Should Australia adopt a national Dementia plan?

 

Anyone who works in healthcare, particularly those in aged care, can attest to the fact that dementia is one of the largest problems facing our aged population. Here are a few Australian facts courtesy of Alzheimer’s Australia:

  • There are more than 413,106 individuals in Australia living with dementia
  • Currently 244 new individuals will be considered has having dementia every day
  • Dementia is the second leading cause of death of Australians
  • In 2017 the cost of caring for those with dementia in Australia is estimated to be 14.67billion
  • Dementia is the single biggest factor leading to disability of adults over the age of 65
  • Dementia accounts for 52% of those residing in aged care facilities (RACF)

It is a huge problem! In an article on the 2nd of June in Australian Ageing Agenda Maree McCabe of Alzheimer’s Australia has strongly encouraged Australia to join the international community in developing and funding a national Australian dementia policy. In the article it states that the World Health Organization (WHO) has adopted a Global Plan of Action on Dementia, and that Australia should join other countries in adopting it.

What is Australia doing about it?

The government’s response has not been favorable to Alzheimer’s Australia’s (AA) request. Dr Margot McCarthy told a Senate estimates committee that, although she was aware of AA’s request there was no national strategy but a series of increased funding for research and new dementia-specific programs. Dr. McCarthy also in her statement referred to the National Framework on Action on Dementia, but said the government had to decide on how to follow-through with the framework.

The National Framework on Action for Dementia 2015-2019 was developed by the  Australian Health Ministers Advisory Council (AHMAC) through a consultative process and merely serves to

The purpose of the Framework is to guide the development and implementation of actions, plans and policies to reduce the risk of dementia and improve outcomes for people with dementia and their carers. It does this by drawing on current evidence to promote dementia friendly societies and delivery of consumer-focused care.

The keywords here is ‘guide’ and ‘development and implementation’. This is NOT a national framework, but merely a fact-finding paper with the results of interviews and consultations on the problem. While the national framework policy does not give any direct action to the problems of dementia, there have been some attempts by the government to tackle dementia issues.

In June of 2016 the government began a commitment to tackle the issue of dementia in the community by the initiation of the Severe Behviour Response Teams (SBRT), a partnership between the government and Hammond Care. The SBRT is meant to be an assessment and management team designed to visit the individual and work to identify and create strategies to handle adults who suffer from dementia-related behaviours. The government also acknowledged at the time that specific dementia facilities for those with behaviours would be needed. Dr. Judd, then chief executive of Hammond Care, indicated that accreditation standards for aged care facilities had led to those facilities increasing in size and therefore “as nursing homes get bigger and bigger, it becomes harder not to have institutional buildings which are less homelike and more regimented… Today, the public areas of some aged care ‘facilities’ look more like airport lounges than lounge rooms” (quote by Dr. Judd taken from this article).

A year later and the Ageing Australian Agenda article confirmed that the special dementia units promised in 2016 were largely not developed. Therefore, the bulk of dementia-specific management of older adults rests squarely on the shoulders of current residential aged care staff and caregivers when dementia-sufferers are at home. But what about the WHO’s Global Action on Dementia? Wouldn’t that give some indication on where Australia should go?

The World Health Organization and Dementia

I have looked through the WHO’s website and cannot see any agreed final document on the global action on dementia. According to the WHO dementia has been labeled as a public health priority in 2012 and a Ministerial Conference on Global Action on Dementia did occur in 2015, resulting in a draft document of the same name. In the push for WHO development of information a site entitled The Global Dementia Observatory was meant to be a sharing house for information relating to statistics on global dementia and development of strategies to treat and handle those with dementia. However, in my research neither has the Global Action on Dementia been finalized nor has the Global Dementia Observatory been created and implemented despite statements made by Alzheimer’s Australia.

So from my perspective after looking at all of the information the WHO is no further in looking for a unified dementia strategy than Australia is. We continue to develop reactionary stop-gap measures to modify behaviours and reduce pressure on caregivers. But that does not help identify and treat the root cause. Non-government organizations like Alzheimer’s Australia and Hammond Care are doing great things to try and help this looming national (and international) epidemic.

We in healthcare are at the front-line of this issue. Of the patients I see a vast majority are over the age of 65, as they take up more acute healthcare beds. And while I do not have specifics of those with dementia I can say with my experience that many who enter our beds do. Dementia causes quite a few issues that can lead to life-shortening situations.

