Ageing

Australians have around 19 000 hip fractures each year,1 and the estimated cost to the health care system was $445 million in 2015–16.2 Surgery within 48 hours of initial presentation to hospital is widely accepted as a clinically meaningful indicator of best practice care, and is supported by the Australian Hip Fracture Care Clinical Care Standard when there are no clinical contraindications.3 However, timely access to emergency orthopaedic hip fracture surgery is difficult in a country as large and geographically diverse as Australia; patients admitted to remote or regional hospitals that do not provide orthopaedic surgery must be transferred to larger regional centres. In a retrospective population study, we evaluated the impact of pre‐surgery hospital transfer and time to surgery on 30‐day mortality for people aged 65 years or more who underwent surgical interventions for fall‐related hip fractures in NSW public hospitals during 1 January 2011 – 31 December 2018. Hospitalisation data from the NSW Admitted Patient Data Collection and deaths data from the NSW Registry of Births, Deaths and Marriages were linked to provide person‐level records. Time to surgery (in calendar days) was estimated from the date of admission for the first episode of care to the date of surgery. Comorbid conditions during the preceding year were identified with the Charlson Comorbidity Index (CCI). Multilevel multivariable logistic regression models were fitted to assess the influence of patient‐level factors (age, sex, comorbidity) and process factors (transfer status, time to surgery) on 30‐day mortality. Operating hospitals were included as a random effect to account for variation between hospitals. Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were calculated and residual variation (variance partition coefficient) assessed. All analyses were performed in SAS Enterprise Guide 7.1 and MLwiN 3.02 (http://www.bristol.ac.uk/cmm/software/mlwin). The NSW Population and Health Services Research Ethics Committee approved the study (HREC/17/CIPHS/45). Of 36 956 patients who underwent hip fracture repair procedures in 36 hospitals, 3916 (10.6%) were transferred from peripheral hospitals to operating hospitals for surgery; 1579 were transferred on the day of presentation (40.3%), 1875 the following day (47.9%), and 462 patients (11.8%) spent at least two days at the admitting hospital before being transferred. Larger proportions of transferred patients than of patients admitted directly to operating hospitals were men (29.4% v 27.8%), under 85 years of age (50.9% v 48.4%), or had CCI scores of 1 or more (60.2% v 56.3%). The proportion of transferred patients who underwent surgery within 48 hours of presentation was smaller than for directly admitted patients (53.9% v 72.4%) (Box). In multilevel models adjusted for inter‐hospital variation, transfer was associated with higher risk of 30‐day mortality than direct admission (aOR, 1.15; 95% CI, 1.01–1.32), but after adjusting for age, sex, and comorbidity, neither transfer (aOR, 1.10; 95% CI, 0.95–1.28) nor delayed surgery (> 2 days v ≤ 2 days: aOR, 0.99; 95% CI, 0.89–1.11) significantly influenced mortality. The most influential factor was comorbidity (CCI ≥ 3 v CCI < 3: aOR, 4.89; 95% CI, 4.32–5.54). The discrimination of our fully adjusted model was adequate (area under the curve, 0.73), and 1.8% of residual variation in 30‐day mortality was attributable to differences between hospitals. In our large study of NSW people with hip fractures, we found that transfer from non‐operating to operating hospitals, after adjusting for patient and hospital characteristics, was not associated with higher 30‐day mortality, despite increasing the time between initial presentation and surgery. This is contrary to the findings of earlier, single centre studies in Australia.4,5,6 However, our study was the first to control for several key person‐level factors that increase the risk of death, and our findings suggest that time to surgery may be less important for health outcomes than these factors when other dimensions of care quality are equal. More research is required to understand the interplay between the effects of patient demographic characteristics, pre‐injury health status, and the quality of hip fracture care on 30‐day mortality for patients. Box – Characteristics of patients with hip fractures, by pre‐surgery transfer, New South Wales, 2011–2018* table#t1 tbody td:nth-child(n+2) P. Pleft { text-align: center; } Not transferred Transferred Number of people 33 040 (89.4%) 3916 (10.6%) Sex Women 23 866 (72.2%) 2766 (70.6%) Men 9174 (27.8%) 1150 (29.4%) Age at admission (years) 65–74 4684 (14.2%) 535 (13.7%) 75–84 11 311 (34.2%) 1458 (37.2%) ≥ 85 17 045 (51.6%) 1923 (49.1%) Weighted Charlson Comorbidity Index score 0 14 437 (43.7%) 1556 (39.7%) 1–2 12 667 (38.3%) 1595 (40.7%) ≥ 3 5936 (18.0%) 765 (19.5%) Time to transfer (days) 0 1579 (40.3%) 1 1875 (47.9%) ≥ 2 462 (11.8%) Time to surgery (days) 0 12 991 (39.3%) 739 (18.9%) 1 10 939 (33.1%) 1370 (35.0%) ≥ 2 9110 (27.6%) 1807 (46.1%) Length of stay (days), mean (SD) Total 27.5 (21.9) 26.8 (20.5) Acute care 11.9 (8.5) 12.8 (9.0) 30‐day deaths 2172 (6.6%) 288 (7.4%) SD = standard deviation. * Linked hospitalisation and deaths data.

Lara A Harvey · Ian A Harris · Rebecca J Mitchell · Adrian Webster · Ian D Cameron · Louisa R Jorm · Hannah Seymour · Pooria Sarrami · Jacqueline CT Close

To the Editor: Despite death being common in aged care, bereavement support for family and others is not part of care.1 In contrast, palliative care inherently extends to the patient’s family members, including after death.2 Coronavirus disease 2019 (COVID‐19)‐related deaths in aged care have left many families bereft. This is a consequence of forced separation in the final stage of life, the family member being transferred to an acute hospital, the question of whether the patient died alone, and limitations on traditional rituals and practices surrounding funerals.3,4 Like many community palliative care services, Melbourne City Mission’s Palliative Care (MCMPC) services have a well established aged care consultative team that provides advice on complex end‐of‐life issues. At the beginning of the COVID‐19 pandemic, MCMPC started to receive referrals for bereavement support — rapid referrals for residents in aged care facilities in the terminal phase of illness to speak with their families both before and after the patient’s death. Examples of catastrophic grief resulting from the COVID‐19‐related deaths in aged care facilities overseas prompted MCMPC’s preparation to respond to traumatised relatives.5 This work simply involved a phone call to families after the patient’s death. What was heard was sobering, summed up by one family member as “it was not meant to be this way”. Families expressed disappointment that the resident had contracted COVID‐19, stating they should have been safe in their home. The bereaved spoke of their enormous loss, having not been able to be with their loved one, in some cases, for a period of over 7 months. While most families were realistic about the frailty of their family member, they also said that “it was not their time,” that COVID‐19 unfairly changed the trajectory of how they expected their last days or months to go. Palliative care has much in common with aged care, notably the care of patients who are facing the final stage of their life. For staff it has been important to give each bereaved person a chance to capture their individual story, to give identity to the person who died, so they are not just another of the many deaths in aged care. In validating family members’ experiences, this simple phone intervention may mitigate poor bereavement outcomes5 by providing a space to honour their loss.

Margaret O’Connor · Bronwyn Wilson

To the Editor: In 1996, two articles showed that bowel cancer screening in subjects aged 45–741 and 45–752 years, recruited in the early 1980s, led to a significant reduction in mortality; since then, the age range in Australia’s screening program remains at 50–74 years. Between 1981 and 2015–2017, the mean life expectancy at birth for men and women in Australia rose by 9.3 and 6.3 years respectively.3 In 2016–2018, the mean life expectancy at 75 years was 12.3 and 14.3 years for men and women respectively, and even at 80 years, the mean life expectancy was 9.1 and 10.6 years respectively,3 suggesting a reduction in morbidity in the 75–79 years cohort over the 1981–2017 period. In 2015, the estimated bowel cancer incidence and mortality rates for Australians in the 75–79 years range were 28% and 82% higher than in the 70–74 years range.4 In the United States, in adults aged 65 years and older, the prevalence of screening was higher than 80% in nine states.5 In Australia, mean participation in the National Bowel Cancer Screening Program (NBCSP) increased with age cohort6 (Box). Although there is an increased risk of complications from colonoscopy with increasing age, a prospective observational study compared the risks in the 75–79 with the 70–74 years range and found no increase in perforation rates.7 A US study found that colorectal cancer screening was cost‐effective at ages 79 and 80 years even in persons with severe comorbid conditions.8 A recent Australian microsimulation study9 suggested that the cost‐effectiveness of screening the 50–79 and 50–74 year groups would be almost identical, although the advantage of a likely high participation in the 75–79 age range was not addressed. It found that the number of immunochemical faecal occult blood tests and colonoscopies would increase by 10–16% and 21–30% respectively if the screening cessation age were extended to 79 years, both of which should be welcomed. Facilities in Australia can cope with such an increase in colonoscopies. In view of the above, the NBCSP age range should be extended to 79 years. At a minimum, a pilot study of such an extension should be undertaken. Box – Australian National Bowel Cancer Screening Program participation Age (years) Participation rates (%) 2014–2015 2015–2016 2016–2017 2017–2018 Mean 50–54 28.5 28.1 29.8 31.9 29.6 55–59 36.8 35.5 35.5 37.3 36.3 60–64 43.2 42.7 43.1 43.7 43.2 65–69 43.5 44.2 47.5 49.6 46.2 70–74 52.5 52.5 52.6 53.1 52.7

