Chapter 4 – Health Care and Health Promotion4.0 Health Care and Health Promotion4.1 Rights of ResidentsThe aim of this chapter is to provide trustees and scheme based staff with some background information which will enable them to give practical advice and information to residents and their families. Trustees and scheme managers will wish to promote a good quality of life for their residents but it should be remembered that people living in sheltered housing have the right to keep their affairs and illnesses to themselves if they wish.4.2 Giving AdviceUnless you are medically qualified you must not give medical advice. However, it is perfectly in order to suggest a visit to a GP, optician or dentist if you feel this would benefit the resident’s health or wellbeing.4.3 The general Practitioner and Procedures for GPS InvolvementResidents can have whichever GP they wish. Many of them will prefer to retain the same doctor who has treated them for years. It is a good idea when a resident is appointed to ask for their permission to contact their GP in case of illness and, if the resident agrees, confirm in writing. If new to the area, or if GP registration has lapsed for any reason, information can be made available about local surgeries to ensure that all residents are registered prior to moving in. It is important that (with the permission of the resident) the charity (scheme manager, warden, clerk or trustee) keeps records of each resident’s next of kin, spare key holder and GP so that the right person can be contacted in an emergency or advice sought, as appropriate. Sometimes residents ignore symptoms, decline treatment or refuse to use an aid because of anxiety or embarrassment. Often, a resident will trust the views of a trustee or warden they know well. If, after having talked with them, the resident is still unwilling to take action try:Putting them in contact with someone who has been through the same circumstancesSuggesting a trial period for a set time, such as a weekInvolving family membersInvolving a well-regarded professional – district nurse or social worker. Ultimately the resident’s health and treatment are not your responsibility. You should not act against your resident’s expressed wishes, unless this impacts upon other residents or staff, but should inform the appropriate person - next of kin or GP - of the difficulties. Some larger charities have a room set aside for the GP to hold regular surgeries. This is particularly useful in rural areas to reduce the need for travelling. In this way a good relationship is developed and a GP will be able to support trustees in their contact with social services and in obtaining more care and support for the residents. The room can also be used for podiatry, nursing or medical procedures. Many GPs have a practice nurse with particular responsibility for older patients who makes regular visits or with whom contact can be made if there is a difficulty. There is considerable emphasis within our society on preventative health care, early detection of difficulties and prompt and early intervention. There is a range of advice available from health professionals and much that residents can do to help themselves. Trustees and scheme managers should encourage self care and a healthy and independent life style. Currently GPs should invite every patient over 75 years for an annual health check. This is not always consistently delivered. The check includes information about family and social support, assessment of physical and mental health, sight and hearing tests. Some charities that have several residents registered with the same doctor arrange for visits on the same day to maximise use of the GP’s time and to save residents having to travel. Note that in some areas there are well persons’ clinics for people aged 60 years and over. There is growing evidence that early detection of problems and timely intervention can facilitate the postponement of disability in later life. Older people are sometimes reluctant or embarrassed to admit that they have problems in these areas but in many cases considerable benefits can be obtained from early diagnosis and treatment. Symptoms that merit prompt attention are:Unexplained or persistent painUnexplained weight loss or persistent loss of appetiteUnexplained breathlessnessUnexplained swellings, especially in the breastUlcers that do not heal properlyBleeding from the rectum or vagina or in urinePersistent cough or hoarseness. Other symptoms that may indicate the onset of a serious illness are:Short-term loss of feeling, confusion or weaknessChanges in vision. Doctors follow guidelines with regard to confidentiality but may provide information to trustees/scheme managers that does not breach the privacy of the resident. However, trustees/scheme managers must ensure that they do not divulge that information to a third party. It is a good rule of thumb to refer all requests for specific information about the health of a resident (even from relatives) directly to the relevant health care professional(s).4.4 Roles of Healthcare ProfessionalsBelow are brief descriptions of the roles of some of the health care professionals with which the charity may come into contact in connection with residents. Chiropody or Podiatry - specialise in keeping feet in a healthy condition Dietetics - promote nutritional wellbeing, prevent food-related problems and treat disease Occupational therapy - help people to overcome physical, psychological or social problems arising from illness or disability, and assess for aids and adaptations. Physiotherapy - treat the physical problems caused by accidents, illness and ageing, particularly those that affect the muscles, bones, heart, circulation and lungs. Prosthetists - design and fit artificial replacements (or prostheses) to upper and lower limbs for patients who have lost or were born without a limb. Orthotists - provide braces, splints and special footwear to help patients with movement difficulties and to relieve discomfort. Radiographers – deliver ionising radiation treatment and examine patients by means of x-rays. Speech and language therapists - work with people who have problems with communication, including speech defects, or with chewing or swallowing. Often work with people recovering from strokes or who have dementia. Nurses: Practice Nurses - give vaccinations, monitor blood pressure, conduct tests and weight management. District Nurses - manage care within the community, leading teams of community nurses and support workers, as well as visiting house-bound patients to provide advice and care. District nurses are able to prescribe medication to patients. Community Psychiatric Nurses - based in the community, assist with referrals to psychiatrists, psychotherapists and other mental health professionals. Experienced with depression and dementia. Continence Nurses - advise on exercises, devices, medication and other measures to improve continence as well as prescribing bed pads etc. to protect bedding. Diabetes Nurses - work closely with physicians caring for diabetic patients, providing help with the control, understanding, medical and practical management of their diabetes and