Informage Volume 2 Issue ii June 2015 Winter Edition by Southern Cross Care (SA & NT)

INFORMAGE Connecting Research with Care

Volume 2, Issue 2 2015 Winter Edition

Healthy healing and wound prevention Better oral health in home care An organisational commitment to quality of life The Journal of the Southern Cross Care Research & Innovation Centre

Introduction Research & Innovation Centre

INFORMAGE

What does ‘quality of life’ mean to you? It’s an interesting question, and one that can be difficult to answer. Some, particularly in health care, relate it to physical health or lack of disease and is often considered from a ‘deficit’ point of view. But many suggest it is much more than this, and that it comprises not only of our physical wellbeing, but many other facets of life that are important to individuals. The Free Dictionary online defines quality of life as:

“Your personal satisfaction (or dissatisfaction) with the cultural or intellectual conditions under which you live (as distinct from material comfort)” The Collins online dictionary says:

“The general well-being of a person or society, defined in terms of health and happiness, rather than wealth” But what does that really mean? If you type “what does quality of life mean” into Google, you will see that quality of life is given attention not just in health care, but also in areas such as advertising and business. Emphasis is given to how an individual can achieve their desired quality of life, despite any limitations they may experience, and this is strongly based on personal preference and perceptions. Kate Kennett’s article begins to explore why it is important to address quality of life for individuals in aged care, and how this can be achieved at an organisational and individual level.

Comments? Feedback? Suggestions? If you would like to get in touch with us in relation to any of the articles in this publication, or if you have any suggestions for future articles, please send us an email at informage@southernxc.com.au

Editorial Board - New members We'd like to welcome Darolyn Harris, Manager Integrated Practice Development (Southern Cross Care Qld) and Rosemary Hogan, Head of Care Residential (Southern Cross Care WA) to the InformAge Editorial Board.

A fundamental approach to maintaining individual quality of life is through preventative health care strategies; in this issue we look at a number of different initiatives underway which endeavour to improve health outcomes and overall quality of life for individuals – Dr Adrienne Lewis (SA Dental Service) presents the fantastic ‘Better Oral Health in Home Care’ initiative, Anthony Dyer (Wound Management Innovation CRC) describes the healthy healing and wound prevention program, and Professor Ian Chapman and Dr Stijn Soenen (Adelaide University) talk about the research being undertaken at Southern Cross Care (SA&NT) which focuses on addressing under-nutrition in older people. Also in this issue, Associate Professor Kay Price (University of South Australia) brings to our attention the importance of quality medication use and challenges us on how ‘medicine wise’ we are. Rajiv Chand (Alzheimer’s Australia SA) highlights the limited health research data available that references LGBTI communities, particularly those with dementia, and the difficulties this poses in providing appropriate services and support. And Dr Faizal Ibrahim (The Queen Elizabeth Hospital and DBMAS, Alzheimer’s Australia SA) shares with us his recent trip to Japan where he visited the Dementia Care Research and Training Centre in Tokyo to learn about Japan’s approach to dementia awareness. Enjoy the second issue of InformAge Volume 2, and if you have any feedback on the articles or suggestions for future topics you’d like to see us cover, please contact us at informage@southernxc.com.au

Emma Leedham Business Development Officer InformAge Editor Southern Cross Care (SA&NT) 2

SOUTHERN CROSS CARE RESEARCH & INNOVATION CENTRE

IAHSA Applied Research Forum SOUTHERN CROSS CARE (AUSTRALIA) SPONSORSHIP The International Association of Homes and Services for the Ageing (IAHSA) extended an invitation to Southern Cross Care (Australia) for its participation and sponsorship of the Applied Research Forum, to be held on 31 August 2015 in Perth as part of the IAHSA/ACSA Joint International Global Ageing Conference. The purpose of the forum is to bring applied researchers together with practitioners to enhance, encourage and understand the obstacles in translating research into practice, and to offer researchers a provider perspective on both translation and research opportunities. The theme of the forum is dementia care – lessons learnt from research in Australia, and will explore key issues in this area. Researchers will discuss important findings specific to approaches to care, support and technology. Providers will reflect on the application of these findings in real world settings and their potential to impact quality of life for service users and their carers (paid and unpaid). The Southern Cross Care (Australia) sponsorship will contribute towards the travel costs for researchers in Australia to present at the forum.

Contents WINTER EDITION 2015

Better oral health in home care

An organisational commitment to quality of life

Healthy healing and wound prevention

Under-nutrition in older people

Dementia doesn’t discriminate

What does quality use of medicines mean to you?

A trip to Japan – Dementia Care Research and Training Centre

Research & Innovation Centre CHANGE OF ADDRESS The Research & Innovation Centre has moved. Staff are now situated next to the Southern Cross Care (SA&NT) Central Office at: 148 Greenhill Road, Parkside SA 5063. OUR CONTACT DETAILS ARE: Mail: PO Box 155, Glen Osmond SA 5064 Phone: 08 8291 8075 Fax: 08 8291 8096 Email: RIC@southernxc.com.au WINTER EDITION 2015

ADRIENNE LEWIS

RN, MNstud, MPM, PhD candidate, Research Fellow School of Nursing Adelaide University Project Director, SA Dental Service

Better oral health in home care Adrienne works for the SA Dental Service. She has been successful in gaining two nationally competitive grants from the Australian Government’s ‘Improving Better Practice in Aged Care’ (EBPAC) initiatives. In doing so, she has been instrumental in initiating the development of contemporary models of oral care for older people in residential and community aged care. This includes the highly successful ‘Better Oral Health in Residential Care Project’ (2007–2009) and more recently the ‘Building Better Oral Health Communities Project’ (2012–2014).

