Transcript Community Health and Aged Care

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
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
Australian Aged Care Policy
Conclusions
• Traditional ‘age structure’ 65+ homogenises older
people, breeds a social-medical divide & needs redefinition 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
Topics
• Population Ageing, Disability & Disease
• Population Age Structure with a brief look at the
Economics of Ageing
• Implications for Australian Aged Care policy
Population Ageing Disability & Disease
Issue 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
Age-standardised deaths – 20th C.
Infections
(per 100,000 persons)
Females
Males
250
200
150
100
50
0
1921 1927 1933 1939 1945 1951 1956 1962 1968 1974 1980 1986 1992 1998
Cumpston Sarjeant Pty Ltd
Age-standardised deaths – 20th C.
Respiratory system
(per 100,000 persons)
Females
Males
400
300
200
100
0
1921 1927 1933 1939 1945 1951 1957 1963 1969 1975 1981 1987 1993 1999
Cumpston Sarjeant Pty Ltd
Age-standardised deaths – 20th C.
Circulatory incl. Stroke
(per 100,000 persons)
Females
Males
1000
800
600
400
200
0
1921 1927 1933 1939 1945 1951 1957 1963 1969 1975 1981 1987 1993 1999
Cumpston Sarjeant Pty Ltd
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 Alzheimer’s &
Parkinson’s 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
Survivor effect - The ageing of the aged
Vaupel: Science 1998
Epidemiology of Ageing
By 2050
• Average life expectancy at birth in Australia is now > 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’
Sydney Older Persons Study: 1992 - 2002
A Study of Systemic and Brain Ageing
(Random Samples of Community Dwellers 75+)
80
70
Frequency
60
Male
50
Female
40
30
20
10
0
75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99
Age
N=522 examined in the home
Systemic disease trends: Prevalence
(N=522. Age trends: * p < 0.05; ** p< 0.01)
2.5
Prevalence rate
2
1.5
1
0.5
0
75
78
81
84
Age
87
90
93
Other Systemic
Peripheral Vascular Disease
Chronic Lung Disease*
Stroke
Obesity
Heart Disease
Arthritis
Neurodegenerative disorders: Prevalence
(N=522. Age trends: * p < 0.05; ** p< 0.01)
3.5
3
2.5
2
1.5
1
0.5
0
75
78
81
84
Age
87
90
93
Parkinsonism**
Dementia**
Motor Slowing (excl. Park.)**
Cognitive Impairment (excl. Dem.)**
Vision**
Ataxia**
SOPS: Community Disability Rates
6 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
Aged Care Policy
Topics
• Population Age Structure with a brief look
at the Economics of Ageing
• Implications for Australian Aged Care
policy
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 <15 + > 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
Traditional ‘age structure’ homogenises the old
For 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
Economics of Ageing
What 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?
Aged Care Policy
Topics
• Implications for Australian Aged Care
policy
Australian Aged Care Policy
Implications
• 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
Australian Aged Care Policy
Where 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
Policy & Planning Areas
SESIAHS
1.2 million people
DADHC
5-700,000 people
Service Delivery Sectors
4
SESIAHS
A Geo-demographic approach
6 Local Service Delivery Sectors
Population 200 - 300,000 ‘urban’
Shoalhaven - 100,000 ‘rural’
5
1
6
3
2
Local Sector Aged Care – a Geo-demographic Approach
HOSPITALS - STATE
3o
Hospital
THE LOCAL SECTOR
• Pop. 250,000 (urban)
to 30-100,000 (rural)
Geriatric Rehabilitation
COMMUNITY CARE
Dementia Care
•72 C/W divisions for
ACATs, GPs, RAC beds
• One or more LGAs
2o
(C/W - STATE Split)
Emerging Interface Services
10% of Funds to Services
Hospital in the Home
Pre & Post Acute Care
Community Rehabilitation
Chronic Complex Care
COMMUNITY AGED CARE
Geriatric Service
Aged Health Care
Support Network
Extended ACAT
Community
Geriatrician
1o
90% of Funds to Beds
Acute Aged Care
Dementia
Care
COMMUNITY
HEALTH
Generalist Nurses
RESIDENTIAL
HIGH CARE
Home Care
NGOs
HACC
RESIDENTIAL CARE
C/W
90% 0f Funds to Beds
Carer
Respite
Local Govt.
DIVISION of
GPs
CACP EACH TACP
RESIDENTIAL AGED CARE
Carer Respite
RESIDENTIAL
LOW CARE
Brain Ageing
The 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
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)