30 HOW TO TREAT : HEALTHY AGEING
30 HOW TO TREAT : HEALTHY AGEING
2 JUNE 2023 ausdoc . com . au conditions to help people age well . Despite the need for this to continue , it has limitations in achieving the overall goal of healthy ageing , that is , to enable people to develop and maintain functional capacity .
Functional capacity is determined by an individual ’ s intrinsic capacity , their environment and the interactions between the two . Box 1 lists the WHO ’ s ICOPE framework ’ s common losses in capacity associated with ageing . 6 The WHO ’ s ICOPE guidelines also recommend a greater focus on addressing falls , urinary incontinence and providing interventions to support carers .
By identifying the factors associated with losses in intrinsic capacity , health professionals can help prevent , slow or reverse decline , enabling healthy ageing . Focusing on modifiable factors , such as health-related behaviours and conditions and addressing these with evidence-based strategies will help maintain independence .
ICOPE also provides recommendations on screening , assessment and management of decline in any aspect of intrinsic capacity . 16 Based on this approach , the authors recommend the steps in box 2 .
KEY FOCUS AREAS IMPACTING ON HEALTHY AGEING
Falls and falls prevention
FALLS are common in older people ; however , they are preventable , not inevitable .
For the purposes of both clinical practice and research , a fall is considered “ an unexpected event in which a person comes to rest on the ground or lower level ”. 21 Regardless of the cause or mechanism behind the fall , fundamentally , a fall results when an individual is unable to maintain or return their centre of gravity to their base of support . Falls are multifactorial , and result from the interaction between a person ’ s individual characteristics and their environment .
Falls are the leading cause of injury and injury-related hospitalisation in Australia , and a leading cause of injury-related death . In 2019-20 there were 224,000 hospitalisations and 5300 deaths as a result of falls . 22 About 30 % of people aged 65 and older living in the community will fall in any given year , rising to at least 50 % for those living in residential aged care . 23
Falls occur more frequently in women , who also experience higher rates of fall-related injury than men , particularly hip fracture . In Australia at least 18,000 hip fractures occur every year , of which 66 % affect women . 24 , 25 Under-recognised in the consideration of falls is fear of falling . There are wide-ranging estimates of the prevalence of fear of falling ( between 20 % and 85 %) but it can be present in those who have experienced a fall and those who have not . 26 This is referred to as ‘ fall-related psychological concerns ’, encompassing the different — but related — concepts of fear of falling , balance confidence , and fall efficacy , the perceived confidence in ability to undertake activities without falling . A high proportion of those who express concerns about their balance do have balance impairment . Additionally , fear of falling can lead to activity restriction , social isolation and increase the risk of functional decline and depression . 27
Adapted from ICOPE implementation framework : Guidance for systems and services . www . who . int / World Health Organization ; 2019 / CC BY-NC-SA 3.0 IGO 6
Figure 1 . Health and aged care ’ s role in supporting functional ability .
Table 1 . Common myths about ageing , adapted from WHO Myth
There is a typical ageing trajectory and a typical older person
Diversity in ageing is random
Most older people require care
Good health is the absence of disease
Source : Adapted from WHO 2015 11
Reality
Box 1 . Common losses in intrinsic capacity associated with ageing
• Hearing capacity .
• Visual capacity .
• Cognitive capacity .
• Mobility .
• Vitality .
• Psychological capacity .