BACKGROUND A rapidly ageing population will bring with it significant changes to older people’s health and oral health profiles (Australian Institute of Health and Welfare, 2014). With future estimates predicting 80 per cent of formal aged care is to take place in the home setting, the home care sector will play a key role in helping older people age well at home (Australian Government Department of Social Services, 2013). Oral health is a significant factor affecting older people’s quality of life, overall health and wellbeing. It is known that many oral conditions commonly experienced by older people can be successfully managed and/or prevented by effective daily oral care and timely access to dental care (Chalmers, 2003; Kandelman et al., 2008; Van der Pullen et al., 2014). Oral care is often taken for granted, but is more difficult to achieve when an older person is compromised by physical frailty, cognitive impairment, functional dependence, chronic disease and polypharmacy. Although older people may or may not visit a dental professional on a regular basis, clients receiving home care frequently see a range of aged care workers who are responsible for assessing and monitoring their health status, as well as assisting with personal care. While oral care should be fundamental to

SOUTHERN CROSS CARE RESEARCH & INNOVATION CENTRE

personal care, this important aspect of health care tends to be overlooked (Chalmers and Pearson, 2005; Miegel and Wachtel, 2009; WeeningVerbree et al. 2013). In the home care context this may be because care coordinators have not routinely considered oral care in care planning, and home care workers lack the oral health knowledge and skills to provide effective oral care for older people. Given the predicted demands for more complex home care, this has significant implications for home care providers. Maintaining older people’s oral health therefore must shift from its current low priority to a high priority.

BETTER ORAL HEALTH IN HOME CARE MODEL A project called ‘Building Better Oral Health Communities’ was funded by the Australian Government Department of Social Services’ ‘Encouraging Better Practice in Aged Care’ (EBPAC) program from 2012–2014. It was led by SA Dental Service as a partnership between dental service provision and home care providers, with the University of Adelaide SA (School of Nursing and the Australian Research Centre for Population Oral Health) overseeing the project evaluation. Its aim was to support ageing well at home through the promotion of better oral health for older people receiving home care. In order to achieve this, the project is built on the success of a previous EBPAC project called ‘Better Oral Health in Residential Care’ (Fricker and Lewis, 2009), which promoted a multi-disciplinary model of care. This model advocated that GPs, registered nurses, care workers and dental professionals should share the responsibility for one and/or more of the four key oral health processes: oral health assessment, oral health care planning, daily oral care and dental referral. The ‘Building Better Oral Health Communities’ project adapted these four key processes to suit the home care context. A simple preventative approach to oral health care was introduced. This focused on the daily care of natural teeth and care of dentures, relief of dry mouth, tooth friendly eating, seeing a dental professional, and quitting smoking. A training program and a set of new resources were developed to support home care staff to encourage and support older people to maintain better oral health care. Evaluation results demonstrated that, following home care worker training and the implementation of the four key processes, there were significant improvements in older people’s oral health-related quality of life. Older people also felt more confident with their own efforts to improve their oral health, especially cleaning their natural teeth and dentures. Furthermore, home care providers used the four key oral health processes as a quality control mechanism to improve oral health care service delivery; thus supporting the principles of Home Care Common Standards and building better oral health connections in aged care.

BETTER ORAL HEALTH IN HOME CARE RESOURCES A significant project outcome was the development of two sets of new resources. One set was designed to build the oral health capacity of the home care workforce. For home care workers, the ‘Better Oral Health in Home Care’ resource forms part of an integrated learning package based on five activities: better oral health care, dementia and oral care, understanding the mouth, care of natural teeth, and care of dentures. The activities have a flexible delivery mode; they can be used as a self-learning resource, be facilitated by staff development educators, or used in conjunction with the delivery of oral health training for a vocational training qualification, such as Certificate III Aged Care or a nursing qualification. The other set of resources was designed to raise the oral health awareness of older people and their families by informing them of what they can do to improve their oral health self-care. This supports the concept of informed consumer directed care choices. The resources consist of a self-care management booklet and bathroom prompts. In addition, a series of posters based on the consumer information was produced for promotional displays. For more information visit www.sahealth.sa.gov.au/OralHealthForOlderPeople

REFERENCES Australian Government Department of Social Services (2014). Key directions for the Commonwealth home support programme, discussion paper, accessed 25 July 2014 <https://www.dss.gov.au/our-responsibilities/ageing-and-aged-care/ aged-care-reform/whats-new/commonwealth-home-support-programme/ discussion-paper-key-directions-for-the-commonwealth-home-supportprogramme>. Australian Institute of Health and Welfare (2014). Australia’s health 2014, Australia’s health series no. 14, cat. no aus 178, Australian Institute of Health and Welfare, Canberra. Chalmers J (2003). ‘Oral health promotion for our ageing Australian population’, Australian Dental Journal, vol. 48 (no. 1): pp. 2–9. Chalmers J and Pearson A (2005). ‘Oral hygiene care for residents with dementia: a literature review’, Journal of Advanced Nursing, vol. 52 (no. 4): pp. 410–419. Fricker A and Lewis A (2009). Better Oral Health in Residential Care Final Report, SA Dental Service, Adelaide. Kandelman D, Petersen PE and Ueda H (2008). ‘Oral health, general health and quality of life in older people’, Special Care in Dentistiry, vol. 28 (no. 6): pp. 224–236. Van der Pullen GL, C de Baat, L De Visschere and Schols J (2014). ‘Poor oral health, a potential new geriatric syndrome’, Gerodontology, vol .31 (issue sup. s1): pp. 17–24. Miegel K and Wachtel T (2009). ‘Improving the oral health of older people in long-term residential care: a review of the literature’, International Journal of Older People Nursing, vol.4 (no.2): pp. 97–113. Weening-Verbree L, Huisman-de Wall G, van Dusseldorp L, van Achteburh T and Schoonhoven L (2013). ‘Oral health in older people in long term care facilities: a systematic review of implementation strategies’, International Journal of Nursing Studies, vol. 50 (issue 4, April): pp. 569–582.

KATE KENNETT

Home Support Services Special Projects

An organisational commitment to quality of life Kate has a background in rural and remote community health services, and international health, which included a year with the World Health Organization in the Pacific. She is about to submit a Doctor of Public Health through Flinders University. There are multiple benefits that can be gained from focusing on quality of life in aged care. This article outlines some of the reasons and ways the concept can enhance aged care service provision, and more importantly the wellbeing of our consumers. At Southern Cross Care (SA&NT) we are actively seeking to embed a quality of life approach into our philosophy of care and here we share some of our thinking.

