Ageing

Objective: To examine the impact of a national current affairs television program about the association between osteonecrosis of the jaw and bisphosphonates on subsequent prescription use, fractures and deaths.Design and setting: National Pharmaceutical Benefits Scheme prescription data for 9 months after the television program were used to estimate the impact of reduced bisphosphonate use on fractures and mortality.Main outcome measures: Prescription rates, fractures and deaths.Results: The estimated reduction of 29 633 in the number of bisphosphonate prescriptions may have resulted in 70 hip fractures, 60 other fractures and 14 deaths that would otherwise have been prevented over the 9-month period of the study.Conclusion: Although it is important for patients to be informed of the risks of medication, media coverage that does not present a balanced view has the potential to do more harm than good.

Philip N Sambrook MD, LLB, FRACP · Jiang S Chen PhD · Judy M Simpson BSc, PhD · Lyn M March PhD, FRACP

Older people living in residential aged care facilities (RACFs) are at considerably higher risk of suffering fractures than older people living in the community. When admitted to RACFs, patients should be assessed for fracture risk to ensure early implementation of effective fracture prevention measures. Routine or regular determination of calcium and phosphate serum levels in institutionalised older people is not indicated. Opinion is divided about the value of routine measurements of serum concentrations of 25-hydroxyvitamin D, parathyroid hormone and bone turnover markers. The non-pharmacological approach to fracture prevention includes multifactorial programs of falls prevention and the use of hip protectors. Vitamin D supplementation is recommended for all patients in RACFs. Dietary calcium intake should be optimised (1200–1500 mg per day is recommended) and supplementation offered to those with inadequate intake. The decision to prescribe calcium supplements should be guided by patients’ tolerance, whether or not they have a history of kidney stones, and emerging data about its cardiovascular safety. Bisphosphonates are the first-choice pharmacological agents for fracture prevention in older persons at high risk. Intravenous administration is as efficient as oral and has the significant advantage of better adherence. Use of strontium ranelate has not been tested on people in RACFs, but evidence in the “old-old” (those aged 75 years and older) suggests it could be a therapeutic option for fracture prevention in this setting. In general, teriparatide should not be considered as a first-line treatment for fracture prevention, particularly for people in RACFs.

Gustavo Duque MD, PhD, FRACP · Jacqueline J Close MD, FRCP, FRACP · Julien P de Jager FRACP · Peter R Ebeling MD, FRACP · Charles Inderjeeth MB ChB, MPH, FRACP · Stephen Lord PhD · Andrew J McLachlan PhD · Ian R Reid MD, PhD · Bruce R Troen MD · Philip N Sambrook MD, FRACP

To the Editor: We describe here some of the difficulties in managing and investigating outbreaks of viral respiratory infection in aged care facilities (ACFs) in the context of an influenza pandemic. This adds to the previous report on logistics in a hospital setting.1 On 12 June 2009, NSW Health received a call from a surveillance officer in a remote town regarding a possible pandemic (H1N1) 2009 influenza outbreak in an ACF. On 9 June, a 77-year-old female resident had become unwell, without specific symptoms of influenza-like illness. From 7 to 10 June, nine of the other 27 residents developed influenza-like illness. On 10 June, nasal swabs were taken from the 10 unwell residents by the local general practitioner for influenza nucleic acid testing (NAT). On 12 June, the index case tested positive for pandemic influenza, while the other residents tested negative. Due to concern that there might be a pandemic influenza outbreak in the facility, the index case and the nine residents with influenza-like illness were given oseltamivir (75 mg twice a day for 5 days) from 13 June; the other 18 residents and the 27 staff were given oseltamivir prophylaxis (75 mg daily for 10 days). A formal outbreak investigation and further laboratory testing (NAT, serological testing) revealed a dual outbreak dominated by rhinovirus (10 cases), with two cases of pandemic influenza and one case of untyped influenza A. All 28 residents and 26 of the 27 staff had received seasonal influenza vaccine in early 2009. This outbreak illustrates that more than one respiratory virus may co-circulate in ACFs during winter outbreaks of respiratory infection. We followed Department of Health and Ageing policy guidelines for oseltamivir use in ACFs2 and the facility was closed to visitors from 12 to 18 June. However, as all residents had received seasonal influenza vaccination, and given that older people are generally at lower risk of pandemic (H1N1) 2009 influenza,3 we could have had a higher threshold for oseltamivir use. The total estimated cost of treatment and prophylaxis was $2750 (55 residents and staff at $50/person) for oseltamivir alone. Co-infection with respiratory viruses may be more common than thought in ACFs; a recent Canadian study found two and three different pathogens in 15% and 4% of respiratory infection outbreaks, respectively, from a total of 83 outbreaks (of which 91% occurred in long-term care facilities).4 If many ACF outbreaks have more than one respiratory virus involved, laboratory investigations should take a multiplex approach that covers common respiratory viruses. As many patients as practical (at least five) should be swabbed and tested to guide treatment, prophylaxis and other investigations. Community influenza surveillance should ideally include information on sensitivity to oseltamivir, and on other circulating respiratory viruses.

