Tuesday, 10 January 2017

Is living in aged care in Australia bad for your mental health?

An estimated 10–15% of older Australians who live in the community experience anxiety or depression (Haralambous et al. 2009). However, research has shown that certain sub-groups of the older population are at higher risk of experiencing poor mental health. For example, just over half (52% or 86,736) of all permanent aged care residents at 30 June 2012 had mild, moderate or major symptoms of depression when they were last appraised (AIHW 2013). [Australian Government, Australian Institute of Health and Welfare, Australia’s welfare 2015]

The Sydney Morning Herald, 7 January 2017:

Tens of thousands of elderly Australians are being  denied effective public health treatments because they live in nursing homes, with experts labelling it a "disgrace" and "blatantly discriminatory".

A Fairfax Media investigation has revealed the mental health of aged-care residents suffers as a result of widespread neglect that legal and health experts attribute in large part to a   "ridiculous" Medicare rule.

Under the rule almost all nursing home residents are denied GP mental health treatment plans and associated psychological therapies provided to other Australians under the Better Access Medicare program, because the government deems residents not to be patients "in the community".

Despite extreme rates of mental illness in nursing homes – with about 82,000 of 176,000 residents estimated to suffer a mental illness (excluding dementia) or significant mental distress – the Turnbull government reaffirmed the regulatory exclusion late last year.

While the government says its funding mechanism assesses depressed residents' care needs, a Fairfax Media investigation has discovered the homes almost never pay for clinical mental health treatments and experts say the government has neither legally compelled nor adequately funded them to do so.

Audits by Sydney and Deakin universities have repeatedly found that fewer than 2 per cent of residents suffering depression have received psychological treatments, such as cognitive-behavioural therapy,  that are clinically recommended for most depression experienced in the aged-care setting…..

Royal Australian College of GPs president and University of Tasmania clinical professor Bastian Seidel agreed the denial of treatment was "systematic" because "the data is out there" and he called for the removal of the Medicare exclusion.

Researchers have found only about half of all residents with depression receive treatment of any kind, whether from psychologists or other clinicians, and that almost all of those are put on antidepressants by GPs, despite their use in the elderly being linked to serious adverse effects, including falls and fractures.

Stigmatising attitudes and ignorance about mental healthcare have also been found to be widespread among nursing home staff, with unpublished Swinburne University survey data suggesting staff commonly dismiss depressed residents as "attention seeking" and lack basic knowledge about mental illness.

While many residents arrive in homes with depression or other mental disorders, others struggle mentally due to challenges experienced in care, such as chronic pain, disabling and terminal medical conditions, progressive loss of brain function and the loss of social role and sense of identity.

"There are commonly acute adjustment disorders … [involving] bereavement, grief, loss," said Adelaide older persons GP Johanna Kilmartin, who described the Medicare restriction as ridiculous.

"You lose your family home [for] … one tiny little room … so you've lost all your material possessions; you've lost your health, because that's why you've moved in; often you've lost your spouse as well.

"This is when you need [psychological help] … [but] we've got the opposite"……

A spokesman for the Department of Health said while Commonwealth-funded residents – understood to be all or almost all aged-care residents – were not eligible for Better Access services, the government's aged-care funding instrument "assesses residents' care needs, including in relation to depression".

He said approved homes were required to "facilitate … access" for residents to health practitioners of their choosing and gave as an example "arranging transport".

But the dean and head of the University of South Australia's law school Wendy Lacey slammed the "weasel words" of the Aged Care Act's care "principles", saying there was "a complete absence of any positive and mandatory legal obligation on the part of facilities to take proactive measures to promote mental health and wellbeing of their residents".

There was "no legal obligation on the residential care provider to pay" for mental health services, and the "current exemptions" –  arising from the Aged Care Act and Medicare regulation – were "a blatant denial of human rights involving discrimination on the basis of age and infirmity".

Australian Catholic University senior research fellow Tanya Davison, whose research has found that half of all clinical cases of depression received no treatment of any kind, cited funding "that runs out very quickly" as among contributing factors to the "critically low" psychological therapy levels…..

The Conversation, 28 July 2015:

More than half (52%) of aged care residents have symptoms of depression, compared with 10-15% of older people living in the community. As well as feelings of sadness and low mood, aged care residents with depression feel uninterested in activities, hopeless about the future, guilty about the past and may desire death.

Some actively contemplate taking their own lives. The prevalence rate of suicidal thoughts in residential aged care settings can be as high as 46%. This is more than three times the rate found in older adults who are housebound but in the community.

People entering residential aged care facilities are, on average, older than those living in the community. They have more complex care needs due to physical and cognitive difficulties. They may also have difficulties adjusting to their loss of independence and routine. These factors all increase their risk of depression and suicidal ideation.

However, mental illness often remains undetected among aged care residents.

There are several reasons for this. People living in residential aged care usually have complex care needs, making the identification of depression difficult, as the emotional symptoms become confused with those of other conditions. Older people are also less likely than younger people to recognise their own symptoms, often attributing them to normal ageing.

Further, although facility-based carers are in a position to act as informants, they often lack the training to detect symptoms of depression and do not routinely screen for suicide ideation.