WHY QUALITY OF LIFE? Firstly, quality of life is a subjective concept that honours individual beliefs, experiences and perceptions. A commitment to quality of life demonstrates respect for the dignity of each individual and what is important to them. Secondly, there is significant theoretical and practical evidence to support a commitment to quality of life. This provides a strong evidence base to guide organisational implementation of best practices. The broad domains, important for quality of life have been well described: physical health, psychological and spiritual wellbeing, social relationships, and environment. So, for example, a residential care home can focus on enhancing opportunities for meaningful social relationships within the whole home, while simultaneously supporting the individual relationships that are important to each resident. WINTER EDITION 2015

Additionally, the importance of quality of life in aged care is increasingly recognised in research and policy arenas, but is yet to be widely adopted in practice (Bowling and Stenner, 2011). There is wide potential to utilise this concept to further improve wellbeing for older adults and share knowledge gained with the industry. At Southern Cross Care (SA&NT) we believe that the concept of quality of life encapsulates our values and provides another avenue to express them with our consumers and communities.

THE CONCEPT OF QUALITY OF LIFE Quality of life is a multi-dimensional concept used to assess an individuals’ perception of their own wellbeing. Quality of life has been defined by the World Health Organization as:

“An individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. It is a broad ranging concept affected in a complex way by the person’s physical health, psychological state, level of independence, social relationships and their relationships to salient features of the environment” (World Health Organization). While components of quality of life may be objectively measured (for example, mobility), it is the person’s own assessment of how this impacts their life and wellbeing that constitutes quality of life (Magennis and Chenoweth, 2009). This is especially relevant in aged care as it has been shown that good quality of life can be achieved regardless of age, health status or disability (Johansson, 2003). While factors related to the ageing process can have negative impacts for quality of life, studies have found that how a person adapts and views themselves is more important for their quality of life than their health status alone (Castro et al., 2014). The resilience of older adults and their capacity to maintain quality of life is further illustrated through studies demonstrating that older adults consistently rate their quality of life better than what others (including aged care staff and family members) assume it must be (Crespo et al., 2011). This highlights the importance of respecting the capacity of everyone, including our oldest old, to live meaningful lives (Muangpaisan et al., 2008). Ways older people adapt to age-related decline include: holding a positive attitude about life, adapting to physical limitations to maintain function (for example, with aids or environmental modifications), having positive and supportive social relationships, and accepting their situation (King et al., 2012). Other important aspects of quality of life for older adults include: being free from pain, physical activity participation, mobility, depression, satisfaction with living environment, spirituality and autonomy (Molzahn et al., 2010; Luleci et al., 2008). These are all factors that an aged care organisation can influence, and hence promote quality of life for our consumers.

HOW THE CONCEPT OF QUALITY OF LIFE CAN BE APPLIED IN AGED CARE The research base for quality of life is rich and provides multiple examples of how the concept can be utilised to benefit older adults. These applications include: 6

SOUTHERN CROSS CARE RESEARCH & INNOVATION CENTRE

• Individual quality of life assessments to identify personal needs (Bodur and Cingil, 2009) • Evaluation of overall quality of life within a setting (for example, a residential care home or population group), including change over time (Magennis and Chenoweth, 2009) • Comparison of quality of life between settings (Kane, 2003) • Research and knowledge generation (King et al., 2012) • Development of program strategies and interventions (Castro et al., 2014) • Program evaluation (Peel et al., 2007) • Informing policy (Johansson, 2003)

CONCLUSION At Southern Cross Care (SA&NT), we believe that a focus on quality of life provides a wonderful opportunity to express our values, utilise a best practice approach and demonstrate aged care leadership. We are actively working to embed quality of life principles and knowledge into our practice at the individual setting and organisational levels.

REFERENCES Bodur S and Cingil DD (2009). ‘Using WHOQOL-BREF to evaluate quality of life among Turkish elders in different residential environments’, The Journal of Nutrition, Health and Aging, vol. 13(7): pp.652. Bowling A and Stenner P (2011). ‘Which measure of quality of life performs best in older age? A comparison of the OPQOL, CASP-19 and WHOQOLOLD’, Journal of Epidemiology and Community Health, vol. 65: pp.273280. Castro PC, Driusso P and OIshi J (2014). ‘Convergent validity between SF-36 and WHOQOL-BREF in older adults’, Rev Saúde Pública, vol. 48(1): pp.63-67. Crespo M, Bernaldo de Quiros M, Gomez MM and Hornillos C (2011). ‘Quality of life of nursing home residents with dementia: a comparison of perspectives of residents, family and staff’, The Gerontologist, vol. 52(1): pp.56-65. Johansson C (2003). ‘Rising with the fall: addressing quality of life in physical frailty’, Topics in Geriatric Rehabilitation, vol. 19(4): pp.239-248. Kane RA (2003). ‘Definition, measurement, and correlates of quality of life in nursing homes: toward a reasonable practice, research, and policy agenda’, The Gerontologist, vol. 43(special issue II): pp.28-36. King J, Yourman L, Ahalt C, Eng C, Knight SJ, Perez-Stable EJ and Smith AK (2012). ‘Quality of life in late-life disability: “I don’t feel bitter because I am in a wheelchair”’, Journal of the American Geriatrics Society, vol. 60: pp.569-576.

Luleci E, Hey W and Subasi F (2008). ‘Assessing selected quality of life factors of nursing home residents in Turkey’, Archives of Gerontology and Geriatrics, vol. 46: pp.57-66.

Muangpaisan W, Assantachai P, Intalapaporn S and Pisansalakij D (2008). ‘Quality of life of the community-based patients with mild cognitive impairment’, Geriatric Gerontology International, vol. 8: pp.80-85.

Magennis T and Chenoweth L (2009). ‘How can we improve residents’ quality of life? Assessing the value and practicality of routine quality of life measurement in a residential aged care facility’, Geriaction, Autumn: p.25.

