Australian Doctor 2nd June 2023 02JUNE2023 issue | Page 33

CF

LEARN MORE ONLINE Visit our Therapy Update

Box 6 lists the specific actions to address risk factors across the life span .

SCREENING There is no single test to determine the presence or absence of dementia ; however , there are several screening tools that inform further investigation . These generally assess global cognition , including behavioural , functional and psychological changes , and memory problems . Two commonly used tests are the General Practitioner assessment of Cognition ( GPCOG ) and the MMSE . 69 , 70 Also consider administering the short-form ( 15-item ) GDS because depression is a comorbidity in up to 30 % of those with dementia . 41 Although the GDS is a broad screening tool for depression , the short-form GDS is readily accessible , requires minimal training to use , and has been validated across many DSM-5 categories , including dementia . 1 , 44 The Cornell Scale for Depression in Dementia may be used in those with probable and suspected severe cases of dementia . 44

These tools are not well suited to culturally and linguistically diverse and Aboriginal and Torres Strait Islander populations because some of their concepts or questions do not translate well into other languages or cultures . 72 Alternative validated screening tools include the Rowland Universal Dementia Assessment Scale for culturally and linguistically diverse populations , and the Kimberley Indigenous Cognitive Assessment tool for Aboriginal and Torres Strait Islander populations . 72-75

MANAGEMENT The current management of dementia focuses on BPSD rather than cognitive decline , as these are more commonly associated with adverse outcomes . 66 Current management emphasises non-pharmacological over pharmacological treatments because there are few pharmacological interventions that arrest cognitive decline or address the symptoms of BPSD . The drugs currently approved to treat cognitive decline are only approved for confirmed Alzheimer ’ s disease . 76 Risperidone is the only drug approved to treat BPSD and is recommended only as a last resort . 77

Non-pharmacological interventions are considered first-line management . 78 , 79 This is because of the common side effects and associated adverse events related to pharmacological management , which is only moderately efficacious in BPSD . 63 , 66 , 67 Pharmacological interventions are reserved for specific settings or as a last resort , and require management by a specialist geriatrician , aged care psychiatrist or neurologist .

Non-pharmacological interventions include sensory and psychosocial practices and structured care protocols . 70 These are effective in reducing BPSD , are side effect free and are person-centred . Interventions that provide support , education and respite for carers of people with dementia are vitally important but are beyond the scope of this How to Treat .

The key aspects with regard to dementia appear in table 3 .

Elder abuse

Elder abuse is defined as “ a single or

Box 7 . Risk factors for the older person

• Cognitive impairment and dementia .

• Functional dependency and disability .

• Poor physical health or frailty .

• Psychiatric illness or psychological problems .

• Social isolation , or a lack of social networks and support .

• Co-residency with the perpetrator ( note that financial abuse remains high irrespective of whether the older person resides with the perpetrator or not ).

• Loneliness .

• Traumatic life events , including past abuse .

• Low income and income dependency .

• Belonging to a minority or nondominant culture .

• Substance abuse ( can compromise decision-making capacity and render older people more vulnerable to being abused ).

Little is known about the drivers or risk factors for perpetrators who are social contacts but risk factors for family member perpetrators include : 87

• Psychiatric illness or psychological problems .

• Substance abuse .

• Social isolation and a lack of social support .

• Childhood experience of family violence .

• Caregiver stress .

• Domineering personality traits .

• Financial problems .

• Dependency on the older person .

repeated act , or lack of appropriate action , occurring within any relationship where there is an expectation of trust , which causes harm or distress to an older person ” and can include financial , physical , sexual , psychological and emotional abuse

80 , 81 and neglect . Elder abuse increases the risk of mortality and morbidity and is linked to an increased risk of falls , incontinence , depression , anxiety and suicide . 82 , 83 One in six older Australians in the community has experienced elder abuse in the past 12 months , the rate is even higher in residential aged care ; the 2020 Royal Commission into Aged Care Quality and Safety estimated almost 40 % of residents were experiencing elder abuse . 84 , 85 These figures are likely to be an underestimation as elder abuse often goes under-reported and unrecognised . 86

Elder abuse is distinct from other forms of family violence insofar as the main perpetrators are adult children ( 18 %), friends ( 11.6 %), and partners / spouses ( 10.4 %). 84

Risk factors for the older person appear in box 7 . 87

SCREENING There is limited evidence about the effectiveness of primary prevention interventions targeting abuse of older people ; intergenerational programs are likely to be most effective . 88 Frontline healthcare staff can play a key role , particularly in secondary and tertiary prevention of elder abuse ;

Table 4 . What older people want from their healthcare Domain Top five priorities Key insights

Healthy and active ageing

Managing multi-morbidity and / or frailty in the community

Healthcare in a crisis for sudden health issues

Regaining independence after being unwell

Needing specialist aged care support

Source : Cecil J 2021 93

1 . Taking an active role in health management 2 . Having a positive outlook 3 . Healthy eating 4 . Access to specialist medical services 5 . Social interaction

1 . Ageing in place , ie , continuing to live in the community , with some level of independence , rather than in residential aged care . 2 . Transport in the community 3 . Adequate financial resources 4 . Age-friendly environments 5 . Access / closeness to healthcare services

