Community care of vulnerable older people: cause for concern.

The projected doubling of the >75-year-old population in the next 20 years presents a major challenge.1 While standards of care in general practice have risen steadily over the past 30 years, for vulnerable older people the picture is different. The term ‘vulnerable’ covers multimorbidity, functional incapacity, and socioeconomic and psychological problems severe enough to put the patients at significantly increased risk of hospital and institutional admission. Routine GP surgery sessions alone are inadequate to assess complex comorbidity, polypharmacy, and adherence, in addition to reviewing disabilities and carer pressure. At the age of 75 years, patients will have, on average, three medical disorders. At least one-quarter will have a significant level of functional disability, rising exponentially with increasing age, and they will often have socioeconomic and psychological problems which loom larger in advanced old age. It is vital that all these problems are addressed if the patient’s needs are to be adequately met. We challenge primary care to develop cost-effective ways to integrate population scanning of the older population, most logically for those over the age of 75 years, leading to risk stratification and a coordinated primary care and community response. Community programmes, working with primary care, are also needed to reduce behavioural risks such as smoking cessation as well as encourage exercise and give dietary advice. In our own practices we valued cooperative work with trained volunteers.2 De Maeseneer, argued that ‘practices integrate individual and population-based care, blending the clinical skills of practitioners with epidemiology, preventive medicine and health promotion’.3.