Ageing

To the Editor: With Australia’s rapidly ageing population and an explosion in the number of retirement villages and nursing homes, Finn and associates are to be congratulated for ventilating the subject of the interface between residential aged care facilities and emergency departments.1 My experience of emergency department (ED) and aged care facility relations spans over 50 years and I have been involved in both sides of the equation. Firstly as a surgeon, then as director of an ED, and finally, as a resident of a retirement village for over 20 years (including, for my wife, 5 years in the affiliated nursing home), and during that time my wife and I have had at least eight episodes as patients in an ED. Retirement villages and nursing homes are not equipped or organised to handle medical or surgical emergencies. Problems of “disposal” arise after ED assessment and treatment in a public hospital. The hospital may not have an empty bed. The patient’s condition may not be serious enough to require a hospital bed, but the patient may not be well enough to return to his or her retirement village. Privately insured patients may have the option of transferring to a private hospital but usually spend an unnecessarily long time in the ED awaiting such transfer. Matters that need attention are: a standing arrangement between public and neighbouring private hospitals to facilitate quick transfer of suitable patients. the removal of long delays in EDs that occur while waiting for the results of investigations and even longer periods awaiting “higher opinions” after receiving these results. a speedier and more detailed hospital summary addressed to the general practitioner (if known) as well as to the aged care facility concerned.

Keith S Jones

Objective: To assess the feasibility of administering an inexpensive preparation of vitamin D3 100 000 IU orally 3 monthly to aged-care residents.Design: Prospective, controlled open-label implementation trial.Setting: Residential aged care, November 2003 to May 2004 (primary study).Participants: 137 ambulant residents: 107 treated (mean age, 85 years; 79 were women), 30 untreated controls (mean age, 87 years; 22 were women).Interventions: Lactose microencapsulated vitamin D3 100 000 IU orally at baseline, then 3 monthly (three or more doses); untreated subjects were observed contemporaneously.Main outcome measures: Serum levels of 25-hydroxyvitamin D [25(OH)D] at 6 months compared with baseline; acceptability of the program to residents and staff.Results: At baseline, 95% of residents assessed (n = 137) had serum 25(OH)D levels below the desirable range of 60–160 nmol/L. At 6 months, all treated residents (n = 98) achieved desired levels, with the mean (± SD) 25(OH)D level increasing from 36.4 ± 12.6 nmol/L (range, 12–75 nmol/L) at baseline to 124.0 ± 27.9 nmol/L (range, 68–244 nmol/L). In no resident did 25(OH)D approach toxic levels. The mean serum 25(OH)D level remained low in the control group (n = 27): 42.8 ± 18.3 nmol/L (range, 18–98 nmol/L). The difference between the mean 25(OH)D levels of treatment and control groups at 6 months was 81.2 nmol/L (95% CI, 69.7–92.0 nmol/L). The cost of the supplement was $4 per resident per annum. Substudies showed mean trough serum 25(OH)D levels in the desired range at 3 months (n = 31), but below the desired range at 6 months (n = 50). Subjects given 3-monthly doses for up to 2 years maintained serum 25(OH)D levels within the desired range, with no trend toward undesirable accumulation (n = 11).Conclusions: Vitamin D3 100 000 IU given orally 3 monthly is a practical, safe, effective and inexpensive way to meet the vitamin D3 requirements of aged-care residents.

Alison E R Wigg BAppScPhysio, MAppScPhysio, MBA · Caroline Prest RN · Peter Slobodian BPharm, MClinPharm · Allan G Need MD, FRACP, FRCPA · Leslie G Cleland MD, FRACP

