The prevalence, trends and determinants of mental health disorders in older Australians living in permanent residential aged care: Implications for policy and quality of aged care services

Improving the Transition of Older Adults into Residential Aged Care: A Scoping Review

OBJECTIVES

The transition into residential aged care (RAC) is often associated with loss, grief, isolation and loneliness. This scoping review aimed to identify quantitative research which focused on reducing the negative effects associated with transition, thereby improving the transition experience.

METHODS

A scoping review, which concentrated on quantitative research, was conducted. MEDLINE, CINAHL andPSYCHINFO databases were searched using the initial search terms "olderadults", "residential aged care" and "transition".

RESULTS

From the 457 original citations identified, four met the inclusion criteria. The interventions used a range of professionals and clinicians, diverse content, and a mixture of outcomes. The content of the more successful studies were underpinned by mental wellness themes and helped to reduce depressive symptoms among new residents.

CONCLUSIONS

Our review provides a summary of interventions aimed at improving the transition experience for older adults moving into RAC and highlights gaps in the literature. This review is limited by the paucity of quantitative research in this area. Further research is required to address the negative psychosocial effects associated with transition into RAC.

CLINICAL IMPLICATIONS

Assessing which of the transition phases an individual is in can help individualize interventions to reduce negative symptoms relating to transition.

Psychological interventions designed to reduce relocation stress for older people transitioning into permanent residential aged care: a systematic scoping review

OBJECTIVES

This study aimed to identify and evaluate psychological interventions or strategies designed to reduce relocation stress in older people making the permanent transition into residential aged care.

METHOD

A scoping review following the Joanna Briggs Institute methodology for scoping reviews and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) was conducted. An electronic search of nine databases and the search engine google scholar was completed in December 2022. Article screening and quality appraisal was undertaken independently by at least two reviewers.

RESULTS

Eight full-text articles were included for review, from which four psychological interventions were identified: 1) Resident peer support; 2) Life review; 3) Mental Health Service for Older Adults; 4) The Program to Enhance Adjustment to Residential Living. No interventions were implemented before transitioning into care; all were implemented within three months of resident relocation into an aged care facility.

CONCLUSION

The transition to residential aged care is an inherently distressing experience. The absence of interventions implemented during the pre- and mid-transition phases presents a gap in the literature and suggests an opportunity for early intervention. As population ageing continues to increase, there is a pressing need for the development and implementation of interventions aimed at reducing symptoms of depression and anxiety for older people undertaking this major life transition.

The prevalence of, and factors associated with, a risk of depression in residential aged care services residents: Findings from the FIRST study

OBJECTIVES

Depression is common amongst Australian residential aged care services (RACS) residents. This study aimed to estimate the risk of depression amongst residents and identify factors associated with this risk. In care settings such as RACS, time-efficient screening tools to identify depression risk may be a preferred tool.

METHODS

The two-item Patient Health Questionnaire (PHQ-2), derived from the nine-item PHQ-9 used commonly in the United States (US), was employed in this study. A resident was identified as being at risk of depression where the score was ≥3. Multivariable logistic regression analysis was used to identify independent factors associated with being at risk of depression.

RESULTS

Residents' mean age was 87.7 (standard deviation: 7.3) years and 73% were female. One-fifth of residents (n = 108 or 20%) were at risk of depression. Age (odds ratio [OR] 0.96, 95% confidence interval [CI] 0.93-0.99); Pain Assessment in Advanced Dementia (PAINAD) score (OR 1.55, 95% CI 1.11-2.16); Epworth Sleepiness Scale (ESS) score (OR 1.08, 95% CI 1.03-1.13); and 38-item Frailty Index (FI) score (OR 1.07, 95% CI 1.03-1.10) were significantly associated with being at risk of depression, whilst sex, urinary incontinence, polypharmacy, Dementia Severity Rating Scale (DSRS) and Nursing Home Life Space Diameter (NHLSD) score were not.

CONCLUSIONS

One in five residents were at risk of depression. Younger age, higher pain, higher daytime sleepiness and higher frailty status were associated with depressive risk. Future studies focusing on interventions targeting these factors may contribute to improved health outcomes.

National Trends in Antidepressant Use in Australian Residential Aged Care Facilities (2006-2019)

OBJECTIVES

Antipsychotics have been the focus of reforms for improving the appropriateness of psychotropic medicine use in residential aged care facilities (RACFs). Comprehensive evaluation of antidepressant use in RACFs is required to inform policy and practice initiatives targeting psychotropic medicines. This study examined national trends in antidepressant use among older people living in RACFs from 2006 to 2019.

DESIGN

National repeated cross-sectional study.

SETTING AND PARTICIPANTS

Individuals aged 65 to 105 years who were permanent, long-term (≥100 days) residents of Australian RACFs between January 2006 and December 2019 were included.

METHODS

Annual age- and sex-adjusted antidepressant prevalence rates and defined daily doses (DDDs) supplied per 1000 resident-days from 2006 to 2019 were determined. Age- and sex-adjusted prevalence rate ratios (aRRs) and 95% confidence intervals (CIs) were estimated using Poisson and negative binomial regression models.

RESULTS

A total of 779,659 residents of 3371 RACFs were included (786,227,380 resident-days). Overall, antidepressant use increased from 46.1% (95% CI, 45.9-46.4) in 2006 to 58.5% (95% CI, 58.3-58.8) of residents in 2019 (aRR, 1.02; 95% CI, 1.02-1.02). Mirtazapine use increased from 8.4% (95% CI, 8.2-8.5) to 20.9% (95% CI, 20.7-21.1) from 2006 to 2019 (aRR, 1.07; 95% CI, 1.07-1.07). Antidepressant use increased from 350.3 (95% CI, 347.6-353.1) to 506.0 (95% CI, 502.8-509.3) DDDs/1000 resident-days (aRR, 1.03; 95% CI, 1.03-1.03), with mirtazapine utilization increasing by 6% annually (aRR, 1.06; 95% CI, 1.06-1.06).

