Geriatric medicine and health care for older people in Australia Purchased

Abstract

Key Points

• The recent Royal Commission into Aged Care Quality and Safety identified substandard care in the deregulated residential aged care sector, which has prompted recent policy changes.

• There are significant unmet needs to support older Aboriginal people, who have a higher prevalence of geriatric syndromes with a younger age of onset than the overall population.

• Geriatric medicine has evolved to a hospital-based specialty, including inpatient acute and subacute care, collaborative models of care with subspecialists, clinics, telehealth and outreach services.

The health care of older people in Australia has seen not only significant policy-induced failures but also incremental research-driven successes. There is universal health coverage in Australia with universal access to aged care services. However, residential aged care and community aged services are fragmented with multiple funders and providers, and there is no single institutional structure that co-ordinates, regulates or is accountable for aged care at a national level [1, 2]. After a spate of media reports about the mistreatment of older people in residential aged care facilities, a Royal Commission (independent government inquiry) into Aged Care Quality and Safety was established in 2018 and published its findings in 2021 [3].

The Royal Commission documented the progressive deterioration in the quality of aged care in the decades following the passing of an Aged Care Act in the late 1990s which led to deregulation, defunding and privatisation of residential aged care. From a free-market and economic perspective, privatisation was successful. There has been a steady growth of large, for-profit residential aged care facilities that return about $1 billion annual profit [3].

Today, there are >220,000 people living in this residential aged care system, which is a consequence of those policies. The Royal Commission report into their care was damning, with observations such as [3]: ‘Substandard care pervades the Australian aged care system. The accounts of substandard care were always sad and confronting’ (Summary, p. 67); ‘In our inquiry we heard of physical and sexual abuse that occurred at the hands of staff members, and of situations in which residential aged care providers did not protect residents from abuse by other residents. This is a disgrace and should be a source of national shame’ (Summary, p. 67); ‘We consider that the extent of substandard care in the current aged care system is unacceptable, deeply concerning, and has been known for many years’ (Volume 1, p. 7); ‘…more than half of Australian aged care residents were living in facilities with unacceptable levels of staffing’ (Volume 1, p. 8); ‘…limitations on funding have been a major contributor to the substandard care so many older Australians experience’ (Volume 1, p. 9); and ‘We consider that the extent of substandard care in Australia’s aged care system is deeply concerning and unacceptable by any measure’ (Summary, p. 72).

There have been policy and funding responses to the Royal Commission. However, the revolutionary change in aged care and public outcry that should be expected from such a report has not eventuated.

The Royal Commission also drew attention to the care provided to older Aboriginal and Torres Strait Islander peoples (respectfully referred to as Aboriginal people). Aboriginal people have the poorest health and most inequitable access to health care of any Indigenous populations in the world [4]. Their life expectancy is shortened by 10 years and <5% of Aboriginal people are >65 years of age compared with 15% of the rest of the population [4]. The ‘Close the Gap’ policy introduced by government in 2008 attempted to establish a broad policy platform to improve the health of Aboriginal people [5]. The 10-year review indicated that it has had limited impact on the health of older Aboriginal people.

Age-related health issues in Aboriginal people include high rates and early onset of dementia and frailty. The Kimberly Indigenous Cognitive Assessment tool showed that the prevalence of dementia is 12% over 45 years of age and is 27% over 65 years of age and is among the highest rate of any population in the world [6, 7]. A 20-item frailty index developed for Aboriginal people showed that over half of those over 45 years of age were frail and more than three quarters over 75 years of age [8]. Moreover, among Aboriginal people over 45 years of age, between one-third to one-half had falls, poor mobility, urinary incontinence and poor hearing [4].

The provision of aged care, particularly residential aged care, to Aboriginal people has been inadequate, particularly for those in remote regions [3]. Aboriginal people, especially as they grow older, prefer that their health services are provided by Aboriginal people, such as the Aboriginal Community Controlled Health Services [9], and these are much more likely to be effective. Programmes that are embedded within these health services and their communities are being evaluated as an approach to target and improve care [10].

