What doctors need to know: Prescribing or not for the oldest old.

Given the global increase in the number of people over the age of 85, there is a growing body of work concerning this group, termed the oldest old. Much of this work is confined to the literature specialising in geriatrics and the more generic health care papers refer to 'older people' with little definition of what is meant by 'older'. Iatrogenesis (ill health caused by doctors) is a major issue and general practitioners (GPs) need practical help in prescribing for the oldest old. This paper presents a narrative review of the literature on prescribing and the oldest old. The results showed that all papers sourced referred to prescribing for the 'old' as those aged over 65, with only scant mention of oldest old. Yet prescribing for the oldest old involves clinical judgement and knowledge of the patient. It includes weighing up what will do good, cause no harm and is acceptable to the individual. GPs have to make treatment choices mostly in isolation from colleagues, during time-limited consultations and with few relevant guidelines on managing multi-morbidities in the oldest old. A major issue in prescribing for people over the age of 85 is that guidelines for diseases are based on trials with younger adults, outline the best practice for one disease in isolation (i.e. not in the presence of other diseases) and take little account of the interactions between the drugs used in managing several diseases in frail older people. There is a growing body of work, however, calling for specialist services for the oldest old.

Palliative care and dementia--A time and place?

The current focus in dementia care places emphasis on the potential of people to live well with the condition. Given the historical tendency to neglect the full rights and citizenship of people with dementia, such an emphasis gives hope and optimism that there is life after diagnosis. This paper seeks to explore the potential compromise of effective preparation for the complexities of advanced illness that may be presented by this consistently up-beat message. Dementia is a life limiting condition, currently without cure. Therefore, the appropriateness of palliative care may seem obvious. Yet, until relatively recently, palliative care was seen as an adjunct to oncology in the minds of professionals and public alike. However, there is a growing recognition that specialist palliative care has much to offer people with a range of long term conditions, including people with dementia. So, whilst 'living well' is an important message-especially following diagnosis-planning for advanced dementia and dying well is equally important. The aim of this paper is to highlight policy on the living well and the palliative care approach for people with dementia. A word limited narrative literature review was conducted to explore how policies have or have not informed the literature on both messages. The findings emphasise the need for a continuum approach to dementia care, with discussion on when, where, and how can palliative care be delivered for people with dementia.

Palliative care: From oncology to all nursing arenas - Good practice or scaring the patients?

The aim of this paper is to encourage critical discussion of an individual's understanding of palliative care and compare this with a health care professional's understanding of palliative care. In doing this, the paper serves to illustrate the importance of words attached to services - so with palliative care - are we providing good care, or scaring the patients? The paper touches on the historical origins of palliative care as an adjunct of oncology, to a specialism in its own right and now as an integral part of all care - in a 'generalist palliative care nurse'. However, it is unlikely that patients and their families are aware of such developments and will see palliative care services as immediate end of life care. It is argued that whatever your thoughts on the use of the term 'palliative care', it is important to understand what has resonance for patients. You may not agree with this paper, and I do not expect all of you to agree, but I hope it has made you think. For those who strongly disagree, take heart from a quote by Frank A. Clark (1860-1936) 'We find comfort among those who agree with us - growth among those who don't'.

An exploration of palliative care provision in Scottish care homes.

This paper suggests that there is an imbalance between the ideal and the actual palliative care provision for some older people living and dying in care homes in Scotland. Successive studies demonstrate that care home residents are increasingly frail and disabled. Many experience challenging physical and psychosocial symptoms which could benefit from a palliative approach to alleviate suffering and promote comfort. However, palliative needs for people with non-malignant conditions, such as dementia, can be complex, and not easily identified or managed. A range of challenging factors currently impact palliative care provision for care home residents in Scotland including: the insufficiency of robust NHS healthcare support, the skill mix of the care home workforce, and the promotion of palliative tools as the primary means of improving the quality of palliative care in non-specialist settings. Issues highlighted in this paper give cause for concern on a number of levels, particularly as the demand for palliative care in care homes is likely to increase in the near future. Therefore, sustained collaborative effort from leaders in the health, social and care home sectors is recommended if practical solutions are to be found for this vulnerable population.