upsetting my parent?

Covers:

• Why these conversations matter
• Timing
• Framing positively
• Listening
• Professional help
• Key questions
• Documentation
• Advance directives

 

5: How do we know when it’s time to transition to residential aged care?

Covers:

• Warning signs
• Options exploration
• Financial planning
• Medical assessment
• Gradual transition
• Managing emotions
• Ongoing advocacy