any of its complications. Macmillan and Marie Curie nurses - give advice and support to people with cancer both in hospital and at home. They often liaise between patients, relatives, GPs and the hospital and can provide bereavement counselling. Admiral nurses – offer skilled assessment of the needs of people with dementia. They provide information and practical advice on caring for a dementia sufferer.4.5 Healthcare ServicesThere may be clinics for heart and blood pressure checks, asthma, diabetes, stopping smoking or weight control. Each surgery has a Patient Participation Group involving patients and carers in promoting the quality of services provided. At the time of writing there are considerable changes underway in the NHS due to the Health and Social Care Act 2012. These changes will affect the NHS in England but not in Scotland or Wales.4.6 When a Resident Becomes Unwell4.6.1 When to call an ambulance Always call 999 if someone is seriously ill or injured, and their life is at risk. Situations requiring an ambulance include:Loss of consciousnessAcute confused state and fits that are not stoppingPersistent, severe, chest painBreathing difficultiesSevere bleeding that cannot be stopped. Crews are highly trained in all aspects of emergency care. An ambulance is equipped with a variety of emergency care equipment such as heart defibrillators, oxygen, intravenous drips, spinal and traction splints and a range of drugs. 4.6.2 GP If the illness does not immediately appear dangerous or life threatening, contact the GP surgery first if possible (but see specific advice regarding chest pain and stroke symptoms below). Patients can still call their GP outside normal surgery hours but will usually be directed to an out- of- hours service. The out-of-hours period is 6.30pm to 8am on weekdays and all day at weekends and bank holidays. 4.6.3 NHS Direct The resident can call NHS Direct on 0845 4647 (number current as at November 2012). They can give advice or directions to the best local service to deal with the condition. Alternatively, they can use the online symptoms checker on the NHS Direct website (www.nhs.uk) to assess symptoms and receive advice on the best action to take.4.6.4 Minor injuries units If the injury is not serious, they can visit a minor injuries unit (MIU), rather than going to an Accident & Emergency department. 4.6.5 Next of Kin With the permission of the resident, a trustee or scheme manager should advise the next of kin if a resident is taken to hospital. 4.6.6 NHS hospital services Treatment at NHS hospitals is free. Since 1st January 2009 nobody should wait more than 18 weeks from the time they are referred by their GP to the start of their treatment unless it is clinically appropriate to do so or they choose to wait longer If someone needs to go to hospital to see a specialist, in most cases they now have the right to choose to which hospital they are referred. Complaints The best people to speak to about any concerns are the ward manager, senior nurse on duty or the hospital receptionist. Most hospitals have a PALS (Patient Advice and Liaison Service) office. They can give advice on how to get a complaint resolved. 4.6.7 Specialist hospital services for older people Physicians and their teams specialising in the medicine of later life (Medical Gerontology) are now numerically the largest speciality of medicine in the UK and provide a service in every acute general hospital. Alongside other medical and surgical specialities, they deal specifically with acute and non-acute medical illness in older (as well as younger) people and provide leadership and specific services related to the wider effects of such illness on ability and independence, relationships and support need and (in the case of hospitalisation) discharge planning. Particularly where health and ability problems in older people are multiple and/or complicated, they have a particular role (in collaboration with GP’s) in bringing together the complex strands of investigation, treatment and rehabilitation, avoiding the discontinuity and bewildering “pillar-to-post” referral phenomena that may otherwise occur. Alongside physicians, the core specialist teams include nurses, physiotherapists, occupational therapists and social workers. In addition they all work closely with clinical psychologists, clinical pharmacists, dieticians and mental health services. GPs are the first point of contact (other than A&E) with medical gerontology services. They will make an initial assessment of the health problem, prescribe medication, and if necessary, arrange referrals to other treatments and services, or refer to the medical gerontology service as appropriate. 4.6.8 Eye Care Services Optician is a general term that covers both optometrists and dispensing opticians. Optometrists carry out sight tests to check the quality of vision and eye health. They look for signs of eye disease that may need treatment from a doctor or eye surgeon and prescribe and fit glasses and contact lenses. An optometrist should be seen every two years (or more frequently if advised). This is important because an eye examination can detect potentially blinding eye conditions. Many opticians will arrange home visits to less mobile patients. To qualify for a free NHS-funded sight test a resident should be:Aged 60 or over orRegistered blind or partially sighted orDiagnosed with diabetes or glaucoma orAged 40 or over and the parent, brother, sister, son or daughter of a person diagnosed with glaucoma, or have been advised by an ophthalmologist that they are at risk of glaucoma orEligible for an NHS complex lens voucher.4.6.9 Pharmacists and Chemists Pharmacists and chemists use their clinical expertise together with their practical knowledge to ensure the safe supply and use of medicines by patients and members of the public.4.7 Medicines PolicyResidents often manage complicated medication regimens well. Health problems are often due to the side effects of prescribed medication. Residents should be encouraged to attend a medication review as follows:All patients over 75 years annuallyThose taking 4 or more medicines should be reviewed every 6 months. If in doubt, request an appointment to assess any change in their medical condition. It may be possible to support residents by co-ordinating repeat prescriptions, ordering and collecting from the regular pharmacy or having prescriptions delivered. Advice can be offered on the return of unwanted medicines and identifying problems such as forgetting, or support in reading, the information on the label. Recent changes in legislation mean that almshouse charities should not be involved in dispensing medicines, changing dressings etc. As residents become frail the charity should liaise with GPs to ensure adequate support from District Nurses.4.8 Medication4.8.1 Monitored Dosage Systems Problems caused by hoarding, a lack of routine, confusion and multiple storage locations have been reported among elderly patients living in their own homes. A monitored dosage system can alleviate these difficulties. They are prescribed as either 7 or 28 day prescription packs. Blister packs pre-package all a patient’s medications. This is not the same as manufacturer’s blister packaging. Dosette boxes may be filled by the pharmacist, or the patient or a carer. The advantage of such systems is that they contain the correct dosage and make it possible to tell when medication should be taken (and if it has been taken). They are applicable to oral medicines. 