Donald J Frommer

The Royal Commission into Aged Care Quality and Safety has highlighted the high rates of polypharmacy and potential medication‐related harm in residential aged care facilities (RACFs) in Australia.1 Residential medication management review (RMMR) is a government‐funded service for facilitating quality use of medicines in RACFs.2 Previous studies have found that RMMRs by accredited pharmacists and general practitioners identify a mean of 2.7–3.9 medication‐related problems per resident, and 45–84% of pharmacists’ recommendations were accepted by GPs.3 Guidelines recommend that residents should generally receive an RMMR on entering an RACF and when their clinical circumstances change,4 but annual claims data5,6 and recent research indicate that not all residents receive RMMRs.7 We examined time to first RMMR after RACF entry by analysing data for the national historical cohort of the Registry of Senior Australians (ROSA).7 In ROSA, de‐identified data collected during aged care eligibility assessments are linked to information about government‐subsidised aged care services, general practice and allied health services subsidised under the Medicare Benefits Schedule (MBS), medicines subsidised under the Pharmaceutical Benefits Scheme (PBS), and the Australian Institute of Health and Welfare National Death Index.8 Non‐Indigenous people aged 65 years or more who first entered permanent residential care during 1 January 2012 – 31 December 2015, had received an entry‐into‐care assessment within 100 days, and had received at least one PBS‐subsidised medication during the preceding year were included. Recipients of Department of Veterans’ Affairs‐funded services and people who had previously undergone RMMRs (eg, during transition care) were excluded. The cumulative incidence function was used to determine time to first MBS claim lodged by GPs for RMMRs (item code 903) or Home Medicines Reviews (HMRs) (item code 900) after entry to permanent residential care, adjusted for competing events (death, or permanent departure from the first RACF for another reason) using the Fine–Gray method,9 with follow‐up to 31 December 2016. Statistical analyses were undertaken in SAS 9.4. The University of South Australia (reference, 200489) and Australian Institute of Health and Welfare (reference, E02018/1/418) Human Research Ethics Committees provided ethics approval for the study. A total of 176 390 residents in 2799 RACFs were followed for a median 479 days (interquartile range [IQR], 149–858 days). Median age at entry was 84 years (IQR, 79–88 years), 108 908 were women (61.7%), and 84 864 were living with dementia (48.1%). In the year preceding entry, residents received a median of 11 unique prescription medications (IQR, 8–16 medications); 109 765 (62.2%) had received at least one high risk medication (as defined by the United States Institute for Safe Medication Practices10), and 7912 (4.5%) had received HMRs in the 12 months prior to RACF entry. By three months after RACF entry, 19.1% of residents (Wald 95% confidence interval [CI], 18.9–19.3%) had received RMMRs, 11.8% (95% CI, 11.6–11.9%) had died without RMMRs, and 5.7% (95% CI, 5.6–5.8%) had left their RACF for other reasons without RMMRs. At 12 months, 43.1% (95% CI, 42.8–43.3%) had received RMMRs, 20.6% (95% CI, 20.5–20.8%) had died without RMMRs, and 9.0% (95% CI, 8.8–9.1%) had left without receiving RMMRs. By 24 months, 49.7% (95% CI, 49.5–50.0%) had received RMMRs, 25.8% (95% CI, 25.6–26.0%) had died without RMMRs, and 10.2% (95% CI, 10.1–10.4%) had left their first RACF for other reasons without receiving RMMRs (Box). The high burden of medication use at the time of RACF entry suggests that most residents could have benefited from RMMRs, but MBS claims for RMMRs were lodged for fewer than one in five residents within three months of RACF entry, and fewer than one in two within two years. Our findings are generalisable to all older Australians entering RACFs, as ROSA captures data for all people aged 65 years or more who access government‐subsidised permanent residential aged care in Australia. We could not determine why residents were not referred for RMMRs, nor the impact of recent program changes2 on RMMR uptake and resident outcomes. In 2014–15, fewer GP medication review claims were reimbursed under the MBS (54 803 RMMRs, 63 872 HMRs) than pharmacist claims (93 517 RMMRs, 72 607 HMRs).5,6 Analysing GP claims may underestimate the number of RMMR reports prepared by pharmacists because GP claims are submitted after the medication management plan is discussed with the resident or family, while pharmacist claims are submitted after the report is sent to the GP.7 MBS claims may not be lodged if the full RMMR process cannot be completed (eg, because the resident died, their clinical circumstances had changed, or the RMMR report was not received or followed up), or claiming may be overlooked. Linkage with pharmacist claims data at the individual resident level could facilitate investigation of these limitations. Despite RMMRs being a key means for minimising medication‐related harm, MBS claims for RMMRs are lodged for only a fraction of residents who enter RACFs. The potential underuse of the program may be a missed opportunity for identifying and resolving medication‐related problems in Australian RACFs. Box – Stacked cumulative incidence function for time to first residential medication management review (RMMR), for first two years of permanent residential care* RACF = residential aged care facility. * For 176 390 residents (in 2799 residential aged facilities) included in the Registry of Senior Australians.8

Janet K Sluggett · J Simon Bell · Catherine Lang · Megan Corlis · Craig Whitehead · Steven L Wesselingh · Maria C Inacio