Gulam Khandaker · Bridget Doyle · Dominic E Dwyer · Robert Booy

Older road users. Myths and realities, a guide for medical and legal professionals. Morris S Odell, Editor. Tucson, Ariz: Lawyers & Judges Publishing Company, Inc, 2009 (xvi + 302 pp). ISBN 978 1 933264 70 7. Traffic medicine is an emerging discipline, so not many resources are available on the subject. The fact that the editor of this book, Morris Odell — a Forensic Physician at the Victorian Institute of Forensic Medicine in Melbourne — is also my former teacher for whom I have great respect, made me read it with added interest. The proportion of elderly drivers is expected to rise significantly in the next 50 years and the role of medical practitioners in assessing their medical fitness to drive will increase. At present, there are no strict guidelines for assessing elderly drivers’ medical fitness to drive since, in many instances, the evidence available is contradictory. This book acknowledges the limitations of the assessment process, but provides abundant information to help readers form their own opinions. I found this approach to be unbiased, unintrusive and fair. The book was commissioned by VicRoads, in response to the 2003 Inquiry into Road Safety for Older Road Users by the Victorian Parliament Road Safety Committee. It addresses the main factors that affect driving skills — vision, cognition and motor function, with particularly interesting chapters on the effects of prescription drugs, and respiratory and sleep disorders. In addition, it examines different patterns of road injuries and the distinct crash epidemiology of elderly drivers. Odell has assembled a stellar team of contributing authors and the information provided is contemporary, easy to understand and backed up by evidence. The assessment options and principles of the assessment process of elderly drivers are explored in detail but the book stops short of recommending a particular assessment tool. Furthermore, it does not take a preferred position or make recommendations for when the elderly should not drive. This omission could be compensated by grabbing a copy of Austroad’s Assessing fitness to drive 2003, which gives strict recommendations for when people should not be driving. Apart from these small omissions, this is a great reference that gave me a lot of answers to questions that I haven’t been able to find for years. It will benefit medical and legal professionals whose work involves elderly drivers, as well as students and young doctors who would like to learn more about the relationship between different medical conditions and their impact on driving safety.

Ilian Kamenoff

Objective: To test the effectiveness of using a full-time project nurse to assist residential aged care facilities in using evidence-based approaches to falls injury prevention.Design, setting and participants: Cluster randomised controlled trial involving 5391 residents in 88 aged care facilities in the Hunter and Lower Mid North Coast areas of New South Wales. Residents were followed for 545 days or until death or discharge. Data were collected from July 2005 to June 2007.Intervention: Employment of a project nurse to encourage best-practice falls injury prevention strategies during the 17-month intervention period.Main outcome measures: Monthly data about falls, falls injury and falls injury prevention programs; audit of hospitalisation for fractured neck of femur.Results: Despite significant increases in the provision of hip protectors and use of vitamin D supplementation in both intervention and control facilities, there was no difference in the number of falls or falls injuries between the intervention and control groups, nor a reduction in falls overall. There was also no difference between the 7-month pre-intervention period and the intervention period in the number of falls or falls injuries. Factors related to residents having an increased risk of falls with fractured neck of femur included being ambulant, having dementia, increasing age, and having a high falls risk assessment score.Conclusion: It is difficult to change falls risk among high-risk populations, including people with dementia. The use of important strategies such as hip protectors and vitamin D and calcium supplementation increased during the study, probably with contamination of control facilities. Longer follow-up may be required to measure the impact on falls outcomes of the strategy of using a facilitating nurse.Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12605000540617.

John A Ward MB BS, FRACP MSc(CommHealth) · Mandy Harden BA, GradDipEd · Richard E Gibson BSc, DipEd, DipMedStats · Julie E Byles BMed, PhD

Objective: To describe the prevalence of depressive symptoms in older male Italian-born Australian immigrants.Design, participants and setting: Cross-sectional study of 335 Italian-born and 849 Australian-born men aged 70 years and over who completed written questionnaires and were interviewed in the baseline phase of the Concord Health and Ageing in Men Project (CHAMP).Main outcome measures: Depressive symptoms assessed by the short (15-item) form of the Geriatric Depression Scale; associations between depressive symptoms and country of birth.Results: The prevalence of depressive symptoms in Italian-born men was 18%, almost twice the prevalence of 10% in Australian-born men (odds ratio [OR], 1.9; 95% CI, 1.2–3.0). After adjusting for socioeconomic and health factors, the relationship between country of birth and depressive symptoms was attenuated and no longer statistically significant (OR, 1.7; 95% CI, 0.9–3.0). The strongest confounders of the relationship between country of birth and depressive symptoms were source of income and satisfaction with social support.Conclusion: Male Italian-born immigrants aged over 70 years report more depressive symptoms than their Australian-born counterparts. This association appears to be explained by increased reliance on a government pension as the sole source of income and lower satisfaction with social support among Italian-born men. However, these findings need to be confirmed longitudinally.

Fiona F Stanaway MB BS, MPH · Robert G Cumming MB BS, MPH, PhD · Vasi Naganathan FRACP, MMed(Clin Epi), PhD, Grad Cert Med Ed · Fiona M Blyth MPH, FAFPHM, PhD · Helen M Creasey MB BS, FRACP · Louise M Waite MB BS, FRACP, PhD · David J Handelsman MB BS, FRACP, PhD · Markus J Seibel MD, FRACP, PhD

Objective: To assess the extent to which general practitioners in Australia are engaged in identifying age-related hearing loss and facilitating its management.Design, setting and participants: Cross-sectional analysis of data collected between 1998 and 2000 from the Blue Mountains Hearing Study (BMHS), a representative population-based cohort of people aged ≥ 50 years in two postcode areas west of Sydney. Also analysed were data collected between 2003 and 2008 from random samples of Australian GPs who participated in the Bettering the Evaluation and Care of Health (BEACH) study, a national continuous cross-sectional survey of GP activity.Main outcome measures: Rate of facilitating management and identification of hearing loss in older patients; content of GP–patient encounters with hearing-impaired people; characteristics of participants seeking help from their GP.Results: Of older people in the BMHS with measured (objective) bilateral hearing loss, about a third reported seeking help frovm their GP. BEACH survey data showed that only about 3 per 1000 GP consultations with patients aged ≥ 50 years involved management of age-related hearing loss. For every 100 age-related hearing problems managed, GPs undertook 12 procedural treatments, provided 20 referrals to specialists, and made 29 referrals to allied health professionals.Conclusion: In their routine consultations with patients, GPs have opportunities to identify hearing loss and appropriately refer patients to specialists or allied health professionals. Although GPs are responding to patient presentations for hearing loss, referring around 50% of cases, there appear to be relatively few cases in which hearing loss is identified opportunistically. Levels of identification and management of hearing loss by GPs in Australia are relatively low.

