Guest Blog: The oldest old and preventative services

This guess blog was written by Chrissy Bishop, an Occupational Therapist.

The term ‘prevention’ in health and social care is promoted as a gold star, a cost saver, a key policy driver; but is it being practiced? Is this term applicable and realistic to apply to the oldest old population (85+)? Are those involved in care of the elderly prepared and sufficiently educated to focus on prevention for a very old individual?

These queries have materialised from my current work in a reablement project. Reablement services are a pivotal, well known incentive of the government’s continued efforts to save costs of long term care packages through enabling independence. But on a controversial note, is the heavy focus on cost saving as opposed to the patients needs?

From a professional experience reablement still seems like an ‘action on crisis’ approach, and highlights a gaping hole in services. Why is this when National Service Frameworks have drummed preventative strategies into health workers for years now? Additionally, studies continue to highlight the overwhelming consequences of the oldest old developing a health problem, which is usually followed by a ‘cascade effect’ with one condition triggering another problem, and another and so on. This downward spiral is a challenge for all health professionals involved, and the medical and nursing protocols are more black and white than the social and emotional support required.

If we are well aware of the ‘cascade effect’ experienced by the oldest old, why do we not have more emergency respite, or support for those at risk? Policy may ‘focus’ on prevention but where is the ‘action’?

There is a large group of the oldest old sitting in something I like to refer to as ‘no man’s land’, who are too independent to meet ‘fair access to care’ criteria, and too poor, unwilling or unable to access a service to provide so called non-essential support such as showering, escorted shopping services, support/befriending for loneliness or bereavement, and managing finances, to name a few. Limitations in these areas can lead to patients turning up at GP surgeries, feeling generally exhausted or unwell but with no specific treatable health problem, perhaps alongside bouts of depression or anxiety due to loss of independence or dealing with the ageing process. Untreated, these issues could lead to increased falls, self neglect or poor nutrition, increasing risk of infections; a small health problem on top of this is a prime example of a cascade effect occurring.

Preventative services should focus on these issues when considering initial treatment plans for the oldest old. With an ‘action on crisis’, approach care and treatment plans can be over complicated. So let’s avoid the cascade effect.

Possible solution? A ‘frequent flyer’, unkempt, anxious or underweight individual turns up at a GP surgery. Alarm bells ring, reablement services act fast.

Reablement could be integrated into GP surgeries and primary care, promoting its value and facilitating referrals. Individuals, personal preferences, personality and needs, are understood, avoiding a clouding of personality by illness and a ‘cascade effect’. Let’s generally get fastidious at the earliest stage possible, rather than react with a rushed ‘act on crisis’ approach. Yes, an older person’s level of physical ability may change, but this small shift in delivery of a service could intensify the chance of older individuals not just receiving fair access to care but who they are as a person.

Read more about Occupational Therapists’ work in Reablement

Read about ‘Establishing Best Practice in Reablement’

4 responses to “Guest Blog: The oldest old and preventative services

  1. Sheila Duffill

    I agree with this literate and well thought out post. When are we considered old these days? I am 73 and still caring for my 97 year old mother
    although she is now in a lovely Care Home it took a long battle to get this OK’d by local authority

  2. A very interesting Blog – and how refreshing to have the perspective of someone addressing “Care in Crisis” practically, rather than politically.

    Two questions, Chrissy:

    a) How does the service adapt to those who are resistant to re-enablement?

    b) When faced with those clients who have complex care needs, service providers typically become resistant to extending the bounds of their own service, where to do so might be considered apporpriate. Has the Re-enablement Service has been able to overcome such “silo mentalities?”

  3. This is an extremely well argued case for more preventative care for older poeople, obviously based on first hand experience and old-fashioned common sense. The key question is why does the Government follow through on its words of support with real resources. The answer lies in short-term economic pressures and the rise in the older elderly chronically ill population. I have written a lot about this in my GrumbleSmiles blog.
    I believe nothing much will change until most older people reluctantly accept that they will have to pay for their own preventative health care.

  4. Thanks very much for your replies. I hope this lengthy answer covers all the questions!

    In our case Reablement is very adaptive, and I think that is one of its successes. It has been one of our biggest challenges educating patients and explaining how the service differs from therapy services and traditional day centre services to both patients and professionals. As we currently receive referrals from a whole range of health professionals we try to do a home visit initially as most of our service involves patients attending a centre to participate in group work, education sessions, meeting others ect.

    I think the very nature of some one being resistant highlights a problem which needs investigating further, and it is usually the case that those who are resistant are the ones that bounce between services, and purely because no one has spent the time to fully understand their needs. Unfortunately the art of persuasion seems to have been diminished when there is a continued focus on rapid assessment and intervention. Our service makes sure that those who are resistant to engage in a reablement programme have their needs met from alternative services where relevant. We make personal visits and signpost alternate services, refer to befriending schemes, voluntary services, local groups and clubs. Sources like this are invaluable when costs may be in implication. Being known to as many services as possible reduces the risk of unnoticed health complaints progressing further.

    A lot of the time those who are resistant are petrified that their care and support is going to be taken away from them, regardless of whether care calls are appropriate for their needs. Alternatively those with complex needs, care companies shy away from complex care plans a lot of the time due to the logistics of staffing levels, length of care calls and the tasks involved, nothing to do with the actual patients needs. And due to anxieties about change. In my experience a lot of care staff are not ready for the change in demographics thus the care required.

    I think older people would be inclined to pay for their care and preventative services if they were properly educated on this process/what they are getting for their money, benefits available, alternative ways to spend their money like social groups, support workers, alternative care approaches, or at least their families/carer was. Not many health professionals I have worked with understand personalised budgets and how patient’s money can be spent to its best advantage.

    In a nut shell people are not prepared for the changes in demographics as well as changes in policy. The solution is simple in the grand scale of things. Training on how to adapt for complexities in the needs of the oldest old population, and learning to be more flexible with this age group, there needs can change rapidly. We have done just this at our service and it has worked very effectively. It is difficult to be this flexible in intermediate care services, which is why services like reablement exist. The oldest old are a unique group which require more attention.

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