A collaborative trial is needed At a time when there is a widely held perception that older people, and particularly nursing home residents, are occupying acute care hospital beds at the expense of others,1 the article by Finn et al2 in this issue of the Journal is very pertinent. It describes the presentation, over a 6-month period, of a cohort of 541 patients from aged care facilities (nursing homes and hostels) to the emergency department of a large tertiary hospital, and notes that the substantial majority (87%) of these presentations were considered to be appropriate. These patients were acutely unwell (most having been so for less than 2 days) and required the investigations and expertise available in the emergency department for diagnosis and management. Sixty per cent of these patients required hospital admission and most (90%) survived to be discharged back to their aged care facility. There are currently about 78 000 people in nursing homes across Australia and about 81 000 in hostel care.3 These numbers will continue to grow as the number of older people increases. Consequently, presentations to emergency departments and admissions to hospital are also likely to increase, placing further strain on already busy hospitals. Hospitals can be dangerous and unfriendly places for frail older people or people with dementia, who are most likely to be residents of aged care facilities. Polypharmacy, undernutrition, skin tears, pressure areas, fall-related injuries, nosocomial infections, and deconditioning are some of the hazards of hospitalisation.4 It is therefore now very appropriate to be looking at methods of reducing the need to hospitalise these patients by providing assessment and management of selected conditions within aged care facilities. Finn et al suggest some of the resources that would be required to prevent inappropriate hospital presentation (such as the ability to insert indwelling catheters and to replace percutaneous endoscopic gastrostomy tubes), but more than this will probably be necessary. Recently, a number of hospitals around Australia have identified the need to work more closely with aged care facilities and general practitioners to provide acute care to patients in nursing homes. For example, Gold Coast Hospital in Queensland has piloted a “Hospital in the Nursing Home” program that delivers acute care to nursing home residents using their own GP and nursing home staff, with medical and nursing input from Gold Coast Hospital staff.5 This service also provides education and information to nursing home staff in areas such as wound care, continence management and intravenous fluid administration, enabling staff to improve their skills in these areas. Clinical pathways are used for management of pneumonia, urinary sepsis, dehydration, palliative care and wounds. The service has treated 400 patients, resulting in hospital bed-day savings of more than 1500 days over 2 years and allowing residents to stay in familiar surroundings while receiving acute care (Ms Kerry Robinson, Project Officer, Aged Care Early Intervention and Management, Gold Coast Hospital, personal communication). This would appear to be a positive outcome for all parties, but a randomised controlled trial would be needed to confirm the effectiveness of the intervention. Finn and colleagues also raise a number of other issues that merit attention, and addressing these issues could potentially avoid some presentations and improve information sharing in others. Their study revealed that a GP had been consulted for only a quarter of patients presenting to the emergency department. Increased GP availability and involvement is clearly important, given that 126 out of the 136 presentations involving GP input were judged “appropriate”, whereas up to 45 of the 71 presentations considered “inappropriate” could have been avoided if GP review had occurred. With the increased use of Enhanced Primary Care Initiatives, in particular, comprehensive medical assessment for permanent residents of residential aged care facilities (Medicare Benefits Schedule item 712), and Aged Care GP Panels, it is hoped that there will be much greater direct involvement of GPs in the care of their patients in aged care facilities. Overseas experience indicates that increased availability of primary care (both medical and nursing) in nursing homes results in fewer hospital admissions.6 The lack of communication between aged care facilities and the emergency department in 61% of presentations is also of concern. Use of a common aged care facility transfer sheet may improve this, and as the use of technology increases (eg, electronic care plans for residents), the use of electronic referrals may assist the process of information transfer. Inadequate communication or documentation between aged care facilities and emergency departments has been shown to increase the likelihood of admission to hospital.7 The preparation and use of advance care directives was also suggested by Finn et al to guide response to acute events occurring in residential care. Advance care directives (also known as “health care directives” or “living wills”) allow residents to document their preferences for treatment and care. The directives may indicate a desire for hospital admission and full treatment or a preference for limited treatment in certain situations. Many aged care facilities already encourage their use and help residents and their families formulate such directives in the weeks following their admission. Advice in preparing these directives is available from a number of sources, such as NSW Health.8 Finn and colleagues have given us an understanding of current presentations of patients from residential care facilities to emergency departments that can assist us in developing different and better quality services for these people. Adequate training and resourcing of staff in aged care facilities, increasing involvement of GPs, and consultation with residents and their families are the first steps in developing these services.

Susan E Kurrle MB BS, DipGerMed, PhD

Objective: To estimate the appropriateness of emergency department (ED) presentations by people aged ≥ 65 years living in residential care facilities.Design, setting and participants: Retrospective cohort study of older residents of residential care facilities who presented to the ED of the Royal Perth Hospital, Western Australia, between January and June 2002. Data were reviewed by an expert clinical panel.Main outcome measures: Appropriateness of ED presentation, presenting complaint, involvement of a general practitioner/locum doctor prior to transfer, proportion of patients admitted to hospital from the ED, survival to discharge.Results: 541 residents aged ≥ 65 years were transferred by ambulance to the ED, comprising 8.3% of all ED presentations of people in this age group. The mean age of the study cohort was 83.7 years (SD, 7.0 years), of which 68% were women. Of the 541 presentations, 326 (60%) resulted in hospital admission, and of these, 276 (85%) survived to hospital discharge. Musculoskeletal disorders accounted for 25% of all presentations, and 22% were falls-related; pneumonia (11% of presentations) was the single largest presenting complaint. ED attendance was deemed “inappropriate” for 71/541 cases (13.1%; 95% CI, 10.5%–16.2%); in only 25% of ED presentations was a GP/locum doctor involved prior to transfer.Conclusions: The majority of ED presentations by aged care residents were considered to be appropriate, but there was scope for improvement in coordinating care between the hospital ED and residential care institutions.