1 . Communication 2 . High-quality care 3 . Being listened to 4 . Being treated with dignity and respect 5 . Timely treatment

1 . Maintaining a positive approach 2 . Receiving a hospital discharge plan 3 . Having strong supports 4 . Having services provided in the home 5 . Access to community-based health services

1 . Remaining at home for as long as possible

2 . Moving to residential aged care only when no longer able to live at home 3 . High-quality care 4 . Planning transition to residential aged care in advance 5 . Continue to be ‘ yourself ’ in residential aged care

there are growing calls from health , legal , and family violence services , government agencies , and researchers , for frontline staff to be involved in screening for elder abuse . Healthcare staff should gain an understanding of screening tools , and referral pathways once elder abuse has been identified . That said , Australian frontline staff have voiced concerns about the screening tools available to them due to the tools ’ use of jargon , lack of culture-fairness , and binary ‘ yes / no ’ questions . 89 Nevertheless , several validated screening tools are available : the Vulnerability to Abuse Screening Scale , Elder Abuse Suspicion Index , Elder Assessment Instrument , Caregiver Abuse Screen , and Brief Abuse Screen for the Elderly .

The National Ageing Research Institute also co-designed a screening tool with Australian providers — the Australian Elder Abuse Screening Instrument . 90 The tool has face validity , but has not yet been statistically validated . Nonetheless , the authors recommend its uptake , as these results concord with the evidence which shows that education for health providers , multidisciplinary team response , and referrals to multidisciplinary services are the most effective combination of interventions to prevent and stop elder abuse . 88

MANAGEMENT Australia ’ s National Plan to Respond to the Abuse of Older Australians includes helplines and websites with

• Older people and carers value community-based programs that support physical activity and social connection

• Computer-based health information ( see figure 4 ) and healthcare is not as easily accessible for some older people ; it is important they are not left behind when virtual care or telehealth services are implemented

• Ageism is seen as a barrier to participation in activities that support healthy ageing

• Older people recognise the importance of having a GP , but do not feel that GPs are well informed or support their healthy ageing goals . They also find access to a regular GP is difficult

• Older people recognise that financial resources play a very important role in helping them to remain at home for as long as possible

• Older people have limited awareness of community services available and how to access them , eg , via My Aged Care

• People familiar with My Aged Care find it extremely difficult to navigate

• Older people want to be active participants in their healthcare , including partnering in decision-making ; they expect high-quality , competent and safe care when in hospital , from staff who understand their needs and preferences

• Older people would like to receive a detailed and meaningful discharge plan ( or other health plan ), tailored to their needs

• Better integration of services is desired

• Older people recognise the need for a strong support network when recovering from an illness ; routine screening about social isolation would assist in identifying those needing extra support

• Older people wish to age in place

• Even though older people recognise the need to plan ahead , few make plans for transitioning into other accommodation

• Older people have a fear of residential aged care , including perceptions about inadequate staffing , poor training , social isolation and becoming dependent

• They worry about difficulty accessing healthcare , eg , GP care or hospital care if needing residential aged care

information for potential victims , monitoring by financial institutions for signs of abuse of older clients , public awareness campaigns , and family mediation ( especially in the early stages or less serious abuse cases ). 91 Specific to residential aged care , mandatory reporting mechanisms are now in place for serious events via the Serious Incident Response Scheme .

Overall , the Australian Government and service agencies have adopted a rights-based or empowerment approach , such as informing the older person experiencing abuse of their rights and choices and assisting them to navigate the services they need with the consent of the older person . This approach has considerable merit because it is respectful of the older person , assuming capacity rather than deficiency . This approach is less effective if the older person is unable to seek assistance because of cognitive or physical decline , dependency on the abuser or being socially isolated by the abuser .

The key aspects to consider regarding elder abuse appear in table 3 .

PERSPECTIVES OF OLDER PEOPLE

HEALTHY ageing includes all stages of the trajectory , up until end of life . As older people experience over 40 % of the burden of disease , 92 it is important to understand their views . The results of a study undertaken by the National Ageing Research Institute for the Victorian Department of Health examined older Victorians ’ and carers ’ perspectives about their needs and preferences for care across the continuum , and how these priorities change . 93 Six key domains were examined , of which five have particular relevance ( end-of-life care excluded ), see table 4 .

CASE STUDY

JOHN , a 72-year-old retiree , consults his GP for a general check-up . He has a history of left knee arthritis and hypertension . Since his wife died four years ago , he has not gone out as much as he used to but is physically active . While John can walk independently and does his own shopping , he needs to rest occasionally to catch his breath . He is not using a gait aid on a regular basis but uses a walking stick occasionally when his knee is sore .

In addition to the routine medical assessment , the GP asks John if he has had any falls — the GP also discusses John ’ s health goals and social circumstances . John has not had any falls but feels his balance has declined a little , and he wants to increase his exercise but is worried that this will make his knee pain worse . He is unsure how to start exercising . John has regular contact with his children but has not gone back to the local lawn bowls club since his wife died . The GP recommends that John becomes more physically active and refers him to a physiotherapist and