Australian Residential Aged Care Research Articles

Osteoporosis management in Australian aged care facilities: a mixed method study

SummaryOsteoporosis is a common but sub-optimally managed disease amongst aged care residents. Pharmacists undertaking comprehensive medication reviews is one strategy to improve osteoporosis management. Analysis of pharmacist medication review recommendations has identified common clinical practice issues that can be addressed to optimise osteoporosis management for aged care residents.PurposeThis study investigates the prevalence of osteoporosis medicine use amongst Australian aged care residents and explores drug-related problems (DRPs) identified during medication reviews and pharmacist recommendations to resolve them.MethodsResident demographics, medications, diagnoses, osteoporosis related DRPs, and recommendations to resolve them were extracted from medication review reports. A mixed methods approach was taken to analysis, involving descriptive statistical analysis and content analysis.ResultsMedication review reports relating to 980 residents were collected. Antiresorptive therapies were used by 21.7% of residents, of which 87.2% were prescribed denosumab. Osteoporosis related DRPs represented 14.0% of all DRPs identified by pharmacists. Vitamin D was involved in 55.4% of these DRPs, the remainder concerned antiresorptive therapies (23.4%), medications contributing to osteoporosis (16.3%), and calcium (4.9%). Frequent deviations in practice from aged care clinical guidelines and consensus recommendations concerning vitamin D and calcium were found. DRPs and accompanying recommendations relating to denosumab revealed inadequate monitoring and inadvertent therapy disruptions.ConclusionPharmacist identified DRPs and recommendations revealed common aspects of clinical practice that can be addressed to improve osteoporosis management for aged care residents. A need to raise awareness of aged care-specific consensus recommendations concerning vitamin D and calcium is evident. Facility protocols and procedures must be developed and implemented to ensure safe and effective use of denosumab.

Adverse Drug Event–Related Hospital Admissions Among Australian Aged Care Residents: A Cross-Sectional Study

ObjectivesTo investigate the proportion, characteristics, causality, severity, preventability, and independently associated factors for adverse drug event (ADE)–related admissions in aged care residents admitted to the major public hospitals in Tasmania, Australia. DesignRetrospective cross-sectional study. Setting and ParticipantsResidential aged care facility (RACF) patients aged ≥65 years who had an unplanned admission to one of the 4 Tasmanian public hospitals between July 1, 2018, and June 30, 2021. MethodsWe accessed the medical records of RACF patients. The ADEs were initially identified via chart review and a trigger tool. Hospitalizations attributable to ADEs were then determined by expert consensus. The causality, preventability, and severity of each ADE admission were assessed using standard criteria. ResultsNinety-one residents (18.2%) of 500 randomly selected experienced potential ADE-related hospitalizations. ADEs were considered possible (n = 58, 64%) or definite/probable (n = 33, 36%). The most common ADEs were falls (n = 19, 21%), hypotension (n = 16, 18%), and confusion or delirium (n = 10, 11%). ADEs were frequently associated with renin-angiotensin system inhibitors (n = 43, 47.3%), opioids (n = 43, 47.3%), and diuretics (n = 40, 44%). Most ADEs were of moderate severity (n = 90, 99%) and considered not preventable (n = 60, 66%). Rheumatologic disease [odds ratio (OR) 1.89, 95% CI 1.09-3.30; P = .024] and previous adverse drug reaction (ADR) (OR 12.91, 95% CI 6.84-24.37; P < .001) were associated with ADE hospitalizations. Conclusions and ImplicationsThis study highlights that hospitalization for moderately severe ADEs is common among RACF residents. Opioids and antihypertensives were the common drug classes associated with harm. Rheumatologic disease (due to opioids) and previous ADR were identified as independently associated factors, which may warrant tailored interventions.

Social participation in Australian residential aged care: A human rights perspective.

The Royal Commission into Aged Care Quality and Safety emphasised the critical need for a human rights-based approach to protect the rights of older people in the Australian aged care context, including 'the right to social participation'. This topic is important because of the widespread social isolation and loneliness in Australian residential aged care. This article demonstrates how a human rights-based framework can provide guidance to governments in approaching issues involving the protection of older people's need for social connection in aged care. In doing so, the article considers examples of how the Australian government can ensure choice of living arrangement, individualised support and access to community services and facilities in the residential aged care context to better protect the right to social participation.

