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Recently in Melbourne, several older people in a high-level-care
residential facility (nursing home) were reportedly found to have an
infestation with the mite Sarcoptes scabiei. They were
supposedly treated with a dilute topical application of a mixture of
volatile hydrocarbons, commonly known as kerosene. Quite rightly,
this practice was widely condemned,1 as it does not conform to
accepted evidence-based guidelines, which recommend the topical
application of compounds such as permethrin, which are safer and more
effective.2 This incident has raised
questions as to whether the standard of healthcare is adequate
throughout the residential care industry.
The residential care system has undergone major changes over the past
15 years. It is a system that has traditionally been divided into two
tiers: high-level care (nursing home care) and low-level care
(hostel care). This situation has been somewhat muddled by
legislative changes enacted in October 1997 allowing
residential care facilities to house residents of any degree of
dependency, and in fact 18% of residents in hostels are classified as
requiring "high-level" care (Commonwealth Department of Health and
Aged Care, WA Branch, personal communication), a situation that
should mean that nursing attention is available 24 hours a
day.3
However, statistics analysed and reported by the Federal Government
over the period 1985-1997 demonstrate a consistent trend towards
fewer nursing home beds and slightly more hostel beds,3 a trend which has
probably continued over the past three years.
Despite a rapidly ageing population, there has been virtually no
growth in the number of nursing home places. In Australia there were 71
503 nursing home beds in 1985 and 74 233 in 1997 -- a reduction in the
ratio of beds per 1000 persons aged 70 years and over from 66.5 to 47.6.
Over the same period, there has been real growth in the number of hostel
places from 34 885 to 64 825 places, or an increase in the ratio from 32.5
to 41.6 beds per 1000 persons aged 70 years and over.
These changes have produced predictable results, with a notable and
sustained increase in levels of dependency of residents in nursing
homes and hostels. In 1987, 30% of permanent nursing home residents
were categorised as "high dependency" (Residential Classification
Scale Index 1 or 2); in 1997, this proportion was 56%. In 1992, only 54%
of hostel residents required assistance with personal care, whereas
in 1997, 80% of residents required such assistance.3
Older people in residential care are the sickest and frailest
subsection of an age group that manifests the highest rates of
disability in the Australian population. For example, in 1998, only
5.2% of people aged 65-69 years required assistance with self-care
activities (eg, bathing, dressing, grooming), while in the age group
80 years and over 31.4% of people required such
assistance.3 As people age, they are not
only more likely to have a severe or profound disability but are also
more likely to be cared for in residential care. Approximately 15% of
Australians aged over 65 years living in the community have a severe or
profound disability, whereas 93% of people in residential care have
such a disability. While one-third of older Australians aged 65 years
and over with severe or profound disability live in
non-private dwellings, the rates rise from only 13% of the
65-69-year-old group to over 50% of women over the age of 80 years. This
increase is almost certainly due to two main factors: the decreased
availability of informal carers for the oldest age group, and the
increasing level of disability.
What are the medical conditions underlying these dependency
statistics? Unfortunately, although the Federal Government is
responsible for both medical and residential care, few data are
available on the common medical conditions of elderly people in
residential care. Probably the commonest condition seen in these
people is some form of dementia. In 1996, there were an estimated 134
809 people with dementia in Australia (this estimate does not include
all people with mild disease).4 Approximately half of these
individuals were housed in residential care.3 Estimates of the
prevalence of dementia in people in hostels and nursing homes were 28%
and 60%, respectively, although rates of cognitive impairment were
even more alarming, at 54% and 90%, respectively.5 The main
disabling conditions of the 707 600 people aged 65 years and over
with a profound, severe or moderate disability (less than 20% of
whom were housed in residential care) were arthritis, other
musculoskeletal conditions, dementia, eye disease and
stroke.3 It would appear that much of
the disability suffered by people in residential care is related to
chronic degenerative conditions.
The pressure of caring for people with increasingly complex and
disabling conditions within the residential care system may place
other parts of the healthcare system under stress -- for example, the
readmission of nursing home patients to the acute hospital system
with acute complications of chronic medical problems. Such
admissions (eg, the referral to an acute hospital of a nursing home
resident with severe Alzheimer's disease complicated by hypostatic
pneumonia) may be precipitated by avoidance of ethically difficult
management decisions. Another part of the health and welfare system
that may come under pressure is community care, despite substantial
real increases in Commonwealth expenditure on Home and Community
Care (HACC). This expenditure has increased, in inflation-adjusted
terms, from $561 million in the financial year 1991-92 to $799
million in 1997-98.3 The pressure exerted by
reduced availability of residential care has led to a waiting time of
several weeks for community care in many parts of Australia, despite
the necessity of providing care to patients discharged from a crowded
acute hospital system.
