Community Health and Aged Care - Future Directions

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A longitudinal look at Australian Aged Care
Policy from A socio-clinical perspective
Australian Social Policy Conference
2005 Professor G A (Tony) Broe Ageing Research
Centre POWMRI
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Background

• In over 40 years, of population health and
  geriatric medicine, I have not seen anyone die of
  old age, or get disabled by ageing
• The older one gets the more likely one is to
  escape systemic (body) diseases the survivor
  effect
• The older one gets the more likely one is to
  accumulate multiple neurodegenerative (brain)
  disorders gradually affecting brain function
• Years of non-disabled life are the key outcome
  -rather than longevity per se

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Australian Aged Care PolicyConclusions

• Traditional age structure 65 homogenises older
  people, breeds a social-medical divide needs
  re- definition as young old, older old and
  oldest old
• How many 65-74? - 75-84? - 85-100?
• Now? Projected? What are their characteristics?
  
• An ageing population is a boon
• Future aged care policy needs to consider
• Our ageing brains better care systems as they
  fail
• Geo-demography of care at a local community level

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Topics

• Population Ageing, Disability Disease
• Population Age Structure with a brief look at the
  Economics of Ageing
• Implications for Australian Aged Care policy

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Population Ageing Disability DiseaseIssue 1
(ABS, Madden, Manton, Fries et al)

• We now have more healthy young-old 60 to 75
• ZPG - less and less babies
• Falling rates of mid-life heart, lung and other
  systemic diseases for the past 40 or more years
• Due to More wealth, less trauma, less smoking,
  better diet, better activity, less alcohol,
  health care
• Compression of morbidity is real in this age
  group
• But not universal, e.g. our Aboriginal population

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Infections
Age-standardised deaths 20th C.
(per 100,000 persons)
Cumpston Sarjeant Pty Ltd
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Age-standardised deaths 20th C.
Respiratory system
(per 100,000 persons)
Cumpston Sarjeant Pty Ltd
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Age-standardised deaths 20th C.
Circulatory incl. Stroke
(per 100,000 persons)
Cumpston Sarjeant Pty Ltd
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Population Ageing Disability Disease Issue 2
(Omran Olshansky - Broe Creasey)

• We will have more older-old people 75 85
• More survivors The ageing of the aged
• But with failing neurons from slowly progressive
  neurodegeneration - prototypically Alzheimers
  Parkinsons disease pathologies These are
• Of unknown environmental/genetic causes but not
  due to the usual suspects (smoking,
  diet, exercise, alcohol) - yet likely to be
  preventable in the future?
• In the older-old, evidence suggests greater
  brain morbidity - rather than compression of
  morbidity

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Survivor effect - The ageing of the aged
Vaupel Science 1998
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Epidemiology of Ageing By 2050

• Average life expectancy at birth in Australia is
  now gt 80 years, with a likely increase to 95
  years by 2050 -
• Then Australia will have around 1.3 M. people 85
  (a 400 increase while the total population grows
  by only 30) - On current figures most will have
  brain impairment
• We need good longitudinal data on ageing in
  people 75 to 100 years of age, living in the
  community
• ABS, and other self report data sets, cannot tell
  us about brain impairment as cognitive deficits
  preclude accurate self-report and slowing-up is
  often called arthritis

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Sydney Older Persons Study 1992 - 2002 A Study
of Systemic and Brain Ageing(Random Samples of
Community Dwellers 75)
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Systemic disease trends Prevalence
(N522. Age trends p lt 0.05 plt 0.01)
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Neurodegenerative disorders Prevalence
(N522. Age trends p lt 0.05 plt 0.01)
Prevalence rate
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SOPS Community Disability Rates6 Year
predictors in 522 subjects aged 75

• In our final models (entering age, somatic
  disorders, neurodegenerative disorders, stroke,
  psychiatric disorders)
• Traditional somatic disorders at baseline
  (heart, lung and vascular disease, obesity, bone
  and joint disease) were minor predictors OR
  1.56 of disability at 6 years
• Mild neurodegenerative disorder at baseline (in
  cognition movement) was the major predictor OR
  5.08 but not other brain disorder i.e.
  stroke or psychiatric
• We need to understand, manage and prevent
  neurodegenerative disorders - as they will
  dominate the aged care agenda in coming decades

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Aged Care PolicyTopics

• Population Age Structure with a brief look at the
  Economics of Ageing
• Implications for Australian Aged Care policy

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Population Age Structure Rand Report (Bloom et
al 2003)

• Demography provides a crystal ball .. to make
  policies for tomorrows world, not yesterdays
  (Bloom)
• The critical variable - for economists growth
  is - Traditional population age structure - rough
  but useful
• How many workers 15-64 yrs? - 600,000 now
  disabled
• Dependency ratio lt15 gt 64 yrs? -how relevant
  today?
• Economic growth is predicted to fall because
• Demographic Dividend of the baby boomers will
  fall
• Age, dependency ratios (and disability rates?)
  will rise

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Traditional age structure homogenises the
oldFor Aged Care Policy we need to define new
age groups predict their numbers?