Access to medications is not a barrier to health care for older Australians because most medications are subsidised by the Australian government through the Pharmaceutical Benefits Scheme. However, polypharmacy and overprescription of psychotropic medicines pervade the aged care system. Addressing these issues and improving the use of medications in older people have been a major focus of research in Australia. Australians were the first to use the term ‘deprescribing’ and have contributed widely to the evidence for deprescribing in the setting of polypharmacy in old age [11–15]. The Australian Deprescribing Network was established to unite researchers and clinicians with an interest in deprescribing, and this model has been taken up by deprescribing networks around the world. A policy document, ‘Quality Use of Medicines to Optimise Ageing in Older Australians: Recommendations for a National Strategic Action Plan (rNSAP) to Reduce Inappropriate Polypharmacy’ was developed by a range of stakeholders to promote deprescribing and to minimise medication-related harms [16]. The Drug Burden Index (DBI) was developed to identify older people at high risk of adverse drug reactions, independent of polypharmacy [17]. This has led to the translation of digital tools into hospital electronic prescribing software that calculates DBI to prompt and facilitate the medication review [18].

A substantial proportion of Australian aged care supports people living with dementia, both in the community and residential aged care, where the majority of residents are identified as having either dementia or cognitive impairment. Dementia has become a priority area for national government research funders [19], and dementia research in Australia has contributed to understanding the role of amyloid in Alzheimer’s disease and early diagnosis by nuclear scanning or biomarkers [20].

In parallel with this research, there has been a growth in memory clinics, particularly in the private sector, where diagnosis is increasingly augmented by PET scan and/or biomarker evidence of amyloid deposition. Memory clinics are now being recruited into a national network registry (ADNeT) primarily focussed on diagnosis, care processes, recruitment for trials and access to novel therapies [21]. This network will potentially have an influential role in determining how amyloid therapies, such as aducanumab, are used in Australian practice, should they become available in Australia despite disappointingly scant evidence [22]. On the other hand, the benefit of deprescribing rather than starting medications for people with cognitive impairment in residential aged care facilities has been identified using Telehealth [23] and in clinical trials where antipsychotic medications were deprescribed in residential aged care facilities [24].

The ‘Clinical practice guidelines for people with dementia’ were developed by a wide range of health care professionals involved in dementia care and were released in 2016 with recommendations on the diagnosis and management of dementia in Australia [25]. Even though one of the first trials showing the benefits of physical activity in cognitive impairment was Australian [26], it has been difficult to translate dementia prevention into clinical practice. Dementia prevention guidelines have recently been included in general practice guidelines and there has been a call to arms to resource and co-ordinate a ‘whole of community’ approach to multifaceted dementia prevention programmes [19].

Falls clinics and falls prevention programmes are common in Australian hospitals [27]. Various multicomponent strategies to reduce the high rates of falling in older people who have been hospitalised have been evaluated [28, 29]. For those older people who fall and sustain a fracture, there are orthogeriatric services in most Australian and New Zealand hospitals. These services contribute to an ‘Australian and New Zealand Hip Fracture Registry’ which generates data and evidence to improve care at the hospital level [30]. Beyond orthogeriatric services, geriatricians are increasingly becoming involved in the perioperative care of older patients in other surgical specialities [31].

Training to become a specialist geriatrician in Australia and New Zealand is operationalised under the auspices of the Australia and New Zealand Society for Geriatric Medicine, which is one of the speciality societies within the Royal Australasian College of Physicians. Positions available for trainees in geriatric medicine have become increasingly competitive as geriatric medicine becomes more popular as a career choice. Over the last decades, geriatric medicine has transitioned from a largely community-based speciality to one that is mostly based in hospitals, delivering a range of services for older inpatients (acute care, rehabilitation, palliative care, delirium care, perioperative care and collaborative care with subspecialist physicians) and where community care is provided as an outreach service via the hospital system. There is a slow growth in the number of geriatricians with research qualifications, creating a future clinical academic workforce to inform improvements in aged care. In many ways, geriatric medicine has evolved to resemble other subspecialties in terms of training and career pathways. The future for geriatric medicine looks bright and, besides the continued expansion of roles within the acute health system, there have been recent discussions to establish more organised care for frail older people in residential and community care.

Declarations of Conflicts of Interest

None.

Declarations of Sources of Funding

None.

References