My thoughts

Those who follow this blog know that I have talked twice about the concept of ‘premature deaths’ a topic surrounding why individuals in aged care facilities are dying from un-natural causes. Falls was listed as the greatest cause of these premature deaths. I wonder if Mr. Ibrahim’s proposed study would look to identify of those falls how many patients have a diagnosis of dementia? Being reasonable and looking at common sense, if I do not have dementia and have all of my faculties would I not use the vast range of mobility aids and ask for help to prevent falling when I look to walk or even stand? Those with dementia do not have the for-sight to realize that they are no longer able to mobilize without help, and therefore are at higher-risk of falling.

Interestingly Dr. Judd in his address in 2016 also talked of aged care facilities becoming larger. This is another troubling point. Larger facilities mean more residents for staff to monitor in a larger space. Another interesting study could look at the amount of time each staff is given per resident. I think it would find that staff have difficulty in adequately supervising residents, particularly those with dementia who are prone to stand and walk- and therefore fall.

Unifying Australia’s stance on dementia and the associated research and programs would give clarity and focus within all aspects of the aged care community. Let’s face it, the aged care population is faced to grow over the next few years. And with it those with dementia is also most likely going to grow. It is a debilitating condition that we need to know more about to effectively care for and treat. I agree with Mrs. McCabe, Mr. Judd and the WHO that we need to put more focus on a unified and strategic plan to deal with this growing epidemic.

References

Australian Ageing Agenda: Australia behind as global dementia plan endorsed

Alzheimer’s Australia: KEY FACTS AND STATISTICS FOR MEDIA – NSW

Australian National Framework for Action on Dementia 2015-2019

Australian Ageing Agenda: Coalition to fund special dementia care units for severe behaviours

Dementia Behaviour Advisory Service

Hammond Care: Severe Behavoiour Response Team

World Health Organization: Dementia

 

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Concerns raised about investigation of premature deaths in aged care facilities.

One day after this and other sites posted about Joseph Ibrahim’s calls to investigate the causes of what a coroner’s report called premature deaths in aged care two other articles have surfaced regarding the same issue.

Falls in residential aged care facilities

In an article in the Medical Journal of Australia Dr. Stephen Judd, chief executive of Hammond care- an aged care provider, discusses potential consequences if nursing home regulation were to be tighten in an attempt to lessen premature deaths from falls.

“If staff think they are going to get rapped over the knuckles if Mary falls over when she goes outside, they’ll lock the door so she can’t get out,” he said.

“All life is about risk; we have to encourage people to enjoy life, not just keep themselves hermetically sealed in a life of boredom,” he said. “Rather than trying to eliminate risks, we must manage risks intelligently.”

Interestingly I wonder if Dr. Judd is aware that most nursing homes do have locks on exterior doors to prevent residents with dementia from travelling outside? From my experience in aged care many, if not most falls, occur in the resident’s bedroom when the patient is found close to their bed. While I have not statistics evidencing this fact, I am sure Dr. Ibrahim’s report would reveal this.

Additionally, I also find it interesting that Dr. Judd stated that ‘staff’ would be responsible for denying freedom for fear of retaliation. Staff of nursing homes answer to the corporate bodies of said homes, so wouldn’t the fear they would be reacting to not come from the disciplinary action from corporate executives should preventable deaths not reduce? The article also reiterates the principles that I discussed in my previous post regarding the role of residential aged care. There exists a conflict between patient safety and freedom of choice. If a resident is unsteady on their feet and a falls risk but fiercely independent and wants to walk around a facility, does that facility have a right to restrain the resident to reduce falls?

Suicide prevention in residential aged care

Yesterday an article in the Australian Ageing Agenda by  Darragh O’Keeffe discusses the federal government’s stalemate on a decision of how to allow residents of Residential Aged Care Facilities (RACFs) to access the Better Access to Mental Health scheme (BAMH). The BAMH scheme, according to the federal Department of Health’s website

” Medicare rebates are available to patients for selected mental health services provided by general practitioners (GPs), psychiatrists, psychologists (clinical and registered) and eligible social workers and occupational therapists.”

However, according to Dr Margot McCarthy, deputy secretary of ageing and aged care, there is still discussion around how the scheme would be made available to residents in care facilities.

If an elderly member of the community was having depressive thoughts surely the GP would jump at the chance of engaging in this service to allow more treatment options for their patients. The same should be true for residents living in aged care facilities. The Medicare funding does change when a person goes into RACF care, however that should not change the available services to them. I hope that in the near future the Department of Health and Department of ageing and aged care can come to an agreement and make this valuable service available for residents in RACF homes, thereby moving towards reducing preventable deaths related to mental health conditions.

What does this mean for nursing staff and residents?