Julie M Schneider BAppSc(Hons), PhD · Bamini Gopinath BTech(Hons), PhD · Catherine M McMahon PhD · Helena C Britt BA, PhD · Christopher M Harrison BPsych(Hons), MSocHlth · Tim Usherwood MD, BS · Stephen R Leeder MD, PhD · Paul Mitchell MD, PhD, FRANZCO

Objective: To update evidence-based guidelines for the treatment of proximal femoral fractures published in the Journal in 2003.Data sources: Systematic search of MEDLINE, CINAHL and EMBASE for articles published from October 2001 to June 2008, and the Cochrane Database of Systematic Reviews (most recent issue searched — Issue 2, 2008).Study selection: Randomised controlled trials and meta-analyses of all aspects of acute-care hospital treatment and rehabilitation for proximal femoral fractures among participants aged 50 years or older with proximal femoral fractures not associated with metastatic disease or multiple trauma.Data extraction: All studies were reviewed independently by two assessors, who recorded individual study results, and an assessment of study quality and treatment conclusions was made according to Cochrane Collaboration protocols. If necessary, a third review was performed to reach consensus.Results: 128 new studies were identified and 81 met our inclusion criteria. Recommendations for time to surgery, thromboprophylaxis, anaesthesia, analgesia, prophylactic antibiotics, surgical fixation of fractures, nutritional status, mobilisation and rehabilitation have been updated. Also, recommendations regarding surgical wound closure, management of postoperative delirium, osteoporosis treatment and hip protectors have been added. The guidelines include the current National Health and Medical Research Council grades of recommendations for clinical guidelines.Conclusions: Significant changes in recommendations have been made, particularly in relation to surgery, rehabilitation and tertiary prevention. Hip fracture should be treated according to the most up-to-date evidence to achieve the best possible outcomes and optimal use of limited resources.

Jenson C S Mak MB BS, FRACP, FAFRM(RACP) · Ian D Cameron MB BS, PhD, FAFRM(RACP) · Lyn M March MB BS, PhD, FRACP

Objective: To evaluate the acceptance and cost of a ward-based geriatric consultation service delivered via a mobile videoconferencing system.Design and setting: Prospective observational study conducted in the geriatric unit of Toowoomba Base Hospital, Queensland, comparing a specialist consultation service delivered by videoconference (VC) with a “traditional” in-person service. The VC system was established in January 2007 and evaluated over an 18-month period. Patient satisfaction with the service was assessed by questionnaire during a 1-week period in September 2008.Main outcome measures: Hospital acceptance of the service; patient satisfaction with the service; comparative cost of providing in-person and VC-mediated consultations.Results: Uptake of the service increased progressively throughout the study period. Patient acceptance levels were high. The cost of video consultations for a 12-patient ward round and case conference was less than the cost of in-person consultations if the total road distance travelled by the specialist (Brisbane to Toowoomba and back) was 125 km or longer.Conclusion: Consultations via VC are an acceptable alternative to in-person consultations, and are less expensive than in-person consultations for even modest distances travelled by the clinician.

Leonard C Gray MB BS, PhD, FRACP · Olivia R Wright PhD · Alison J Cutler MB BS, FRACP · Paul A Scuffham BA, PhD · Richard Wootton DSc, PhD

Objectives: To estimate the prevalence of depression among older Australians with common medical morbidities, and to determine the association between poor physical health and depression in this age group.Design: Cross-sectional, postal questionnaire survey.Setting and participants: 20 183 community-dwelling adults aged 60 years and over, under the care of 383 general practitioners participating in the Depression and Early Prevention of Suicide in General Practice (DEPS-GP) project (conducted between 2005 and 2008; the data in this article were collected during the baseline phase of the study in 2005).Main outcome measures: Depressive symptoms (measured by the nine-item depression scale of the Patient Health Questionnaire), health status (measured by the 12-item Short Form Health Survey and a medical morbidity inventory), social support (measured by the subjective support subscale from the Duke Social Support Index), and demographic and lifestyle information.Results: 18 190 participants (90.1%) reported having at least one chronic physical health condition, while 1493 (7.1%) experienced clinically significant depression (3.1% major depressive syndrome; 4.0% other depressive syndrome). Most chronic physical illnesses were associated with increased odds of depression, and participants with numerous medical morbidities and a high level of functional impairment were three to four times more likely to have a depressive illness.Conclusions: Depression is more the exception than the rule in later life, and among those who are medically unwell, the level of associated impairment may determine their risk of depression more than their acquired physical illness. Many of the factors associated with depression in medically ill patients are amenable to treatment, and GPs are in a unique position to address this important public health issue.

Jon J Pfaff PhD, MSc · Brian M Draper MD, FRANZCP · Jane E Pirkis PhD, MPsych · Nigel P Stocks MD, FRACGP · John A Snowdon MD, FRANZCP · Moira G Sim MB BS, FRACGP, FAChAM · Gerard J Byrne PhD, FRANZCP · Nicola T Lautenschlager MD, FRANZCP · Leon A Flicker PhD, FRACP · Ngaire M Kerse PhD, FRNZCGP · Robert D Goldney MD, FRANZCP · Osvaldo P Almeida PhD, FRANZCP

Objective: To determine the number of older Western Australians who had a gastrostomy tube (GT) placement from 1994 to 2004, to describe their characteristics, and to examine outcomes after GT placement, including rehospitalisation for complications and survival.Design and data sources: Secondary analysis of hospital (inpatient) data and linked mortality data from the WA Data Linkage System.Main outcome measures: Patient characteristics (age, sex and morbidity profile); numbers of GT closures, replacements and complications within 1 year of GT placement; age- and sex-specific survival outcomes calculated at 7, 30, 60 and 180 days, and 1 and 3 years; and mortality hazard ratios calculated for six conditions of interest, identified using all available diagnosis information on the inpatient record.Results: In Western Australia, 2023 people aged 65 years or older underwent a GT placement for the first time during the period 1994–2004, half of whom had a known history of cerebrovascular disease (50.3%). Rehospitalisation within 1 year for a GT replacement procedure, mechanical complications and incident pneumonitis occurred in 13%, 4% and 9% of patients, respectively. More than half of the patients who underwent a GT placement died within 1 year. Survival outcomes were poorest for patients with motor neurone disease and metastatic cancer.Conclusion: To better understand this complex area of health care, questions regarding decision making — by patients, families, physicians, hospitals and other caring organisations — about GT placement and maintenance need to be addressed.

