The interface between Aged Care

Transcription

1 The interface between Aged Care and Palliative Care: Friend or Foe? A/Prof Jenny Schwarz FRACP, Grad Dip Ed, Grad Dip Pall Med

2 A considerable body of evidence shows that older people suffer unnecessarily, owing to widespread under assessment and under treatment of their problems and lack of access to palliative care. Dr A Tsouros Head, Centre for Urban Health WHO Regional Office for Europe in Better Palliative Care for Older People WHO 2004

3 Aged Care and Palliative Care Aged Care Maximize function Symptom control Support families Respite care End of life care Palliative Care Maximize function Symptom control Support families Respite care End of life care Residential care Hospice care

4 Aged Care meets Palliative care: Friend or Foe?

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8 Better Palliative Care for Older People WHO 2004 Traditionally, high quality care at the end of life has mainly y, g q y y been provided for cancer patients in hospices

9 Better Palliative Care for Older People WHO 2004 Traditionally, high quality care at the end of life has mainly been provided for cancer patients in hospices 25% of all deaths are due to cancer

10 Better Palliative Care for Older People WHO 2004 Traditionally, high quality care at the end of life has mainly been provided for cancer patients in hospices 25% of all deaths are due to cancer 75% of deaths from cancer occur in people aged over 65

11 Better Palliative Care for Older People WHO 2004 Traditionally, high quality care at the end of life has mainly been provided for cancer patients in hospices 25% of all deaths are due to cancer 75% of deaths from cancer occur in people aged over 65 73% of cancer patients <60 are referred to palliative care services compared with 58% of those > 80 (Australian data)

12 Better Palliative Care for Older People WHO 2004 Traditionally, high quality care at the end of life has mainly been provided for cancer patients in hospices 25% of all deaths are due to cancer 75% of deaths from cancer occur in people aged over 65 73% of cancer patients <60 are referred to palliative care services compared with 58% of those > 80 (Australian data) 30% of hospice inpatients have non cancer illnesses (cardiac failure, COPD, stroke, dementia & renal failure)

13 Illness trajectories Adapted from: Lynn J Adamson DM Living well at Adapted from: Lynn J, Adamson DM. Living well at the end of life; adapting health care to serious chronic illness in old age. Arlington, VA, Rand Health, 2003

14 The defining characteristic of our time seems to be that we are both younger longer and older longer; wearemorevigorousatagesthatonceseemedvery old and we are far more likely to suffered protracted periods of age related disability and dependence because we live to ages that few people reached in the past. The President s Council on Bioethics (accessed07/07/2011)

15 Because we live longer we die differently; and because medicine i can better confront the illnesses that would kill us quickly, we are far more likely to die after a period of protracted physical disability and cognitive impairment. The President s Council on Bioethics (accessed07/07/2011) p// g /p / p / g_ / p

16 Illness trajectories 25% of all deaths 20% of all deaths Adapted from: Lynn J, Adamson DM. Living well at the end of life; adapting health care to serious chronic illness in old age. Arlington, VA, Rand Health, % of all deaths

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18 Onset of incurable cancer time often a few years but decline usually seems < 2 months Decreased self care & frequent hospitalisations time 2 5 years but death often seems sudden Onset of functional deficits time quite variable but usually 6 8 years

19 Onset of incurable cancer time often a few years but decline usually seems < 2 months Decreased self care & frequent hospitalisations time 2 5 years but death often seems sudden Onset of functional deficits time quite variable but usually 6 8 years Strengthening palliative care: Policy and strategic directions DHS draft document

20 Onset of incurable cancer time often a few years but decline usually seems < 2 months Decreased self care & frequent hospitalisations time 2 5 years but death often seems sudden Onset of functional deficits time quite variable but usually 6 8 years Strengthening palliative care: Policy and strategic directions DHS draft document

21 Onset of incurable cancer time often a few years but decline usually seems < 2 months Decreased self care & frequent hospitalisations time 2 5 years but death often seems sudden Onset of functional deficits time quite variable but usually 6 8 years Strengthening palliative care: Policy and strategic directions DHS draft document

22 What is frailty?

23 Frailty

24 Frailty Fried s Criteria 1. Unintentional weight loss 2. Weakness 3. Exhaustion 4. Slow walking speed 5. Low physical activity Pre frail 1 or 2 criteria Frail 3 criteria Fried L. Frailty in older adults; Evidence for a Phenotype. J of Gerontol. Series A 2001

25 Co morbidity, Disability & Frailty Co morbidity Concurrent presence of 2 chronic disease Disability Physical or mental impairment that limits 1 major ADL Frailty State of high vulnerability for adverse health outcomes