• 65 to 74? - Healthy or Young old (90 brain
  intact)
• Mobile independent with good initiative,
  judgment and mental capacity - running their
  lives and their jobs and managing physical
  illness independently
• 75 to 84? - At-risk or Older old (50 brain
  intact)
• Generally mobile independent cognitively
  together, but in 50 brain function is at risk if
  stressed then they need some assistance - 16
  have a dementia
• 85 to 100? - Frail or Oldest old (30 brain
  intact)
• 70 have difficulties with cognition, executive
  tasks and/or with balance, gait, mobility and IADL

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Economics of AgeingWhat else could drive future
economic growth?

• The neglected demographics include
• An expanded population age structure
• Better education, activity brain growth over
  the lifespan? Less disabled adults?
• And less older people with dementia?
• Work productivity changes? Technology?
• Better jobs? With longer working lives?
• Women equalising in the workforce
• Counting the contribution of informal carers?

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Aged Care PolicyTopics

• Implications for Australian Aged Care policy

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Australian Aged Care PolicyImplications

• Keep government honest
• Population ageing is more likely to drive future
  wealth than mop up intergenerational resources (R
  Fogel 2004)
• Improve the system
• We can better manage, and eventually prevent,
  brain failure if we accept a socio-biological
  model of ageing
• Along with good management practices a
  home-like atmosphere, quality aged care requires
  strong outcome measures (falls, restraint use,
  psychotropic drugs) medical interventions
  (health/behaviour/palliative care)
• We need to define a geo-demographic sector to
  network Community, Residential Hospital Aged
  Care

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Australian Aged Care PolicyWhere are services
best delivered coordinated?

• Australian Aged Care Policy and Planning has to
  operate at multiple levels Federal, State,
  Area, LGA - involving multiple Govt Depts
  NGOs
• However Aged Care Service Delivery requires
  complex networks of providers - on the ground -
  best coordinated at a local community level for
  the older old - the heaviest users

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Policy Planning Areas
SESIAHS 1.2 million people DADHC 5-700,000 people
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Service Delivery Sectors
SESIAHS A Geo-demographic approach 6 Local
Service Delivery Sectors Population 200 - 300,000
urban Shoalhaven - 100,000 rural
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5
1
3
6
2
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Local Sector Aged Care a Geo-demographic
Approach
HOSPITALS - STATE 90 of Funds to Beds
3o
Hospital Acute Aged Care Geriatric
Rehabilitation Dementia Care

• THE LOCAL SECTOR
• Pop. 250,000 (urban) to 30-100,000 (rural)
• 72 C/W divisions for ACATs, GPs, RAC beds
• One or more LGAs

COMMUNITY CARE (C/W - STATE Split) 10 of Funds
to Services
Emerging Interface Services
Hospital in the Home
Pre Post Acute Care Community
Rehabilitation Chronic Complex Care
2o
RESIDENTIAL CARE C/W 90 0f Funds to Beds
COMMUNITY AGED CARE
Geriatric Service Aged Health Care Support
Network
Extended ACAT
Home Care
NGOs
Community Geriatrician
Dementia Care
HACC
Carer Respite
COMMUNITY HEALTH
Local Govt.
1o
DIVISION of GPs
CACP EACH TACP
Generalist Nurses
RESIDENTIAL AGED CARE
RESIDENTIAL HIGH CARE
RESIDENTIAL LOW CARE
Carer Respite
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Brain AgeingThe Future? Do we all wind up
demented in Aged Care?

• Healthy brain ageing is a realistic goal in the
  21st C. - with recent knowledge that our neurones
  can survive, grow and multiply at any age -
  including old age
• The question is rather - Will the world survive
  the capitalist urge for continuous economic
  growth?
• Population ageing, smaller populations, lifelong
  education and good dementia research - are
  healthier alternatives for growth
  non-disabled lifespan

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Education brain activity create brain growth
and protect against cognitive decline/dementia

• Life long education is producing new cohorts of
  older people?
• Fertility decline From 1800 education (human
  capital accumulation) reduced family size and
  grew wealth (Lucas 2002)
• Early Life Brain size and mental ability in
  early life predict health status, cognition,
  dementia, longevity in old age (Scottish/Nun
  studies)
• Adult Life In London Taxi Drivers the
  hippocampus (navigation) increases in volume with
  time on the job (Welcome MRI Study, 2002)
• Life-span Cohort increases in fluid intelligence
  (1889 to 1996) parallel educational advances
  longevity (KW Schaie 1996)
• Later Life Educated older people are healthier,
  make better health choices and, as a cohort, are
  protected against dementia (Jama 2002)