Judith C Finn PhD, RN, FRCNA · Leon Flicker MB BS, PhD, FRACP · Eileen Mackenzie RN, GDCritCare · Ian G Jacobs BAppSci, PhD, RN · Daniel M Fatovich MB BS, FACEM · Shelley Drummond RN · Michelle Harris RN · D'Arcy C D J Holman MB BS, MPH, PhD · Peter Sprivulis MB BS, FACEM, PhD

To the Editor: Healthy ageing is listed as a National Research Priority by the Australian Government. The higher prevalence of sensory, cognitive and mobility impairments in older people presents a major challenge in achieving this goal. The effects of single impairments are recognised,1,2 but the cumulative effects of multiple impairments have not been reported from population-based samples. We aimed to assess the impact of multiple impairments (vision, hearing, cognitive, mobility) on health-related quality of life (HRQOL), hospitalisation, and aged-care service use in an older Australian population. In the second cross-sectional Blue Mountains Eye Study,3 HRQOL was measured by means of the self-administered Short Form 36-item Health Survey (SF-36)4 (n = 3509; mean age, 66.7 years; 57% women). Visual impairment was defined as best-corrected visual acuity (after refraction) of less than 6/12 (better eye). Hearing impairment was defined as average hearing threshold (pure-tone air conduction, frequencies 500–4000 Hz) over 25 decibels (better ear). Possible cognitive impairment was defined as Mini Mental State Examination scores less than 24/30. Mobility impairment was recorded. General linear regression was used to calculate age-adjusted SF-36 mean scores,5 and logistic regression was used to estimate likelihood ratios for use of health and aged-care services. Models were age-adjusted to eliminate confounding. For 2873 participants who had completed the SF-36 (90.9%), the mean physical component score (PCS) was 44.9 (95% CI, 44.5–45.3) and the mean mental component score (MCS) was 51.9 (95% CI, 51.5–52.2). Age was significantly associated with the prevalence of these impairments (P < 0.001). After adjusting for age, people with any of the impairments had poorer mean PCS and MCS than those without the impairment (Box 1). Hospitalisation within the last year was reported by 743 participants (23.5%; 58.3% women), and 97 (3.1%; 65.0% women) reported regular use of community support services. Use of community support services was reported more frequently by people with any impairment, except possible cognitive impairment (Box 1). The presence of two or more impairments was associated with a cumulative, linear decline in HRQOL (Box 2). The successive addition of each impairment was associated with a decrease of 4.0 in mean PCS and 2.1 in mean MCS, and with greatly increased reporting of regular community support service use. The likelihood of participating in or completing the SF-36 decreased with increasing number of impairments. Hence, the prevalence of impairments and the extent of detrimental impacts on HRQOL may be underestimated. Nevertheless, our data highlight a linear increasing pattern of cumulative effects from multiple impairments on HRQOL, hospitalisation, and use of aged-care services. Preventing and reducing these impairments is crucial in maximising healthy ageing. 1 Prevalence, mean SF-36 physical and mental component scores, and use of services by impairment Impairments Prevalence (%) Age-adjusted mean SF-36 scores (95% CI) Use of services: %, age-adjusted and sex-adjusted odds ratio (95% CI) Physical component score Mental component score Hospitalisation in past 12 months Regular use of community services Visual impairment 2.7 42.8 (39.9–45.7) 47.6 (44.8–50.3)* 34.9%, 1.3 (0.8–2.2) 24.2%, 2.9 (1.4–6.0) Hearing impairment 33.4 43.8 (43.0–44.7)* 51.1 (50.3–51.9)* 27.5%, 1.1 (0.9–1.3) 7.4%, 2.7 (1.4–5.0) Cognitive impairment 2.2 42.2 (39.5–44.8)* 46.0 (43.4–48.5)* 28.2%, 1.0 (0.6–1.6) 14.1%, 1.7 (0.8–3.7) Mobility impairment 7.6 32.3 (30.8–33.7)* 48.1 (46.7–49.5)* 41.0%, 2.0 (1.5–2.7) 21.3%, 6.8 (4.2–11.0) All mean values adjusted to 66.7 years, the overall sample mean age. SF-36 = Short Form 36-item Health Survey.4 * Significantly lower than without disability. 2 Mean physical and mental component scores and use of services by increasing number of impairments No. of impairments* Age-adjusted mean SF-36 scores (95% CI) Use of services: %, age-adjusted and sex-adjusted odds ratio (95% CI) Physical component score Mental component score Hospitalisation in past 12 months Regular use of community services 0 (n = 1031) 46.6 (45.9–47.2) 52.8 (52.6–53.8) 22.0%, 1.0 0.4%, 1.0 1 (n = 616) 42.6 (41.8–43.3) 51.0 (50.3–51.7) 25.3%, 1.1 (0.8–1.3) 4.2%, 7.4 (2.7–19.8) 2 (n = 121) 38.6 (37.1–40.0) 48.8 (47.4–50.2) 35.5%, 1.5 (1.0–2.3) 19.0%, 24.9 (8.5–73.2) ≥ 3 (n = 31) 34.5 (32.2–36.8) 46.6 (44.5–48.8) 45.2%, 2.0 (0.9–4.1) 41.9%, 47.4 (13.1–171.4) SF-36 = Short Form 36-item Health Survey.4 * Includes vision, hearing, cognitive and mobility impairments.