26 Co morbidity, Disability & Frailty Disability n=67 5.7% 21.5% 46.2% Co-morbidity n = 2131 Fried et al J Gerontol 2004; 59: % Frailty n = 98

27 Vulnerable Elders Survey (VES 13) > 65 years old Community Dwelling Elderly l risk of functional decline or death in the next 2 years Easy to administer Saliba et al JAGS 49: , 2001

28 Age Vulnerable Elders Survey (VES 13) Community Dwelling Elderly Self rated health Difficulty performing physical ltasks 6 items (5 point Likert scale) Reaching above shoulder level ADL limitation due to health issues 5 items (Yes, No, Don t do) Shopping for personal items

29 Vulnerable Elders Survey (VES 13) Community Dwelling Elderly l maximum score = 10 score 3 32% of people 4.2 times the risk of death or functional decline over a 2 year period screening tool for oncology, nephrology etc. Saliba et al JAGS 49: , 2001

30 Prevalence of Dementia Incidence doubles every 5 years Over 60 ~5% At age 70 ~10% At age 80 ~ 25%

31 Features of Dementia Memory impairment, plus one or more of aphasia, apraxia, agnosia, disturbed executive functioning (ie planning, organizing, sequencing, abstracting) Significant impairment in social or occupational functioning, or significant decline from previous functioning The deficits are not exclusively during the course of delirium, other neurologic og or psychiatric c disorder

32 Differential diagnosis of dementia Vascular dementias Multi infarct dementia Vascular dementias + Alzheimer s disease Other dementias Frontal lobe dementia Creutzfeldt Jakob disease HIV Alcohol Many others Dementia with Lewy bodies Parkinson s disease Diffuse Lewy body disease Alzheimer s Disease AD + dementia with Lewy bodies 5% 10% 65% 7% 8% 5% Small GW et al. JAMA1997; 278: Morris JC. Clin Geriatr Med 1994;10: American Psychiatric Association Am J Psychiatry 1997;154(Suppl): 1 39.

33 Living and dying in a Residential i Aged Care Facility 87 beds per 1000 people > 70 yo (178,000 beds) 75% high level care & 25% low level care Female : Male = 2:1 55% > 85 yo 20% > 90 yo 59% dementia 27% other mental illness 14% no mental tlhealth lthdiagnosisi AIHW Residential Aged Care in Australia

34 Living and dying in a Residential i Aged Care Facility Separations: 88% death 3% return to the community 3% discharged to hospital 3% move to other residential aged care 3% other AIHWResidential Aged Carein Australia

35 Living and dying in a Residential i Aged Care Facility Length of Male Female Total stay % % % < 1 month < 3 months < 6 months < 1 year Average length of stay (male) 109 weeks Average length of stay (female) 165 weeks AIHW Residential Aged Care in Australia

36 Living and dying in a Residential i Aged Care Facility Staffing recruitment t and retention ti issues No requirement for specific Aged Care training No staffing ratios Lower pay rates than the acute care sector On average $ per week (2004) National Aged Care Alliance : Principles of Staffing Levels and Skills Mix in Aged Care Settings. December 2004

37 Living and dying in a Residential i Aged Care Facility Staffing recruitment t and retention ti issues Burden of documentation 13% of nurses feel there is enough patient contact time 19% of other staff feel there is enough patient contact time 40% of nurses spend <1/3of timein in direct patient care 25% of allied health workers <1/3 of time in direct patient care National Aged Care Alliance : Pi Principles i of Staffing Levels and Skills Mix in Aged dcare Settings. Stti December 2004

38 Living and dying in a Residential i Aged Care Facility Staffing recruitment t and retention ti issues medical Complexity of medical issues Financial constraints Time constraints Relocation issues

39 Living and dying in a Residential i Aged Care Facility Is it home? Is it hospital? Is it hospice?

40 Living and dying in a Residential i Aged Care Facility Is it home? Is it hospital? Is it hospice? but 88% death rate

41 Recommendations/Wish list Increased undergraduate education in Aged Care and Palliative Care Diploma in Geriatric Medicine for GPs Mandatory rotation in Palliative Care for Geriatricians i i Mandatory rotation in Geriatric Medicine for Palliative Care physicians Appropriate p funding and staffing in RACF

42 People are almost always pretending something, but these people had lost that need.i felt it enabled me as a photographer to get as close as it s possible to get to the core of a person; when you re facing the end, everything that s not real is stripped away. You re the most real you ll ever be, more real than you ve ever been before. (Walter Schels Interview with the Guardian) Accessed 24/07/2011

43 Thank you