Peel NM, Bartlett HP and Marshall AL (2007). ‘Measuring quality of life in older people: reliability and validity of WHOQOL-OLD’, Australasian Journal on Ageing, vol. 26(4): pp.162-167.

Molzahn A, Skevington SM, Kalfoss M and Schick Makaroff K (2010). ‘The importance of facets of quality of life to older adults: an international investigation’, Quality of Life Research, vol. 19: pp.293-298.

World Health Organization, WHOQOL: Measuring Quality of Life, accessed online at <http://www.who.int/healthinfo/survey/whoqolqualityoflife/en/>.

To address the growing challenge of wound care, the Wound Management Innovation Collaborative Research Centre (WMI CRC) was formed in 2010 and brings together the best of industry, academia and end-user organisations (WMI CRC, 2014). The Australian Government’s CRC program supports industry-led collaborations between key stakeholders to develop new technologies, products, and services to ultimately transform the lives of Australians and the economy.

DR ANTHONY DYER

Research Director Wound Management Innovation Collaborative Research Centre

Healthy healing and wound prevention As Research Director of the Wound Management Innovation CRC, Anthony provides leadership and management of research activities, driving these projects towards commercialisation and/or improvements in patient care. Anthony has a PhD in molecular biology from Flinders University and is a graduate of the Australian Institute of Company Directors. Wound management poses a significant challenge to the health care system (Dyer and Griffiths, 2014). In Australia alone, it is estimated that more than 433,000 people suffer from chronic wounds such as leg ulcers, pressure injuries or non-healing surgical wounds at any one time (Graves and Zheng, 2014). Yet, the true incidence is not really known as many people never seek help for their wound problems. In Australia, it is conservatively estimated that the problem of wounds costs the health care system more than $2.85 billion a year, which equates to almost 2 per cent of the Australian national health care budget (Graves and Zheng, 2014). In addition, formal education and training for health care professionals is fragmented due to wound care not being recognised as a discrete health care field.

The WMI CRC Research Portfolio is divided into three multi-disciplinary research programs that focus on the identification and development of new diagnostics, prognostics, therapeutics and wound management products, through to the delivery of best practice wound care and translating evidencebased care into practice. A key area of activity for the WMI CRC is the dissemination of evidencebased best practice clinical resources to health care providers (Graves et al., 2014). The implementation of evidence-based best practice has been initiated in a number of GP clinics and residential care homes by providing hands on training and education, resulting in improved knowledge and confidence in the prevention of wounds, successful treatment of wounds and improved client outcomes. The CRC is aiming to expand this concept towards self-sustainable business models that provide services beyond the CRC’s term, including providing tele-health and education services into aged care. With this in mind, the WMI CRC has teamed up with Southern Cross Care (SA&NT) and the University of South Australia to conduct a pilot study to test the benefits of education and support services to residents and staff, while also determining the cost effectiveness of this to an organisation as a whole. While it is clear that implementation of evidence-based wound care coincide with health improvements, there is a lack of evidence to demonstrate that investing in wound care and prevention will save costs overall. As such, the project includes the collection of health economics data and modelling which will aim to demonstrate financial incentives for this innovative approach. The pilot study will utilise and build on the education materials developed by participants of the WMI CRC, which aim to improve wound prevention and management throughout Australia. The services offer a number of activities including: online wound education programs, face-to-face training, WINTER EDITION 2015

educational resources and publications, wound prevalence surveys, and a wound advisory service (tele-health). Working with Southern Cross Care (SA&NT) staff, the pilot project will provide remote and hands-on education and training to improve outcomes for residents with wounds, and promote organisational, clinical and educational strategies for the prevention of wounds in residential aged care. Commencing this month at two Southern Cross Care (SA&NT) sites in South Australia, this joint research initiative will start by collecting data on the current levels of staff knowledge and also evaluating the prevalence and severity of wounds. A number of education and prevention initiatives will then be implemented over the next six months, which will be tailored to meet the needs identified in the baseline data. It is hoped that the outputs from this project will include: • Improved resident outcomes demonstrated by a reduction in the prevalence and severity of wounds • Improved staff knowledge, clinical skills proficiency and confidence in wound management • A cost efficiency analysis demonstrating the economic value of adopting education, prevention and support services Ultimately, it is hoped that this innovative project will lead to the development of a sustainable model which promotes and ensures wound prevention through education and support services to residential aged care nationally. This model could also lead the way for other settings such as hospitals and GP clinics in metropolitan and rural areas.

REFERENCES Dyer A and Griffiths I (2014). ‘Guest editorial: The cost of wound management’, Wound Practice and Research: Journal of the Australian Wound Management Association, vol. 22(1): pp.1-2. Graves N, Finlayson K, Gibb M, O’Reilly M and Edwards H (2014). ‘Modelling the economic benefits of gold standard care for chronic wounds in a community setting’, Wound Practice and Research, vol. 22(3): pp.163168. Graves N and Zheng H (2014). ‘Modelling the direct health care costs of chronic wounds in Australia’, Wound Practice and Research: Journal of the Australian Wound Management Association, vol. 22(1): pp.4-12. Wound Management Innovation Cooperative Research Centre (2014). Annual report 2013-14, retrieved from <http://www.woundcrc.com/ documents/1314_WMICRCAnnualReport_final.pdf>.

PROF IAN CHAPMAN

DR STIJN SOENEN

Discipline of Medicine, University of Adelaide

Under-nutrition in older people Professor Ian Chapman, an endocrinologist and metabolic physician, and Dr Stijn Soenen, a post-doctoral scientist, are members of a multi-disciplinary research group at the University of Adelaide studying nutrition in older people. The group comprises clinician researchers, post-doctoral scientists and PhD students, and is particularly focused on detecting, preventing and treating under-nutrition, and thus reducing its adverse effects. The group is part of the Centre for Research Excellence in Translating Nutritional Science to Good Health, which has been funded by the National Health and Medical Research Council since 2007 to undertake this work.