Ee-Munn Chia · Jie Jin Wang · Elena Rochtchina · Paul Mitchell

Falls and related injuries among seniors are a compelling ongoing priority for Australian health research Falls and fall-induced injuries among older people are a major public health concern worldwide, accounting for over 80% of all injury-related admissions to hospital of people over 65 years.1-3 Falls are also the leading cause of unintentional injury death in these individuals and responsible for appreciable morbidity, including bone fracture, head injury, joint disruption, and soft tissue contusion and laceration resulting in pain, functional impairment, disability, fear of falling, depression, loss of independence and confidence, and admission to residential care.1,4,5 Moreover, this major health problem is likely to increase, as the number and mean age of older people are increasing worldwide and epidemiological studies suggest that, for some types of fall-related injuries, the age-standardised incidence (ie, average individual risk) of injury is also rising.1,6 . . . a hospital setting is not a safe place for elderly people but is actually associated with increased risk of falling. Somewhat paradoxically, a hospital setting is not a safe place for elderly people but is actually associated with increased risk of falling. On admission, the older patient accumulates additional falls risk factors including a new, strange environment with poorly recognised external dangers for falling. This is often combined with confusion, acute illness and balance-affecting medication, in addition to chronic risk factors such as comorbidities, muscle weakness and impaired balance and gait.2,7 A recent systematic review found no consistent evidence for the effectiveness of interventions to prevent falls among older inpatients.8 Since then, two large randomised trials have shed light on this issue. Healey and colleagues,9 using a cluster randomised study design, examined the effect of a simple core-care plan targeting risk factor reduction in elderly care wards of a general hospital. They observed that the relative risk of falls in the intervention wards was 30% lower than in the control wards. Haines and coworkers10 reported that a targeted falls prevention program in a subacute rehabilitation hospital resulted in a 30% reduction in falls after 45 days of observation. Although these studies did not show a significant reduction in fall-related injuries, the results are encouraging and require verification in other hospital settings.5,11 In this issue, Fonda and colleagues12 report the results of a prospective quality improvement project in which they used a hospital-based, multistrategy prevention approach to reduce the risk of falls and fall-induced serious injuries among frail, older patients in hospital aged-care wards. This large study included 1905 inpatients in the year 2001 as a baseline or historical control group and 2056 inpatients in 2003 as the intervention group (mean age of both groups, 82 years). In both time periods, over 60% of the patients were women. The multistrategy intervention, phased in towards the end of 2001, was a hospital staff-led program incorporated into all levels of the organisation. The intervention consisted of various strategies to reduce falls and injuries, including risk screening with the Falls Risk Assessment Scoring System, after-fall assessments, appropriate modifications of patient and environmental risk factors, work practice changes, environmental and equipment changes, and staff and family support and education. Staff compliance with the risk assessment was also studied as part of evaluating the success of implementing the intervention. The total number and incidence (per 1000 occupied bed-days) of falls and fall-induced serious injuries were key outcome variables. The intervention program was associated with a 19% reduction in the risk of falls and a 77% reduction in the risk of falls resulting in serious injury. Staff compliance with completing the falls risk assessment tool increased from 42% to 70%, and 60% of the staff reported that they had changed their work practices to prevent falls. While Fonda and colleagues are to be congratulated on having successfully conducted this important trial, with impressive results, hospitals need to be cautious about applying this type of falls prevention strategy without first weighing up the limitations of the study. Firstly, as the authors point out, the study was not a randomised controlled trial — the “gold standard” of all clinical studies — but a prospective quality improvement project, and so a direct cause and effect relationship between the intervention and reduction in falls and serious injuries cannot be established. Secondly, a critical reader would like to see more detailed analysis of the success in executing the multistrategy falls prevention program. The article does not detail the level of compliance or adherence of the individuals in the intervention group to each recommendation and protective action throughout the 12-month period — information that is crucial to interpret the data. Thirdly, more information about the fallers and the fall and injury data collection system would allow the reader to draw firmer conclusions from the study. The authors note that they recorded many minor events in the follow-up data that were unlikely to have been coded during the baseline year, thus blurring the falls (although not injury) comparison between the baseline year and follow-up year (albeit in favour of underestimating the benefit of the intervention). A limitation of falls prevention research to date has been that fall definition and registration systems have not been standardised. However, the PROFANE (Prevention of Falls Network Europe) Collaboration Group has recently provided soundly based recommendations to address this problem and has suggested strategies for more uniform scientific reporting of falls data and outcomes.13 In various settings, not only in the hospital environment, multifactorial intervention strategies have been shown to prevent falls among elderly adults by 20%–45%,5 but many interesting and important questions remain unanswered.5 Firstly, even in randomised controlled trials, it is not always clear which components of the intervention are effective and which are not. A great deal of time and effort may be put into implementing a complex intervention, when, in truth, using one or two of its components might be equally effective.5,11 Secondly, the cost-effectiveness of interventions is seldom evaluated. Thirdly, little is known about elderly people’s long-term compliance with the recommendations and actions to prevent falls. We may deem the content of an intervention ineffective, when the truth may be that there was insufficient effort to implement the intervention (type III error).5 An additional difficulty with multifactorial falls prevention interventions is that they can be very labour intensive. So, in view of all the above considerations, should we now abandon the results by Fonda and colleagues12 especially since the study was not a randomised trial? Definitely not! Instead, we should pick up all the positive tips from the project, analyse them carefully and try to apply them in the hospital environment. The importance of careful selection of the content of a multifactorial falls prevention program and the target group to which it is applied cannot be overemphasised. The new evidence-based guidelines on preventing falls in older people14 can greatly assist in this implementation. If future clinical experience proves to be as positive as that of Fonda and colleagues, the next step should be a large-scale randomised falls prevention trial, which would probably need cooperation between several centres. The importance of this health problem — falls and related injuries among seniors — makes it a compelling ongoing priority for Australian health research.

