Wir werden älter...

Challenges of daily living

Trish Groves, deputy editor, BMJ

tgroves@bmj.com

How many of us went on holiday this summer thinking "Will my mother or father be OK while I’m away?" We know from experience with ageing relatives that it’s well worth taking time to be prepared for crises and, when possible, to nip problems in the bud. But can doctors find enough time and commitment to do this with their older patients?
Over the next month we will be publishing four Clinical Reviews, along with related podcasts and videos, on assessing older people. In the first review Terry Quinn and colleagues argue that all doctors working with adults should be able to spot and respond to the functional difficulties that hasten older people’s decline from illness and disability (doi:10.1136/bmj.d4681). Reviewing evidence mostly about people aged 80 and over, the authors explain how to assess patients’ functional ability opportunistically during medical consultations. Fully evaluating someone’s activities of daily living is best done at home and takes a lot longer, as a related video on bmj.com and the BMJ iPad app shows (www.bmj.com/site/video/functionalassessment.xhtml), but it may be a good investment of time for both patient and doctor.
Whether it will be feasible for most non-geriatricians to follow Quinn and colleagues’ recommendations on functional assessment is moot, but their advice is certainly practical and down to earth. It includes asking the patient and carers about their expectations of tests and treatments, making the distinction between "what the patient wants to do, what they can do, and what they actually do," and focusing on the patient’s priorities "for example, food preparation and outside mobility are important only if the patient still needs or wishes to engage in these tasks." Assessment should be as much about establishing what doesn’t need attention as what does.
Ray Moynihan tells the story of an 88 year old American woman, Fervid Trimble, for whom polypharmacy led to rapid physical and cognitive deterioration (doi:10.1136/bmj.d5184). Once her family realised what had happened, they asked her doctors not to put her on any new medicines without their permission, and Fervid’s daughter Johanna became a patients’ advocate, promoting the idea of drug holidays in an evidence based presentation called "Is your mom on drugs?" One key study on such "de-prescribing" was conducted by general practitioner Dee Mangin, and Moynihan clearly supports her assertion that "improving the art of ‘not doing’ is what will determine quality care [for older people] in the next few decades."
Graham Mulley acknowledges that care for older people isn’t always good enough, but he is fed up with the relentless bashing it receives at the hands of the media (doi:10.1136/bmj.d5391). When invited to be a consultant adviser for a BBC expose of nursing homes, he declined to help and asked "why they did not consider making a truly original programme, which celebrated all the excellent work that is taking place in many care homes. There was a long silence." He ends with a challenge "Perhaps all of us who witness such excellence—relatives, professionals, and other visitors—should write or tweet positive messages to balance the prevailing nihilism." Please do.
Cite this as: BMJ 2011;343:d5524