CONCLUSIONS AND IMPLICATIONS

This nationwide study identified a substantial increase in antidepressant use among residents of Australian RACFs, largely driven by mirtazapine. With nearly 3 in every 5 residents treated with an antidepressant in 2019, findings highlight potential off-label use and suggest that interventions to optimize care are urgently needed.

Social participation in Australian residential aged care: A human rights perspective

The Royal Commission into Aged Care Quality and Safety emphasised the critical need for a human rights-based approach to protect the rights of older people in the Australian aged care context, including 'the right to social participation'. This topic is important because of the widespread social isolation and loneliness in Australian residential aged care. This article demonstrates how a human rights-based framework can provide guidance to governments in approaching issues involving the protection of older people's need for social connection in aged care. In doing so, the article considers examples of how the Australian government can ensure choice of living arrangement, individualised support and access to community services and facilities in the residential aged care context to better protect the right to social participation.

Psychological therapies for depression in older adults residing in long-term care settings

BACKGROUND

Depression is common amongst older people residing in long-term care (LTC) facilities. Currently, most residents treated for depression are prescribed antidepressant medications, despite the potential availability of psychological therapies that are suitable for older people and a preference amongst many older people for non-pharmacological treatment approaches.

OBJECTIVES

To assess the effect of psychological therapies for depression in older people living in LTC settings, in comparison with treatment as usual, waiting list control, and non-specific attentional control; and to compare the effectiveness of different types of psychological therapies in this setting.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, five other databases, five grey literature sources, and two trial registers. We performed reference checking and citation searching, and contacted study authors to identify additional studies. The latest search was 31 October 2021.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and cluster-RCTs of any type of psychological therapy for the treatment of depression in adults aged 65 years and over residing in a LTC facility.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles/abstracts and full-text manuscripts for inclusion. Two review authors independently performed data extraction and risk of bias assessments using the Cochrane RoB 1 tool. We contacted study authors for additional information where required. Primary outcomes were level of depressive symptomatology and treatment non-acceptability; secondary outcomes included depression remission, quality of life or psychological well-being, and level of anxious symptomatology. We used Review Manager 5 to conduct meta-analyses, using pairwise random-effects models. For continuous data, we calculated standardized mean differences and 95% confidence intervals (CIs), using endpoint data, and for dichotomous data, we used odds ratios and 95% CIs. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included 19 RCTs with 873 participants; 16 parallel group RCTs and three cluster-RCTs. Most studies compared psychological therapy (typically including elements of cognitive behavioural therapy, behavioural therapy, reminiscence therapy, or a combination of these) to treatment as usual or to a condition controlling for the effects of attention. We found very low-certainty evidence that psychological therapies were more effective than non-therapy control conditions in reducing symptoms of depression, with a large effect size at end-of-intervention (SMD -1.04, 95% CI -1.49 to -0.58; 18 RCTs, 644 participants) and at short-term (up to three months) follow-up (SMD -1.03, 95% CI -1.49 to -0.56; 16 RCTs, 512 participants). In addition, very low-certainty evidence from a single study with 82 participants indicated that psychological therapy was associated with a greater reduction in the number of participants presenting with major depressive disorder compared to treatment as usual control, at end-of-intervention and short-term follow-up. However, given the limited data on the effect of psychological therapies on remission of major depressive disorder, caution is advised in interpreting this result. Participants receiving psychological therapy were more likely to drop out of the trial than participants receiving a non-therapy control (odds ratio 3.44, 95% CI 1.19 to 9.93), which may indicate higher treatment non-acceptability. However, analyses were restricted due to limited dropout case data and imprecise reporting, and the finding should be interpreted with caution. There was very low-certainty evidence that psychological therapy was more effective than non-therapy control conditions in improving quality of life and psychological well-being at short-term follow-up, with a medium effect size (SMD 0.51, 95% CI 0.19 to 0.82; 5 RCTs, 170 participants), but the effect size was small at postintervention (SMD 0.40, 95% CI -0.02 to 0.82; 6 RCTs, 195 participants). There was very low-certainty evidence of no effect of psychological therapy on anxiety symptoms postintervention (SMD -0.68, 95% CI -2.50 to 1.14; 2 RCTs, 115 participants), although results lacked precision, and there was insufficient data to determine short-term outcomes.

AUTHORS' CONCLUSIONS

This systematic review suggests that cognitive behavioural therapy, behavioural therapy, and reminiscence therapy may reduce depressive symptoms compared with usual care for LTC residents, but the evidence is very uncertain. Psychological therapies may also improve quality of life and psychological well-being amongst depressed LTC residents in the short term, but may have no effect on symptoms of anxiety in depressed LTC residents, compared to control conditions. However, the evidence for these effects is very uncertain, limiting our confidence in the findings. The evidence could be strengthened by better reporting and higher-quality RCTs of psychological therapies in LTC, including trials with larger samples, reporting results separately for those with and without cognitive impairment and dementia, and longer-term outcomes to determine when effects wane.

Prototype development of the Mental Health benchmarking Industry Tool for residential aged Care (MHICare Tool): a protocol paper of a two-stage sequential and mixed methods codesign study

OBJECTIVES

Current mental health practices for people living in residential aged care (RAC) facilities are poor. In Australia, there are no mechanisms to monitor and promote mental health for people living in RAC, including those who experience changed behaviours and psychological symptoms. The aim of this study is to improve current practices and mental health outcomes for people living in RAC facilities by codesigning a Mental Health benchmarking Industry Tool for residential aged Care (MHICare Tool).