4.8.2 Message in a Bottle System ‘Message in a Bottle’ is a free system that encourages people to keep their basic personal details and details of their current medication, in a common place where it can be found in an emergency. The small plastic container is kept in the fridge where emergency services will find it. They will know residents use this system by two discreet labels. One is fixed to the resident’s accommodation front entrance, the other is displayed on the fridge where the information is kept. The system is usually a community based project operated by The Lions or in partnership with other local social, health or emergency services. 4.8.3 Collection of Medicines Most pharmacists will deliver medications to the resident’s home. Many GP’s surgeries will send a repeat prescription to a pharmacist, who will then deliver the medication. There are also online services where the resident can register and have their prescriptions delivered to them by companies such as Boots or ‘pharmacy2u’ free of charge. These companies will also remind subscribers when their repeat prescription is due. For some residents the fear of going into hospital is very real. They may be afraid that they will not be able to return home, or indeed that they may not leave hospital at all. Only suitably qualified people can give medical advice but the charity and its representatives can be calm, reassuring and provide general information to reduce the resident’s stress.4.9 Care PackagesWhen residents need extra help in the form of personal care and day to day assistance the local authority and the NHS and have a variety of services they can offer. Often the need for extra help is triggered by an event, such as a hospital discharge (see Chapter 9.3) but sometimes gradual failing health can lead to the need for care packages. Please refer to Chapters 7.6 and 7.7 regarding Care Packages.4.10 Preventive ActivityIt is never too late to adopt a healthier lifestyle and habits in order to lead a healthier and happier life. Encouragement of residents to follow medical advice, eat a varied and well balanced diet, and engage as far as possible in physical activity, has great value but must not infringe individual autonomy. 4.10.1 Healthy Eating Diet can play a substantial part in some chronic conditions such as heart disease and diabetes. Encouragement from trustees and staff can help residents make the adjustments needed to their eating patterns. A well balanced diet should be varied and include plenty of fruit, vegetables and food rich in starches (potatoes, bread, rice and pasta) and fibre (wholemeal bread, potatoes with their skin on and bran). Fruit and vegetables Research shows that people who eat plenty of fruit and vegetables are less likely to develop heart disease, certain cancers and eye conditions. Meat, poultry, fish, eggs, beans, lentils and nuts These contain protein, which build and repair the body. Meat or fish does not need to be eaten every day – cheese, well-cooked eggs, beans, lentils or tofu are also sources of protein. Oily fish (salmon, mackerel or sardines) are rich in vitamin D and a type of fat that helps to prevent heart disease. Avoid frying meat or fish. Foods containing fat and sugar Cut down on foods that are high in saturated fat or sugar such as butter, ghee, cakes, biscuits, sausages, meat pies, paté and fatty meat. Saturated fats raise the level of cholesterol in the blood and increase the risk of heart disease and stroke. Breads, other cereals and potatoes Starchy food (bread, chapattis, breakfast cereal, potatoes, yams, rice or pasta) should be eaten with every meal. Wholegrain foods such as brown rice or wholegrain bread or pasta contain B vitamins; minerals and fibre that help prevent constipation. Milk and dairy foods These foods contain calcium, which helps to keep bones strong. Lower-fat versions, such as semi-skimmed milk, half-fat cheese and low-fat yoghurt may be more suitable for those watching their weight. Advice is to aim for 3 portions a day. 4.10.2 Exercise Regular exercise strengthens muscles and bones, keeps joints mobile, keeps people steady on their feet, and keeps hearts and lungs working efficiently. Often it promotes a feeling of well-being and a good sleeping pattern. Some sensible precautions need to be taken for people with high blood pressure or heart or chest ailments and medical advice should be sought before starting an exercise routine. The answer is usually to listen to one's body and not exercise to the point of discomfort or be too ambitious. Gentle, regular exercise is more beneficial than throwing oneself into something very energetic occasionally. Walking, swimming and yoga are all enjoyable exercises that can be done at one's own pace. Cycling, if road conditions permit, is also beneficial and can have the added benefit of making people independent of public transport for local journeys. Gentle exercise classes in the communal room provide a pleasant, social occasion and there are many local contacts who may provide sessions tailored to residents. The aim should be to do some physical activity every day. It is important that older people spend as little time as possible being inactive. Extend provides gentle exercise to music for older people and for anyone of any age with a disability. Its aims are to promote health, increase mobility and independence, improve strength, co-ordination and balance and to counteract loneliness and isolation. It does this through a national network of qualified teachers. British Osteoporosis Foundation has a website with many gentle exercises suitable for people with weakened bones 4.10.3 Stopping Smoking All forms of smoking are unhealthy: cigarettes, cigars and pipes. Smoking increases the risk of heart disease, lung disease (especially bronchitis and lung cancer) and osteoporosis. It also reduces the chances of survival after a heart attack. It is never too late to give up smoking and feel the benefits. There is plenty of help available. Trustees can promote awareness of the health benefits. GPs will assist in providing support. Advice can be obtained from ASH or QUITLINE. (See Appendix B). The charity should make residents aware of the safety hazards of leaving lit cigarettes unattended or falling asleep whilst smoking. However, it should be remembered that an almshouse dwelling is the resident’s home and the charity has no power to prevent individuals from smoking in their own home. 4.10.4 Chiropody Foot problems are common and important causes of poor mobility in later life. Many older people appreciate regular attention to their feet, if only to have out-of-reach toe nails cut. If toenails or corns are ignored the resulting discomfort can contribute to a person’s unwillingness to take exercise. For anyone with diabetes, foot care is especially important because the blood supply or nerve