Comparison of polypharmacy and potentially inappropriate medication use in older adults with and without dementia receiving residential medication management reviews.

Among residents who had a residential medication management review (RMMR), there is a lack of studies assessing exposure to polypharmacy and potentially inappropriate medications (PIMs) in people with dementia. This study compared the exposure to polypharmacy and PIMs in residents with dementia and without dementia receiving RMMR. A retrospective analysis was performed using data of 16,261 residents living in 343 Australian residential aged care facilities who had an RMMR in 2019. Medication use was assessed as polypharmacy (defined as ≥9 medications) and use of ≥1 PIMs using the 2019 updated Beers criteria. Dementia diagnosis was determined with ICD-10 coding from medical records. Descriptive analyses reported resident demographics and patterns of medication use. Pearson's χ2 tests and logistic regression analysis were conducted to compare medication exposure between residents with and without dementia. Among 16,261 residents, 6781 (42%) had dementia. Residents with dementia were significantly more likely to be exposed to polypharmacy and PIMs, compared to those without dementia (74% vs. 70% and 83% vs. 73%, p < .001 respectively). Residents with dementia had 1.31 times the odds of exposure to polypharmacy (adjusted OR: 1.31, 95% CI: 1.22-1.41, p < .001) and 1.88 times the odds of being prescribed ≥1 PIMs than people without dementia (adjusted OR: 1.88, 95% CI: 1.73-2.04, p < .001). In a study of residents receiving RMMR, polypharmacy and PIMs were highly common, and those with dementia were more likely to be exposed to inappropriate polypharmacy. There is a need for targeted deprescribing strategies to immediately address inappropriate prescribing in residents, particularly those living with dementia.

Cross-sectional survey of staff and family perspectives on the use of CCTV in Australian residential aged care.

To describe staff and family members' opinions about closed-circuit television (CCTV) in communal and private areas of residential aged care facilities (RACF), and to investigate how this relates to perceptions of care quality. A cross-sectional survey was developed to capture perceptions of CCTV's influence on care quality, and acceptable locations for CCTV placement. Data were recorded as ordinal-scale and open responses. Non-parametric tests of association were conducted. The survey was completed by 81 staff and 74 family members. Both staff and family were satisfied with care quality and safety, irrespective of CCTV use. More family members were in favour of CCTV in both public and private areas, compared to staff who favoured public areas. Staff and family assumed there was real-time monitoring, leading to a belief that CCTV monitoring would improve safety and prevent falls and abuse. Concerns were raised that CCTV could be used instead of improving staff-to-resident ratios and interaction. Overall, participants supported the use of CCTV more in public than in private areas and believed it reveals and prevents poor care. There was no association between CCTV use and satisfaction with care. Closed-circuit television can have positive impacts if all stakeholders are involved in implementation.

Exploring occupational therapy practice in Australian residential aged care facilities: A cross-sectional survey.

Occupational therapy in residential aged care facilities (RACFs) can enhance residents' occupational engagement and wellbeing. However, industry reports suggest that occupational therapists in Australian RACFs have mostly provided physical therapies such as pain management via massage and not addressed residents' occupations. There is limited literature on what constitutes occupational therapists' practice in RACFs to inform policy and practice. The aim of this cross-sectional survey was to explore practice patterns of occupational therapists working in Australian RACFs and influences on their practice. Occupational therapists working in Australian RACFs were invited from July 2019 to March 2020 to complete a self-report online questionnaire via email and advertisements on industry websites, newsletters, and social media. The questionnaire asked therapists about their caseload, referrals, assessments, and interventions. Data were analysed descriptively and presented as frequencies and percentages. A total of 214 occupational therapists completed the survey. Occupational therapists' daily practice largely focussed on pain management; other areas of practice included falls prevention, pressure care, and mobility. The Aged Care Funding Instrument in place at the time of the survey was identified as the leading factor influencing therapists' choice of assessments and interventions. Organisational policies and procedures were also perceived as key factors influencing occupational therapy practice. This paper highlights the influence of government funding and organisational policies in limiting occupational therapists' scope of practice and their ability to fully address the occupational needs of residents. Occupational therapists and the profession in general should be aware of factors in aged care funding models, and their application, that restrict occupational therapy practice and inhibit residents' function and advocate for change where needed. With the introduction of the Australian National Aged Care Classification funding model replacing Aged Care Funding Instrument, future research should explore potential changes to therapists practice following the implementation of the new funding model.