METHODS

A two-stage sequential and mixed methods codesign methodology will be used. Stage 1 will include qualitative interviews and focus groups to engage with residents, family/care partners and RAC staff to ascertain mental healthcare practices and outcomes of greatest significance to them. Adapted concept mapping methods will be used to rank identified issues of concern in order of importance and changeability, and to generate draft quality indicators. Stage 2 will comprise a Delphi procedure to gain the wider consensus of expert panel views (aged care industry, academic, clinical) on the performance indicators to be included, resulting in the codesigned MHICare Tool.

ETHICS AND DISSEMINATION

This study has been reviewed and approved by the University of Queensland Human Research Ethics Committee (HREC/2019002096). This project will be carried out according to the National Statement on Ethical Conduct in Human Research (2007). The study's findings will be published in peer-reviewed journals and disseminated at national and international conferences and through social media.

CONCLUSION

This protocol reports structured methods to codesign and develop a mental health performance indicator tool for use in Australian RAC.

Excess mortality in residents of aged care facilities during COVID-19 in Australia, 2019-22

BACKGROUND

To date, the excess mortality experienced by residential aged care facility (RACF) residents related to COVID-19 has not been estimated in Australia. This study examined (i) the historical mortality trends (2008-09 to 2021-22) and (ii) the excess mortality (2019-20 to 2021-22) of Australian RACF residents.

METHODS

A retrospective population-based study was conducted using the Australian Institute of Health and Welfare's GEN website data (publicly available aged care services information). Non-Aboriginal, older (≥65 years old) RACF residents between 2008-09 and 2021-22 were evaluated. The observed mortality rate was estimated from RACF exits compared with the RACF cohort yearly. Direct standardization was employed to estimate age-standardized mortality rates and 95% CIs. Excess mortality and 95% prediction intervals (PIs) for 2019-20 to 2021-22 were estimated using four negative binomial (NB) and NB generalized additive models and compared.

RESULTS

The age-standardized mortality rate in 2018-19 was 23 061/100 000 residents (95% CI, 22 711-23 412). This rate remained similar in 2019-20 (23 023/100 000; 95% CI, 22 674-23 372), decreased in 2020-21 (22 559/100 000; 95% CI, 22 210-22 909) and increased in 2021-22 (24 885/100 000; 95% CI, 24 543-25 227). The mortality rate increase between 2020-21 and 2021-22 was observed in all age and sex groups. All models yielded excess mortality in 2021-22. Using the best-performing model (NB), the excess mortality for 2019-20 was -160 (95% PI, -418 to 98), -958 (95% PI, -1279 to -637) for 2020-21 and 4896 (95% PI, 4503-5288) for 2021-22.

CONCLUSIONS

In 2021-22, RACF residents, who represented <1% of the population, experienced 21% of the Australian national excess mortality (4896/22 886). As Australia adjusts to COVID-19, RACF residents remain a population vulnerable to COVID-19.

Anxiety Symptoms in Australian Memory Clinic Attendees with Cognitive Impairment: Differences Between Self-, Carer-, and Clinician-Report Measures

OBJECTIVES

To identify the prevalence of anxiety symptoms using a variety of instruments in an Australian memory clinic sample.

METHODS

This is an exploratory cross-sectional study using a purposive consecutive series sample of 163 individuals and their carers who attended a Brisbane, Australia, memory clinic in 2012-2015. Descriptive statistics and correlation analyses were performed to explore different approaches to measuring anxiety in the sample, using clinician-rated, self-report and carer-report measures.

RESULTS

The mean age of participants was 78 years, nearly 53% were females. Over 70% of participants with mild cognitive impairment (MCI) and dementia (n = 163) experienced mild to moderate anxiety per a clinician-rated measure (HAM-A), which moderately correlated with carer-report anxiety (IQAD; rs =.59, p < .001). Only weak correlations of these measures with self-report anxiety (GAI) were detected.

CONCLUSIONS

Mild to moderate anxiety symptoms were frequent in memory clinic attendees diagnosed with MCI or dementia using the HAM-A, suggesting experiences of subclinical anxiety symptoms.

CLINICAL IMPLICATIONS

Self- as well as carer-report screening tools should be used in memory clinics in addition to routinely administered neuropsychiatric assessments to support early identification of anxiety symptoms and mapping of available post-diagnostic care pathways for people diagnosed with cognitive impairment.

Death by suicide among aged care recipients in Australia 2008-2017

OBJECTIVE

To characterize the features of aged care users who died by suicide and examine the use of mental health services and psychopharmacotherapy in the year before death.

DESIGN

Population-based, retrospective exploratory study.

SETTING AND PARTICIPANTS

Individuals who died while accessing or waiting for permanent residential aged care (PRAC) or home care packages in Australia between 2008 and 2017.

MEASUREMENTS

Linked datasets describing aged care use, date and cause of death, health care use, medication use, and state-based hospital data collections.

RESULTS

Of 532,507 people who died, 354 (0.07%) died by suicide, including 81 receiving a home care package (0.17% of all home care package deaths), 129 in PRAC (0.03% of all deaths in PRAC), and 144 approved for but awaiting care (0.23% of all deaths while awaiting care). Factors associated with death by suicide compared to death by another cause were male sex, having a mental health condition, not having dementia, less frailty, and a hospitalization for self-injury in the year before death. Among those who were awaiting care, being born outside Australia, living alone, and not having a carer were associated with death by suicide. Those who died by suicide more often accessed Government-subsidized mental health services in the year before their death than those who died by another cause.

CONCLUSIONS

Older men, those with diagnosed mental health conditions, those living alone and without an informal carer, and those hospitalized for self-injury are key targets for suicide prevention efforts.

Study protocol for ELders AT Ease (ELATE): a cluster randomised controlled trial of cognitive behaviour therapy to reduce depressive symptoms in aged care residents

BACKGROUND

This protocol describes a study of the effectiveness of cognitive behaviour therapy (CBT) for reducing depressive symptoms in older adults living in residential aged care (RAC) facilities in Australia. Depressive symptoms are highly prevalent in this population, yet the benefits of CBT for reducing such symptoms in RAC facilities have not been widely investigated. Elders at Ease (ELATE) is a 16-session CBT intervention designed for implementation in RAC facilities. The intervention includes cognitive, behavioural and reminiscence strategies and is delivered by mental health trainees (MHTs) in collaboration with RAC facility staff and residents' family.