function may be impaired. Chiropody is available on the NHS free of charge in most areas of the UK, although the availability in your local area will depend on the local Clinical Commissioning group (CCG). Each case is also assessed on an individual basis. Whether or not treatment is free of charge will depend on how serious the condition is and how quickly it needs to be treated. If the condition is unlikely to affect the patient’s health, or mobility, they may not be eligible for treatment. To have treatment with a chiropodist, a referral is needed from the GP or practice nurse. A chiropodist will also be able to advise on suitable footwear. At some almshouses it may be possible, if a room is available, for block bookings to be made with the chiropodist. This may allow those who have to pay for their treatment to obtain it at a reduced cost. It is worth noting that wearing slippers does not usually give adequate support to the foot. 4.10.5 Alcohol Government guidance is that we should drink in moderation, which means that:Men should not regularly drink more than three to four units a dayWomen should not regularly drink more than two to three units a day. 1 unit is half a pint of beer; a 125ml glass of wine; a small measure of spirits; a small glass of sherry. Although there is evidence that alcohol intake within the recommended limit in later life may confer some benefit, the risks of habitual intake (particularly dependency) are also greater. It is wise to aim to drink less than the guidelines. Alcohol should be avoided when taking certain medicines. Residents should be encouraged to always read the leaflet that comes with medicines. If in doubt, ask the Pharmacist. Raising the subject with a resident whose drinking may be adversely affecting the lives of others should be approached from a point of offering support rather than criticism. It is their choice whether they wish to begin a cycle of change to address the problem. The GP is a good starting point to assist a resident who expresses a wish to moderate their alcohol consumption. Contact numbers: Drinkline 0800 917 8282. Alcoholics Anonymous 0845 769 7555. With residents who will not admit to a problem, the best course of action is to minimize the damage to others. Aggressive behaviour makes others feel threatened or unsafe especially if the offender disregards advice or further warnings. Family and friends can be of great assistance and it may be possible to enlist their help in restricting access to alcohol. It is essential to monitor and record events. If no amount of persuasion or warnings and all other explored avenues fail to alter behaviour, the trustees may have to consider setting aside the resident’s appointment. 4.10.6 Dehydration Water makes up over 60 per cent of our body weight, and it is important to keep hydrated to maintain this. Not drinking enough can lead to dehydration, which can cause constipation, headaches, tiredness, irritability, low blood pressure and kidney problems. Residents should be encouraged to drink about six to eight cups of liquid a day. This does not have to be water. Tea, coffee, fruit juice or squash will do, but avoid fizzy drinks as they contain a lot of sugar and calories, which can result in weight gain. Feeling thirsty is an unreliable guide, as the sense of thirst may become weaker with increasing age. Drinking plenty is particularly important in hot weather. Some older people are reluctant to drink enough fluid because of fear of continence problems or rising in the night. Problems of this kind should prompt a health assessment and should be resolved by measures other than fluid restriction. 4.10.7 Keeping Warm Draught proofing windows and doors and insulating walls and ceilings will help to reduce heating bills and carbon emissions. The Warm Front scheme provides heating and insulation improvements to households on certain income-related benefits (including Pension Credit) living in properties that are poorly insulated and/or do not have a working central heating system. The charity should ensure that the heating in a resident’s home is in good repair and regularly serviced. Some charities pay the heating bills and recharge the resident on a weekly basis. This encourages the residents to make full use of their heating in cold weather without fear of large bills.Encourage the residents to set their heating to the right temperature. During the day set the thermostat to 21°C (70°F), and during the night set it to 18°C (64°F)Set the heating to come on just before getting up and switch off after going to bed. If it is very cold, set the heating to come on earlier and turn off later rather than turning the thermostat upIf a resident is unwilling to use the heating advise them to heat the living room throughout the day and their bedroom just before going to bed. Close curtains and shut doors to keep heat in the rooms most usedHot water bottles, microwaveable heat pads and electric blankets are low cost ways of keeping warm in bed. Hot water bottles and electric blankets should not be used together and electric over-blankets should be serviced. 4.10.8 Heat Exhaustion In the UK, cases of heat exhaustion and heatstroke usually only occur during periods of unusually hot weather. The Department of Health's heat wave plan 2011 (see www.dh.gov.uk) has advice on how to cope during a heat wave, including recommendations for preventing heat-related illnesses.4.11 Residents With Dementia A Practical GuideDespite the greater awareness of dementia in recent years, a diagnosis often occurs sometime after the symptoms have started to show. Confusion and agitation may be a result of physical illness rather than the first stages of dementia, but when a diagnosis has been made the progression of the disease is unpredictable. Residents with dementia often cope best by following their normal routine and being in familiar surroundings. Changes that are made should be introduced carefully and with the help of professionals within the community mental health team as well as the resident’s family. 4.11.1 Common functional problems for residents with dementiaShort term memory lossOrientation difficultiesLack of comprehensionReduced ability to learn new information. 