Pekka Kannus MD, PhD · Karim M Khan MD, PhD, FACSP · Stephen R Lord PhD, DSc

Objective: To determine whether the rate of falls and associated serious injuries in a hospital aged care setting can be reduced using a multistrategy prevention approach.Design, setting and participants: Three-year quality improvement project comparing data at baseline (2001) and at 2-year follow-up (2003) after interventions to reduce falls. All patients admitted to the Aged Care Services wards at Caulfield General Medical Centre, Melbourne, between January 2001 and December 2003 were included.Interventions: Multistrategy approach phased in over 3 months from September 2001 and involving data gathering, risk screening with appropriate interventions, work practice changes, environmental and equipment changes, and staff education.Main outcome measures: Total number of falls; number of falls resulting in serious injuries (fractures, head injuries, death); staff compliance with the risk assessment.Results: Over a 2-year period, there was a 19% reduction in the number of falls per 1000 occupied bed-days (OBDs) (12.5 v 10.1; P = 0.001) and a 77% reduction in the number of falls resulting in serious injuries per 1000 OBDs (0.73 v 0.17; P < 0.001). Staff compliance with completing the falls risk assessment tool increased from 42% to 70%, and 60% of staff indicated they had changed their work practices to prevent falls.Conclusion: A multistrategy falls prevention program in an aged care hospital setting produced a significant reduction in the number of falls and a marked reduction in serious fall-related injuries. Incorporating a falls prevention program into all levels of an organisation, as part of daily care, is crucial to the success and sustainability of falls prevention.

David Fonda MD, FRACP, FAFRM · Jennifer Cook BSc, BPhysiother(Hons) · Vivienne Sandler BScPhysiother, GradDipBusiness(HlthSci) · Michael Bailey BSc(Hons), MSc(Stats), PhD

Sports participation among children is declining. Sport and physical activity are important in childhood for optimising bone mass and reducing obesity and insulin resistance. Physical activity reduces cardiovascular risk factors in adults, and can improve survival in patients with cardiac failure. Musculoskeletal injury is the most common complication of sports participation in adults — not cardiac events. Some of the decline in function which occurs with ageing can be positively affected by regular physical activity.

Carolyn R Broderick MB BS, FACSP, GDSSc · Gregory J Winter FACSP, FRACGP, MSpMed · Roger M Allan FRACP, FCSANZ, FACC

Objective: To identify risk factors for dementia in an elderly Australian cohort.Design and setting: A longitudinal cohort study conducted in Dubbo, NSW.Participants: 2805 men and women aged 60 years and older living in the community and initially free of cognitive impairment, first assessed in 1988 and followed for 16 years.Main outcome measure: Admission to hospital or nursing home with any kind of dementia.Results: There were 115 cases of dementia in 1233 men (9.3/100) and 170 cases in 1572 women (10.8/100). In a proportional hazards model for dementia, any intake of alcohol predicted a 34% lower risk, and daily gardening a 36% lower risk. Daily walking predicted a 38% lower risk of dementia in men, but there was no significant prediction in women. The lowest tertile of peak expiratory flow predicted an 84% higher risk of dementia, the upper tertile of depression score predicted a 50% higher risk.Conclusion: While excess alcohol intake is to be avoided, it appears safe and reasonable to recommend the continuation of moderate alcohol intake in those already imbibing, as well as the maintenance of physical activity, especially daily gardening, in the hope of reducing the incidence of dementia in future years.