Janine Calver PhD · Kieran A McCaul PhD · Melinda Burmas BCM · Barbara J Horner PhD · Leon Flicker MB BS, PhD, FRACP

To the Editor: There can be little disagreement with Richmond’s assessment that Australia needs more research on the oldest old.1 Certainly, data on centenarians are sparse and unreliable, and there is a need for more thorough and more informed evaluation. The 2006 census was the first recent census to record centenarians’ ages. The 2001 census recorded ages to “100 +”,2 while previous censuses had recorded ages to “99 +”.3 Pre-2006 centenarian percentage age distributions are non-validated “guestimates”.4 Further, the number of centenarians enumerated is questionable5 because of its dependence on age reporting, which suffers inaccuracies from proxy reporting, age exaggeration and rounding. Adjusted population estimates for mid 2007 include 2832 centenarians6 — considerably lower than the 2006 count of 3154 quoted by Richmond.1 Errors in centenarian numbers mean that census tabulations of centenarians’ characteristics (marital status, living arrangements) and derived demographic measures (sex ratios, growth rates) are unreliable. Mortality estimates are also affected. Alternative data, collected through administrative sources or special studies that verify birth and death dates, are needed to reliably estimate mortality in the oldest old and the probability of survival to 100 years and beyond. Richmond’s discussion of the “fastest growing age segment” does not make a clear distinction between growth in the proportion of the population who are centenarians and growth in the number of centenarians. Growth of centenarians as a proportion of total population depends on population structure. Relatively recent fertility declines will have had a similar effect on the proportion of the population aged 60–99 years as on centenarians. Reductions in infant, child and maternal mortality serve to increase the proportion of people who are in younger age groups and thus reduce the proportion who are centenarians. The recent rapid increase in the centenarian proportion is actually the combined effect of larger cohorts reaching old age and increased survival at older ages.7 In Australia, past migration is a major determinant of the relative size of different cohorts. Comparing the cohort aged 100–104 years in 2001 with the cohort of the same age in 2006 (the younger), births data show there were 11 300 more people at birth in the younger cohort.8 Large fluctuations in the difference between the sizes of these cohorts in the age range 25–84 years (from 20 100 to 43 300), calculated from successive population age distributions,9 demonstrate the influence of migration on relative cohort size. Whatever the effects of recent changes in fertility and mortality, historical determinants of population structure significantly influence the number of centenarians from one census date to the next. Two further factors apply to growth in numbers: first, it is easy to achieve a high growth rate for a small group, and second, the 100+ age interval is expanding (whereas younger age groups are of fixed width).

Heather Booth

Objective: To describe the steps taken by health professionals to diagnose dementia and the timeframes for these steps, as reported by carers.Design, setting and participants: A cross-sectional, anonymous survey was mailed or distributed by Alzheimer’s Australia New South Wales, six Sydney residential aged care facilities and 13 Sydney general practitioners to 415 carers or family members of patients with dementia between May and August 2007.Main outcome measures: First symptoms noticed and actions taken; time to first health professional consultation and diagnosis; reported actions of first health professional; satisfaction with first consultation; and use of dementia and chronic illness resources.Results: 209 surveys were returned. Family members noticed the first symptoms of dementia at a mean of 1.9 years before the first health professional consultation about dementia, and 3.1 years before a firm diagnosis. Resource use first occurred 2.8 years after the first symptoms. Most carers (72%) were satisfied with the first consultation, which was usually with a GP (84%). Two-thirds of carers (64%) reported that the first health professional had performed a memory test.Conclusions: Delays in presentation, diagnosis and resource use may have clinical and social implications for people with dementia and their families, in addition to the challenges of the process of obtaining a firm diagnosis.

Catherine M Speechly BMedSc, FRACGP · Charles Bridges-Webb MD, FRACGP · Erin Passmore BA(Hons)

Objective: To assess the quality of Australian clinical guidelines for chronic diseases and their relevance to older people with multiple comorbid conditions. Design: Selection and assessment of national clinical guidelines for chronic conditions listed as National Health Priority Areas: cardiovascular health, diabetes mellitus, mental health, asthma, arthritis and musculoskeletal conditions, and cancer. Main outcome measures: Standardised mean scores obtained with the Appraisal of Guidelines Research and Evaluation (AGREE) instrument (criteria grouped into six domains: scope and purpose; stakeholder involvement; rigour of development; clarity and presentation; applicability; and editorial independence). Relevance of guidelines for older people with multiple comorbid conditions. Results: 17 guidelines were included in the study. Guidelines approved by the National Health and Medical Research Council (NHMRC) scored significantly better than those not approved by the NHMRC in all domains except for editorial independence and clarity and presentation. The mean quality of guidelines not approved by the NHMRC was below 50% in all domains except clarity and presentation. Half of the guidelines addressed treatment for older patients or for patients with one comorbid condition, but only one addressed treatment for older patients with multiple comorbid conditions. Conclusions: Professional societies and charities should be encouraged and supported to develop clinical guidelines in compliance with NHMRC requirements. Future guidelines should place more emphasis on the management of older people with multiple comorbid conditions.

Agnes I Vitry PhD · Ying Zhang MB BS, PhD

Objective: To develop screening tools for predicting falls in nursing home and intermediate-care hostel residents who can and cannot stand unaided.Design and setting: Prospective cohort study in residential aged care facilities in northern Sydney, New South Wales, June 1999 – June 2003.Participants: 2005 people aged 65–104 years (mean ± SD, 85.7 ± 7.1 years).Main outcome measures: Demographic, health, and physical function assessment measures; number of falls over a 6-month period; validity of the screening models.Results: Ability to stand unaided was identified as a significant event modifier for falls. In people who could stand unaided, having either poor balance or two of three other risk factors (previous falls, nursing home residence, and urinary incontinence) increased the risk of falling in the next 6 months threefold (sensitivity, 73%; specificity, 55%). In people who could not stand unaided, having any one of three risk factors (previous falls, hostel residence, and using nine or more medications) increased the risk of falling twofold (sensitivity, 87%; specificity, 29%).Conclusions: These two screening models are useful for identifying older people living in residential aged care facilities who are at increased risk of falls. The screens are easy to administer and contain items that are routinely collected in residential aged care facilities in Australia.