4.11.2 Help with communication It is common for the resident who has dementia to deny that there is a problem. This can make communication very difficult. Aim to reduce distress, maximise their self-esteem and start from the reality they are living inRemember the individual character, their likes/dislikes, background, notable events in their life and try and use that in the conversationAvoid asking direct questions – this can be difficult as questions are part of our everyday life, but avoid asking questions such as “Who is that smiling child?” and try instead “What a lovely smile that child has” which may prompt a conversationTake your timeUse non-aggressive, relaxed body languageTry and understand the world the resident is in and approach the subject from thereBe patient. People with dementia tend to live in the moment; they repeat themselves because they have forgotten that they have asked that question before, even if it was only minutes previouslyGo along with them. Don’t say “but your husband died 20 years ago!” try “I think he’s just popped out for a few minutes” it’s far less distressing for the residentIf the conversation becomes difficult and you need to achieve an outcome from the discussion, change tack, use distraction and then return to the subject from a different angleYou may find a resident is calmer if you talk with them in their homeIf the resident asks you to verify something they are experiencing and you cannot (for example, you are being asked to agree that someone has stolen their wallet) it may be best to state clearly that you understand what they are saying and how they feel without committing yourself furtherIf the resident becomes agitated reassess your body language, keep calm, use outside distractions. It is best not to confront or be forceful with the resident. Try again later. Seek professional help if necessaryConsider non-verbal communication (whiteboards, photographs, music).Changes to the residents’ accommodation Simple changes can make a positive and notable difference to the resident’s well-being and ability to cope with everyday life: Assistive Technology and Telecare Telecare is a general term relating to aids and appliances used to assist someone to stay living independently within their own home. They are often seen as part of a care package and, to be most effective, usually rely on a telephone link to a 24-hour response centre who can then contact a family member or the emergency services. Telecare can be obtained privately or, if the resident is eligible, through social services. Changes in the Home EnvironmentContrasting colours can assist recognition – change the toilet seat colour to contrast with the pan and cisternIncrease the visibility to the bathroom with signs, landmark objects and a clear sign on the doorChange the colour of the toilet roll holder to that of the wallIntroduce bright lighting and increase natural light where possibleSlowly declutter the rooms and be aware of the trip hazards for someone with a shuffling gaitPlace a clear-faced analogue clock on a prominent wall so that it is easily visibleAvoid colour changes in floor coverings from room to room to avoid confusionAim for flush fittings over thresholdsUse fixtures and fittings that clearly express their useUse contrasting colours for handrails and door handlesMirrors can be disturbing – have a cover available or make them easily removablePlace restrictors on windowsAvoid overly patterned fabrics for shower curtains, blinds and soft furnishingsUse lever taps that are clearly signed hot and cold. Day to day practical helpSome people with dementia have difficulty in swallowing because their slow reflexes cause them to choke. This can cause them to avoid eating and drinking. A speech therapist can be of great assistance in such casesSome day centres have helpers who have been trained in looking after those people with dementia at varying stagesThere are voluntary organisations who offer befriending services and sitters (such as Age UK)In some parts of the country specialist dementia nursing through Admiral Nurses is available The Department of Health has made funding provision for specialist Dementia Support Workers to be allied to GP surgeries enabling one person to stay as a single point of contact with a patient from diagnosis through to end of life.4.12 Simple Adjustments to a Residents HomeOver time some residents may not be able to cope as well in their home as they once did. There are some inexpensive alterations that can be made that will improve their quality of life and enable them to remain independent for longer. These alterations can also be made to communal areas. Below are some suggestions which fall into two categories:Those the charity can makeThose the resident (and their family) could be advised to make themselves. 4.12.1 Changes the Charity May ConsiderChange cupboard door handles so they are more easily gripped by someone with arthritic or weakened handsInstall taps with lever handlesFit a spatulate handle on the lavatory cisternFit a second handrail on a stairwayFit grab rails to assist with using the lavatory or bathFit handrails to outside stepsProvide a ramp – but remember that the slope of the ramp should not be more than 1 in 12 – an 18mm (7inch) step requires a ramp of 2.2m (just over 7 feet), so this may not be practical in all cases. For some almshouses there may be planning and conservation issues.Lights with movement sensors can be fitted in bedrooms and bathroomsSpecially designed sink and bath plugs can be used to prevent floods from taps that have been left runningProvide a pendant programmed to an existing telecare system. 4.12.2 Changes Residents and Family May ConsiderDe-clutter so that frequently used items are easy to reachRemove trip hazards such as trailing wires and rugsRearrange furniture to make it easier to use a walking aid (may not be an option for someone with visual impairment or dementia)Use blocks to raise the height of chairs and bedsInstall a toilet frame and/or a raised WC seatUse a shower seatUse a bath seatAlarm monitoring via their own telephone e.g. LifelineUse brighter light bulbsTouch-sensitive lights– these are activated by touching the lamp baseLamp pads that switch on a light when stood upon (useful when getting out of bed at night and designed to fit under a carpet or rug)Remote controlled lightingRemote controlled curtains. Neither of these lists are exhaustive. There are many suppliers of mobility and disability aids, for local stockists check Yellow Pages or the internet. You may find it useful to keep a catalogue for reference.4.13 Common Illnesses and How They PresentThe emphasis on maintaining health and preventing illness is vital. There is a growing body of evidence to support the benefits of this, particularly in the postponement of disability in later life. Many health conditions nevertheless become more common with increasing age and it is equally important to recognise, diagnose and treat these without delay for precisely the same reasons. It is well known that delay or lack of care in diagnosis and negative attitudes to treatment response almost always lead to a poorer outcome amongst older people. There will otherwise be unnecessary longer-term dependency. Ageing is known to change or mask the way many disorders present, increasing the risk of delay and the possibility of missing the problems until it is too late. Older people and those who care for them are often quick to attribute symptoms to “old age”, when actually there is a real and treatable health problem. This is particularly likely when such symptoms masquerade as ‘stereotypes’ of old age and frailty. Another reason why older people may be reluctant to complain is the fear that this may lead to being “put away” or to serious loss of independence and autonomy. In reality, however, the evidence increasingly shows that age itself makes little or no difference to the treatment results of much modern medicine and surgery and that advances in technology are often advantageous to older people. Of particular importance are the onset of falls, unexplained changes in mobility, impairment of orientation or