METHODS AND ANALYSIS

ELATE will be evaluated using a cluster randomised trial comparing outcomes for residents who participate in the intervention with those living in usual care control facilities. The participants are RAC residents aged 65 years or above, with depressive symptoms (Patient Health Questionnaire-2 ≥ 3) and normal cognition or mild cognitive impairment (Standardised Mini Mental Status Examination ≥ 21). They are assessed at four time points: baseline prior to randomisation (T1), mid-treatment (T2; 2.5 months post randomisation), post-treatment (T3; 5 months post-randomisation) and 3-month follow-up (T4; 8 months post randomisation). The primary outcome is change in depressive symptoms between T1 and T3. Secondary outcomes are depressive symptoms at T4, anxiety, suicide ideation, sleep problems, quality of life, staff and family knowledge of late-life depression, stress levels and efficacy in caring for residents, and MHT levels of geropsychology competencies. Residents receiving the intervention are hypothesised to report a greater decrease in depressive symptoms between T1 and T3 compared to residents receiving usual care. The primary analysis is a regression, clustered over site to account for correlated readings, and independent variables are condition and depressive symptoms at T1. A cost-utility analysis is also undertaken.

DISCUSSION

ELATE is a comprehensive CBT intervention for reducing depressive symptoms in RAC residents. It is designed to be implemented in collaboration with facility staff and residents' families, individually tailored to residents with normal cognition to mild cognitive impairment and delivered by trainee therapists. ELATE offers a model that may be widely applicable across the RAC sector.

TRIAL REGISTRATION

Trial registered with the Australian and New Zealand Clinical Trial Registry (ANZCTR) Number ACTRN12619001037190, prospectively registered on 22 July 2019.

A review of excluded groups and non-response in population-based mental health surveys from high-income countries

National mental health surveys play a critical role in determining the prevalence of mental disorders in a population and informing service planning. However, current surveys have important limitations, including the exclusion of key vulnerable groups and increasing rates of non-response. This review aims to synthesise information on excluded and undersampled groups in national mental health surveys. We conducted a targeted review of nationally representative adult mental health surveys performed between 2005 and 2019 in high-income OECD countries. Sixteen surveys met our inclusion criteria. The response rate for included surveys ranged between 36.3% and 80.0%. The most frequently excluded groups included people who were homeless, people in hospitals or health facilities and people in correctional facilities. Males and young people were the most commonly underrepresented groups among respondents. Attempts to collect data from non-responders and excluded populations were limited, but suggest that mental health status differs among some of these cohorts. The exclusion of key vulnerable groups and high rates of non-response have important implications for interpreting and using the results of national mental health surveys. Targeted supplementary surveys of excluded or hard-to-reach populations, more inclusive sampling methodologies, and strategies aimed at improving response rates should be considered to strengthen the accuracy and usefulness of survey findings.

The association between frailty and anxiety: A systematic review

OBJECTIVES

Previous systematic reviews show a clear relationship between frailty and depression, however the association with anxiety is much less frequently explored. Previous single studies indicate evidence is mixed. We completed a systematic review and meta-analysis to identify the relationship between frailty and anxiety.

METHODS

We searched five electronic databases for observational studies in older people in community, care home and outpatient settings with any/no health conditions that measured the association between anxiety and frailty using validated measures. Studies were screened by one reviewer with 10% checked by a second reviewer. The Mixed Methods Appraisal Tool was used to assess study quality. We used meta-analysis to aggregate study findings, with subgroup analyses to explore heterogeneity.

RESULTS

Out of 1272 references, a total of 20 cross-sectional and 1 longitudinal studies were eligible. Older adults with frailty were substantially more likely to display anxiety symptoms than robust populations, across both dichotomous and continuous data sets (n = 10, OR = 3.48, 95% CI: 2.08, 5.81, p < 0.0001, I²  = 94%; N = 5, SMD = 3.13, 95% CI: 1.06, 5.21, I²  = 98%). Similarly, pre-frail older adults were more likely to have anxiety symptoms than robust older adults but to a lesser extent (N = 6, OR = 1.95, 95% CI: 1.41, 2.71, I²  = 63%; N = 3, SMD = 1.70, 95% CI: 0.01, 3.38, I²  = 98%).

CONCLUSIONS

There is a clear association between pre-frailty/frailty and anxiety in older adults. However, data are heterogeneous and primarily from cross-sectional studies so causality cannot be determined. Future research should evaluate the effectiveness of anxiety screening and treatments in frail older adults.

Age-varying relationships between family support and depressive symptoms in Chinese community-dwelling older adults

BACKGROUND

Adequate family support is an important factor in reducing the risk of depressive symptoms in older adults. We aimed to explore the age-varying relationships of family support and depressive symptoms in community-dwelling older adults.

METHODS

A total of 22,163 person-waves of older adults aged 60 to 85 years from the China Health and Retirement Longitudinal Survey were included. Depressive symptoms were assessed by the Center for Epidemiological Studies Depression Scale. Family support was divided into instrumental family support and emotional family support. A Time-Varying Effects Model was utilized to analyze the age-varying relationships.

RESULTS

There were age-varying relationships between family support and depressive symptoms in community-dwelling older adults. Around age 70 was an important turning point of age. In instrumental family support, access to living care can reduce the risk of depressive symptoms in almost all age groups. At least medium-level financial support was required to be protective against depressive symptoms, and high-level financial support was necessary after age 70. In emotional family support, meeting children with high frequency was significantly associated with a lower risk of depressive symptoms before age 70. Contacting children with low or medium frequency added the risk of depressive symptoms before age 70.