Kim Delbaere MPT, PhD · Jacqueline C T Close MD, FRCP · Hylton B Menz BPod(Hons), PhD · Robert G Cumming MB BS, PhD · Ian D Cameron MB BS, PhD · Philip N Sambrook MD, LLB · Lyn M March MB BS, PhD · Stephen R Lord PhD

To the Editor: Although there are data on the population needs for residential aged-care facilities (RACFs)1 and models of engagement by general practitioners once someone is resident in a facility,2-4 there are ongoing administrative barriers for people trying to secure a place in an RACF. The aim of requesting data before admission is to provide continuity and quality of care, but the burden of paperwork currently falling on family members and GPs is of concern. We initiated an audit when it became apparent that local acute public and private hospital inpatient units had a policy of insisting that once an inpatient was eligible for RACF residency, he or she was required to be placed on waiting lists for 8–10 different RACFs. As part of a broader project to coordinate better care at times of transition, all RACFs in southern Adelaide (feeder population 400 000) were approached to provide us with the forms that need to be completed before someone can be placed on their waiting list. All 22 facilities in southern Adelaide provided a copy of the application pack that they normally give to a family member. A median of 4.5 forms had to be completed before a person could be placed on a waiting list (range, 0–13). The most frequently requested forms were an Aged Care Assessment Team form (17 facilities), an application form (15 facilities), a medical history form (12 facilities), and an assets declaration (9 facilities). One RACF required direct debit payment forms to be filled out before considering an application, and another required documentary evidence of funeral arrangements. By contrast, four RACFs required no forms at all. GPs were responsible for the medical history form. This form was unique to each RACF, with the result that similar data had to be provided multiple times in different formats. GPs were also potentially required to witness several other forms for each different application. There is an inherent challenge in balancing the need to run a financially viable RACF and provide best care from the moment a resident arrives with minimising the paperwork that frail spouses or busy family members are often expected to generate or replicate for many facilities simultaneously. These forms, most of which will never be used, create a burden on family members at an already stressful time. An agreed national industry standard for an Aged Care Assessment Team form, an assets form and a medical history form (to be filled out once by a GP) would ease stress at arguably one of the more difficult transitions any person and his or her family can face.

Aine G Greene · Bernadette Kenny · David C Currow

At the time of the 2006 Census, there were 3154 centenarians in Australia, 797 men (25%) and 2357 women (75%). This number is expected to increase to 12 000 by 2020. In Australia we are experiencing a demographic transition in which the proportions of people in the oldest age groups are increasing while the proportions in the youngest age groups are decreasing. Centenarians are the fastest growing age segment of the Australian population. Their numbers have increased by 8.5% per year over the past 25 years. In 2006, they represented 0.12% (3154/2 644 469) of the population aged 65 years and over. More than half of centenarians live in private dwellings, with 27% of men and 14% of women living on their own. Government policies are starting to address the issues of an ageing population, including provisions for financial support, improved access to medical services, and appropriate housing and transport facilities. However, we need specific social, medical and financial estimates of the impact of living to 100 years and beyond.

Robyn L Richmond MA, PhD, MHEd

Objective: To compare attitudes and practices of Australian medical practitioners, by specialty, to a range of medical decisions at the end of life.Design, setting and participants: As part of an international study, in 2003, a structured questionnaire was mailed to 2964 medical practitioners drawn from membership registers of Australian and Australasian professional colleges. Data from 1478 questionnaires were statistically analysed using validated instruments.Main outcome measures: Practitioners’ willingness to comply with requests from patients and/or their relatives for symptom relief which might also hasten death; provision of terminal sedation and euthanasia, or willingness to provide these on their own initiative.Results: Respondents reported being much more willing to comply with a patient’s request for increasing symptom relief, even at risk of hastening death, than for terminal sedation. Over a quarter of respondents would provide terminal sedation to competent patients on their own initiative. A small number of respondents would intentionally hasten death. There were significant differences by specialty for all three actions. Oncologists, palliative care physicians and geriatricians were least likely to actively hasten death, and more likely to act unilaterally to relieve symptoms as a medical necessity.Conclusions: Perceptions about the causation of death and aspects of medical culture appear to influence physicians’ attitudes towards medical decisions at the end of life. Our findings have implications for medical education, interprofessional communication and discussion between the medical profession and the community.

Malcolm H Parker MLitt, LLM, FACLM · Colleen M Cartwright PhD, MPH, BSocWk(Hons) · Gail M Williams PhD, MSc, MSc(Epidem)