Australian services for people with dementia are fragmented, challenging to navigate and hard to access The coronavirus disease 2019 (COVID‐19) pandemic has led to reflections around reforming Australia’s health care system.1 In view of future reforms, this article is intended to provoke policy and clinical discussion regarding what an effective, efficient model of service delivery meeting the needs of people with dementia and their families may look like. The opinion presented here belongs to the members of the National Health and Medical Research Council (NHMRC) National Institute for Dementia Research Special Interest Group in Rehabilitation and Dementia. For the purposes of this article, we define a model of service delivery as the systemic framework through which services are organised, accessed, funded and delivered. Services in Australia for people with dementia are inadequate Dementia is the leading cause of disability, the second leading cause of death in Australians aged over 65 years, and the leading cause of death in women in Australia. In 2020, it is estimated that Australia will spend $8.1 billion on health care and $3.8 billion on social services for people with dementia, with a further $6.1 billion in lost productivity and earnings.2 Australian services for people with dementia are often fragmented, challenging to navigate and hard to access.3 It can be difficult for people with dementia to obtain a diagnosis, there are limited health and social services for early dementia, including post‐diagnostic support, and existing services are often poorly coordinated.3,4 Services face workforce shortages and gaps in worker knowledge and skills related to dementia.5 People with dementia and their care partners have called for support and information after diagnosis; flexibly delivered services that support their quality of life, including meaningful activity; and inclusion in decision making.6 A philosophical and societal shift in thinking is required: from provision of care to enablement, where people living with dementia are empowered to continue to direct their own lives.7 We are not meeting the human rights of people with dementia to health care Australia does not currently meet the human rights of people with dementia to timely and accessible health services of appropriate quality or to participation in health care decisions.4,6 The right to quality health care is affected by the variable delivery of best‐practice dementia care by memory clinics,8 acute hospitals,9 primary care,10 and community and residential aged care,11 perhaps because the role of each of these is unclear. Australia’s systems and context Australia has a long‐standing commitment to a universal health system and to long term care for older people. The health and aged care systems were developed largely in isolation from one another and have failed to resolve conflicts around medical and social models of care for older people. Health care systems are slowly adapting to this era of chronic disease and population ageing,12 but person‐centredness and integration within and across acute, primary, community and residential aged care systems remain a challenge.11 Principles underpinning models of service delivery for Australians with dementia Members of our group reviewed principles underpinning services such as the Department of Health Aged Care Sector and the Council of Australian Governments National Disability Insurance Scheme. 13,14 We reached a consensus that the following principles should apply to models of service delivery for dementia that: has an overarching objective to maintain positive health and wellbeing of people with dementia, their care partners and families; recognises dementia as a disability, consistent with the World Health Organization Convention on the Rights of Persons with Disabilities, and promotes autonomy, social participation and rehabilitation; takes into account the cognitive disability of people with dementia in accessing support and being a partner (along with their families) in planning care through supported decision making; is delivered by a multidisciplinary workforce who have knowledge and skills around dementia; is accessible for all people with dementia and care partners; is ongoing, cost‐effective and economically sustainable; is needs‐based, not capped according to central budgets; is integrated for seamless experience for people with dementia and care partners, within and across primary, acute and subacute health care, aged care and social services; and is evidence‐based. Review of possible models of service delivery for dementia We identified models of service delivery for dementia and other chronic conditions based on input from our broad authorship group and searching the peer‐reviewed and grey literature. These models are described in the and considered in terms of fit with the principles above. We included care pathways even though these are not a model because they are often used to improve service access and integration. In addition, we map the models of service delivery to our health and aged care funding systems, illustrating the limited integration across systems (Box). Learnings from these models: The self‐directed approach places the needs of the person with dementia centrally but may require processes to ensure supported decision making. Information is also needed regarding the risks and benefits of self‐management versus budget holding or service provider management, integration with health care, and consideration of costs. Case management improves outcomes for the person with dementia and could be flexible and needs‐based if sufficient workforce and integration across systems could be achieved. However, it would require a significant investment of resources. Strengths of the primary care chronic disease management model include equity and familiarity of access, and care coordination by a trusted health professional or practice team. Weaknesses include the limited amount of treatment (ie, current cap of five subsidised allied health consultations per year), limited dementia management skills in some general practitioners and practice nurses, and often poor integration with aged care. Shared and stepped care models may be able to be adapted to combine the strengths of the primary care chronic disease and specialist approaches, but integration of aged care services would be essential. Stepped care may not be the best fit for people diagnosed with dementia in other settings (eg, hospitals or residential care facilities). A specialist team approach with a skilled workforce is well equipped to provide evidence‐based care, although this is unlikely to be made universally accessible (eg, in regional areas) and may be cost‐prohibitive. Navigator and care pathway approaches may increase access to services, but do not improve the type or amount of supports or treatment available. None of the models of service delivery that we identified in Australia or overseas appear to sufficiently meet the principles above. There is no clear recognition that dementia is both a social and a medical issue. Australia has moved strongly in the direction of recognising the rights of people with disabilities including social participation but there is limited appreciation of this need in respect to most models for dementia. Recognition of dementia as a disability is only apparent in the self‐directed care model. The models also do not sufficiently consider the needs of the person with dementia and care partners together. Barriers to all the current models are the poor dementia knowledge and the tendency to stigmatise people with dementia by many health and aged care professionals.15 Next step: investment in model development We need to combine desirable elements in the primary care chronic disease management, case management, and specialist multidisciplinary care models. Having a system with a point of entry through primary care could maximise accessibility. Having a dementia and aged care specialist (eg, dementia nurse or case manager) working with GPs would bring the required skills and knowledge. A close partnership with a specialist multidisciplinary team (in person or using telehealth) would assist with diagnosis, ongoing support and management of complex cases, with possibly the most complex cases being managed by the specialist team. There needs to be investment to develop a model that is accessible, integrated and effective in meeting the needs of people with dementia. Our service delivery model needs to be co‐designed with people with dementia, their care partners, health, aged care, and state and federal government stakeholders, including treasury departments. Public health, social equity and human rights principles should underpin model design. Research is needed to explore proposed models and their elements with current recipients, service planners and providers. Methodologies may include service mapping; gap, risk and unintended consequence analysis; and economic modelling. Potential models will then need to be tested in a coordinated series of pilots and rigorous health system trials building towards national implementation. History has shown that piecemeal demonstration pilots and practice improvement projects will not bring about large‐scale change. Australia’s last National Framework for Action on Dementia 2015–2019 has just lapsed.16 Our new framework should include the development of a model of service delivery that considers accessible pathways to diagnosis and effective and seamless ongoing support of health and wellbeing throughout the course of dementia. Box – Current service funding structures and service models for Australians with dementia GPs = general practitioners; NDIS = National Disability Insurance Scheme; NGOs = non‐government organisations; PHNs = primary health networks.

NHMRC National Institute for Dementia Research Special Interest Group in Rehabilitation and Dementia

Complementary medicines are used by more than half the people in Australia, incurring out‐of‐pocket health expenses of about $5.2 billion in 2019.1 Information about their use by older adults in Australia is more than a decade old.2 Given subsequent demographic changes and doubling in sales of vitamins and supplements,1 we should update our knowledge in this area. We analysed data from the ASPirin in Reducing Events in the Elderly (ASPREE) Longitudinal Study of Older Persons (ALSOP) to assess self‐reported use (every day, occasionally, never) of complementary medicines (fish oil, glucosamine, ginkgo, coenzyme Q10, calcium, zinc, vitamins B, C, D and E, multivitamins, Chinese or herbal) by healthy people over 70 years of age residing in metropolitan or regional Victoria, South Australia, Tasmania, the Australian Capital Territory or southern New South Wales, recruited through their usual general practitioners.3 We summarised data as descriptive statistics; we assessed differences between groups in χ2 tests (categorical variables). Analyses were conducted in SPSS Statistics 23 (IBM). ALSOP was approved by the Monash University Human Research Ethics Committee (reference, CF11/1100). During January 2012 – July 2015, 14 757 of 16 703 ASPREE participants returned ALSOP Baseline Medical Questionnaires3 with at least partial responses to the questions on complementary medicines (response rate, 88%); their mean age was 75.2 years (standard deviation, 4.3 years), and 8068 (55%) were women). A total of 10 961 respondents (74.3%) reported using them either daily or occasionally; fish oil (6563 of 14 757 respondents, 44.5%), vitamin D (4995, 33.8%), glucosamine (3940, 26.7%), and calcium supplements (3652, 24.7%) were the most frequently reported items (Supporting Information, table 1). Complementary medicines were used by larger proportions of women (6637 of 8068, 82.3%) than of men (4324 of 6689, 64.6%; P < 0.001), and of people with more than 12 years of education (4418 of 5838, 75.7%) than of people with less education (6542 of 8918, 73.3%; P = 0.001). The proportions of complementary medicine users who reported a history of depression (987 of 4053, 24.4%) or osteoarthritis (3060 of 5240, 58.4%) were larger than for non‐users (depression, 264 of 1347, 19.6%; P = 0.002; osteoarthritis, 705 of 1598, 44.1%; P < 0.001); self‐reported diabetes was more common among non‐users (363 of 3790, 9.6%) than among complementary medicine users (815 of 10 944, 7.4%; P < 0.001) (Box; Supporting Information, tables 2 and 3). Almost three‐quarters of people in our sample of community‐dwelling older adults in south‐eastern Australia used complementary medicines, with fish oil the most common product. While proprietary complementary medicines are generally regarded as safe, their widespread use by older people, who generally have a greater burden of disease, higher medical expenses, and low or fixed incomes, raises questions about their marketing and promotion.5 Our study population represents Australians over 70 who regularly visit general practitioners, and we included participants from geographically and socio‐economically diverse backgrounds.3 As we pre‐specified a limited number of products, our use estimates may be conservative. In our study, complementary medicine use was defined differently to some earlier studies; for example, the Australian Health Survey which asked about complementary medicine use in the previous 24‐hour period.6 This difference may account for our estimates being slightly higher. Our findings provide the most comprehensive information to date on complementary medicine use by Australians over 70 years of age. Box – Characteristics of respondents to survey of community‐dwelling Australians over 70 years of age on their use of complementary medicine

for the ALSOP Complementary Medicine Research Group*

Recommendations to guide residential aged care facilities in preparing for and managing infectious disease outbreaks