LIMITATIONS

Limited sample size of participants aged 80 years and above, lack of assessment for expectations of family support.

CONCLUSIONS

Providing the appropriate type and intensity of family support for older adults at a suitable age was encouraged. Future research should further verify and explicate the age-varying relationships longitudinally.

Utilisation willingness for institutional care by the disabled elderly and its influencing factors based on Andersen's model: a cross-sectional survey of Henan, China

OBJECTIVE

To explore the factors that influence institutional care for the disabled elderly in China and the key factors that influence individuals based on the Andersen model.

DESIGN

Cross-sectional survey.

SETTING

The research was conducted in 18 cities in Henan Province, China.

MAIN OUTCOME MEASURES

A multistage, stratified sampling design was employed. The χ² test was used to compare the differences in basic information of the disabled elderly. A binary Logit model was used to examine the factors influencing the willingness to institutionalise elderly people with disabilities. The determinants of willingness to care in an institution were also explored in a stratified study by gender, age and region to identify the key differences affecting institutionalisation. The Andersen model was used as the theoretical framework to infer the impact strength of each model.

RESULTS

Of the 2810 disabled elderly people in Henan, China, 7.4% of the elderly had a willingness for institutional care. In the binary logistic regression analysis, whether living alone (OR (95% CI)=0.596 (0.388 to 0.916)), medical payment method (basic medical insurance for urban employees: OR (95% CI)=2.185 (1.091 to 4.377)), having mental illness (OR (95% CI)=2.078 (1.044 to 4.137)) had a statistically significant difference (p<0.05) on the impact on the willingness of the disabled elderly to receive institutional care. Validation of the fitted coefficients of the model revealed that the needs factor had the most significant effect on the enabling variable, while the predisposing factor had more minerally effect.

CONCLUSIONS

Several factors influence the willingness of the disabled elderly to institutionalise. Therefore, it is recommended that relevant authorities take targeted measures to focus on the disabled elderly to identify more precise elderly care services to deal with the ageing crisis.

Demographic and clinical profile of residents living with dementia and depressive symptoms in Australian private residential aged care: Data from the Music Interventions for Dementia and Depression in ELderly care (MIDDEL) cluster-randomised controlled trial

OBJECTIVES

1) To describe the demographic and clinical characteristics of residents with dementia and depressive symptoms in the Australian private residential aged care (RAC) context; and 2) to investigate the association between neuropsychiatric symptoms, depression and quality of life and their interactions with dementia severity.

METHODS

This study examined the baseline demographic and clinical data from the Australian arm of the Music Interventions for Dementia and Depression in ELderly care (MIDDEL) study, a multinational, cluster-randomised controlled trial. Demographic characteristics, neuropsychiatric symptoms, depression, quality of life and dementia severity were collected in 330 residents of 12 private RAC facilities across Melbourne, Australia. Descriptive statistics, the Kruskal-Wallis test and the Pearson Χ² test were used to describe and compare the demographic and clinical characteristics according to dementia severity. The association between clinical characteristics and dementia severity was examined using linear regression analyses.

RESULTS

Residents' mean age was 86.5 years, 69% were female, and 44.2% had severe dementia. There were no significant differences between the dementia severity groups on age, sex and education. Residents with severe dementia were more likely to have a diagnosis of Alzheimer's disease (40.3%) and be born overseas (46.8%). Higher levels of neuropsychiatric symptoms, distress and depressive symptoms, and lower quality of life were associated with more severe dementia.

CONCLUSIONS

The findings from our study highlight the diverse and complex care needs of people living with dementia in the Australian private RAC setting, which can be used to inform targeted, person-centred dementia care planning, staff training and allocation of resources.

Registry of Senior Australians (ROSA): integrating cross-sectoral information to evaluate quality and safety of care provided to older people

PURPOSE

The Registry of Senior Australians (ROSA) was established to evaluate aged care experiences in Australia. In this manuscript, we describe the ROSA framework, the two ROSA cohorts, highlights from research findings, and future plans.

PARTICIPANTS

The South Australian ROSA Prospective Cohort (August 2018-June 2020) enrolled 26 605 participants, of which 59.2% (N=15 745) are women, with a median age of 83 (interquartile range (IQR) 77-88). The National ROSA Historical Cohort (January 2002-June 2020) includes 1 694 206 participants with an aged care eligibility assessment, of which 59.1% (N=1 001 705) are women and the median age is 78 (IQR 72-83).

FINDINGS TO DATE

Most research using the ROSA has focused on dementia, service accessibility, quality and safety of care, falls and injuries and quality use of medicines. The ROSA has also examined the experience of individuals with highly prevalent and understudied conditions in aged care settings (eg, eye and mental health) and aspects of services (eg, built environment) and innovation (eg, mobile radiological services) that can affect older people's health. Important learnings from the ROSA's development include the significant resources and multidisciplinary expertise required for establishing this platform. Between 2018 and 2022, 43 academic publications, eight reports of the Australian Government Royal Commission into Aged Care Quality and Safety, and several reports to state health authorities and professional societies have used the ROSA.

FUTURE PLANS

Our plans include to: (1) continue delivering high-quality evidence to support the improvement of ageing and aged care services; (2) influence and improve the quality of research in and for the aged care sector; (3) expand scope to facilitate examining aims in more depth; (4) include future aged care sector data collections within the ROSA; (5) inform best practices and innovate how consumer engagement occurs in research; (6) monitor and evaluate the impact of the 2021 Australian Aged Care Reforms.

Psychiatric service delivery for older people in hospital and residential aged care: An updated systematic review

OBJECTIVE

To review studies reporting on the effectiveness of psychiatry service delivery for older people and people with dementia in hospital and residential aged care.