memory, problems of continence, or just “frailty” or failure to thrive. Any or all of these should alert to the possibility of an underlying health problem. The charity should be alert to such changes and encourage residents to have confidence in reporting problems and seeking early medical help. Some disorders especially common or important in later life 4.13.1 Falls and Blackouts Almost any of the illnesses itemised below may present with falling and some with episodes of loss of consciousness. This is because ageing can affect the “reserve” efficiency and reliability of some or all of the mechanisms concerned with standing upright. This includes position sense in the lower limbs, visual function, maintenance of blood pressure and blood flow to the brain, “processing” of information by the brain and muscle strength in responding to that information. This means that illnesses are more likely to affect these mechanisms than is the case with younger adults. Episodes of falling, particularly if repeated or unexplained should always prompt a proper medical and health assessment, including a careful review of medication. Risk factors for falls are usually subdivided into (1) those that are part of an individual’s health or functional ability (intrinsic factors) and (2) those that are found in the individual’s environment or risk-taking behaviour (extrinsic factors). Most falls happen indoors as someone gets up from a chair, out of bed, coming downstairs or getting in or out of a bath (another reason to encourage level-access showers). Of these, only a small proportion results in a fracture but there can be other serious consequences if the person is unable to get up, such as hypothermia, bronchopneumonia or pressure injury. This is a good example of how summoning help through an emergency alarm pendant or pull-cord may prevent a ‘long lie’ and its consequences. The most common injuries from falls are fractures of the hip or wrist and head injuries. Many hospital departments of medical gerontology have already established specialist falls assessment services and referral by GPs should be considered if there is:A history of recurrent fallsReadily detectable impairment of balance, gait or mobility. Scheme managers/wardens may identify such indicators of high risk in residents and may wish to encourage referral for advice on prevention. The National Institute of Clinical Excellence (NICE) published a clinical guideline in 2004. There are some easy steps to take in a resident’s environment to help prevent falls, the most obvious being to identify and remove risk factors like rugs, uneven flooring, or trailing flexes. (see Risk Assessment and for more information: www.preventinghomefalls.gov.uk or www.balancetraining.org.uk). A confidential diary should be kept for residents who fall with any frequency and it is particularly important to try to establish the circumstances and details of the fall, especially if there were any warning symptoms and any disturbance of consciousness occurred, however brief. This ‘collateral’ third party information may provide invaluable and essential information if and when a more detailed assessment of causes is required – whether concerned with the resident’s health or the environment. Blackouts may be caused, for example, by an exaggerated fall in blood pressure when standing or sitting (postural hypotension), by abnormalities of heart rhythm (too slow or too fast) or by atypical fits. Drug side effects may contribute. 4.13.2 Loss of Mobility Unexpected or unexplained loss of mobility should always be taken seriously. It may be due to muscle, joint or nervous system disorders, but can also be a signal of any general illness, including mental illness. If there is a history of falling, the possibility of fracture, especially hip fracture, must be considered. Hip fracture does not always cause severe pain; patients are known to walk into casualty departments with a fractured hip. There are very few circumstances in which some solutions to the mobility problems of older individuals cannot be found, either by direct treatment of the underlying problem or by skilled assessment and management using multidisciplinary approaches. The latter commonly involve staff crossing the bridges between community care and hospital-based care. The initial route is most commonly via outpatient referral by the GP. Thereafter, part of the process may include assessment of an individual in the home by an occupational therapist and/or a period of attendance, supported by transport, as a day patient. 4.13.3 Continence Problems Ageing may cause some reduction in the overall efficiency of bladder and bowel function, but this does not cause continence problems unless something else is wrong. Urinary continence problems may be due to specific problems of bladder function in both women and men, the vast majority of which can be effectively treated or managed, provided the diagnosis is accurately identified. (Although common and important, the simple diagnosis of urinary tract infection [UTI] is probably used too frequently, thus delaying the search for other important underlying disorders). The same applies to bowel continence problems and underlying bowel function disorders. Both may also be symptoms of other general health problems, including the side effects of drugs. Incontinence must always be approached as a symptom – never a diagnosis. There are often major problems (because of perceived stigma) for health care in persuading those with the problem to accept or acknowledge its existence and present for expert help. Nurse specialists in continence advice are under-resourced but available in most health districts. Specialist assessment of bowel or bladder function is available in departments of medical gerontology, urology, gynaecology or gastroenterology, depending on the particular local arrangement. 4.13.4 Delirium Sometimes termed an “acute confusional state”, delirium occurs more commonly as a symptom of acute illness in older people than in younger adults. The sufferer is often disorientated and may exhibit delusions, paranoid ideas, aggressive behaviour or even hallucinations (especially at night time). Depending on the underlying cause, recovery is commonly complete if the delirium and its underlying cause are expertly managed and treated, but the consequences may be serious if this is not done. Specialist departments for the care of older people specialise in all the relevant professions (e.g. medicine, nursing, physiotherapy, occupational therapy, speech and language therapy, clinical psychology and social work). They are based in facilities resourced and dedicated to these needs. None of these problems should be accepted as non-remediable without the benefit of a thorough specialist assessment. 