Georgia E Aitken · Alice L Holmes · Joseph E Ibrahim

Controlling the exit from work and accumulating multiple resources early predict adjustment to retirement The traditional approach to leaving a career in medicine has been informal. The fact that about 10% of medical practitioners in Australia are aged 65 years or over1 — a seemingly natural consequence of increased life expectancy, improved quality of life and fluctuations in financial markets — highlights the need for a more methodical process for leaving medicine. The final transition in a medical career is one that the profession has largely ignored, thereby risking unplanned departures that affect succession planning for practices, continuity of care for patients, and the wellbeing of the practitioner. The eventual introduction of proposed mandatory health checks for practitioners aged 70 years and over in Australia2 may hasten the retirement of some, which only increases the urgency of retirement planning becoming a routine task for all practitioners. The aim of this article is to describe a framework that examines how this transition may be achieved, so that practitioner wellbeing and adjustment to retirement are enhanced. For all the changes in medical culture that must occur — and to which the colleges, employers and other professional organisations must contribute — the individual practitioner ultimately remains responsible for their own welfare across the career cycle. While this article is aimed mainly at clinicians, its principles remain pertinent to other medical practitioners. Understanding the process of retirement Retirement is not a lone event. It is better understood as a longitudinal process that comprises three phases that may overlap.3 In the “pre‐retirement” phase, the practitioner continues to work but may anticipate and prepare for retirement. In the “transition” phase, decisions are made about how and when the practitioner should approach stopping work. The final phase of “adaptation” may involve some paid work but the practitioner is principally retired. Each phase is considered a critical turning point, in which action or neglect can influence the outcome of subsequent phases. Some practitioners may chart a non‐linear transition, moving in and out of work. Any approach to determining the optimal time to transition out of a career in medicine must consider individual motivation as well as other competing factors. The first is the right of all and the desire of some older practitioners to continue working versus the extrinsic demands of family expectations or life events, such as illness in a loved one. The second is the continued provision of clinical services by senior medical practitioners, usually within well established patient relationships, versus the right of patients to receive the highest level of care possible. In this regard, older practitioners are at increased risk of physical and cognitive changes that may potentially affect practice, such as poorer patient outcomes,4 and may lead to being the subject of a complaint to a regulatory authority.5 Why retirement planning may be hard When the transition away from work should start is an individual decision. Yet a cross‐sectional survey found that more than one‐third of older practitioners working in Australia had failed to even reach the pre‐retirement phase, as they reported no intention of retiring or were unsure about doing so.6 Moreover, not intending to retire was an occupational factor that predicted practitioners’ perceptions of ageing successfully.7 This suggests that even considering leaving work may be viewed as a sign of personal weakness. Financial factors related to inadequate superannuation funds, continuing debt, or other commitments have been found to prevent retirement planning.8 Several other reasons for continued practice and delayed retirement, however, reflect more intrinsic difficulties in detaching from medicine. These include a feeling of responsibility for patients, a lack of interests outside of medicine, and a fear of potential changes in their relationship with a spouse.8 These factors may be the result of a lifetime of work centrality whereby medicine takes precedence over other life roles.6 For many doctors, self‐identity is bound up in their work and the drive to further their careers. A study of academics suggested that work–life balance was more nebulous because outside interests, including family, were considered an inconvenient distraction.9 Conversely, emotional connections towards a workplace or institution may strengthen. Prioritising work limits social connections and creative pursuits, thereby perpetuating a reluctance to retire. A structured transition to retirement plan The purpose of adequate retirement planning is to enhance wellbeing after ceasing work. Pre‐retirement planning is a long term goal‐oriented behaviour that has been associated with retirement satisfaction.10 In addition, retirement adjustment is predicted by the conditions of exit — namely, control over how and when one leaves work11 — and resource acquisition in multiple domains.12 While the elements of planning should occur throughout the career cycle, we recognise that it is not a compelling consideration for many practitioners. We would still propose that all practitioners formally write an initial transition to retirement plan by the age of 55 at the latest, review it regularly, and the intervals between reviews should become more frequent with time (Box). The proposed introduction of the mandatory health check for practitioners aged 70 years or over should be an important incentive for self‐care. Traditional pre‐retirement planning has tended to consist only of financial advice such as wealth creation, tax optimisation, and estate planning. This is an essential task as people tend to underestimate how much money will be required in retirement, but should not be used as the sole criterion of fitness for retirement. The more pertinent questions are how time in retirement will be spent and how much it will cost to support, rather than a pre‐determined goal of wealth accumulation. Resource accumulation While adequate financial resources do contribute to retirement adjustment, so do adequate physical health, social engagement and emotional resources.12 This means a much broader spectrum of planning that uses advice from multiple professionals is required. Methods for optimising financial, physical and leisure resources are relatively easily sourced. What may be more difficult to manage, however, are the emotional resources needed to navigate the transition to retirement. In particular, the inevitable loss of self‐identity may lead to anticipatory grief and bereavement.13 That intending to retire is viewed as a mark of ageing less well by practitioners not only poses a considerable challenge for their retirement planning, but highlights the importance of understanding successful ageing in any discussion of transitioning away from full‐time work in medicine. Successful ageing is a concept that has evolved from a biomedical model, requiring an absence of physical disease and good physical functioning, to a more subjective notion that emphasises adaptation and autonomy.14 A sense of engagement, a prominent feature of self‐rated successful ageing, is inherent in the work of medical practitioners and is reflected in the pursuit of continued stimulation and learning, a sense of purpose and utility to society.15 Successful occupational ageing is based on insight into personal strengths, a dynamic process of goal setting, generativity (guiding and mentoring the next generation), and self‐care.14 There are a number of areas that are important for self‐reflection, such as the original motivations for training in medicine, the reasons for continuing to work, the anticipatory grief of the loss of identity and role, and the fear of ageing.14 Not every practitioner will be capable of self‐reflection, so that professional help may be required via a career development counsellor or vocational psychologist. While many practitioners will set a pre‐determined age or personal milestone at which to retire, others may continue to work indefinitely, thereby increasing the risk of practising with an impairment. This may be prevented by incorporating a professional advance care plan16 that outlines a set of premorbid views about ongoing practice in the event that capacity to practise is impaired. Permission would be given to one or more people, such as a spouse, friend or colleague, to monitor fitness to practise and to provide regular feedback. “Red flags” to stop working may include physical illness or concern from a trusted source about deterioration in cognition or procedural or clinical skills. Developing an encore career Developing an encore career is the final aspect of the transition plan that allows the use of skills and experience developed over a career, and helps maintain meaning and engagement. Giving consideration to the encore career while still working enables the practitioner to better position themselves to access greater opportunities. Up until this point, the practitioner may have found integrating different life roles challenging and pursuing outside interests unnecessary. An encore career can lead to feeling purposeful, provide goals to strive towards, and opportunities for intellectual and social pursuits. For example, a general practitioner keen to maintain patient contact but reduce caseload may want to specialise in an area of medicine (eg, mental health). Some may investigate governance roles with accrediting bodies, sit on guardianship or mental health review tribunals, or take up committee membership. Others may wish to provide leadership through directorships or management roles in hospitals or medical services. Others may wish to apply their lifetime of insights to teaching or research pursuits. Examples include teaching medical students, mentoring trainees, writing research grants and articles. It might be worthwhile revisiting those businesses or volunteering opportunities that were set aside before a medical career became the sole focus. Conclusion Retirement should not be viewed as a single endpoint but as an anticipatory process that involves the accumulation of social, emotional, financial and other resources. Active participation in retirement planning is essential to ease the transition, gain a better sense of control and enhance emotional adaptation. Encore careers provide the opportunity to capitalise on a lifetime of accumulated wisdom by integrating training, experience, interests and strengths. Given medicine’s long‐standing neglect of retirement planning, there is also a need for professional bodies to provide education about the transition process and for practitioners themselves to share stories of encore careers and inspire peers to explore avenues for transition. Box – My plan for transitioning to retirement I will accumulate the following resources: Physical resources ► What am I doing to take care of my health (diet, exercise, adherence with medications)? ► How often am I seeking independent health care, including consulting my general practitioner? Financial resources ► How do I optimise my finances (reduce debt, maintain income)? ► Who is my professional adviser? How often do I consult with them? Emotional resources ► Who are the people I can connect with for emotional support? Who do I support in return? ► Who do I know who has aged well and transitioned well? What can they share? ► What types of professional assistance do I need to support the transition? Social resources ► How do I maintain healthy relationships (spouse, children, family and friends)? ► Who can provide professional support to help me manage these relationships now and when I am not working? ► What relationships have lapsed that I want to re‐initiate? ► What interests can I develop or revisit? Cognitive resources ► What intellectual pursuits outside medicine can I follow? ► How do l want to learn, develop and grow? ► What creative pursuits do I want to develop? ► What courses or training might help to reposition me for an encore career? My professional advance care plan I will discuss the timing of transition and retirement with my peers and loved ones I will engage my junior colleagues in a discussion about succession planning I will reduce my hours, stop procedural work etc, at age X or if the following health or practice problems occur … I will stop working at age X or if the following health or practice problems occur … I will set up a peer mentoring system with close colleagues so that we can provide each other with feedback on professional issues and review skill levels. Encore career What are some professional aspirations I can pursue given greater time availability? How do I convert my passions and interests into pursuits? Do I want to focus on areas of expertise, governance, leadership or teaching and research? Was there a business opportunity I considered before my medical career that I want to revisit? What other career options have people who have successfully transitioned considered?

Chanaka Wijeratne · Joanne Earl

Lessons learnt from COVID-19 outreaks in residential aged care facilities could limit future impacts

Gwendolyn L Gilbert

Objectives: To develop and validate a frailty index, derived from aged care eligibility assessment data. Design: Retrospective cohort study; analysis of the historical national cohort of the Registry of Senior Australians (ROSA). Participants: 903 996 non‐Indigenous Australians aged 65 years or more, living in the community and assessed for subsidised aged care eligibility during 2003–2013. Main outcome measures: 44‐item frailty index; summary statistics for frailty index score distribution; predictive validity with respect to mortality and entry into permanent residential aged care during the five years after assessment. Results: The mean frailty index score during 2003–2013 was 0.20 (SD, 0.07; range, 0–0.41); the proportion of assessed older people with scores exceeding 0.20 increased from 32.1% in 2003–2005 to 75.0% in 2012–2013. The risks of death and entry into permanent residential aged care at one, three and five years increased with frailty index score level (at one year, high [over 0.35] v low scores [under 0.05]: hazard ratio for death, 5.99; 95% CI, 5.69–6.31; for entry into permanent residential aged care, 8.70; 95% CI, 8.32–9.11). The predictive validity (area under the receiver operating characteristic curve) of Cox proportional hazard models including age, sex, and frailty index score was 0.64 (95% CI, 0.63–0.64) for death and 0.63 (95% CI, 0.62–0.63) for entry into permanent residential aged care within one year of assessment. Conclusions: We used Australian aged care eligibility assessment program data to construct and validate a frailty index. It can be employed in aged care research in Australia, but its application to aged care planning requires further investigation.