While the powers-at-be continue to struggle with how to research and tackle the issue of ‘premature deaths’ nursing staff in aged care facilities will continue to be in the firing line. Without clear-cut guidelines their actions and assessments will put the responsibility for minimizing the risks sits squarely on them. For residents and families the falls, suicides and choking will continue until the federal government and corporate aged care executives agree on a standard measure along with established preventative measures to minimize, and hopefully, eliminate the term premature deaths in aged care from existence.

References

The Medical Journal of Australia: Aged care falls deaths: a question of balance

The Australian Aged Agenda: No end in sight to aged care’s mental health blockage

The Department of Health: Better access to mental health care: fact sheet for patients

 

Coroner asks NSW health privacy rules be relaxed to fight terrorism

A report by SKY news has indicated that the Coroner Michael Burns in investigating the Lindt Cafe siege has found the Personal Information Protection Act and the Health Records Information act were too stringent and did not allow ASIO investigators to have information needed. Coroner Burns has asked the NSW government to review the privacy legislation through his findings. The Sydney Morning Herald, reporting on the findings stated that “Mr Barnes says the government should consider whether NSW Health should more readily share information so that “fixated lone actors”  can be identified and monitored earlier.

However, reviewing the coroner’s report the findings aren’t so clear. Monis did visit several General Practitioners (GPs) who referred him to psychiatrists. Monis did, on one occasion, see a psychiatrist (through a private practice) who diagnosed him with mild depression. He was also seen by the Cantebury mental health team over a period of 16 months. However, according to the coroner’s report Monis was felt to have a personality condtion and not a psychiatric disorder. Additionally, Monis was felt to have manipulated the system to present him as a person with mental instability for some reason.

While the report is obviously a summary of the information gained at the inquest I wonder what good the health information would be in assisting ASIO or any other agency in identifying and removing Monis from the streets prior to the Lindt cafe siege? He appeared to be using the system for his own gains. Monis saw at least 10 GPs within the community, all who I would presume to be in private practice; and therefore not within the confines of the NSW Health system regarding privacy and information sharing. I am wondering how ASIO would be able to know that Monis had seen so many private practitioners and that he failed to follow-up on psychiatric referrals?

I, like many of my countrymen and women, do not want to see terrorist attacks in Australia as occurred in the Lindt cafe siege and in other horrific attacks around the world. And I would be prepared to assist authorities if it was needed. But unless there could be a reasonable explanation as to what benefit would be gained from relaxing the two privacy legislative bills in regards to apprehending potential ‘lone actors’ and preventing terrorist attacks then I fail to see how this would provide benefit over cost to the general public?

NSW Health takes privacy very seriously, and that is a welcome position in my book as a healthcare practitioner and patient. While I am not completely opposed to relaxing privacy legislation I do think we owe it to the general public to have an open discussion regarding what we as that public would be prepared to give up in terms of our privacy for the safety of others. By relaxing privacy legislation, particularly in mental health situations, you risk potential patients staying away from treatment in order to protect their privacy.

Yes, it is a slippery slope. But I am willing to take that slide if there would be real benefit and recognized limits on who the information is shared with and how it will be used. The public has a right to be involved in any discussion.

Your thoughts?

References

Coroner’s report into the Lindt Cafe siege

Sky news report on the findings

Sydney Morning Herald: Lindt inquest: Mistakes cannot be papered over, coroner Michael Barnes finds

 

 

Can we use restraint and seclusion in hospital and mental health units?

I have an admission to make: mental health is a hard area for me to work in. Currently I work in a fairly busy emergency department attached to a PECC (Psychiatric Emergency Care Centre) and both adult and children’s mental health units. Therefore, we regularly see mental health cases in our beds. Oftentimes they are agitated, maybe high on drugs, and a clear danger to themselves or others in the department.

As an emergency department we do have some physical locks on doors to prevent egress, but our layout is very open to provide for easy access and movement throughout the ward as our work entails. So when patients become aggressive our options to calm the patients down and keep them and others safe is limited. But I also see the concerns about the use of restraint methods and the potential harm they can do. It is only a ‘quick fix’ which takes care of the here-and-now without treating the underlying problem. The use of chemical restraint also delays treatment as the patients are often needing to rid themselves of the medication before being seen.

Nine news has aired a story today that a review is being undertaken about the use of restraints and seclusion for mental health patients. I applaud this as I think we need to have experts look at what can and needs to be done to help while providing a safe healing environment.

I don’t think that we will ever be able to rid ourselves of the need for some restraint methods in dealing with patients. There are times where nurses and doctors need to intervene to allow for a safe environment. However, we need to get it right. Minimize interventions to allow for maximum treatment while providing for a safe environment.

Your thoughts?

 

The nine news report onto the review