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

What we need to knowWhat we need to do

David H Wilson PhD · Sarah L Appleton BSc · Robert J Adams MD · Richard E Ruffin MD

What we need to knowWhat we need to do

Michael J Abramson PhD, FRACP

What we need to knowWhat we need to do

Dianne P Goeman MA, GradDipSoc · Jo A Douglass MD, FRACP

What we need to knowWhat we need to do

Norbert Berend AM, MD, FRACP

What we need to knowWhat we need to do

Julie E Byles PhD

What we need to knowWhat we need to do

John W Wilson PhD, FRACP

What we need to knowWhat we need to do

Amanda Barnard BA, FRACGP · C Dimity Pond PhD, FRACGP · Timothy P Usherwood MD, FRACGP, FRCP

What we need to knowWhat we need to do

J Paul Seale PhD, FRACP

Objective: To conduct a systematic review of the evidence for the effectiveness of a range of possible treatments for depression in older people.Data sources: Literature search using the PubMed, PsycInfo and Cochrane Library databases.Data synthesis: Treatments that have been suggested to be effective for depression were grouped under three categories: medical treatments, psychological treatments, and lifestyle changes/alternative treatments. We describe each treatment, review the studies of its effectiveness in people aged ≥ 60 years, and give a rating of the level of evidence.Conclusions: The treatments with the best evidence of effectiveness are antidepressants, electroconvulsive therapy, cognitive behaviour therapy, psychodynamic psychotherapy, reminiscence therapy, problem-solving therapy, bibliotherapy (for mild to moderate depression) and exercise. There is limited evidence to support the effectiveness of transcranial magnetic stimulation, dialectical behaviour therapy, interpersonal therapy, light therapy (for people in nursing homes or hospitals), St John’s wort and folate in reducing depressive symptoms.

Cathy J Frazer PhD · Helen Christensen PhD · Kathleen M Griffiths PhD

Identifying these reactions is a good start, now we must focus on managing and preventing them Australia’s voluntary reporting system for adverse drug reactions has one of the highest per capita reporting rates in the world. Reports to the Australian Adverse Drug Reactions Advisory Committee have played a significant international role in identifying previously unrecognised adverse drug reactions (ADRs), such as hepatitis with flucloxacillin and amoxycillin–clavulanic acid. However, in this issue of the Journal (page 267), Burgess and colleagues remind us that, although identifying ADRs is important, managing and preventing them are equally critical. Their study in Western Australia showed that the rate of ADRs associated with hospitalisations in people aged 60 years and over more than doubled between 1991 and 2002. South Australian data for all age groups showed a similar rise and correlated strongly with changes in medication use in the community.3 National data also show increases,3,4 although the correlation with medication use is less clear. As the Australian coding standards allow ADR codes to be applied to any diagnosis, not just the principal diagnosis,5 the WA data may represent all ADRs, not just those linked to admission or length of stay. Efforts to improve coding will have contributed to some of the observed rise as, for example, rates in SA increased in the year casemix funding was introduced. Increases in the number of hospital admissions over time will also have contributed, but the strong correlation with medication use in SA suggests an exposure effect. The rise in ADRs is not inevitable. The Quality in Australian Health Care Study estimated that 43% of adverse drug events were potentially preventable.6 Similarly, an Australian study of ADRs in oncology patients demonstrated that 48% of predictable ADRs were potentially preventable.7 The questions raised by Burgess et al’s study are: why are ADR rates rising and why have we been unable to prevent the rise, given the preventability estimates? Burgess et al suggest the rise represents a failure of the national strategies to improve the quality and safety of medicine use. There are many data available with which to dispute this claim. Over 100 performance indicators are used to routinely monitor the National Strategy for Quality Use of Medicines, with more than 85% of them demonstrating improvements over time and significant development of services and resources.4 The National Prescribing Service (NPS) has driven cultural change about quality prescribing in general practice, with more than 50% of general practitioners now voluntarily participating in initiatives to improve prescribing.8 Improvements in antibiotic, antidiabetic, analgesic and antihypertensive use have been seen, in keeping with NPS messages.8 The Safety and Quality Council are also driving cultural change, supporting the National Medication Safety Breakthrough Collaborative, which has worked with 100 hospitals and over 480 staff. This initiative is now focusing on disseminating knowledge of and sustaining successful practices. What the data on ADRs in hospitals indicate is our failure to focus on management strategies for ADRs as a specific topic within the national initiatives. Quality use of medicines and safety initiatives have generally focused on development of services, appropriate selection of medicines and error reduction. The focus for ADRs has remained predominantly on reporting and identification, with less emphasis on management. To improve ADR management, we must improve our information sources. Product and consumer information list ADRs but usually fail to provide management strategies. Incidence estimates in product information are based on the initial clinical trials and not easily updated when postmarketing surveillance is based on voluntary reporting. Information on the duration of side effects and consumer experience with medicines is also limited. Providing lists of ADRs does little to change behaviour; management strategies are required.9 The data-linkage studies now under way will enable better incidence data to be developed, as well as identify population groups most at risk of ADRs. The newly established consumer reporting service will also facilitate better understanding of consumer perspectives. This must be incorporated into information sources and supported by clear instruction on management. Detection of ADRs in routine clinical practice must also be improved, with more training needed in this area for health professionals. An Australian study of older people considered at high risk of medication misadventure found that 19% had had an ADR which had not been detected in routine clinical care, even though most were using multiple medicines, had comorbidities and were aged over 65 years.10 The other major requirement is to increase participation in services demonstrated to improve use of medicines and to help prevent ADRs. While consumer medicine information is now available for over 2000 products, it is not provided routinely and continues to be regarded negatively among some health professionals, despite consumer calls for information on side effects.11 Home-medication reviews involving general practitioners, pharmacists and patients have been shown to resolve or ameliorate ADRs in 56% of cases.12 However, the 26 000 home-medication reviews undertaken in 2003–200413 represented about 10% of the population likely to benefit from the service. Other multidisciplinary approaches such as clinical pharmacy, hospital discharge planning and case conferencing services have all been shown to reduce adverse drug events,3 but only 13 000 case conferences and 96 000 discharge-planning services were funded under Medicare’s Enhanced Primary Care packages in 2003–2004.14 The latter services account for 3% of hospital admissions involving overnight stays. These services are relatively new, which may contribute to the low uptake. However, their administrative requirements also need to be streamlined, as general practitioners have found them to be bureaucratic and onerous.15 In addition, trying to incorporate new services on top of existing practice may be adding to the burden and low uptake. It may be necessary to redesign general-practice systems to accommodate these new ways of working. Finally, we require a cultural and attitudinal change to the preventability of ADRs and to multidisciplinary practice. ADRs are often considered part of the price to be paid for the therapeutic benefit of medicines. The rise in ADRs despite preventability estimates suggests that we are currently paying too high a price. Preventing ADRs requires active participation by everyone.