4.13.5 “Heart Attack” This rather unhelpful term is generally taken to mean thrombosis (blood-clot blockage) of a coronary artery resulting in the loss of blood supply to a part of the heart muscle (myocardial infarction). The term is also used, however, when the heart pumping action suddenly fails (acute heart failure). Both events may occur as part of the same process. Characteristically, myocardial infarction causes severe compressing chest pain at rest, that may spread to neck or arms, but in some older people pain may be less severe or even absent. If myocardial infarction is suspected, it is vital to call an emergency ambulance, since modern cardiac treatment, if undertaken quickly enough, can enable the artery to be unblocked and permanent heart damage to be avoided or reduced. Acute heart failure most commonly causes severe shortness of breath. In that event do not delay getting a doctor or ambulance, whichever will be quicker, and stay with the resident until help arrives. 4.13.6 Angina Angina is a tight chest pain occurring with physical effort or stress, due to a reduction of blood flow (but not complete blockage) in a coronary artery, and hence of oxygen supply to the heart (ischaemia). Both angina and myocardial infarction are more common in smokers or people with diabetes or uncontrolled high blood pressure (hypertension). Angina sufferers usually have medication or a mouth spray to use under the tongue. If angina is not relieved by the medication within a fairly short time, it suggests a possible impending heart attack and medical help should be sought. 4.13.7 Heart Rhythm Disorders If the normal heart rhythm is disturbed, it may become (1) very fast (tachycardia) (regular or irregular) causing palpitations, breathlessness or angina, or (2) excessively slow (bradycardia), leading to blackouts, unexplained falls, dizziness or breathlessness. Both types are more common with increasing age and may occur independently or due to other conditions (e.g. thyroid disorders). Effective treatment is almost always available. 4.13.8 Chronic Obstructive Pulmonary Disease (COPD: chronic bronchitis and emphysema) COPD is especially common amongst older people, particularly smokers. Normal activity may be restricted by breathlessness, but autumn/winter viral and bacterial infections can cause life threatening respiratory failure and constitute one of the most common causes of acute hospital admissions. COPD can sometimes be considerably helped by the use of bedside systems (e.g. nasal ventilation) at night time in the home. 4.13.9 Maturity Onset (Type 2) Diabetes Maturity onset diabetes (sometimes called “non-insulin-dependent diabetes” – NIDDM) is common amongst older people. It is usually (though not invariably) detected and treated before advanced age is reached. Many of the complications of diabetes depend directly on its duration and are therefore prevalent in later life. These include:Atherosclerotic disorders such as stroke, coronary heart disease, disease of arteries supplying the kidneys and poor arterial circulation in the lower limbsDamage to the peripheral nerves with loss of sensation in the feet and/or handsDamage to the retina and/or cataract formation with impaired eyesightKidney failure. Some of these long-term problems are delayed or prevented with careful diabetic control, often with insulin. The benefits of "ideal" control, particularly in very elderly people, have to be weighed against the risks of episodes of too low blood glucose (hypoglycaemia). Nevertheless, if good control proves difficult with low carbohydrate diet, perhaps supplemented by glucose-lowering medication, many older people manage their insulin regimens extremely well, either independently or with specialist nursing support and benefit considerably. The symptoms of hypoglycaemia include delirium, disorientation or aggressive behaviour, or in severe cases clouding of consciousness or coma. The symptoms of too high a blood glucose (hyperglycaemia) due to poor diabetes control include thirst, urinary frequency and weight loss, or in severe cases overbreathing, drowsiness or coma. The risk of foot ulcers (due to poor blood supply, peripheral nerve damage, or both) is especially high so meticulous foot care is a key element of diabetes management. 4.13.10 Osteoporosis Osteoporosis (low bone density) is the commonest cause of fractures in older people. Contributory factors include the menopause in women, advanced age, lack of exposure to sunlight, physical inactivity, poor diet and alcoholism. The process progresses much faster in women after the menopause than in men of a corresponding age, but male osteoporosis is also a significant problem. Together with falls prevention, the early detection and treatment of osteoporosis are recognised as of equal importance in the prevention of fractures. Osteoporosis risk assessment has recently been included in the Quality Outcomes Framework for primary care and should be routinely offered to all older people. Current recommendations are that calcium and vitamin D supplements should be given to older people living in residential or nursing care, or in sheltered housing. In addition, those with established osteoporosis are likely to require additional medication with “bone anti-resorptive” drugs, or equivalent, that have been shown to be effective in preventing fractures in those at risk. 4.13.11 Arthritis The two most common types of joint disease amongst older people are osteoarthritis and rheumatoid arthritis, of which osteoarthritis is the more frequent. Pain and stiffness in the joints can make daily life difficult. Physiotherapy, pain relief and, if appropriate, joint replacement can help to relieve symptoms. A range of useful equipment to help sufferers with everyday functions can be obtained from Disabled Living Centres and Arthritis Care can advise residents on every aspect of the disease. 4.13.12 Stroke A stroke is due to disruption (by clot formation or bleeding) of the circulation to a part of the brain. Like heart problems, it is more common in those with uncontrolled hypertension. The result is that some brain tissue dies and the physical activity or sensation it controls is lost (e.g. paralysis or loss of co-ordination of a limb or limbs on one side, loss of speech, loss of sensation in a limb or limbs, loss of consciousness, disturbance or loss of vision). There have been recent advances in the treatment of acute stroke by the use of “clot-dissolving” drugs (thrombolysis), and a recent national publicity drive has stressed the importance of rapid transfer to a suitably equipped hospital for those with tell-tale symptoms. Someone recovering from a stroke will require specialist rehabilitation and considerable support, both in regaining independence, with or without the use of physical aids, as well as emotional and psychological help in coming to terms with their new, more limited, circumstances. Families and friends can be distressed at these changes but can also receive advice and support from the Stroke Association. Every effort should be made to ensure that older almshouse residents who suffer with stroke disease are dealt with and cared for by the health and social services in accordance with standards laid down in NICE Guidance, particularly if they have no relative or other strong advocate to represent their interests. 4.13.13 The Dementias The dementias, by contrast with delirium, are characterised by impairment of mental function, which is gradual over time and usually irreversible. There are several types of dementia but the most common are Alzheimer’s Disease and Multi-Infarct Dementia. (Further information on the care of people suffering with dementia is set out in Chapter 5.4). 