There is strong , high-quality evidence about what works to prevent falls in certain settings , and clear guidelines for practitioners to follow when providing clinical services for those aged 65 and older . A comprehensive , systematic review of fall prevention clinical guidelines found broad consistency among the various recommendations , and the authors ’ recommendations for screening and assessment are based on these . 28
SCREENING Most screening tools aim to stratify falls risk in community settings , where case-finding is more relevant than in high-risk settings such as residential aged care . A commonly used
Older age is characterised by heterogeneity , with greater heterogeneity than at any other stage of life Similarly aged individuals may have very different health and care requirements Healthcare requires tailoring to an individual ’ s capacities and needs rather than to chronological age
The heterogeneity seen in older age is determined by the cumulative circumstances experienced by a person throughout their life Socioeconomic advantage or disadvantage influence whether a person will age well
In Australia , most older people live at home , with about 191,000 ( only 6 %) of older people living in
12 , 13
residential aged care In contrast , more older people receive community-based formal aged care services through the Commonwealth Home Support Programme ( about 840,000 people in 2019 ) or Home Care Packages ( about 170,000 people in 2021 ) The greatest proportion of care is provided by informal or unpaid carers 3
Most people over 65 will have one or more comorbidities
The most common self-reported chronic health conditions affecting older Australians are : a . Arthritis b . Back problems c . Mental health conditions , eg , depression and anxiety d . Cardiovascular disease 14
While dementia was the leading cause of death in women in 2020 , most older people will not develop dementia 15 algorithm for primary care settings , developed by the American and British geriatric societies , includes information about screening and suggested actions . 29 Ask about falls in the previous year ( including trips / slips ) with management depending on the answer ( see box 3 ).
Note that many older people do not seek advice from a health professional after a fall and may be reluctant to disclose falls for fear that their ability to live at home will be questioned .
MANAGEMENT Management is tailored and will depend on the nature of the fall ; however , exercise has the strongest evidence-base , reducing the rate of falls by up to 34 % for older people living in the community . 23 To be most effective , exercise programs should incorporate balance , functional exercises and resistance training . 23 There is also emerging evidence to support the effectiveness of exercise in reducing falls for people living in residential aged care , including those with dementia or mild to moderate cognitive impairment . 31-33 It is vital that older people , regardless of residential setting , receive information about the benefits of exercise and are able to access exercise programs or activities that are ongoing , of sufficient frequency ( for example , at least three hours per week ), and incorporate the types of exercise known to prevent falls , that is , resistance exercise and balance training . 34
In addition to exercise , some common falls and injury prevention interventions are recommended across several clinical practice guidelines ( see box 4 ). 28 Not all these have strong evidence of effectiveness , and effectiveness is dependent on setting and relative risk . The following non-exercise interventions are applicable to people with particular risk factors : podiatry interventions for people with foot pain , cardiac pacemakers for people with carotid sinus hypersensitivity , cataract removal , vitamin D supplementation for those who are deficient , and occupational therapy home safety assessment and home modifications for people at high risk of falls . 35 Hip protectors for hip fracture prevention are most likely to be effective for individuals
36 , 37 living in residential aged care .
Box 2 . Recommendations on screening , assessment and management of decline in any aspect of intrinsic capacity
• Step 1 : Community screening for intrinsic capacity loss : — As part of GP visits , formal and comprehensive annual health reviews , or through assessments such as the 75 years and older health assessment .
— When individuals interact with health professionals other than their GP , eg , community or allied health .
— If no loss or anticipated loss in intrinsic capacity is identified , provide generic health and lifestyle information ( see table 2 ) and usual care for existing conditions in a format accessible to the individual and one that considers an individual ’ s cultural background and social context .
— If intrinsic capacity loss is identified perform step 2 .
• Step 2 : In-depth assessment : — Detailed assessment and management of loss in intrinsic capacity and other relevant issues including falls , urinary incontinence and the patient ’ s social situation .
— Consider the patient ’ s values , needs and preferences , and culture and beliefs .
— Assess and , with the patient , manage underlying conditions contributing to intrinsic capacity loss in an integrated , multidisciplinary and holistic manner .
If someone presents after a fall , the priority is injury management if injury is present , and then assessment of falls risk factors using a validated assessment tool such as the National Ageing Research Institute ’ s Falls Risk for Older People in the Community tool , before recommending and implementing targeted actions relevant to each identified risk .