WEIGHT LOSS, LOW BODY WEIGHT AND UNDERNUTRITION IN OLDER PEOPLE Despite the emphasis in the media and elsewhere on obesity and its associated adverse effects, there is growing evidence that under-nutrition is a common and major problem in older people. It is often not appreciated that, after the age of about 65 years, weight loss is more common than weight gain. For example, in one American study, men aged over 65 years lost on average 0.5 per cent body weight per year, and 13 per cent had substantial involuntary weight loss each year (Newman et al., 2001). While older people are more likely to lose than gain weight, the adverse effects of being overweight and obesity are less in older than young adults;

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the body mass index (BMI: weight [kg] divided by height2 [m]) associated with maximum life expectancy actually increases with age, and is between 27 and 30 kg/m2 in people over 65 years, compared to 20 to 25kg/ m2 in younger adults. Consistent with this, the lower-end of the optimum BMI range for life expectancy is higher in older than young adults, at about 22kg/m2 (Chapman et al., 2011).

(gastrointestinal disease, infections, respiratory disease), psychological factors (depression, dementia and bereavement), social factors (poverty, difficulties with shopping, meal preparation and self-feeding, living alone, social isolation and loneliness) and physical factors such as poor dentition. The majority of these causes are at least partly responsive to treatment, so their recognition is important.

Both low body weight (particularly a BMI <22kg/m2) and weight loss are strong predictors of poor outcomes in older people. Involuntary weight loss of more than five per cent of body weight is associated with major adverse effects (Chapman et al., 2011). For example, in the American study mentioned above, weight loss over three years of five per cent or more was associated with a 70 per cent increase in mortality, irrespective of the initial weight, whereas weight stability or weight gain were not associated with increased mortality (Newman et al., 2001).

SKELETAL MUSCLE LOSS

PREVALENCE AND HAZARDS OF UNDER-NUTRITION IN OLDER PEOPLE Under-nutrition, to the point of malnutrition causing adverse effects, is common in older people, particularly among those in residential care homes or in acute hospital care where the prevalence is reported to be 20-85 per cent (depending on the diagnostic methods used), but also in 5-20 per cent of community-dwelling older people (Chapman et al., 2011). Emphasising this point, our group has found that 45 per cent of community dwelling recipients of domiciliary care services in Adelaide were under-nourished, or at risk of under-nutrition (Visvanathan et al., 2003). Under-nutrition in older people has numerous adverse effects. These include anaemia, immune dysfunction, increased inflammation, reduced cognitive function, poor wound healing, reduced muscle strength and gait speed; and most importantly, adverse outcomes of major functional relevance, including greater rates and durations of hospitalisation, increased rates of needing to move from home into supported accommodation, reduced functional capacity and increased mortality. In our domiciliary care study, undernourished subjects were three times more likely to be hospitalised for more than one month in the following year, compared to well-nourished controls (Visvanathan et al., 2003).

WHY ARE SO MANY OLDER PEOPLE UNDERNOURISHED? Even apparently healthy people have reduced appetite and energy intake and a tendency to lose weight as they age – the so-called ‘anorexia of ageing’. People aged 80 years consume approximately 30 per cent less energy than those aged 20 years. The causes of the ‘physiological anorexia of ageing’ are multiple, and include reductions in central and peripheral feeding drives (which tell you when to eat) and increased activity of central and peripheral satiety signals (which tell you when you are full). All too frequently, pathological anorexia and weight loss are superimposed on the ‘physiological anorexia of ageing’. This can result from conditions that become more frequent with age, including medical conditions

An important cause of the adverse effects associated with weight loss and under-nutrition in older people, is that weight loss in older people is mainly made up of skeletal muscle, and this muscle loss is exacerbated by pathological factors including inflammation or illness-induced inactivity, more common in older people. In severe cases, muscle loss leads to sarcopaenia (age-related loss of skeletal muscle) and/or cachexia (wasting of the body), which is strongly associated with adverse outcomes, including frailty and increased rates of falls.

RESEARCH AND DEVELOPMENTS IN THE AREA Despite a growing awareness of the problem, under-nutrition and weight loss in older people are still under-recognised. This is a problem, as identification and treatment of a specific cause, such as depression or poor dentition, is often the most effective form of management. Moreover, many people who could benefit from nutritional assessment and treatment (for example, with supplements) are not being identified. Our group and others are working to increase awareness of this problem among older people and their carers. The key is to be aware of the problem and look for it. Signs of under-nutrition include low body weight (< BMI 22 kg/m2) or weight loss (particularly if more than five per cent of body weight, is unintentional and is in someone who is already underweight). Research is also being undertaken to develop the most accurate, time- and resource-effective ways of diagnosing under-nutrition in older people, and identifying those most at need of further assessment and treatment. We are currently undertaking a detailed study of older residents in Southern Cross Care (SA&NT) residential care homes in Adelaide, involving baseline and longitudinal measures of factors including appetite, weight, body composition, function (strength and mobility), depression and quality of life. This work is likely to lead to better treatment of this condition; this, and other such studies, will provide us with both a picture of the nutritional state of these people and its association with functional and other outcomes (by following them for one year), and information about the best way of readily identifying those older people at risk of, or suffering from, under-nutrition.

NUTRITIONAL SUPPLEMENTS The use of nutritional supplements, usually in the form of high energy, mixed macronutrient drinks, is increasing in older people. There is evidence that protein-enriched supplements are beneficial in preserving and even increasing muscle mass and function in at-risk older people, and these supplements have been shown to lead to some increase in life expectancy, although relatively modest (Milne et al., 2001). Little research has been WINTER EDITION 2015

done however, on developing the optimum timing and composition of such supplement use. Our group is undertaking research to determine the best way of giving protein supplements to older people. We have shown that protein supplements suppress hunger and subsequent food intake less in older than young adults, and they may even increase overall energy intake (Soenen et al., 2014). We are now working on identifying the optimum composition of such supplements and the optimum timing of their administration.