4.13.13.A Alzheimer’s Disease This may affect middle-aged people but increases in frequency with advancing age. The common form affecting older people is sometimes referred to as Dementia of Alzheimer-Type (DA-T). Its most common distinguishing features are gradual loss of short-term memory, gradual occurrence of changes or deterioration in personality and susceptibility of some sufferers to behavioural disturbance and active wandering. There have been some recent developments in symptomatic treatment with a group of drugs called anticholinesterases, which bring about a useful improvement in the symptoms of some sufferers, especially in mild or early DA-T, at least for a time. It is, therefore, important that an early assessment is promoted. NICE has produced a clinical guideline covering dementia. 4.13.13.B Multi-Infarct Dementia (MID) This is a gradual, often stepwise, deterioration in brain function due to progressive deterioration in blood supply to the brain. Often the ‘steps’ are sudden and may present as episodes of delirium, sometimes with symptoms and signs of ‘small strokes’. There may be improvement for a time before the next event occurs. The features differ from DA-T in that personality tends to be better preserved initially, although sufferers may sometimes find difficulty in controlling emotion – with unpredictable and inexplicable outbursts of tearfulness, which then resolve quickly. About 25% of dementia sufferers have both conditions to varying degrees. 4.13.14 Depression It is now well recognised that clinical depression is seriously under-diagnosed and under-treated in old age. The possibility of treatable depression should be considered in any older person whose self-care capacity or level of function deteriorates. It is also well known that older people with depression may appear to have disorientation or reduced memory function (pseudo-dementia). Particular risk factors for depression in older people include pain or disability, particular illnesses, caring for others or grief/loss. To help identify depression look for these symptoms:Persisting sadness and loss of interest in pleasures of lifeWithdrawal from social contactsWeight change, insomnia, loss of appetite and energyFeelings of worthlessnessThoughts of death or suicide. The results of treatment may be excellent, so early assessment and diagnosis are very important. 4.13.15 Hypothermia Hypothermia is defined as a core temperature (measured in the rectum or auditory canal) less than 35 degrees C (95 degrees F). It cannot be diagnosed with certainty except by using a special low-reading thermometer (others give a falsely high result). Older people in poor health, with poor mobility or taking sedative medications (especially phenothiazines) are at particular risk, sometimes even in a warm environment, because their normal temperature regulating mechanisms may be impaired. Severe hypothermia may be fatal. Signs include clouding of consciousness, disorientation or apparent speech difficulty, slow and shallow breathing, slowing of the heart rate and muscle stiffness or twitching. Treatment, which usually requires hospital admission, includes slow, carefully controlled re-warming and treatment of the underlying cause. Every effort should be made to ensure that almshouse residents live in adequately heated accommodation. Heating is often deemed to be expensive by older people, so that some residents avoid turning up the heating when necessary. When possible, heating costs should be averaged out during the year to avoid high winter fuel bills. Fitting thermostats to individual radiators will assist with even temperatures and heat areas as required. The cost of the valve is reasonable, although there will be a variation in the labour costs to fit such thermostats. Not all radiators will be able to be adapted. There are many convector heaters available which are economic to run for long periods and have built-in thermostats. Ill-fitting doors and window frames are two areas where there can be increased heat loss. Poorly fitting clothes, inadequate clothing and dehydration are also contributory factors and they are easily remedied if residents are encouraged to keep warm.4.14 Some General Principles Relevant to HealthcareThe more evidence emerges, the more the benefits of good health care and health promotion amongst older people become apparent. Postponing disability and long-term dependency are becoming increasingly attainable goals for more individuals. The importance and value of careful, early and thorough diagnosis of health problems should never be underestimated. Do what you can to discourage delay or apathy. Any significant change in functional or social performance should prompt a call for health assessment as well as social assessment and intervention. The capacity of older people to recover from illness should never be underestimated. Decisions about accommodation, capabilities or the future of the resident should not normally be taken in an acute crisis. Specialist medical and multidisciplinary advice should always be obtained in such circumstances. For Further Information: Admiral Nurses: www.dementiauk.org follow links what we do/admiral-nursing Advice about types of equipment: www.livingmadeeasy.org.uk Age Cymru: www.agecymru.org.uk Age Scotland: www.agescotland.org.uk ASH: www.ash.org.uk British Geriatrics Society: www.bgs.org.uk British Heart Foundation: www.bhf.org.uk Care Quality Commission: www.cqc.org.uk Carer’s Direct: www.nhs.uk/Carersdirect Citizen’s Advice Bureau: www.adviceguide.org.uk Dementia UK: www.dementiauk.org Department of Health: www.dh.gov.uk Diabetes UK: www.diabetes.org.uk Disabled Living Foundation: www.dlf.org.uk EAC (Elderly Accommodation Council): www.housingcare.org Everybody’s Business: www.everybodysbusiness.org.uk Extend: www.extend.org First Stop Advice: www.firststopadvice.org.uk Fit as a Fiddle project and details of local Age UK offices: www.ageuk.co.uk Health in Wales: www.wales.nhs.uk Information Commissioner’s Office: www.ico.gov.uk Macmillan Cancer Support: www.macmillan.org.uk National Health Service: www.nhs.uk National Institute for Health and Clinical Excellence: www.nice.org.uk National Institute on Ageing: www.nia.hih.gov National Osteoporosis Foundation: www.nof.org NHS screening: www.screening.nhs.uk Quitline: www.quit.org RNID / Action on Hearing Loss: www.actiononhearingloss.org.uk Royal College of Nursing: www.rcn.org.uk Royal National Institute for the Blind: www.rnib.org.uk Scotland’s Health On the Web: www.show.scot.nhs.uk The Alzheimers’ Society: www.alzheimers.org.uk The Lions Message in a Bottle Scheme: www.lionsmd105.org The Social Care Institute for Excellence (SCIE): www.scie.org.uk The Social Care Institute for Excellence: www.scie.org.uk The Stroke Association: www.stroke.org.uk University of Stirling dementia design: www.dementia.stir.ac.uk Warm Front Grants: www.carillionplc.com For further details of the above organisations please see Appendix B © 2013. 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