Elizabeth E Roughead PhD

Objective: To examine trends in adverse drug reactions (ADRs) in people aged 60 years or over causing admission to or an extended stay in Western Australian hospitals between 1981 and 2002.Design and setting: Secondary data analysis of case series.Patients: 43 380 patients admitted to WA public and private hospitals with an (International Classification of Diseases) ICD external cause code for an ADR, identified by the population-based WA Hospital Morbidity Data System.Main outcome measures: Age-specific, age-standardised and drug-specific rates of ADR-related hospital stays.Results: The age-standardised rate of ADR-related hospital stays increased from 2.5 per 1000 person-years (py) in 1981 to 12.9 per 1000 py in 2002. The largest increases occurred in those aged 80 + years (tenfold in men and sevenfold in women). The most common drug group involved was cardiovascular agents (17.5%), while anticoagulants (7.5%), cytotoxics (7.4%) and antirheumatics (6.8%) were the more specific drug classes most often implicated. ADRs from the last three classes of drugs were still rising at the end of the study, whereas ADRs from corticosteroids and antihypertensives peaked in 1996 and from opioids in 2000.Conclusions: Increases in hospital admissions or extended lengths of stay due to ADRs in WA have continued despite programs to promote rational and safer use of medicines. The sharp increase in ADRs from anticoagulants warrants attention to revised clinical guidelines.

Christel L Burgess BHlthSc(Hons) · C D’Arcy J Holman MB BS, MPH, PhD · Anthony G Satti BEd

Jeanette I Nordon Retired, 42 Milroy Avenue, Kensington, NSW 2033. To the Editor: I spent a lot of my working life treating patients in an area with an ageing population. I am now elderly and I hear many of my peers complaining bitterly about their doctors. Even if they have a serious illness they are often told, “What can you expect at your age?”. This unhelpful attitude does nothing to alleviate the patients’ concerns. Often, after some questioning, it may be apparent that these patients have some conditions that are eminently treatable and, without this questioning, may be missed. With the advances in medicine and surgery, the proportion of elderly people in our population is increasing. “He or she has had a good innings” was a comment that I heard doctors make in the past. But, doctors change their tune as they age, and these platitudes are much less frequently used! So, in spite of the fact that we are living much longer, with new joints, new transplanted organs, new patent coronary arteries, better means of treating neoplasms, and more exotic investigations to make more exact diagnoses, we must still address our patients in a civil manner, and remember that often the older methods of diagnosis are still important. And don’t let us forget that doctors also get old.