REFERENCES Chapman IM (2011). “Weight loss in older persons”. Med Clin N Am 95, 579-593. Milne AC, Potter J, Vivanti A and Avenell A (2001). “Protein and energy supplementation in elderly people at risk from malnutrition”. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD003288. doi: 10.1002/14651858.CD003288.pub3. Newman AB, Yanez D, Harris T, Duxbury A, Enright PL and Fried LP; Cardiovascular Research Group (2001). “Weight change in old age and its association with mortality”. J Am Geriatr Soc 49, 10, 1309-1318. Soenen S, Giezenaar C, Hutchinson AT, Horowitz M, Chapman I and Luscombe-Marsh ND (2014). “Effects of intraduodenal protein on appetite, energy intake and antropyloroduodenal motiligy in healthy older compared with young men in a randomized trial. Am J Clin Nutr 100, 4, 1108-1115. Visvanathan R, Macintosh C, Callary M, Penhall R, Horowitz M and Chapman I (2003). “The nutritional status of 250 older Australian recipients of domiciliary care services and its association with outcomes at 12 months”. J Am Geriatr Soc 51, 7, 1007-1011.

RAJIV CHAND

Head of Education and Service Innovation Alzheimer’s Australia SA

Dementia doesn’t discriminate Rajiv has extensive experience working with people with dementia in acute, community and aged care. Rajiv began his career working as a Registered Nurse and has a Bachelor’s Degree in Nursing. His involvement with Alzheimer’s Australia SA (AASA) commenced in 2008 when he started working in a clinical role for the Dementia Behaviour Management Advisory Service (DBMAS), which he later went on to lead. Rajiv attained his Masters in Business Administration, specialising in Health, in 2012. Rajiv’s role is diverse within AASA, where he is the Deputy Director of the South Australia & Northern Territory Dementia Training Study Centre and oversees Dementia Care Essentials education, National Dementia Support Programs, and Home and Community Care programs. Dementia is now Australia’s second leading cause of death after heart disease (Australian Bureau of Statistics [ABS], 2013). There are currently more than 342, 800 Australians living with dementia (ABS, 2013) and without a medical breakthrough, the number of people with dementia is expected to be almost 900,000 by 2050 (Australian Institute of Health and Welfare [AIHW], 2012).

SOUTHERN CROSS CARE RESEARCH & INNOVATION CENTRE

• There are some health disparities between transgender and intersex people and the wider population; such as, disproportionately high rates of mental health issues, some cancers and cardiovascular disease (National LGBTI Health Alliance, 2013). The poorer health outcomes are thought to stem from marginalisation and discrimination. • LGBTI people may be more reliant on formal services; recent Australian data reveals that it is primarily partners and children who act as carers for people with dementia living in the community. Whilst this data does not specifically include transgender and intersex populations, it is recognised in the literature that LGBT older people are two and a half times less likely to have children or a partner (Croghan, 2014). Intersex people who received ‘normalising’ treatments to modify their genitals are likely to be sterile and consequently not have biological children to provide assistance. Dementia, as with many other chronic illnesses, does not discriminate in that it affects people irrespective of age, ethnicity and community; such as, Lesbian, Gay, Bisexual, Transgender and Intersex (LGBTI) people*. The LGBTI community makes up a considerable proportion of the Australian population – see Figure 1 (Department of Health and Ageing, 2012). Although dementia is not a normal part of ageing, it is more common amongst people aged 65 years and older (Deloitte Access Economics, 2011), and by the year 2051, it is expected that this will increase to 500,000 LGBTI people over the age of 65 years (National LGBTI Health Alliance, 2013). Therefore, in the years to come there will be more LGBTI people with dementia.

FIGURE 1

Australian LGBTI population

• LGBTI people may play an important and unique role in care giving; specifically, several surveys identified that LGBT people act as carers for members of their family of origin or their ‘family of choice,’≠ and in certain situations, both (Fredriksen-Goldsen, 2011). Care for members of a family of choice is especially important in the case where there is no other support network available. Exploration into the experience of transgender and intersex people who act as carers, has received little attention in the literature. Better understanding of the enablers and barriers to providing care and accessing support services is required to ensure that these significant carers are supported in their invaluable role. • Over half of the people living in permanent residential care homes that have dementia (53 per cent), and the majority of people living with dementia in the community (77 per cent), need access to some level of formal services for assistance (AIHW, 2012). The main areas of support include assistance with mobility and self-care (such as personal hygiene and grooming). Literature suggests that there is a reluctance for transgender and intersex people to access needed health care and services for fear of discrimination and concerns that they will not be welcomed, or receive lower quality of care if their sexual orientation, gender identity or intersex status were known.

KEY RECOMMENDATIONS INCLUDE: • National data collection into population health and dementia should include LGBTI communities as a means to create a nationwide picture of health, current utilisation of services, and how this can be improved. In 2014, Alzheimer’s Australia South Australia (AASA) reviewed the existing literature regarding transgender† and intersex‡ people and ageing and dementia.

KEY FINDINGS INCLUDE: • Transgender and intersex people are largely invisible within the research literature; they are not included in large population health research, making it difficult to gain an understanding of health information over a period of time.

• LGBTI cultural awareness training should be included as a compulsory component of training for all staff working within aged care. • Support should be provided to aged care providers to undertake the process of becoming LGBTI inclusive; for example, the preliminary ‘How 2 Aged Care’ program and ultimately the ‘Rainbow Tick Accreditation’, the gold standard for LGBTI inclusive care. • Further investigation into the response of service providers in regard to LGBTI people’s needs is required to identify how this can be enhanced.

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• The needs of LGBTI people (specifically transgender and intersex people) with dementia, and as carers for others with dementia, needs further exploration; particularly as dementia is such a significant health issue, yet so little is known about how it affects minority groups such as LGBTI people who are vulnerable to poor health outcomes.