Jyoti Khadka · Renuka Visvanathan · Olga Theou · Max Moldovan · Azmeraw T Amare · Catherine Lang · Julie Ratcliffe · Steven L Wesselingh · Maria C Inacio

Objective: To develop a casemix classification to underpin a new funding model for residential aged care in Australia. Design, setting: Cross‐sectional study of resident characteristics in thirty non‐government residential aged care facilities in Melbourne, the Hunter region of New South Wales, and northern Queensland, March 2018 – June 2018. Participants: 1877 aged care residents and 1600 residential aged care staff. Main outcome measures: The Australian National Aged Care Classification (AN‐ACC), a casemix classification for residential aged care based on the attributes of aged care residents that best predict their need for care: frailty, mobility, motor function, cognition, behaviour, and technical nursing needs. Results: The AN‐ACC comprises 13 aged care resident classes reflecting differences in resource use. Apart from the class that included palliative care patients, the primary branches were defined by the capacity for mobility; further classification is based on physical capacity, cognitive function, mental health problems, and behaviour. The statistical performance of the AN‐ACC was good, as measured by the reduction in variation statistic (RIV; 0.52) and class‐specific coefficients of variation. The statistical performance and clinical acceptability of AN‐ACC compare favourably with overseas casemix models, and it is better than the current Australian aged care funding model, the Aged Care Funding Instrument (64 classes; RIV, 0.20). Conclusions: The care burden associated with frailty, mobility, function, cognition, behaviour and technical nursing needs drives residential aged care resource use. The AN‐ACC is sufficiently robust for estimating the funding and staffing requirements of residential aged care facilities in Australia.

Kathy Eagar · Rob Gordon · Milena F Snoek · Carol Loggie · Anita Westera · Peter David Samsa · Conrad Kobel

OECD data indicate that Australia is a comparatively high user of residential aged care The Royal Commission into Aged Care Quality and Safety interim report highlighted many concerns about aged care in Australia.1 These include that “the system designed to care for older Australians is woefully inadequate”, and that “aged care services … have simply not been seen as a priority by successive Australian Governments”. To inform the Royal Commission, we undertook a review of international approaches to the provision of aged care.2 As a component of our review, we examined data reported to the Organisation for Economic Co‐operation and Development from 13 countries.3 The list of countries included in the review was developed in consultation with experts and with input from representatives from the Royal Commission. Countries were selected based on the availability of information, applicability to the Australian aged care system, and to ensure a diverse range of countries were represented. Long term care is the provision of services for medical needs, personal care and assistance in living independently for people with long term dependencies due to their health care needs. Long term care can be provided in institutions (eg, nursing homes or residential aged care facilities) or by providing services to assist people to remain living in their own homes, including community services such as respite care. The OECD defines long term care institutions as specifically designed nursing and residential care facilities that provide accommodation and care as a package, with the predominant service being care. Institutional long term care recipients are those receiving formal long term care in institutions other than hospitals. We compared numbers of older long term care recipients in institutional care (12 countries) and estimates of long term care expenditure for older people (12 countries) (Box). Australia provides institutional long term care for almost 20% of the population aged ≥ 80 years, and 6% of those aged ≥ 65 years. This places Australia as the nation with the highest proportion of older people living in institutional care compared with 11 other nations (Box). The relative use of institutional care, as opposed to home or community care, was also highest for Australia, with 52.5% of long term care recipients aged ≥ 65 years and 58.6% of long term care recipients aged ≥ 80 years in institutional care. This is in comparison to a range of 21.6% in Japan to 34.6% in the Netherlands for recipients aged ≥ 65 years, and 23.1% in Japan to 41.8% in Canada for those aged ≥ 80 years (Poland is an exception, with institutional care provided for 94.1% of long term care recipients aged ≥ 65 years, and 100% aged ≥ 80 years, based on 2006 data; however, long term care is highly limited, with only 1.6% of the population aged ≥ 80 years receiving care). Our estimates of gross domestic product (GDP) expenditure on long term care for older people comprise the health component of government/compulsory long term care expenditure (not age‐specific) plus social expenditure on old age benefits in kind, as reported to the OECD. This approach best captures Australia's long term care expenditure on older people. Benefits in kind are services such as the home care packages program. However, this estimate does not capture cash benefits such as the carer allowance in Australia or direct cash payments that are a component of aged care benefits in some other nations (eg, Germany, England, Poland). In the OECD database, these payments cannot be separated from non‐care related cash provisions for older people, such as the age pension. The expenditure estimates indicate that many other nations spend a much greater proportion of their GDP on long term care for older people (Box). Different approaches to funding are used in other countries, including the provision of universal social care insurance, some of which includes compulsory contribution schemes such as in Japan and Germany.5 Limitations in these international comparisons include possible differences between nations in reporting or definitions of institutions, lack of data on the dependency levels of care recipients, and comparisons being limited to OECD nations reporting institutional care use. Nevertheless, the data indicate that in Australia a comparatively high proportion of older people live in institutions, with a relatively low financial investment in the whole aged care sector. While many countries have wait lists for home care services, the wait times of over 12 months for home care packages at the approved level (for level 2 and above; ie, beyond basic care needs, providing low to high level care) may lead to premature admission to institutional care for some people.6,7,8 In November 2019, the Australian government announced funding of an additional 10 000 home care packages at a cost of $496 million.9 However, in September 2019, there were about 63 000 people waiting for an approved home care package, and an additional 49 000 people were offered, while waiting, a package at a level lower than that approved.6 Some countries focus on keeping older people at home, with greater emphasis on preventive and rehabilitation approaches.10,11 In Denmark, for example, legislation obliges local municipalities to assess all older people applying for home care for their suitability for reablement: short term home‐based training programs aiming to increase people's independence.11 To reduce the number and proportion of older Australians living in residential aged care, there needs to be an increase in investment across the sector, particularly in home‐ and community‐based care. Box – Estimates derived from OECD data2 on proportion of older population receiving long term care (LTC) in institutions (A), and LTC estimates for expenditure on older people as a proportion of gross domestic product (GDP) (B) Notes: Data refer to 2015 or nearest year. A: Data not available for UK; it is unclear whether or not older people living in skilled nursing facilities are counted in US data. B: Data not available for New Zealand. Old age benefits in kind were not reported for Canada or Poland; Germany reports zero expenditure as benefits in kind. US expenditure may only include institutional care.4 Data extracted on 6 May 2019 (A) and 15 September 2019 (B) from https://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT.3