METHODS

A systematic search of four databases was conducted to obtain peer-reviewed literature reporting original research published since June 2004 evaluating a psychiatry service for older people (aged 60 years and over) or people with dementia in inpatient or residential aged care settings.

RESULTS

From the 38 included studies, there was consistent low-to-moderate quality evidence supporting the effectiveness of inpatient older persons' mental health wards (n = 14) on neuropsychiatric symptoms, mood, anxiety and quality of life. Inpatient consultation/liaison old age psychiatry services (n = 9) were not associated with improved depression, quality of life or mortality in high-quality randomised studies. However, low-quality evidence demonstrated improved patient satisfaction with care and reduced carer stress. The highest quality studies demonstrated no effect of psychiatric in-reach services to residential aged care (n = 9) on neuropsychiatric symptoms but a significant reduction in depressive symptoms among people with dementia. There was low-quality evidence that long-stay intermediate care wards (n = 6) were associated with reduced risk for dangerous behavioural incidents and reduced costs compared to residential aged care facilities. There was no effect of these units on neuropsychiatric symptoms or carer stress.

CONCLUSIONS AND IMPLICATIONS

The scarcity of high-quality studies examining the effectiveness of old age psychiatry services leaves providers and policy-makers to rely on low-quality evidence when designing services. Future research should consider carefully which outcomes to include, given that staff skill and confidence, length of stay, recommendation uptake, patient- and family-reported experiences, and negative outcomes (i.e. injuries, property damage) are as important as clinical outcomes.

Trajectory and Predictors of Mental Health Symptoms and Wellbeing in Newly Admitted Nursing Home Residents

OBJECTIVES

This study determined changes in multiple aspects of mental health and wellbeing in newly admitted nursing home residents, and identified risk and protective factors.

METHODS

Participants were 204 residents recently admitted to one of 42 nursing homes in Melbourne, Australia. A subgroup of 82 participants were followed up eight months post-admission. Depression, anxiety, stress, adjustment, and quality of life were assessed at baseline and follow-up. Predictive factors (demographics, health, transition factors, nursing home characteristics) were examined in multiple regression analyses.

RESULTS

Rates of depression and anxiety were high at both baseline and follow-up. Low self-rated health and medical comorbidity predicted poor wellbeing at baseline. Higher perceived control in the relocation to the nursing home and engagement in meaningful activities were associated with better post-admission outcomes. Baseline psychotropic medication use predicted lower anxiety at follow-up but did not impact depressive symptoms.

CONCLUSIONS

There were no significant changes in mental health and wellbeing from one to eight months post-admission. The negative effect of residing in a for-profit nursing home requires further investigation.

CLINICAL IMPLICATIONS

Individual activity scheduling and an opportunity to participate in relocation decision-making and planning may support resident wellbeing post-admission.

Psychological distress, multimorbidity and health services among older adults in rural South Australia

OBJECTIVE

Psychological distress may relate to higher health services use. However, data on psychological distress and health services use among rural older adults are limited. This study investigates psychological distress in older adults (aged ≥60) and evaluates the relationship between psychological distress, multimorbidity and health services utilization.

DESIGN

A cross-sectional design was adopted using data on older adults (≥60) (n = 5920) from the South Australia's 2013-2017 population health survey. The Modified Monash Model MM2-7 was used to designate rural areas. The dataset provides information on reported physical health conditions, psychological distress, and patterns of health services use. The Kessler Psychological Distress Scale (K10) was used to compute scores for reported mental health disorders in this population.

RESULTS

The mean (SD) age of the study participants was 72.1 (8.1) years. Women constituted 58.8% of the sample. The mean (SD) score for psychological distress was 12.5 (3.6). One-fourth (33.7%) report one-chronic condition, 20.4% reported 2 chronic conditions and 13% had more than 3 chronic conditions. High psychological distress was associated with female gender (χ² = 14.4, p < 0.001), <80 years (χ² = 11.7, p = 0.019), lower education (χ² = 10.9, p = 0.027). Similarly, multimorbidity was associated with female gender (χ² = 51.1, p < 001), increasing age (χ² = 173.6, p < 0.001) and lower education (χ² = 28.8 p < 0.001). Psychological distress and multimorbidity were independently associated with health service use. High psychological distress was associated with general practitioner (GP) visit (odds ratio 3.6 (95% CI 2.6-5.1), p < 0.001), emergency department (ED) visit (odds ratio 2.5 (95% CI 1.2-5.0), p < 0.001) and hospital admission (odds ratio 2.3 (95% CI 1.3-4.3), p < 0.001). Multimorbidity was associated with general practitioner (GP) visit (odds ratio 6.8 (95% CI 5.6-8.3), p < 0.001), emergency department (ED) visit (odds ratio 2.5 (95% CI 1.4-4.3), p < 0.001) and hospital admission (odds ratio 3.1 (95% CI 1.9-5.1), p < 0.001). Model included age, gender, education, number of chronic condition and psychological distress.

CONCLUSION/IMPLICATION

Psychological distress and multimorbidity were independently associated with health services use. Thus, psychological distress, particularly in the presence of multimorbidity, presents an opportunity for intervention by clinicians that may reduce the demand on rural health services.

Government-subsidised mental health services are underused in Australian residential aged care facilities

ObjectiveTo describe patterns of use of the available Government-subsidised mental health services among people living in Australian residential aged care facilities.MethodsA retrospective population-based trend analysis was conducted, including all non-Indigenous people living in an Australian facility between 2012 and 2017. Adjusted incidence proportions and trends were estimated for four groups of mental health services.ResultsThe use of Medicare-subsidised mental health services was very low overall. The proportion of residents who accessed primary care mental health services increased from 1.3% in 2012/2013 to 2.4% in 2016/2017, while psychiatry service use increased from 1.9 to 2.3%. Claims for clinical psychology increased from 0.18 to 0.26%, and claims for a registered psychologist, occupational therapist or social worker rose from 0.45 to 1.2%. People with dementia were less likely than people without dementia to access all services aside from psychiatry services.ConclusionsLess than 3% of residents accessed funding subsidies for mental health services and people with dementia experienced pronounced barriers to service access. Mental health care is a pillar of the publicly-funded health system in Australia, and low use of these services among aged care residents indicates a need for organisational and policy changes to improve access.

