Ageing

To the Editor:There are some populations for whom unequal health cannot be overcome and a preoccupation with preserving health detrimentally affects their quality of life.1 Imagine you live in residential aged care, your health is irreversibly poor and you have days left to live. You want to go for a walk in the sunshine, but are prevented from doing so in case you fall and harm yourself. Your health cannot improve; yet, you are denied the opportunity to enjoy life. Quality of life is influenced by health, as well as social support, autonomy and spiritual fulfilment.2 Society encourages younger people to take risks to fulfil their potential and enjoy life; however, we prevent older people from doing the same. By denying this population the “dignity of risk”,3 we are denying them an opportunity to optimise their quality of life. This optimisation requires recognising that focusing on inequality in health will not always overcome an unequal quality of life, especially for vulnerable older people. Most residents of aged care facilities have multiple comorbidities contributing to poorer health, but this need not equate to a suboptimal quality of life. The goal should be to enable older people to enjoy their life by supporting them to fulfil their potential. People with a similar stage of dementia who live at home report a higher quality of life than those in residential aged care.4 Living at home provides greater independence, illustrating the importance of considering a multifaceted quality of life. If professionals focus only on improving health and not all factors contributing to quality of life, then inadvertently, neither health nor quality of life will improve. Enabling individuals to make choices, even those with a risk of harm, is a pathway to improving quality of life for everyone, including people with irreversible poor health.

Alice L Holmes · Marta H Woolford · Joseph E Ibrahim

To the Editor: I read with some concern the study by Ibrahim and colleagues1 published in the Journal. In their epidemiological study of deaths of nursing home residents reported to the coroner, the authors reported a more than quadrupling of the rate of deaths due to falls over the decade from 2002 to 2012, and deemed these deaths to be preventable and premature. In their discussion, Ibrahim and colleagues1 insinuate that this increased rate of deaths due to falls relates to some extent to a decline in the standard of care provided to nursing home residents. As this study lacks a control group, fundamentally, there is a problem in making any assumptions about preventable deaths and care provided to nursing home residents. This problem is particularly pertinent in light of data published by the Australian Institute of Health and Welfare which show an almost 40% increase in the rate of injury hospitalisations for older Australians, predominantly due to falls, over a similar 10-year period.2 A subsequent publication by the Australian Institute of Health and Welfare reports that 50% of all falls in older people resulting in hospitalisation occur in or around the home and that only 22% occur in an aged care facility.3 Therefore, one could ask whether there has been a similar increase in the rate of premature and preventable deaths due to falls of older Australians who live in their own homes. Clearly, further research on falls in general is required before any conclusions about possible causes can be made.

Henry Zeimer

To the Editor: Ibrahim and colleagues1 are to be congratulated for finding a source of information that throws some light on what is happening in Australian aged care facilities, because there is so much positive rhetoric and so little reliable data about aged care coming from the sector itself. The study by Ibrahim and colleagues1 reveals an increase in deaths from external causes, including falls and choking, but we need context. In his 1993–94 report, Gregory2 indicated that in the proposed market-driven aged care system “neither the current standards monitoring system, nor any alternatives considered, would be able to prevent the diversion of funding from nursing and personal care to profit”. However, the government policy is driving consolidation and corporatisation using a competitive profit-driven model. International data indicate that an increased focus on profitability in aged care is associated with poorer staffing and increased failures in care.3 Studies in Australia and the United States over the past 35 years indicate that, on average, 4 hours or more per person per day of nursing care are required for safe care. Available data indicate that, in Australia, only 2.8 hours are provided. As acuity has increased, the proportion of trained staff has fallen. Our residents receive less than half the nursing time from registered and trained nurses compared with the US and an hour less of total nursing care each day.3 Safe care cannot be provided with these staffing levels; yet, over 95% of facilities are accredited by the Australian Aged Care Quality Agency. Braithwaite and colleagues,4 who have studied the regulation of aged care, conclude that aged care regulation has been captured by the market and is ineffective and warn that “the community should be concerned”. While politicians and the industry talk up our system, it is becoming increasingly clear that the many failures (often in recently accredited facilities) reported in the press are red flags to systemic problems that a succession of captured inquiries into a system that is anything but world class have avoided addressing. With some exceptions, our profession seems to have disengaged from the sector and one wonders if they have been captured too.

J Michael Wynne

To the Editor: The study published by Ibrahim and colleagues1 raises questions about the quality of care delivered in residential aged care facilities. This analysis of routinely recorded coronial data identified that 15% of premature and preventable residents’ deaths resulted from external causes, with falls being the most frequent culprit. Falls in residential aged care facilities are well recognised, with about half of all residents falling within a given year.2 Residents tend to be older and frailer, have higher rates of dementia and higher rates of psychotropic medication use compared with community-dwelling older people, which contributes to higher rates of falls. A falls risk assessment, using validated tools and appropriately qualified personnel, has the potential to reduce the rate of falls and related injuries by addressing individual and environmental risk factors.3 While the residential aged care sector is subject to variation in staffing numbers and skill mix, mandatory education related to falls prevention is also needed. The Australian Commission on Safety and Quality in Health Care’s Preventing falls and harm from falls in older people — best practice guidelines for residential aged care facilities4 provide a helpful framework. In a separate study, Ibrahim, the lead author of the MJA article, and Davis5 state that residents in aged care facilities are entitled to the “dignity of risk” principles that allow them autonomy to accept risks that may be associated with short term increases in their quality of life. However, the reality is that a person’s quality of life is often determined by risk management rather than autonomy,6 which reflects a form of age discrimination whereby the risk of injury of falls and its consequences outweighs the older person’s quality of life, by making assumptions about their ability to make choices about their everyday activities. Promoting dignity and autonomy for older residents in aged care may see greater falls rates but it will allow residents to enact their choices. The work by Ibrahim and colleagues1 needs to be understood within this context.

Judy A Lowthian · Claudia Meyer · Dianne Goeman · Colette Browning

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Joseph E Ibrahim · David L Ranson · Lyndal Bugeja

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David Scott · Barbora de Courten · Peter R Ebeling