Gender is more than just a variable to be controlled for in statistical analyses Does ageing affect men and women equally? If not, how might differences affect research — and subsequently clinical practice? To answer this and related questions, the Mars and Venus: Does Gender Matter in Ageing? conference was convened by the University of Newcastle’s Research Centre for Gender, Health and Ageing, in association with the Australian Association of Gerontology and the Healthy Ageing Theme of the Australian Research Council/National Health and Medical Research Council (NHMRC) Research Network in Ageing Well.1 The 2-day conference, held in Newcastle in July 2007, featured longitudinal studies of ageing that have given specific attention to the health of men or the health of women, and introduced an NHMRC-funded initiative to link two of these studies. The conference also included a 1-day research workshop, sponsored by the Ageing Well Network, which involved researchers from longitudinal studies of ageing being conducted in Australia, and considered how such studies might take greater account of gender in their design and analysis. The conference attracted 85 participants from across Australia and overseas, who came together to consider ways in which the effects of ageing are unequal between men and women, and how these differences might be further exaggerated through interactions with socieconomic status and background. Conference overview: seeking balanced debateThe theme of the conference was set by Cherry Russell (School of Behavioural and Community Health Sciences, University of Sydney), who gave a keynote address, Ageing and the gender agenda: a critical reflection, which outlined gender differences in life expectancy, health, income, care needs, and level of social isolation, along with a discussion of gender biases in policy and service provision. Compared with men, women have more chronic illness and greater health service use at older ages; but they also live longer. Men have more fatal illness at younger ages.2 For instance, men have coronary artery disease earlier and have a higher death rate. Lung cancer is more common among men, who have had higher rates of smoking than women. Women have a higher incidence of musculoskeletal problems and a higher prevalence of incontinence, although these problems are also important for men. Although hip fracture also affects older men, the incidence increases at a later age and fewer men survive to the age of high risk. Women, therefore, dominate the clinical picture. Some health differences are related to biological sex; however, many differences are strongly linked to social influences of gender. These less obvious differences include environmental, occupational and behavioural risks, behaviour, and different adaptive techniques. There are also considerable differences in social roles and access to financial and social resources — which significantly affect the experience of ageing. Cherry Russell noted that there has been little balanced debate as to what the unequal effects of ageing for men and women mean and where they stem from. Debates about gender and ageing have focused on loss of men’s work roles, older women’s double disadvantage from age and gender inequality, and on a “paradigm of competitive suffering”. In contrast, this conference aimed for greater balance in considering how gender influences the health and wellbeing of men and women as they age. This theme was reflected in the proffered papers and workshops. Papers explored age and gender issues such as living arrangements; health and engagement for older men; gender bias in health service programs; retirement issues; and current research on gender differences, including results from the Household, Income and Labour Dynamics in Australia (HILDA) study and Melbourne Longitudinal Studies of Healthy Ageing (MELSHA). Workshop topics explored the needs of homosexual and transgender people, gender issues in dementia and sexuality in residential aged care, and the practicalities of conducting a large longitudinal study: the Australian Longitudinal Study on Women’s Health. Longitudinal studies: a focus on genderKeynote addresses throughout the conference featured longitudinal studies of older men and women. The Concord Health and Ageing in Men Project (CHAMP), presented by Bob Cumming (Centre for Research and Education on Ageing, School of Public Health, University of Sydney), involves 1705 men aged 70 years and over. Early findings from this study show a sharp increase in multiple falls, and declines in continence, cognitive function, and activities of daily living starting after the age of 80.3 The Florey Adelaide Male Ageing Study (FAMAS), presented by Gary Wittert (School of Medicine, University of Adelaide), focuses on chronic physical and psychological disease and reproductive and sexual health.4 Measures of testosterone show an age-associated increase in sex-hormone-binding globulin and a decrease in free testosterone, a change that may be adaptive rather than pathological. The Health in Men Study (HIMS), presented by Leon Flicker (Graduate Research School, University of Western Australia), involves 4262 men, and focuses on physical and psychosocial morbidity (including depression), health risks, weight and body mass index, cognition and mortality. One finding from this study has been the importance of health and lifestyle factors in determining cognitive function, even in advanced old age.5 Emily Banks (National Centre for Epidemiology and Population Health, Australian National University) provided an overview of the United Kingdom’s Million Women Study (MWS), which has shown increased risks of breast cancer,6 endometrial cancer,7 and ovarian cancer with use of hormone replacement therapy,8 and a protective effect on fracture.9 Annette Dobson (Division of Epidemiology and Social Medicine, University of Queensland) represented the Australian Longitudinal Study on Women’s Health (ALSWH), which has been running since 1996, and has investigated many factors affecting women’s health and ageing, particularly the influence of social context on health and health care use.10 Recent reports from this study emphasise the burden of illness associated with non-fatal conditions such as arthritis, the preventable burden of obesity, and safe levels of alcohol intake for older women.11 Leon Flicker, Annette Dobson and Julie Byles (Research Centre for Gender, Health and Ageing, University of Newcastle) also gave an overview of the recently funded Men, Women and Ageing Study, linking HIMS and ALSWH to generate cross-gender analyses. Additionally, Gita Mishra (University College, London) showed how gender interacts with effects of childhood socioeconomic status in determining early mortality in the 1946 British Birth Cohort. For example, a father’s occupation had a strong effect in women, but no significant effect in men. Studies of men and studies of womenWhat are the similarities and the differences?A workshop involving investigators from longitudinal studies and other researchers compared and contrasted issues, approaches and findings of longitudinal studies of men and women. Identified commonalities and differences between studies of men and women are shown in the Box. The main differences were conditions that could not be experienced by the opposite sex, such as hysterectomy for women and prostate disease for men. However, studies of men had a focus on testosterone and sexual function that was not mirrored by female equivalents. Studies of women measured oestrogen levels and sexual problems in relation to menopausal changes, not in relation to health in later life. Other differences were more subtle. For instance, while prostatism is a male issue, lower urinary tract symptoms are also experienced by women. It was agreed that more emphasis on these symptoms may be appropriate for studies involving women. As a general observation, studies involving men applied a biological framework, whereas studies of women applied a social model. For instance, caring has been emphasised in women’s studies but caring may be an equally important, although different, issue for men. Health after the death of a spouse has also been given greater emphasis in studies of women. Men are more likely to repartner, but this comparison is confounded by the construction of relationships, with men preferring to cohabit and women preferring to live apart from a new partner. Transport and mobility were also identified as major issues for women. This need may be experienced differently by men, for whom loss of a drivers licence may present more than a practical problem of “how to get around”, as it may also lead to depression and general decline. Cross-gender analyses: what are the opportunities?The workshops also explored how longitudinal studies of ageing can be analysed from a gendered perspective. It seems that almost any question on the ageing research agenda can be subjected to a gendered analysis. For instance, comparing genders: Which differences exist at a biological level, and which are socially determined? Does socioeconomic disadvantage have a differential effect on health? Does caring by men and women involve different activities and dimensions? What is the effect of ageing on sexual function, sensuality and spirituality? Is there a differential change in the importance of these outcomes with age? How do men and women engage with the health care system? Does health care need to become more gender-sensitive? Are there differences in diet and nutrition? Does nutrition have a differential effect on health outcomes according to gender? Are the predictors of survival and longevity different among women and men? For example, does comorbidity have a stronger effect in men? Do men and women have different health goals? If health is seen not as an end, but as a means to achieving life goals, then health will have different effects in men and women if their life goals are not the same. Gendered comparisons: simple or complex?However, gendered comparisons may not be as simple as stratifying variables by age and sex. Men and women may exhibit different levels of accuracy and reliability in reporting exposures and outcomes, and many measures have a strong gender bias. For instance, caring appears to have very different meanings and manifestations for men and women. Physical activity has a different nature, context, and inherent value. Even when the same measures can be used, different categorisations may be needed, especially if underlying distributions and associations vary by gender. Further, influences of gender may interact strongly with cognitive status, marital status and other socioeconomic factors. Cohort effects are also likely to be important, with changes in the social meaning of gender over time (for instance, disparities in education, employment, occupation, and assets have changed over the past century). The power that can be achieved by combining data from existing longitudinal studies, as will occur in the Men, Women and Ageing Study referred to above and in the Dynamic Analyses to Optimize Ageing (DYNOPTA) project led by Kaarin Anstey of the Australian National University, will allow robust statistical analysis of gender interactions and, in the case of DYNOPTA, the use of nested cohorts to control for cohort and geographical effects. Closing remarksJulie Byles and Hal Kendig (Faculty of Health Sciences, University of Sydney) noted that the discussion from the conference and the longitudinal studies workshop provided valuable insights into basic gender differences and will inform research for years to come. Sex and gender differences matter not only to the experience of ageing, but are also manifested in the design of the research projects which, to date, have shown a clear gender-specific focus. Participants agreed that gender is more than just a variable to be controlled for in statistical analyses — it needs to be understood within a social context and be included in all future analyses. In this way, we may achieve not only greater understanding but also greater benefits in future clinical practice. Commonalities and differences between studies of men and women identified at the workshop Commonalities Medication Obesity and weight Cardiovascular outcomes (heart attack, stroke) Health risks: smoking and alcohol Diabetes and the metabolic syndrome Falls Fracture and osteoporosis Hearing and vision Anxiety and depression Sleep Other medical history Quality of life Mobility and dependence Housing and neighbourhood Social support Health service availability, access and use Living arrangements and marital status Differences Men (Mars) Women (Venus) Testosterone levels Effects of hormone replacement therapy Hysterectomy Dementia and Alzheimer’s disease Sarcopenia (age-related muscle loss) Incontinence: urine flow Incontinence: leaking urine Lower urinary tract symptoms Dysuria Widowhood Caring Transport Prostate cancer Breast cancer Endometrial cancer Ovarian cancer Erectile dysfunction