Exploring the relationship between co-worker and supervisor support, self- confidence, coping skills and burnout in residential aged care staff

BACKGROUND

Staff working in residential aged care facilities face unique challenges and stressors in their workplaces which increase their risk for occupational burnout. Burnout in this workforce results in low job satisfaction, increased levels of absenteeism and poor retention rates. Given Australia's ageing population and the demand for residential aged care staff, it is imperative to explore predictors of burnout in this cohort in order to help staff prevent and manage burnout.

METHODS

This study examined the extent to which co-worker and supervisor support, self-confidence and adaptive coping skills predicted burnout among residential aged care staff, after controlling for staff demographics, organisational climate and work patterns. One hundred and thirty three residential aged care staff across Australia were surveyed using online questionnaires measuring levels of co-worker and supervisor support, self- confidence, adaptive coping skills and burnout.

RESULTS

Regression analyses indicated that, overall, co-worker and supervisor support, self-confidence, and adaptive coping predicted each dimension of burnout (emotional exhaustion, depersonalization and personal accomplishment). After controlling for covariates and other predictors: confidence significantly predicted all three dimensions; support significantly predicted emotional exhaustion and depersonalization, and adaptive coping significantly predicted emotional exhaustion.

CONCLUSION

These findings suggest that co-worker and supervisor support, self- confidence and adaptive coping skills need to be addressed to prevent and manage occupational burnout for residential aged care staff in Australia.

Clinical effectiveness of music interventions for dementia and depression in elderly care (MIDDEL): Australian cohort of an international pragmatic cluster-randomised controlled trial

BACKGROUND

Dementia and depression are highly prevalent and comorbid conditions among older adults living in care homes and are associated with individual distress and rising societal costs. Effective, scalable, and feasible interventions are needed. Music interventions have shown promising effects, but the current evidence base is inconclusive. The present study aimed to determine the effectiveness of two different music interventions on the depressive symptoms of people with dementia living in residential aged care.

METHODS

We implemented a 2 × 2 factorial cluster-randomised controlled trial to determine whether group music therapy (GMT) is more effective than no GMT with standard care, or recreational choir singing (RCS) is more effective than no RCS with standard care, for reducing depressive symptoms and other secondary outcomes in people with dementia with mild to severe depressive symptoms living in residential aged care. Care home units with at least ten residents were allocated to GMT, RCS, GMT plus RCS, or standard care, using a computer-generated list with block randomisation (block size four). The protocolised interventions were delivered by music therapists (GMT) and community musicians (RCS). The primary outcome was Montgomery-Åsberg Depression Rating Scale score at 6 months, assessed by a masked assessor and analysed on an intention-to-treat basis using linear mixed-effects models, which examined the effects of GMT versus no-GMT and RCS versus no-RCS, as well as interaction effects of GMT and RCS. We report on the Australian cohort of an international trial. This trial is registered with ClinicalTrials.gov, NCT03496675, and anzctr.org.au, ACTRN12618000156280.

FINDINGS

Between June 15, 2018, and Feb 18, 2020, we approached 12 RAC facilities with 26 eligible care home units and, excluding six units who could not be enrolled due to COVID-19 lockdowns, we screened 818 residents. Between July 18, 2018, and Nov 26, 2019, 20 care home units were randomised (318 residents). Recruitment ceased on March 17, 2020, due to COVID-19. The primary endpoint, available from 20 care home units (214 residents), suggested beneficial effects of RCS (mean difference -4·25, 95% CI -7·89 to -0·62; p=0·0221) but not GMT (mean difference -0·44, -4·32 to 3·43; p=0·8224). No related serious adverse events occurred.

INTERPRETATION

Our study supports implementing recreational choir singing as a clinically relevant therapeutic intervention in reducing depressive symptoms for people with dementia in the Australian care home context.

FUNDING

National Health and Medical Research Council, Australia.

Strategies to support older adults' mental health during the transition into residential aged care: a qualitative study of multiple stakeholder perspectives

Background

The move from home into residential care is one of the most stressful life experiences for older adults. ‘Relocation stress’ is a significant risk factor for anxiety and/or depression in aged care residents. Whether long-term or recently diagnosed, these mood disorders are associated with a decline in overall well-being, daily functioning and independence. The mental health needs of older adults are often poorly recognised and supported, including during the transition into residential care. Despite growing interest in how to facilitate this major life transition, few studies have taken the perspective of multiple stakeholders. The aim of this study was to explore resident, relative and staff experiences of the transition into residential aged care, and to identify strategies to support the mental health of older adults at this time. The role of pastoral care practitioners to facilitate transitions and support residents’ mental health was also examined.

Methods

This phenomenological study involved individual interviews with 35 aged care residents, relatives and staff, between January and April 2021. Participants were selected using purposive sampling. Audio-recorded interviews were transcribed verbatim and supported by field notes. Data analysis followed Giorgi’s steps for qualitative data analysis.

Results

Results were distilled into three main categories related to the overall transition experience, recognising and responding to residents’ mental health needs, and tailoring support to individual needs. A novel contribution of this study relates to the need to address a broad misunderstanding of the role of pastoral care and subsequent under-utilisation of a potentially valuable resource.

Conclusions

By describing transition experiences and the resources to support residents’ mental health, findings of this study provide practical, ‘real world’ suggestions for reducing relocation stress. New resources developed from the findings include guides, checklists and short question-and-answer films, in which current residents and staff describe strategies to support mental health and overall quality of life. Similar resources could be used to support transitions in other care settings.