Suzanne M Dyer · Madeline Valeri · Nimita Arora · Dominic Tilden · Maria Crotty

Meeting the need for culturally appropriate discussions regarding patient values and preferences at end of life Advance care directives are pre‐emptive discussions that anticipate a future loss of ability to make or communicate decisions. There is no uniformity in advance care directives in Australia, with each state or territory having differing terminologies and requirements.1 The Northern Territory has the lowest population density but the highest proportion of Aboriginal people of any Australian jurisdiction.2 In the NT, an individual can make a common law or statutory advance care directive,3 referred to as an advance personal plan (APP).4 The NT APP enables documentation of legally binding directives in reference to resuscitation and life support, as well as the appointment of substitute decision maker(s).5 We have previously documented the utility of the NT APP for Aboriginal people but highlighted the need for a more culturally appropriate document.6 For patients with life‐limiting diagnoses reviewed at Top End Health Service (TEHS) hospitals, the APP could previously be used in conjunction with a not‐for‐resuscitation form. TEHS and community‐based clinicians noted clear patient care imperatives for a move away from decisions targeted solely towards cardiac arrest. Expanding capacity based on a more patient‐focused goals of care (GOC) framework also aligned with expanding evidence in the literature in support of such a focus.7 In the NT, there has been growing recognition of the need for improved discussions regarding patient values and preferences regarding end of life, informed specifically by cultural understandings.6,8 An important example of this includes determination of the site of death; for many Aboriginal people from rural and remote regions, the land holds particular spiritual and cultural significance.8 For such patients, the need to “finish up” (a culturally appropriate term for death and dying) “on country” (ancestral lands) may be paramount and may take precedence over life‐prolonging treatments in tertiary centres.8 Exploring cultural requirements The TEHS GOC committee was formed in March 2017. This group had wide stakeholder engagement across three TEHS hospitals and included medical, allied health, administrative, nursing, primary health care and Aboriginal practitioner representation. Through the committee, the NT Department of the Attorney‐General and Justice was enlisted to assist in updating the APP (governed under the Advance Personal Planning Act 2013 (NT)). Officers representing the Attorney‐General worked with the GOC committee to explore the core cultural values to be reflected in an updated APP. A Palliative Care Australia document was used as reference material for these discussions.9 The APP is a territory‐wide document (unlike the GOC) and the Attorney‐General's office additionally undertook consultation in Central Australia. An updated APP was released in June of 2018.4 New questions asked in the section concerning values and preferences (Section B) include: Where would you like to die/finish up? If nearing death, what is unacceptable to you? If nearing death, what are your goals/priorities? After death, what is important to you? People completing the APP are now able to specify cultural rituals such as ceremonial smoking, or to make a request for their body to be returned to their birth country. The capability to provide advance directives concerning cardiopulmonary resuscitation (CPR) if appropriate and other life‐sustaining treatments, as well as to nominate substitute decision makers, was retained. The ability to nominate a substitute decision maker in the event of future impairment of capacity is of utmost importance in the NT, as unlike other Australian jurisdictions, the NT does not recognise default decision makers (next of kin or responsible person in other states and territories).3 An educational video was produced with involvement of rural Aboriginal APP champions to illustrate the method and advantages of completing an APP. The new GOC form (Supporting Information) was progressively released throughout the TEHS in 2018. The trigger for commencing GOC discussions is if the treating clinician feels that their patient may be in their last year of life (the “surprise question”). This includes patients with advanced malignancy, end‐stage organ failure, dementia or other progressive neurodegenerative conditions. It also includes specific reference to GOC in neonatal and paediatric patients. Uptake of the form in this patient population remains small but important. The resuscitation component of the GOC form documents the appropriateness of rapid response/code blue calls as well as ceilings of care (possible options range from full intensive care unit care to supportive and palliative care). This allows staff caring for dying patients outside the hospice setting to obtain immediate clinical support as required, irrespective of whether CPR is to be performed. The GOC form also allows people to document their wish to remain in their regional hospital for end‐of‐life care. The implications of this and inherent ceilings of care require detailed discussion with patients and family. The TEHS GOC form also requires the documentation of barriers to understanding, cultural responsibility and patient wishes. For some Aboriginal people, in certain instances, the patient may not be the key decision maker (despite having decision‐making capacity). The appropriate clinical information — the “right story” — needs to be provided to the appropriate person, usually referred to as the “right person”.6 The GOC form provides structured assistance to the completing clinician, to consider the involvement of Aboriginal liaison officers, interpreters and the culturally defined right people. Finally, it requires the completing clinician to consider whether the patient wishes to finish up on country. The revised NT APP and the GOC form were significant steps towards improved and patient‐focused end‐of‐life care. The working group also recognised that improved documentation required a more comprehensive strategy informed by data collection and research, and enriched by communications training for clinicians in order to be robust and capable of developing over time. Data collection and research In February 2019, Royal Darwin Hospital participated in a Commonwealth‐funded national study, led by Advance Care Planning Australia, which captured the prevalence of advance care directives and other types of advance care planning documentation in Australian health and residential aged care facilities.10 These data were useful to Top End clinicians regarding the impact of the recently introduced GOC framework. Health records of people aged 65 years and older who had been admitted for 48 hours were reviewed for advance care directives and medical orders or clinical care plans. The GOC forms are non‐statutory (not based in legislation) and were classified as medical orders. The prevalence of medical orders in audited health records at Royal Darwin Hospital was 46%. By comparison, the average prevalence of medical orders across all participating hospitals was 49%. The majority of these reflected either some limitation of treatments or were aimed at symptom control. A small number of patients (eight out of 50) had both an APP and a GOC plan. Only one document showed an incongruence between the APP wishes and the GOC wishes. This was related to the documentation of CPR provision in a patient who had stated in their APP that they did not wish to have CPR. Despite being only a single example, this discrepancy is consistent with findings elsewhere indicating that clinicians have a tendency to provide more care or more interventions than patients would choose were their wishes specifically discussed and followed.11 Communications training As part of the strategy to enhance the concept of shared decision making, which underpins patient‐centred care, the TEHS provided the first set of communications training workshops in March 2019. The workshops were iValidate (developed and delivered by Barwon Health) and Paediatric SimCom training (developed by Deakin University). Over 40 clinicians including nurses, doctors, allied health workers, Aboriginal health practitioners from hospital and community as well as primary health care practitioners attended the training. Additional Aboriginal and non‐Aboriginal participants were trained “on the run” as actors and helped to develop scenarios alongside experienced iValidate simulation actors. This enhanced the cultural context and the clinical authenticity of the scenarios used. Further workshops were held in June and a workshop was held in a regional hospital in November 2019. Facilitator training has also commenced in parallel to the communications courses in order to develop a local facilitator faculty enhancing the sustainability of the program. Next steps The development of a GOC framework and a culture of shared decision making is an evolving process. The next step is specific research on the effectiveness of GOC frameworks from the patient's perspective and the development of communications training that is increasingly informed by the concept of shared decision making. Significant areas that remain to be addressed include an improvement of the end‐of‐life experience on wards outside of the hospice, bereavement services within the hospital, mortuary services, and services to those who wish to die in regional hospitals, at home or on country.

Emma Spencer · Eswaran Waran

The existing system is failing to deliver the care that Australia expects Australia's aged care has changed considerably in recent decades. In response to consumer demand, old institutional‐style nursing homes have been progressively phased out in favour of better facilities. Home‐like furnishings and decor and single bedrooms personalised with residents’ own belongings have increasingly become the norm. In the process, they have become residential aged care facilities (RACFs), and there is no longer a distinction between low and high care.1 At the same time, older people want to stay in their own homes longer and have increasingly been able to do so because more community care is now available. Along with significant accommodation bonds and other charges, this has also served government objectives of reigning in the costs of Australia's ageing population.1 Contemporary residential care is no longer a lifestyle choice, it is now primarily for people who can no longer live at home. However, funding and staffing have not kept pace with this change.1 Aged care residents’ needs People living in RACFs now are typically very frail and have complex physical, cognitive and social care needs. During 2018, we independently assessed 5000 people living in RACFs.2 Only 15% of residents were independently mobile, one in two (50%) required mobility assistance, and over a third (35%) were not mobile. The bedridden group was at greatest risk of pressure injuries. People living in RACFs are vulnerable; the typical resident lacks energy and struggles with everyday activities. Most residents (> 80%) need help with activities such as showering, getting dressed or using the toilet. Moreover, many residents have memory, understanding and communication problems. Almost half of the residents find it difficult to interact with others and may become distressed when care staff try to assist them with personal hygiene, for example. Mental health problems are rife. Agitation is the most prevalent problem (43%), followed by depression (35%) and irritability (35%).3 There are about 180 000 residential care beds in Australia occupied on any one day by permanent residents.4 About 60 000 permanent residents die each year and about the same number take their place.5,6 The number of residents who die in their RACF is unclear. What is known is that many thousands are transferred to hospital due to staff not having the skills, confidence, capacity, resources or back‐up to provide the care they need.7 Neglect, the recently released interim report of the Royal Commission into Aged Care Quality and Safety, concluded that “substandard care is much more widespread and more serious than … anticipated”.7 Staffing in residential aged care facilities To inform its work, the Royal Commission requested a research study be carried out into residential care staffing.1 This involved a review of staffing standards internationally and an assessment of current Australian staffing levels against international and national standards. Australian staffing levels were calculated based on a time and motion study we conducted in 2018.3 Residents in Australia receive on average 188 minutes of care per day, which includes 36 minutes by registered nurses, 8 minutes by allied health professionals (mostly physiotherapists) and 144 minutes by personal care assistants.1 Anecdotally, registered nurses and allied health professionals are required to spend a disproportionate amount of time on paperwork for funding purposes, leaving even less time to spend on care. Adequate care time and staffing mix and levels So how can we tell if a RACF is providing adequate care time and has the right mix of staff? Our Royal Commission research considered these questions.1 The international literature consistently reports that staff time requirements are driven by resident function, cognition, behaviour and technical nursing requirements, and our 2018 research confirmed that these same drivers apply in Australia.3 The clear evidence in the international literature of a direct causal relationship between staff numbers and skill mix and resident safety and quality outcomes is equally applicable to Australia.8,9,10 Over 150 studies documented in systematic reviews, primarily from the United States, Canada, the United Kingdom and northern Europe, confirm a “strong positive impact of nurse staffing on both care process and outcome measures”.11 Organisational factors, such as professional staff mix (ratio of registered nurses to total staffing levels), staff turnover rates, use of agency staff, and consistency in staffing also have an impact on quality. We found that the five‐star rating system used in the US by the Centers for Medicare and Medicaid Services (CMS) is the most relevant system internationally for judging aged care in Australia. It has a strong evidence base and has been in widespread use for nearly 20 years.12 While it does not address allied health staffing levels, it could be developed to do so if such an approach were adopted in Australia. The CMS considers the amount of care time provided to residents by nursing and personal care staff and adjusts this according to the needs of residents in each home. The outcome is a rating of between one and five stars. The more stars the better. The five‐star threshold is the point at which there is no evidence of any additional quality improvements for residents (Box).12 As seen in the Box, Australian RACFs rate poorly compared with US RACFs. They also do badly compared with the standards in place in Germany and Canada and with the standards set down by the state governments of Victoria and Queensland.1 Research into the CMS system found that homes are more likely to “experience quality concerns” when staffing levels fall below a certain level.12 This threshold is equivalent to the minimum requirement for a three‐star rating (ie, 30 minutes of registered nurse time and 215 minutes of total time). Therefore, we determined that anything less than three stars is inadequate for Australian RACFs.1 Using these metrics, more than half of all Australian aged care residents (57.6%) are in RACFs that have inadequate (one or two stars) staffing levels. A little over a quarter (27.0%) are in RACFs that have three stars, 14.1% of residents are in RACFs with four stars, and 1.3% are in RACFs with five stars, which we consider best practice.1 Bringing all RACFs in Australia up to at least three stars would require an average staffing increase of 37.3% in those RACFs currently rated one or two stars, which would result in an overall increase of 20% in total care staffing across Australia. Achieving four stars would increase total staffing by 37.2% and five stars by 49.4%. Importantly, these increases are total numbers for the sector as a whole and need to be adjusted according to the mix of residents when applied to individual RACFs.1 The best international benchmark for allied health staff currently is from the Canadian province of British Columbia, which recommends a minimum of 22 minutes of allied health services per resident per day. Only 2% of Australian aged care residents currently receive this level of care. An additional 175% in allied health staffing is required to achieve this international standard.1 The evidence is clear Our research was requested by the Royal Commission against a background of numerous examples of poor quality care experienced by older people living in RACFs.1 A recurring theme has been the lack of staffing to meet the wide‐ranging and increasingly complex needs of residents — assertions that have been supported by the results of our research.1 It is clear from our research and from the evidence presented to the Royal Commission that there is a compelling case for additional resources in RACFs. This includes improving the staffing mix and increasing staffing levels to an acceptable standard. As the Royal Commission's interim report notes,7 the existing system has failed to ensure residents receive quality care. It is no longer acceptable to describe RACFs simply as a person's home or for advocates to argue that what is required is a social model of care delivered with a wellness philosophy.13,14,15 While on the surface it sounds attractive and in line with what consumers want, the evidence from the Royal Commission is that these arguments are now being used as a justification for inadequate care.7 Conclusion Residents in Australian RACFs have a right to be safe and to receive clinically competent and adequate care. This care needs to be provided within a non‐institutional environment that is respectful of individual choices and affords every resident the opportunity to be meaningfully engaged to the extent possible. There does not need to be a trade‐off between a social model of care and a clinically competent model. Aged care residents have a right to both and do not have the time to wait. Box – Star rating system for aged care facilities: comparison between Australia and the United States

