A longitudinal look at Australian Aged Care Policy from A socio-clinical perspective

1. 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

2. 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

3. Australian Aged Care PolicyConclusions • Traditional ‘age structure’ 65+ homogenises older people, breeds a social-medical divide & needs re- definition 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

4. Topics • Population Ageing, Disability & Disease • Population Age Structure with a brief look at the Economics of Ageing • Implications for Australian Aged Care policy

5. Population Ageing Disability & DiseaseIssue 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

6. Age-standardised deaths – 20th C. Infections (per 100,000 persons) Cumpston Sarjeant Pty Ltd

7. Age-standardised deaths – 20th C. Respiratory system (per 100,000 persons) Cumpston Sarjeant Pty Ltd

8. Age-standardised deaths – 20th C. Circulatory incl. Stroke (per 100,000 persons) Cumpston Sarjeant Pty Ltd

9. 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

10. Survivor effect - The ageing of the aged Vaupel: Science 1998

11. Epidemiology of AgeingBy 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 figuresmost 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’

12. 80 70 60 50 Male 40 Frequency Female 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 Sydney Older Persons Study: 1992 - 2002 A Study of Systemic and Brain Ageing(Random Samples of Community Dwellers 75+)

13. 2.5 2 1.5 Prevalence rate 1 0.5 0 75 78 81 84 87 90 93 Age Other Systemic Peripheral Vascular Disease Chronic Lung Disease* Stroke Obesity Heart Disease Arthritis Systemic disease trends: Prevalence (N=522. Age trends: * p < 0.05; ** p< 0.01)

14. 3.5 3 2.5 2 1.5 1 0.5 0 75 78 81 84 87 90 93 Age Parkinsonism** Dementia** Motor Slowing (excl. Park.)** Cognitive Impairment (excl. Dem.)** Vision** Ataxia** Neurodegenerative disorders: Prevalence (N=522. Age trends: * p < 0.05; ** p< 0.01) Prevalence rate

15. SOPS: Community Disability Rates6 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

16. Aged Care PolicyTopics • Population Age Structure with a brief look at the Economics of Ageing • Implications for Australian Aged Care policy

17. Population Age StructureRand 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

18. Traditional ‘age structure’ homogenises the oldFor 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

19. Economics of AgeingWhat 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?

20. Aged Care PolicyTopics • Implications for Australian Aged Care policy

21. Australian Aged Care PolicyImplications • 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

22. Australian Aged Care PolicyWhere 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

23. Policy & Planning Areas SESIAHS 1.2 million people DADHC 5-700,000 people

24. Service Delivery Sectors SESIAHS A Geo-demographic approach 6 Local Service Delivery Sectors Population 200 - 300,000 ‘urban’ Shoalhaven - 100,000 ‘rural’ 4 5 1 3 6 2

25. Local Sector Aged Care – a Geo-demographic Approach HOSPITALS - STATE 90% of Funds to Beds 3o Hospital Acute Aged Care Geriatric Rehabilitation Dementia Care • THE LOCAL SECTOR • Pop. 250,000 (urban) to 30-100,000 (rural) • 72 C/W divisions for ACATs, GPs, RAC beds • One or more LGAs COMMUNITY CARE (C/W - STATE Split) 10% of Funds to Services Emerging Interface Services Hospital in the Home Pre & Post Acute Care Community Rehabilitation Chronic Complex Care 2o RESIDENTIAL CARE C/W 90% 0f Funds to Beds COMMUNITY AGED CARE Geriatric Service Aged Health Care Support Network Extended ACAT NGOs Home Care Community Geriatrician Dementia Care HACC Carer Respite COMMUNITY HEALTH Local Govt. 1o DIVISION of GPs CACP EACH TACP Generalist Nurses RESIDENTIAL AGED CARE RESIDENTIAL HIGH CARE RESIDENTIAL LOW CARE Carer Respite

26. Brain AgeingThe 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

27. 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)