Jeanette I Nordon

Mark Mackay,* Peter Millard† * PhD student, Department of Psychology, Level 4, Hughes Building, University of Adelaide, Adelaide, SA 5005, and Principal Project Officer, SA Department of Health; † Emeritus Professor of Geriatric Medicine, St George’s Hospital Medical School, and Visiting Professor — Health and Social Care Modelling Group, University of Westminster, London. mmbmATiprimus.com.au To the Editor: Gray, Yeo and Duckett used the wrong basis of measure for their analysis of bed trends.1 Bed use per thousand of the population masks the trends in total bed-days or separations and does not address the issue of supply. These issues have important ramifications for policy decision-making. Using the same sources of data,2,3 we compared bed-related statistics and population changes for the periods 1993–94 and 2001–02. What should be of most interest to planners is that the number of multi-day bed-days only declined marginally (from 14 434 to 14 231; −1.4%), despite the significant increase (from 1698 to 3343; + 96.8%) in same-day activity. Although multi-day separations and bed-days did decline (separations, − 4.2%; bed-days, − 14.9%) for those aged 65–74 years, for those aged 75 years or over bed-days and separations increased significantly (separations, + 41.6%; bed-days, +27.7%). Furthermore, same-day activity increased significantly for those aged 65 or more years. Furthermore, the authors failed to highlight the implications of changes in the relative age mix of activity. For those aged 75 years or more, the increase in proportion of separations (+ 5.8 percentage points) and bed-days (+ 1.8 percentage points) was greater than the increase in this proportion of the population (+ 1.1 percentage points). For the 65–74-years age group, the proportion of same-day hospital activity increased (+ 1.3 percentage points), unlike the reduction in that proportion of the population (− 0.2 percentage points). Moreover, the question of whether an ageing population has resulted in the need for more beds can not be answered without considering the supply of beds. From our experience, the growth in same-day activity has been achieved, at least in part, by substituting same-day beds for inpatient beds. The need for increased same-day beds has been considerable. Statistics relating to same-day beds do not appear to be reported for Australia as a whole. However, the increasing implied bed occupancy (including same-day) shown in the Box supports this conclusion. We surmise that the reduction in supply of multi-day beds combined with a marginally altered demand for multi-day beds has led to increasing numbers of bed crises. Given that relative growth in same-day activity can be attributed to people aged 65 years or over, and that the number of multi-day bed-days for those aged 75 years or more has increased, it appears that the ageing of the population, combined with the manner in which the substitution of beds has occurred, has contributed to increasing bed crises. Changes in implied bed occupancy Financial year Change from 1998–99 to 2001–02 1998–99 1999–00 2000–01 2001–02 Total bed-day utilisation (000s) 22 323 22 597 22 467 23 218 + 4.0% Total available bed-days (000s) 28 868 28 540 28 675 28 787 − 0.3% Implied occupancy 77% 79% 78% 81% + 4.3%

Mark Mackay · Peter Millard

Len C Gray,* Stephen J Duckett† * Professor in Geriatric Medicine, University of Queensland, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, QLD 4102; † Professor of Health Policy, Latrobe University, Melbourne, VIC lgrayATsoms.uq.edu.au In reply: Mackay and Millard have raised some important issues in relation to our analysis. Our article was developed to encourage wider reflection and their response is thus welcomed. The primary criticism levelled by Mackay and Millard was that we underplayed the importance of supply of beds in our interpretation of the trends. We agree that bed supply is an important driver of utilisation patterns. We acknowledged this, in part, in the discussion as a possible explanation for rising separation and declining bed-utilisation rates in the older patient population. We are also sympathetic to the hypothesis that there may be a process of substitution of same-day separations for multi-day separations. However, data relating to bed availability are not readily available, and thus could not be included in our study. Our article was designed to highlight different trends between age groups, which have not previously been reported. Now that these trends have been identified, further research and analysis is required to fully explain them, with a view to supporting an intelligent strategy to prepare for future population ageing.

Len C Gray · Stephen J Duckett

Objective: To describe fall-related injuries due to pets in an older population.Design: Case series.Participants and setting: Patients aged 75 years and over presenting to the emergency department of a metropolitan hospital in northern Sydney over 18 months, with a fracture directly related to their pet.Main outcome measures: Type of fracture; circumstances of injury.Results: 16 cases (mean patient age, 81 years) are described; 13 (81%) involved women. Animals of five species were involved, with cats and dogs being the most common pet hazard.Conclusions: Pets are a potential environmental hazard in the occurrence of fall-related injuries in older people, with dogs and cats most likely to be involved. Women appear more likely than men to be injured.

Susan E Kurrle PhD, DGM · Robert Day FACEM · Ian D Cameron PhD, FAFRM(RACP)

To the Editor: I read with interest the article by Byles and colleagues that shows the minimal impact of health assessments in a section of the older Australian community.1 While these assessments may not be identical to the assessments covered by Enhanced Primary Care (EPC) items on the Medicare Benefits Schedule, my experience performing the latter in older people leads me to believe that they also have limited impact. I am now in part-time clinical practice, with a reasonably well-defined practice population, comprising mostly older patients with complex problems. My practice philosophy is closer to the (perhaps old-fashioned) notion of continuing, comprehensive care, which means I have not been afraid to spend the time needed to understand those patients and to document their health information. So far, I am not sure I have learned anything new in any of the EPC health assessments in which I have participated, although they have been useful for initial assessments of newer patients, as at least they remunerate practices better for the time-consuming task of doing this well. However, EPC assessments may be performed every 12 months. Is this really necessary, unless patient circumstances change? In my practice the answer is probably no, although they may be more useful in practices with less stable doctor–patient relationships. Would it not be a more effective use of resources to instead allow for better-funded initial assessments and assessments when a patient’s condition changes, irrespective of the timing?

Richard B Hays