How should the provision of healthcare for people in nursing homes and
hostels be organised? This issue has essentially not been addressed
to date, and improvement in this area will require more than increased
funding. Over the past 15 years, the focus of aged care services has
been to prevent or delay the need for residential care by
comprehensively assessing patients to identify those who might
benefit from multidisciplinary rehabilitation and community
services. The rationale for this approach is sound and clearly
evidence based,6 and the policy has been very
successful. While cynics may claim that the Federal Government has
promoted the policy to halt the previous exponential growth in
nursing home care, there is no doubt that older people themselves
eschew the residential care option to remain in their own homes, if at
all possible.7 However, the healthcare of
people who go into residential care seems to be far less coordinated.
Recent developments (part of the Enhanced Primary Health Care
Initiative) that support medical practitioners in screening the
over-75-years group and in care planning, exclude people in nursing
homes. Furthermore, the organisation and proposed evaluation of
this initiative do not appear ideal.8 The very high
prevalence of cognitive impairment among people in residential care
limits the usefulness of surveying residents about their perceived
needs and decreases their ability to be effective advocates for their
own care.
I believe several steps need to be taken to improve healthcare for
people in residential facilities:
- We need to recognise
that most older people do not choose residential care for "social"
reasons. They do so because of chronic medical conditions resulting
in permanent disability.
- Healthcare professionals need professional development
involving training, peer review and transparency of operations,
something that is apparent from the experience of acute care
hospitals. (While accreditation of facilities may be a useful and
long overdue stage in the development of residential care
facilities, it is unlikely to improve the quality of healthcare
provided.)
- Educational institutions, expert groups and professional
organisations need to form strategic partnerships to establish what
is currently accepted best practice in residential care and where
investment should be made in targeted research.
- Health professionals working in the residential care environment
should be trained in dealing with people who have major disabilities.
This particularly applies to general practitioners, who should be
encouraged to acquire specific qualifications and rewarded by
increased remuneration.
- We need to develop a multidisciplinary team approach to healthcare
delivery in residential facilities.
- Appropriate agencies, such as governments and private
health insurers, need to provide sufficient funding to
support the level of professional care required.
Medical practitioners and some other health professionals may be
able to get expert support from regional aged care teams; however,
these services are currently under considerable stress because
their funding has not kept pace with the increasing number of older
people requiring care.3 A wider role for
geriatricians and psychogeriatricians in supporting these
developments is crucial.9
There is no need for the widespread nihilism that has pervaded the
issue of healthcare in residential facilities -- indeed, it
has been shown that legislative changes10 and educational
initiatives11 can decrease the rate of
inappropriate psychotropic drug use in nursing home residents.
Healthcare for people in residential care is provided not only by
medical practitioners, but also by other professionals. The largest
group of professional carers are nurses, for whom professional and
best practice guidelines are similarly underdeveloped. For
example, there are no guidelines specifying which of the available
care strategies for people with dementia (such as validation
therapy,12 reality
orientation13
or reminiscence therapy14) works best, and for whom.
Similarly, other healthcare workers, such as dentists, pharmacists
and allied health practitioners, all need to pay special attention to
this vulnerable section of the population. A recent survey of
Adelaide dentists15 revealed that their
interest in and provision of services to people in residential care
were low and that dentists provided little educational assistance
for staff of nursing homes. A concurrent survey of the needs of the
residents found a high level of standard dental treatment
needs, with the severely cognitively impaired residents having the
highest incidence of oral disease.15 Clearly, a diverse range
of best practice guidelines for the care of residents of nursing homes
and hostels is needed, together with appropriate resources to
implement them.
It is sometimes argued that these residents have "reached the end of
the road" and that further attention to their needs is unjustified.
This argument is usually rejected by the very many Australians whose
relatives and friends are housed in residential care. Perhaps more
telling is the realisation that entry into residential care is a
common occurrence in our society, and in fact any individual who lives
to the age of 65 years has a 33% chance of requiring a nursing home bed
during their remaining life and a 20% chance of requiring a hostel
bed.3
It is in the interests of all members of society to provide more
adequate healthcare in this challenging environment.
Disclosure statement: No conflict of interest.
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Gregory A Lewis and Robert W Pegram. Residential aged care and general practice: workforce demographic trends, 1984-2000 Med J Aust 2002; 177 (2): 84-86. [GP Workforce — Research]