Julie E Byles BMed, PhD · Matthew Carroll BA(Hons), PhD · and the Mars and Venus Writing Team

Objective: To estimate hospital inpatient costs by age, time to death and cause of death among older people in the last year of life.Design and setting: Cross-sectional analytical study of deaths and hospitalisations in New South Wales from linked population databases.Participants: 70 384 people aged 65 years and over who died in 2002 and 2003.Main outcome measures: Hospital costs in the year before death.Results: Care of people aged 65 years and over in their last year of life accounted for 8.9% of all hospital inpatient costs. Hospital costs fell with age, with people aged 95 years or over incurring less than half the average costs per person of those who died aged 65–74 years ($7028 versus $17 927). Average inpatient costs increased greatly in the 6 months before death, from $646 per person in the sixth month to $5545 in the last month before death. Cardiovascular diseases (43.1% of deaths) were associated with an average of $11 069 in inpatient costs, while cancer (25.0% of deaths) accounted for $16 853. The highest average costs in the last year of life were for people who died of genitourinary system diseases ($18 948), and the highest average costs in the last month of life were for people who died of injuries ($8913).Conclusion: Population ageing is likely to result in a shift of the economic burden of end-of-life care from the hospital sector to the long-term care sector, with consequences for the supply, organisation and funding of both sectors.

Katina Kardamanidis RN, MPH · Kim Lim RN, BEc, MAppStat · Cristalyn Da Cunha BSc, MHA · Lee K Taylor MB BS, MPH, FAFPHM · Louisa R Jorm BVSc, MSc(Epid), PhD

To the Editor: The Transition Care Program (TCP) is a joint federal and state government program that provides short-term (8–12 weeks) support and therapy to improve functioning for older people who are hospitalised (either in public or private hospitals) and would otherwise require admission to a residential aged care facility.1 Participants are provided with a care package that assists with activities of daily living, and provides limited allied health, nursing and medical input, with the aim of improving functional status, if possible. The TCP is currently being implemented across Australia. We selected and audited three transition care services that commenced operation early in the program (2005 and early 2006), with the aim of describing the outcomes of these services, and determining whether the older people participating in the various services were similar. Approval was obtained from the relevant ethics committees. Three services were purposefully sampled: two services in Adelaide (Service A providing packages in a community setting, and Service B providing packages in a high-level care, residential aged care setting); and one service in Sydney (Service C providing packages in a community setting). The residential package allocates temporary residential placements for patients with defined rehabilitation goals, and thus also frees up acute care hospital beds. These services supplied de-identified audit data about the first 30 participants, who were in the program between June and December 2006. A summary of the data is given in the Box. The participants in the residential program tended to be older, more likely to be male, and less likely to have “fracture or fall” as their primary diagnosis. These older people also had more severe disability that generally does not improve, and were significantly less likely to return to community living. The two community-based programs were generally similar. The data suggest that there is considerable variation between the TCP services, with the residential service providing packages to older people with severe disability who generally remain in a residential aged care program, although some may improve from high- to low-level aged care services. By contrast, the outcome of the community-based services is generally maintenance in the community and is associated with an improvement in functioning. This profile is similar to that of a community-based rehabilitation service for older people. It is not clear from the TCP guidelines whether this level of variation in program implementation was anticipated.1 This limited audit suggests that the Australian TCP is not homogeneous and is substituting for other forms of treatment and care. Thus, there is provision of high-level residential care as a substitute for waiting for residential aged care in a hospital bed, and community rehabilitation as a substitute for rehabilitation services provided by state health departments. This situation is potentially beneficial to older people who previously did not have access to these services, but it also could mean that state governments may not establish rehabilitation services for older people, or may even cease providing these services. Comparison of background, status and outcomes for participants in three Transition Care Program (TCP) services Service A (community) (n = 30) Service B (residential) (n = 30) Service C (community) (n = 29) Statistical significance* Mean age (SD) in years 80.9 (7.9) 84.5 (5.1) 80.4 (8.0) ns Female 60% 47% 59% ns Living alone 40% 47% 62% ns Primary diagnosis — trauma (fractures and falls) 43% 20% 41% ns Barthel Index On admission to the TCP — mean (SD) 66.9 (13.8) 55.2 (26.8) 69.2 (19.1) F = 3.85; P = 0.025 On discharge from the TCP — mean (SD) 72.8 (17.6) 56.4 (34.2) 82.8 (22.0) F = 7.69; P = 0.001 Mean change (SD) 5.9 (21.3) 1.5 (19.0) 11.6 (13.3) ns Discharge status — in the community† 60% 20% 76% χ2 = 35.6; P = 0.000 * Based on a comparison between the three groups (χ2 test for categorical data, and analysis of variance [F test] for continuous data). † Patients were in the Program for 12 weeks unless they left early because of admission to hospital or permanent admission to a residential care facility. ns = not significant.