Kathy Eagar · Anita Westera · Conrad Kobel

An objective measure could support GPs’ clinical judgement and aid discussions about the need for on‐road testing or driving cessation Assessing fitness to drive in older people is an increasingly important but challenging role for general practice. General practitioners are often the first port of call for concerned family or friends, and many Australian states and territories require older drivers to undergo regular assessment of their health and fitness to drive. Some GPs are uncomfortable in this role, citing concern to maintain relationships with older patients, concern about the impact of driving cessation, lack of familiarity with legal responsibilities and local resources, lack of training and clear guidance, lack of an objective measure, and poor access to on‐road driving assessments.1,2,3,4 Some GPs report sleepless nights having assessed an older person as fit to drive for another year.1 While the answer might be simple — that is, to speak to the older person and their family — this is not always straightforward. An objective measure of driving fitness could help. The number of older drivers in Australia is increasing, as is the number of seriously or fatally injured very old drivers (≥ 85 years of age).5 Older people are more vulnerable in road traffic accidents and are more likely to die or suffer severe injury.5,6 While road deaths in Australia have decreased overall in the past ten years (19%), road deaths in older people (≥ 75 years of age) have increased (23%).7 Driving is a complex task requiring sensory input (vision, hearing), cognitive function (attention, comprehension, memory, decision making, reaction time), and motor function (power, coordination).8 Ageing is associated with decline in sensory, cognitive and motor function. Accidents can happen to anyone, but road traffic accidents involving older drivers often receive widespread media attention. Recent examples include Prince Philip's driving accident at the age of 97 years, and the 86‐year‐old driver on the Sunshine Coast who reversed over and killed a 6‐year‐old girl.9 However, the loss of a driver's licence can be a devastating blow to independence and wellbeing.10 While many older drivers are safe and cautious drivers aware of their limitations, some are not. GPs play a key role in monitoring driver safety. GPs have two main responsibilities: to assess and make a recommendation on a driver's health and fitness to drive when requested, and to report to the relevant licensing authority any impairment adversely affecting a driver's ability to drive safely when impairment is known. The duty to report is discretionary in most Australian states, but in South Australia and the Northern Territory it is mandatory. Doctors who report in good faith are protected from civil and criminal liability for breaching patient confidentiality, except in the NT where there is no express legal protection.8 The requirements for medical assessment in older drivers of private vehicles vary across Australian states and territories (Box).8 In Queensland, the Australian Capital Territory and New South Wales, drivers are required to undergo an annual medical assessment from the age of 75 years; in Western Australia, drivers are required to have an annual assessment from 80 years of age; while in SA, the NT, Victoria and Tasmania, there is no specific age‐based requirement. Some states require on‐road testing from the age of 85 years for some licence classes. Each state licensing authority has developed its own medical assessment form, with substantial variation in the information collected. SA has the longest assessment form, with 73 tick‐boxes listing medical conditions. SA and WA also collect information about recent involvement in road traffic accidents. Most states require drivers to submit the completed form to the licensing authority themselves, but some states give GPs the ability to complete and submit the form online, preventing drivers discarding unfavourable assessments and doctor‐shopping. The GP role in assessment is to ensure that the health of older drivers meets medical standards and does not unduly increase their crash risk. Austroads and the National Transport Commission have produced an extensive document to guide GPs in assessment.8 While the Austroads document has much useful information, some GPs say its utility in the time‐pressured context of general practice is limited, and that the document lacks clear guidance on referral thresholds and use of screening tests.1,2 The document recommends that GPs assess functional ability across three domains — sensory, cognitive and motor function — and that the key question GPs should consider is: “Is there a likelihood the person will be unable to control the vehicle and act or react appropriately to the driving environment in a safe, consistent and timely manner?”.8 The document provides detailed guidance on the medical standards for driver licensing purposes for many medical conditions; however, it is less clear regarding the increasingly common grey zone where an older person may be mildly impaired across several domains, with multiple interacting conditions including mild cognitive impairment and multiple medications. The document recommends: “Professional judgement must determine what is acceptable decline … and what is irreversible, hazardous deterioration in driving‐related skills that requires reporting to the licensing authority”.8 If GPs are uncertain or concerned, the document recommends that they refer older drivers to a medical specialist or general occupational therapist for assessment, or to a driver assessor occupational therapist for on‐road testing.8 On‐road testing “remains the most accurate way of determining fitness to drive”.11 However, on‐road testing is likely an imperfect predictor of future crash risk,12 especially in the context of fluctuating health conditions, and in Australia can be difficult to access, especially in rural and remote areas, and costly.1,2 In practice, GPs often use the relevant state or territory medical assessment form to guide their assessment, and make their recommendation based on clinical judgement sometimes informed by a single cognitive screening test.1 The in‐office screening tools that GPs report using most often in Australia include the Montreal Cognitive Assessment, the Mini‐Mental State Examination, the clock‐drawing test, and the Trails Making Test.1,2,4 However, despite their widespread use in clinical practice, single screening tests do not reliably predict driving risk.13,14,15 A toolkit comprising a composite battery of tests correlates better than any single test with the on‐road driving assessment.13,14,15,16 A toolkit validated for use in general practice is needed. Such a toolkit would not replace the occupational therapist on‐road assessment, but could support GP clinical judgement in differentiating older drivers in need of on‐road testing or driving cessation, and could be used as a communication tool to support a recommendation for further assessment or driving cessation while preserving relationships (“the test says …”). A toolkit used regularly, say annually, might demonstrate change over time, which could guide discussions about the need to plan for eventual driving cessation. Several toolkits have been developed and tested internationally, but their uptake in general practice has been limited, sometimes by the need for special equipment or input from family members.11,14,17 To be feasible in the Australian general practice context, any toolkit would need to be easy and quick to administer and require no expensive equipment or special training. Ideally, a toolkit would assess across all three functional domains and have face validity with older drivers, as some older drivers may, for example, consider memory tests irrelevant to their driving ability. A toolkit developed and tested by a Belgian group looks promising.18 This toolkit comprises visual acuity using the Snellen chart, the Functional Reach Test,19 and a road signs recognition test (a component of the Stroke Drivers Screening Assessment20). These tests assess across all three functional domains and are potentially readily accessible in general practice. When tested in Belgian drivers aged ≥ 70 years, the three tests together correctly classified two‐thirds of drivers compared with the on‐road driving assessment.18 Preliminary use of the toolkit in three Australian GP practices (JM, GS) suggests that the toolkit is acceptable to both patients and practitioners, and that the tests can be completed in a timely fashion. No toolkit is likely to be perfectly sensitive and specific — there will always be a need for GPs to use clinical judgement. Nevertheless, an objective measure could support GPs’ clinical judgement and aid discussions about the need for on‐road testing or driving cessation. Work remains to validate and test a toolkit for use in Australian general practice. Box – Regulatory requirements for medical assessment of older drivers of private vehicles, and practitioner reporting duties, by Australian state or territory8 State or territory Medical assessment Patient declares crashes Duty to report Australian Capital Territory Annually from 75 years of age No Discretionary Not liable if report in good faith New South Wales Annually from 75 years of age No Discretionary Not liable if report in good faith Northern Territory Only when condition notified No Mandatory No express indemnity Queensland Annually from 75 years of age No Discretionary Not liable if report in good faith South Australia No prescribed period or age for licence class C, otherwise annually from 70 years of age Traffic crashes in past 5 years Mandatory Not liable if report in good faith Tasmania No prescribed period or age, but may occur if a condition or concern is declared or reported No Discretionary Not liable if report in good faith Victoria No prescribed period or age, but may occur if a condition or concern is declared or reported No Discretionary Not liable if report in good faith Western Australia Annually from 80 years of age, unless a medical condition requires earlier assessment Traffic offences and crashes Discretionary Not liable if report in good faith