Depression is a manageable condition and the symptoms can be improved or managed through therapy and medication. Medications are effective but are often associated with side effects, and for older adults may not be recommended alongside some other medications and conditions.

Yet, when residents are recognised to have symptoms of depression, they are often only prescribed medications (particularly antidepressants) despite the effectiveness of non-medication approaches. Research shows interventions such as cognitive behavioural therapy (a talk therapy that addresses how you think and act) are at least equally effective as anti-depressants for improving late-life depression.


National Ageing Research Institute, Depression in older age: A scoping study, Final Report, September 2009:

4.1 Depression and anxiety in older people

It is a common misconception that depression is a normal part of ageing, but the evidence shows that multiple health problems often account for any initial association between depression and older age (Baldwin, 2008; Baldwin, Chiu, Katona, & Graham, 2002). Depression is essentially the same disorder across the lifespan, although certain symptoms are accentuated and others are suppressed in older people. For example, older people with depression typically report more physical symptoms and less sadness compared to younger people with depression (Baldwin, 2008; Chiu, Tam & Chiu, 2008). Additionally, psychotic symptoms, melancholia, insomnia, hypochondriasis, and subjective memory complaints are more likely to occur in older people with depression compared to younger people with depression (Baldwin, 2008; Baldwin et al., 2002). A recent review found that when confounding variables are controlled (for example, age at study entry), remission rates of depression in patients in late-life are not different from those in midlife, although relapse rates appear higher in older people (Mitchell & Subramaniam, 2005).

Anxiety disorders are also common among older people. However, research in this area is less compared to research undertaken in other mental disorders in older people, such as depression (Wetherell, Maser, & van Balkom, 2005). Of the anxiety disorders, phobic disorders and generalised anxiety disorder (GAD) are the two most common in older people (Beyer, 2004; Bryant et al., 2008; Rodda, Boyce, & Walker, 2008). There has been a certain amount of clinical interest in post-traumatic stress disorder (PTSD), because the survivors of the Second World War and the Holocaust are now well into old age. Moreover, Vietnam Veterans are also approaching old age with well-documented high levels of psychopathology (Owens, Baker, Kasckow, Ciesla, & Mohamed, 2005) that can also have serious effects on the mental health of family members (Galovskia & Lyons, 2003). Prevalence data on PTSD, however, are very limited (Sadavoy, 1997). American studies of Holocaust survivors have found that up to 46% meet criteria for PTSD (Sadavoy, 1997). Weintraub and Ruskin (1999)’s review emphasises the similarities between PTSD in older and younger groups. Other authors have disputed this, and further research is required to establish how different the presentation of PTSD is in older adults from that in younger people.

A recent Australian study found that 11.6% of men and 8.6% of women aged over 65 reported re-experiencing symptoms associated with past events (DSM IV criteria), and concluded that quality of life may be significantly affected in this group (Creamer & Parslow, 2008). This study highlights some of the difficulties in the application of the DSM IV criteria to older adults.

Research on interventions for older people with PTSD is very limited indeed. A recent review of assessment and treatment of PTSD in older combat veterans identified only five studies of psychotherapeutic intervention (Owens et al., 2005). All of these were case studies. A literature search carried out for this review did not identify any randomised controlled trials of psychological intervention for older people diagnosed with PTSD.

Comorbidity of depression and anxiety disorders is highly prevalent (Beekman et al., 2000). A community-based study in the Netherlands found 47.5% of older people with major depressive disorders also met criteria for anxiety disorders, whereas 26.1% of those with anxiety disorders also met criteria for major depressive disorders (Beekman et al., 2000). Mixed anxiety and depressive disorders (where symptoms of both anxiety and depression do not reach diagnostic criteria for either disorder) also frequently occur in older people (Chiu et al., 2008; Rodda et al., 2008). Older people with depression have a 35% lifetime and 23% current prevalence of a co-morbid anxiety disorder (Beyer, 2004). Furthermore, when anxiety symptoms first occur in a person over 60 years of age with no history of anxiety, it generally suggests underlying depression (Baldwin, 2008; Chiu et al., 2008). Indeed, it is quite uncommon that people develop late-onset anxiety disorders for the first time in later life (Chiu et al., 2008), although there are researchers who disagree with this (Wetherell, Maser et al., 2005). Older people with co-morbid depression and anxiety typically have more severe depressive symptoms, an increased likelihood of suicide ideation, lower social functioning (Beyer, 2004; Rodda et al., 2008) and poorer outcome (Schoevers, Beekman, Deeg, Jonker, & van Tilburg, 2003)…..

The 2007 National Survey of Mental Health and Wellbeing found that the 12-month prevalence for depression and anxiety was 2% and 5%, respectively for older people living in private dwellings (Australian Bureau of beyondblue depression in older age: a scoping study. Final Report - National Ageing Research Institute (NARI), September 2009 - 13 - Statistics, 2008). Another Australian study found that the prevalence of depression was 8.2% among a sample of 22,252 community-dwelling older people (Pirkis et al., 2009). However, the prevalence rate is much higher in residential aged care facilities and a recent Australian study found that 34.7% of aged care residents suffered from depression (Snowdon & Fleming, 2008).

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