**Older Person’s Health Assessment (≥75 years)**
Date: 01/11/2024
Doctor: Dr. Emily Carter, GP
Patient: Mrs. Agnes Davies
DOB: 12/03/1938
Today I conducted an Older Person’s Health Assessment for Mrs. Agnes Davies, aged 86. They consent to the plan being performed and have been offered a copy of the plan.
Function (Physical, Psychological & Social):
- Physical function: Mrs. Davies reports some difficulty with mobility, particularly getting up from a chair. She manages ADLs independently, but with some slowing. No falls reported in the last 3 months.
- Cognition and mood: MMSE score of 28/30, indicating mild cognitive impairment. Reports feeling low in mood recently.
- Social supports and caring responsibilities: Lives alone, but has regular visits from her daughter and receives some support with shopping and housework.
Examination & Screening:
- BP: 140/80 mmHg
- Pulse rate: 72 bpm, regular rhythm
- Immunisation status: Up to date with influenza and pneumococcal vaccines.
Medication Review:
- Current medications: Lisinopril 10mg daily, Amlodipine 5mg daily, Simvastatin 20mg nocte. Adherence is good. No reported side effects. No known interactions. Deprescribing considerations discussed for Simvastatin due to age and frailty. Not webster packed.
Preventive Health:
- Preventive health advice: Encouraged to continue with regular exercise and social activities. Discussed importance of good nutrition.
- Vaccinations: Up to date with influenza and pneumococcal vaccines.
- Education offered: Provided information on local support services for older adults.
- Referrals if indicated: Referred to a social worker for assessment of social support needs.
- GP Chronic Conditions Plan: In place, due for review in 6 months.
Management Plan & Reporting:
- Summary of agreed plan: Continue current medications, review Simvastatin in 3 months. Referral to social worker. Encourage regular exercise and social activities.
- Written report provided to patient.
"Review of Plan: 12 months"
Next clinical review due: 6 months