Ian D Cameron · Owen Davies

Providing spiritual care is about tapping into the concept of spirituality: core meaning, deepest life meaning, hope and connectedness. The search for meaning, connectedness and hope becomes more significant as older people are faced with the possibilities of frailty, disability and dementia. Spirituality, ageing and meaning in life can be discussed in the context of an alternative view of “successful ageing”. A model of spiritual tasks in older age can help explain the spiritual dimension and provide a starting point for spiritual assessment.

Elizabeth B MacKinlay PhD · Corinne Trevitt RN, MN, GradDipGerontics

Objective: To assess whether a diagnosis of the metabolic syndrome (MetS) improves the prediction of cardiovascular disease or total mortality beyond that already provided by conventional risk factors.Design and setting: A longitudinal cohort study conducted in Dubbo, New South Wales.Participants: 2805 men and women aged 60 years and older living in the community, first assessed in 1988–1989 and followed for 16 years.Main outcome measures: Coronary heart disease (CHD) events, ischaemic stroke events, and total mortality.Results: MetS was present in 31% of men and 34% of women. Crude CHD, ischaemic stroke, and total mortality rates were higher in the presence of MetS in men and women. In proportional hazards models that included conventional risk factors, but excluded variables used to define the presence of MetS, MetS was a significant predictor of CHD, stroke and total mortality. In men, the respective hazard ratios were 1.64 (95% CI, 1.37–1.96), 1.31 (95% CI, 0.97–1.77), and 1.53 (95% CI, 1.30–1.79). In women, the respective hazard ratios were 1.70 (95% CI, 1.43–2.02), 1.37 (95% CI, 1.04–1.82), and 1.35 (95% CI, 1.15–1.59). The use of MetS variables on an ordinal scale produced broadly similar conclusions.Conclusions: A diagnosis of MetS provides additional prediction of CHD events, stroke events, and total mortality beyond that provided by other conventional risk factors.

Leon A Simons MD, FRACP · Judith Simons MACS · Yechiel Friedlander PhD · John McCallum DPhil

Alzheimer’s disease (AD) is the most prevalent dementia (accounting for 50%–75% of cases of dementia in people aged over 65 years), followed by frontotemporal dementia (FTD) (10%–20% of cases). AD is characterised histopathologically by Aβ-containing amyloid plaques and tau-containing neurofibrillary tangles, whereas FTD exhibits neurofibrillary tangles alone. Current symptomatic treatments of AD are of limited benefit, as they are not directed at the underlying biological basis of the disease. The development of transgenic animal models has provided insight into disease mechanisms and helped define novel drug targets. More than 50 drugs are currently in clinical trials, and novel and more effective drugs targeting both AD and FTD are expected to become available within 5–10 years.

Jürgen Götz PhD · Lars M Ittner MD · Nicole Schonrock PhD

To the Editor: Recent articles in the Journal by Kurrle1 and Finn and colleagues2 referred to advance care directives aiding the management of acute illness in elderly residents of aged care facilities. It is our experience that these directives are often unhelpful in elderly patients and, outside certain progressive medical conditions, can result in triage of elderly patients to inappropriate lower levels of care. In chronic medical conditions where the clinical course allows time for patient or family understanding, and the course of organ failure is predictable, then certain supportive but ultimately futile therapies can be avoided by instituting an advance care directive that specifically excludes them. However, these directives are less helpful in acute illnesses. They usually refer to “intensive care”, and “life support”, sometimes specified as mechanical ventilation, dialysis or cardiopulmonary resuscitation. These “general” advance care directives fail, as they assume that prognosis is immediately apparent, and that treatment is “all or nothing”, both of which assumptions are clearly untrue. Determining an accurate prognosis for recovery from a critical illness is difficult and takes time. It involves diagnosing the cause of the illness, quantifying the severity of comorbidities and, most importantly, assessing response to initial treatment. Whether severe sepsis is arising from the urinary tract or abdominal cavity may not be apparent initially. Many elderly patients survive severe septic shock caused by urosepsis with haemodynamic monitoring and short-term high-dose vasopressors. It is also not possible to distinguish which patients with severe respiratory failure will respond to non-invasive ventilation. We followed up critical care patients aged 75 years and over who survived to hospital discharge over a 12-month period and confirmed that acceptance of critical care admission in elderly people is high (unpublished study; details available from the authors). This is the very population that, in our experience, frequently says they do not want to be placed on “life support”, if asked when well. Together with the fact that an accurate prognosis takes time, then a prudent approach should begin with the presumption of aggressive treatment for acutely unwell elderly patients, rather than a presumption of limited therapy or palliation. Advance care directives that refer to therapies need to be specific and to recognise that critical care therapy can be graduated and readily terminated once a more accurate prognosis is known. Furthermore, some critical care therapies, such as non-invasive ventilation and high-concentration oxygen, can significantly improve patient comfort while management plans are formulated. In our experience, patients and their families are often very surprised when they understand the full implications of an advance care directive that refers to generic therapies, such as cardiopulmonary resuscitation and “intensive care”.

Andrew W Holt · Alnis E Vedig