Preliminary evidence for the impact of digital life stories about aged care residents on staff knowledge and understanding regarding those residents; A single arm trial

AIMS AND OBJECTIVES

This study aimed to examine the impact of digital stories about aged care residents on staff knowledge and understanding regarding those residents.

BACKGROUND

More than a quarter of a million older Australians live in residential aged care facilities. This living arrangement can inhibit the expression of a person's sense of identity. Without objects and cues that reflect the person's selfhood, it can be difficult for a person to express their uniqueness. Staff may not sufficiently appreciate the resident's individuality and therefore may not be able to customise care for the resident.

DESIGN

This study used a single-arm trial design.

METHODS

The study was conducted in four residential aged care facilities. Short digital life stories (3-4 min) of eight residents were constructed by student volunteers over 6 months. Participants (n = 53 care staff) completed a self-report measure of their knowledge and understanding of a resident before and after watching the resident's story. The study adhered to guidelines for Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) (see Appendix S1).

RESULTS

Pre- and post-test scores of the measure were compared using paired samples t-tests. These scores changed significantly, showing an improvement of knowledge and understanding regarding residents.

CONCLUSIONS

Watching digital life stories were associated with improvements in knowledge and understanding by staff, and hence have the potential to foster a greater level of understanding of residents by such staff, and more person-centred care practices within residential aged care facilities.

RELEVANCE TO CLINICAL PRACTICE

Digital stories about aged care residents are quick and efficient methods for improving aged care staff members' knowledge and understanding of the residents under their care. With such understanding, staff may be able to better customise care for residents, thereby validating residents' sense of identity and elevating residents' quality of life.

Barriers and facilitators to the use of e-health by older adults: a scoping review

Background

Limited attention has been paid to how and why older adults choose to engage with technology-facilitated health care (e-health), and the factors that impact on this. This scoping review sought to address this gap.

Methods

Databases were searched for papers reporting on the use of e-health services by older adults, defined as being aged 60 years or older, with specific reference to barriers and facilitators to e-health use.

Result

14 papers were included and synthesised into five thematic categories and related subthemes. Results are discussed with reference to the Unified Theory of Acceptance and Use of Technology2. The most prevalent barriers to e-health engagement were a lack of self-efficacy, knowledge, support, functionality, and information provision about the benefits of e-health for older adults. Key facilitators were active engagement of the target end users in the design and delivery of e-health programs, support for overcoming concerns privacy and enhancing self-efficacy in the use of technology, and integration of e-health programs across health services to accommodate the multi-morbidity with which older adults typically present.

Conclusion

E-health offers a potential solution to overcome the barriers faced by older adults to access timely, effective, and acceptable health care for physical and mental health. However, unless the barriers and facilitators identified in this review are addressed, this potential will not be realised.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11623-w.

Befriending Older Adults in Nursing Homes: Volunteer Perceptions of Switching to Remote Befriending in the COVID-19 Era

Objectives: Residents in nursing homes are being isolated to prevent exposure to COVID-19. Many are prone to depression, anxiety and loneliness, and extra isolation leaves them vulnerable to compromised mental health. In this study, trained volunteers providing befriending for residents with symptoms of depression, anxiety and loneliness switched to remote befriending during COVID-19. The purpose of this study was to gauge volunteer perceptions of the switch.Methods: A qualitative phenomenological approach was used to understand how switching to remote befriending impacted on volunteers and residents. A convenience sample of 18 participants responded to questions either in individual or group interviews.Results: Volunteers adapted their befriending visits, switching from face to face visits to remote options. The format was decided collaboratively. Hearing impairments hindered phone calls. Residents sometimes felt uncomfortable with digital technology but on the whole, the change to remote "visiting" was accepted.Conclusions: Further research is being conducted to gauge mental health outcomes for residents. Most volunteers and residents accepted the switch to remote befriending as better than no contact.Clinical implications: Volunteers can provide valuable support for residents living with social isolation during COVID-19. The format for social support needs to be decided collaboratively between volunteer and resident.

BEFRIENding for Depression, Anxiety and Social support in older adults living in Australian residential aged care facilities (BEFRIENDAS): randomised controlled trial protocol

BACKGROUND

This protocol describes an ongoing study of the impact of befriending on depression, anxiety and loneliness in older people living in residential aged care facilities in Australia. While systematic reviews of befriending have indicated positive benefits of befriending for people in a range of ages and settings, there have been no randomised controlled trials (RCTs) of befriending for older people living in residential aged care with depression and no studies of the cost effectiveness of befriending in residential aged care facilities (RACFs) in Australia.

METHODS AND ANALYSIS

We are conducting a single blind pragmatic RCT comparing two groups of older people living in RACFs, one receiving an intervention consisting of weekly befriending for 4 months from a trained volunteer and the other receiving treatment as usual. Participants undergo eligibility screening for depression (GDS-15 ≥ 4) and cognitive impairment (GPCog ≥ 4) and assessments at three measurement time points: baseline prior to randomisation, 2 months post-baseline and 4 months post-baseline. The primary outcome measure is depression, and secondary outcome measures are anxiety, loneliness, social isolation and quality of life. The economic evaluation will take the form of a cost-utility analysis based on the outcome of quality of life. The primary and secondary outcomes will be analysed using negative binomial and logistic regressions utilizing the Generalised Estimating Equations approach.

DISCUSSION

To our knowledge, this is the first RCT evaluating the effectiveness of befriending on older people with depression living in residential aged care. It is expected that the befriending intervention will reduce the severity of depression symptoms experienced by older people living in residential aged care. If the intervention proves effective it may be incorporated into volunteer training programs and adopted as a way of supporting older people's mental health.

TRIAL REGISTRATION

Trial registered with the Australian and New Zealand Clinical Trial Registry (ANZCTR) Number: ACTRN12619000676112 , registered 06/05/2019 - retrospectively registered.