Deloitte Access Economics (2011). Dementia Across Australia: 20112050, viewed 22 April 2015 <https://fightdementia.org.au/sites/default/ files/20111014_Nat_Access_DemAcrossAust.pdf> Department of Health and Ageing (2012). National Lesbian, Gay, Bisexual, Transgender and Intersex (LGBTI) Ageing and Aged Care Strategy, viewed 16 April 2015 <https://www.dss.gov.au/our-responsibilities/ageing-andaged-care/older-people-their-families-and-carers/people-from-diversebackgrounds/national-lesbian-gay-bisexual-transgender-and-intersex-lgbtiageing-and-aged-care-strategy> Fredriksen-Goldsen K (2011). ‘Informal Caregiving in the LGBT Communities’, in Witten TM and Eyler AE (eds.), Gay Lesbian, Bisexual and Transgender Aging: Challenges in Research, Practice and Policy, The John Hopkins University Press, Baltimore. National LGBTI Health Alliance (2013). LGBTI Health 2013: People, profile and perspectives summary version 2013, retrieved from < http:// lgbtihealth.org.au/wp-content/uploads/2014/10/LGBTI-Health-2013Summary-Version.pdf>.

For access to the full report please contact Alzheimer’s Australia South Australia on (08) 8372 2100 or sa.admin@alzheimers.org.au The importance of appropriate terminology is recognised. For the purpose of this article, the National Lesbian, Gay, Bisexual, Transgender, Intersex (LGBTI) Ageing and Aged Care Strategy definitions have been adopted. However, it is acknowledged that the ways in which individuals identify is unique and one size does not fit all. *

Transgender is an umbrella term used to describe a diverse group of individuals who do not fit the usual, culturally defined, male and female gender roles. It includes all gender non-confirming people, including transsexual, cross-dressers, drag performers, and gender queer people.

ASSOCIATE

Intersex refers to people born with intermediate or atypical combinations of biological and/or physiological features that distinguish females from males. This may include variations in chromosomes, hormones, reproductive organs, genitals and other physiological features.

School of Nursing & Midwifery University of South Australia

†

‡

A ‘family of choice’ is a series of supportive relationships that can be likened to that of biological family. ≠

REFERENCES Australian Bureau of Statistics (2013). Causes of death, cat. no. 3303.0, Australian Bureau of Statistics, Canberra. Australian Institute of Health and Welfare (2012). Dementia in Australia (cat. no. AGE 70), retrieved from < http://www.aihw.gov.au/workarea/ downloadasset.aspx?id=10737422943>. Croghan CF, Moone RP and Olsen AM (2014). ‘Friends, family, and caregiving among midlife and older lesbian, gay, bisexual and transgender adults’, Journal of Homosexuality, vol. 61 (1): pp.79-102.

SOUTHERN CROSS CARE RESEARCH & INNOVATION CENTRE

PROF KAY PRICE

What does quality use of medicines mean to you? Associate Professor Kay Price is a research leader in the School of Nursing & Midwifery, University of South Australia. She has 40 years of extensive local, national and overseas experience as a registered nurse, educator and researcher. Her main focus is working through the diversity of issues that surround health and aged care services in order to advance the health and wellbeing of all people. Kay developed the Decision-Making Tool: Supporting a Restraint Free Environment in Residential Aged Care (2012) and in Community Aged Care (2012). Kay is a Company Director, NPS MedicinesWise and will be contributing regularly to InformAge on the quality use of medicines.

The picture shows an array of medicines found in the domestic home of an older person. Medicines management, given the potential harm that can occur with medicines (whether unintended or not), creates increasing burden (social and economic) for consumers, policy makers and health and social care professionals. Indeed, medication-related hospital admissions remain a significant problem in the Australian health care system and are the second most common type of incident reported in Australian hospitals. There has always been a recognised need for all people in their everyday lives to have the information they need to make decisions about medicines; the National Medicines Policy (2000) exemplifies this. The purpose of this article is to ask, how many of you know the National Medicines Policy, in particular the Quality Use of Medicines (QUM) strategy? Please visit: www.health.gov.au/internet/main/publishing.nsf/Content/nationalmedicines-policy.

Did you know that there is a requirement in the Therapeutic Goods regulation that each prescription medicine must have a Consumer Medicine Information (CMI)? CMIs are designed to inform consumers about prescription and pharmacist-only medicines. The CMI gives important facts to know before, during and after taking a medicine. How many staff provide older people with the relevant CMI when a new medicine has been prescribed for them? If they are not being provided, why not? To learn more about CMIs please visit: www.nps.org.au/topics/how-to-be-medicinewise/finding-information-onmedicines/what-is-consumer-medicine-information. Achieving QUM as an everyday reality is not without its difficulties. Common breaches in the standard of care with respect to medicines administration are: • Failure to obtain consent • Unclear orders • Incorrect use of telephone orders • Transcribing medications orders • Administration of the wrong medicine • Failure to check medicines • Incorrect dose • Incorrect patient/client/resident • Incorrect route

In 1991, the Australian Government, following pressure from consumers, introduced the concept of quality use of medicines to provide a framework to improve the use of medicines (both prescription and over the counter) for, and by, all Australians – indeed all people across the world. QUM continues to be situated as one of the four central objectives of the National Medicines Policy (2000) and focuses on ensuring the judicious, appropriate, safe and effective use of medicines. The overall aim of the National Medicines Policy (2000) is to meet medicines and related service needs so that both optimal health outcomes and economic objectives are achieved. The intent is access to, and wise use of, medicines. The term ‘medicine’ includes prescription and non-prescription medicines, including complementary health care products. How to assist older people to decide what choice is best for them in the context of their lives, becomes a significant issue. Staff working with older people can influence how and why people may use certain medicines, how they can maximise benefits from their medication regimen and prevent medication-related problems, and ensure that therapeutic alternatives are considered. Helping older people make well-informed decisions and plan ahead for life’s transitions is an important role for aged care staff. Nurses and personal care workers can also support QUM where PRN drugs (when required) are ordered, especially in relation to bowel, pain and sleep management. Staff need to focus also on identifying therapeutic alternatives to medicines that may be more appropriate than PRN medicines.