Katharine A Wallis · James Matthews · Geoffrey K Spurling

Individualised care plans that take greater account of the behavioural and psychological needs of residents are needed

Gerard J Byrne

Objectives: To evaluate whether an alternative model of care in aged care facilities, including in‐house general practitioners, influenced health outcomes for residents. Design: Stepped wedge, cluster randomised controlled trial over 90 weeks (31 December 2012 – 21 September 2014), with a 54‐week pre‐trial retrospective data period (start: 19 December 2011) and a 54‐week post‐trial prospective data collection period (to 4 October 2015). Participants, setting: Fifteen residential aged care facilities operated by Bupa Aged Care in metropolitan and regional cities in four Australian states. Intervention: Residential aged care facilities sought to recruit general practitioners as staff members; care staff roles were redefined to allow registered nurses greater involvement in care plan development. Main (primary) outcome measures: Numbers of falls; numbers of unplanned transfers to hospital; polypharmacy. Results: The new model of care could be implemented in all facilities, but four could not recruit in‐house GPs at any time during the trial period. Intention‐to‐treat analyses found no statistically significant effect of the intervention on the primary outcome measures. Contamination‐adjusted intention‐to‐treat analyses identified that the presence of an in‐house GP was associated with reductions in the numbers of unplanned hospital transfers (incidence rate ratio [IRR], 0.53; 95% CI, 0.43–0.66) and admissions (IRR, 0.52; 95% CI, 0.41–0.64) and of out‐of‐hours GP call‐outs (IRR, 0.54; 95% CI, 0.36–0.80), but also with an increase in the number of reported falls (IRR, 1.37; 95% CI, 1.20–1.58). Conclusions: Recruiting GPs to work directly in residential aged care facilities is difficult, but may reduce the burden of unplanned presentations to hospitals and increase the reporting of adverse events. Trial registration: Australia New Zealand Clinical Trial Registry, ACTRN12613000218796 (25 February 2013).

Terry P Haines · Andrew J Palmer · Petra Tierney · Lei Si · Andrew L Robinson

Objective: To examine the prevalence of psychotropic medicine dispensing before and after older people enter residential care. Design: Retrospective national cohort study; analysis of Registry of Senior Australians (ROSA) data. Setting, participants: All concession card‐holding residents of government‐subsidised residential aged care facilities in Australia who entered residential care for at least three months between 1 April 2008 and 30 June 2015. Main outcome measures: Proportions of residents dispensed antipsychotic, benzodiazepine, or antidepressant medicines during the year preceding and the year after commencing residential care, by quarter. Results: Of 322 120 included aged care residents, 68 483 received at least one antipsychotic (21.3%; 95% CI, 21.1–21.4%), 98 315 at least one benzodiazepine (30.5%; 95% CI, 30.4–30.7%), and 122 224 residents at least one antidepressant (37.9%; 95% CI, 37.8–38.1%) during their first three months of residential care; 31 326 of those dispensed antipsychotics (45.7%), 38 529 of those dispensed benzodiazepines (39.2%), and 25 259 residents dispensed antidepressants (19.8%) had not received them in the year preceding their entry into care. During the first three months of residential care, the prevalence of antipsychotic (prevalence ratio [PR], 3.37; 95% CI, 3.31–3.43) and antidepressant dispensing (PR, 1.05; 95% CI, 1.04–1.07) were each higher for residents with than for those without dementia; benzodiazepine dispensing was similar for both groups (PR, 1.01; 95% CI, 0.99–1.02). Conclusions: Dispensing of psychotropic medicines to older Australians is high before they enter residential care but increases markedly soon after entry into care. Non‐pharmacological behavioural management strategies are important for limiting the prescribing of psychotropic medicines for older people in the community or in residential care.

Stephanie L Harrison · Janet K Sluggett · Catherine Lang · Craig Whitehead · Maria Crotty · Megan Corlis · Steven L Wesselingh · Maria C Inacio

Compared with age-matched men, women tend to have poorer health status but longer life expectancy

Emily H Gordon · Ruth E Hubbard

To the Editor: In July 2019, sarcopenia — a progressive and generalised skeletal muscle condition involving loss of skeletal muscle mass and function1 — was awarded a code in the International Classification of Diseases, tenth revision, Australian modification (ICD‐10‐AM). This recognition has arrived 30 years after Irwin Rosenberg first described the condition in 1989.2 Sarcopenia is independently associated with poor quality of life, falls, fractures, institutionalisation and mortality.1 About 13–19% of community‐dwelling older adults may have this condition, and prevalence is highest among those living in residential care.1 All individuals experience declines in muscle mass and function during ageing, but only those who meet the criteria described in the Box are considered to have sarcopenia. The definition currently promoted by the Australian and New Zealand Society for Sarcopenia and Frailty Research is the initial European Working Group on Sarcopenia in Older People definition,3 which was adopted after a Delphi consensus.5 Measures of muscle strength and physical performance such as grip strength, chair stands and gait speed are cost‐effective and easy to perform in clinical practice. Obtaining measures of muscle and lean mass may be challenging outside of the research setting. Therefore, in individuals with low muscle strength or physical performance, in the absence of other potential causes (eg, osteoarthritis), sarcopenia should be suspected and safe and effective interventions can be offered. Patients with, or at risk of, sarcopenia should be recommended exercise therapy, in particular, progressive resistance training.1 This type of training prescribed by treating clinicians can be implemented by allied health professionals, including exercise physiologists and physiotherapists. Protein supplementation can prevent loss of muscle, but this is most beneficial when combined with progressive resistance training.1 A number of randomised controlled trials are underway examining different therapeutics for the treatment of sarcopenia.1 With the advent of the ICD‐10‐AM code, primary care clinicians, allied health staff, and members of the public will begin observing sarcopenia diagnoses on medical correspondence. Hospital funding models may adjust in line with the ICD‐10‐AM code and in recognition of the increased complexity and risk of complications that comes with caring for patients with sarcopenia. An understanding of this condition, its implications and treatment is key in providing evidence‐based care to patients living with sarcopenia. Box – Diagnostic tools and measurements to diagnose sarcopenia* using the initial European Working Group on Sarcopenia in Older People (EWGSOP) definition†3 Component Thresholds and equipment Low muscle strength Hand grip strength using dynamometer: Men: < 30 kg Women: < 20 kg Low physical performance Men and women over 4 m course: Gait speed: ≤ 0.8 m/s Low lean mass ALM using whole‐body DXA (adjusted for height, m2): Men: < 7.26 kg/m2 Women: < 5.50 kg/m2 ALM = appendicular lean mass; DXA = dual x‐ray absorptiometry. * Diagnosis of sarcopenia is based on low lean mass and low physical performance or muscle strength. † The EWGSOP have developed a revised definition for sarcopenia (known as EWGSOP2);4 however, this has not yet been recommended for use in Australia.

Jesse Zanker · David Scott · Sharon L Brennan‐Olsen · Gustavo Duque

… but how are we deciding which patients are selected for ICU referral and admission?

Alison M Mudge