• Failure to check for adverse effects • Incorrect use of standing orders For QUM to be an everyday reality, it is imperative that all partners in QUM ensure judicious, appropriate, safe and effective use of medicines. All staff need to know their specific responsibilities; for example, in relation to: • Self-administration • Standing orders • Nurse-initiated medicines • Alteration of oral formulations • Dose administration aids • Storage of medicines • Disposal of medicines • Emergency supplies of medications • How to avoid misadventures and errors WINTER EDITION 2015

Let us remember that quality use of medicines means, for all of us: 1. Selecting management options wisely 2. Choosing suitable medicines, if a medicine is considered necessary 3. Using medicines safely and effectively. Free education and evidence about medicines and medical tests is available for all people – please visit NPS: MedicinesWise at www.nps.org.au/. NPS: MedicinesWise programs are funded by the Australian Government, Department of Health.

respect. Faizal helped organise ‘SA’s Mindful of Dementia Open Day’ held at TQEH in collaboration with Alzheimer’s Australia SA (AASA), which has been running since 2010. Faizal works as the Medical Director of Dementia Behaviour Management Advisory Services (DBMAS) Alzheimer’s Australia SA and also lead the Port Lincoln GEM clinical services. He is the current Chair of the Alzheimer’s Consumer Alliance SA. Japan had, for a long time, been high on my list of places to visit, since learning Japanese in High School and more recently, since seeing the reports of leading electronics companies developing “companionship” robots for older people and those with dementia. In February 2015, I was very privileged to receive an invitation from Dr Akira Homma, Director of the National Dementia Care and Research Centre, Tokyo, to visit the centre and to deliver the Dignity in Dementia Care presentation. Getting into Japan through Tokyo Narita Airport was easy and I found everyone to be welcoming and extremely polite. Thankfully, many people I met spoke some English and so easily got to my hotel. Tokyo is a very large city of about 13 million people and like London, most people travel by public transport, usually by train, for which they have a very good service.

DR FAIZAL IBRAHIM

FRACP Edin FRACP Au CCT MRCP UK MBBCh BAO LRCPSI Ireland Geriatrician, The Queen Elizabeth Hospital, CALHN Medical Director, DBMAS Alzheimer’s Australia SA Chair of the Alzheimer’s Consumer Alliance SA

A trip to Japan DEMENTIA CARE RESEARCH AND TRAINING CENTRE Dr Faizal Ibrahim currently works as a Consultant in Geriatric Medicine at The Queen Elizabeth Hospital (TQEH) and has an interest in dementia and delirium. He previously worked as a Consultant in Geriatric Medicine and Acute Medicine at the University Hospitals Birmingham (UHB) where he was also the Lead Physician for Dementia Care and piloted the ‘Delirious about Dementia’ and ‘Dignity in Care’ programs. He proudly champions the Dignity in Care campaign with Ms Maggie Beer as the Patron, which aims to change the culture of Australian health services by reinforcing the importance of treating people with dignity and

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Dr Homma and his team gave us a very comprehensive overview of the care of people with dementia in Japan, which was slightly different to the impression I had gained before arriving. By 2025, it is projected that 12.8 per cent of Japan’s older population (or 470,000 people) will be living with dementia. It is also estimated by the United Nations that by 2050, Japan will have the population with the highest percentage of older people in the world (at about 35 per cent), followed by Korea and Italy. In recent years, the Japanese government has legislated that, due to longer life expectancy and a higher prevalence of dementia being reported, the Japanese population in general needed to be educated as to what dementia is and what the best options for care are. Considering the large population in Japan (approximately 127 million), everyone knew that this was going to be a large task and so three Dementia Care Research and Training Centres were set up. The role of the centres is to: • Improve the quality of care for people with dementia • Conduct research and educational practices • Build up a network among care workers • Provide the latest and useful information to professionals as well as to the general public The centres organise and oversee training for everyone, from family members to government employees and customer facing staff. Course duration depends on the requirements and range from a 90 minute introduction to dementia course, to a three week trainer course. The philosophy of the centres includes key phrases such as:

Tokyo Dementia Care Research and Training Centre

• Everyone’s heart is still alive after suffering from dementia

• Advocate for better understanding of dementia

• We aim for care focusing on the total individual being of people with dementia

• Provide appropriate medical and long-term care for people with dementia, based on their condition

• We will work towards the creation of a society where people with dementia could live together, sustaining their dignity

• Enhance support for people with younger onset dementia

The regional centres incorporate telephone consultation centres for early onset dementia and also undertake the creation of systems to support families in preventing the occurrence of physical abuse by caregivers. There was a feeling that Japan had been lagging behind in dementia care knowledge, but now every effort is being made to get everyone up to speed. Many ordinary people are taking the course on ‘Training for Dementia Care Leader Cultivation.’ The government is aware of the trend towards lower birth rates in Japan, and that there is a large number of retirement age people without the resources of a young population to support them. It was interesting to note that, despite the cultural differences (diet and social experiences), the expectancy for the proportion of population experiencing some form of dementia was very similar to western countries; and there was a determination, in the form of legislation, that Japan should not suffer the effects in the future.

• Provide support for caregivers • Promote the development of dementia friendly communities • Promote research and development in dementia prevention, diagnosis, rehabilitation and care models • Respect and reflect ideas/suggestions from people with dementia and their families Although the challenges are great in that there has been a rapid increase in the number of older people in Japan, there is a shortage of care workers, and the quality of dementia care is variable, the team are motivated by the words of Hippocrates – the father of medicine: “Cure sometimes, treat often, comfort always.”

The Japanese government’s ‘New Orange Plan’ (The National Japanese Dementia Strategy) was announced in January 2015. It aims to:

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Research & Innovation Centre Southern Cross Care (SA & NT) Inc Research & Innovation Centre 148 Greenhill Road, Parkside, SA 5063 PO Box 155, Glen Osmond SA 5064 Phone Fax Email Web

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Southern Cross Care (SA & NT) Inc ARBN 129 895 905, South Australia, liability limited. Published June 2015 Southern Cross Care would like to extend its thanks to our generous sponsors for their support of this issue.