Implementation of an intervention to reduce urine dipstick testing in aged care homes: a qualitative study of enablers and barriers, and strategies to enhance delivery

ObjectiveThe ‘To Dip or Not to Dip’ (TDONTD) intervention aims to reduce antibiotic prescribing for urinary tract infection (UTI) by reducing low-value dipstick testing. The aims of this study were...

Prototype development of the Mental Health benchmarking Industry Tool for residential aged Care (MHICare Tool): a protocol paper of a two-stage sequential and mixed methods codesign study

ObjectivesCurrent mental health practices for people living in residential aged care (RAC) facilities are poor. In Australia, there are no mechanisms to monitor and promote mental health for people living...

Extracting Symptoms of Agitation in Dementia from Free-Text Nursing Notes Using Advanced Natural Language Processing.

Nursing staff record observations about older people under their care in free-text nursing notes. These notes contain older people's care needs, disease symptoms, frequency of symptom occurrence, nursing actions, etc. Therefore, it is vital to develop a technique to uncover important data from these notes. This study developed and evaluated a deep learning and transfer learning-based named entity recognition (NER) model for extracting symptoms of agitation in dementia from the nursing notes. We employed a Clinical BioBERT model for word embedding. Then we applied bidirectional long-short-term memory (BiLSTM) and conditional random field (CRF) models for NER on nursing notes from Australian residential aged care facilities. The proposed NER model achieves satisfactory performance in extracting symptoms of agitation in dementia with a 75% F1 score and 78% accuracy. We will further develop machine learning models to recommend the optimal nursing actions to manage agitation.

Who speaks my language? Linguistic diversity among people living in Australian residential aged care facilities.

Australia's migration programs mean that an increasing number of people living in residential aged care (RAC) were born in a non-main English-speaking country (NMESC) and have a preferred language other than English (LOTE). This study describes the number of such residents in aged care facilities in Australia and discusses the implications for their care. This study presents a secondary analysis of the Australian Institute of Health and Welfare (AIHW) National Aged Care Data Clearinghouse 2020-2021 to examine the country of birth and preferred language of people living in RAC in each state and territory and the number of residents who are lone speakers of their language in their facility. Less than half (45 per cent) of the residents born in a NMESC had a preferred LOTE. Of those, 50 per cent spoke Italian, Greek or Cantonese. At least 60 other preferred languages were recorded, the majority with very few speakers. Australia-wide, more than one in five residents with a preferred top 20 LOTE are the lone speaker of their language in their facility. The proportion of lone speakers is highest in Tasmania, the ACT and Queensland. Understanding the extent of language diversity, location and linguistic isolation of people living in RAC is essential for planning to ensure residents with a preferred LOTE receive high-quality, individualised care. There is a need for consistent and timely data collection about the diversity of aged care residents and workers in this sector.

A Five-Step Workflow to Manually Annotate Unstructured Data into Training Dataset for Natural Language Processing.

Natural Language Processing (NLP) is a powerful technique for extracting valuable information from unstructured electronic health records (EHRs). However, a prerequisite for NLP is the availability of high-quality annotated datasets. To date, there is a lack of effective methods to guide the research effort of manually annotating unstructured datasets, which can hinder NLP performance. Therefore, this study develops a five-step workflow for manually annotating unstructured datasets, including (1) annotator training and familiarising with the text corpus, (2) vocabulary identification, (3) annotation schema development, (4) annotation execution, and (5) result validation. This framework was then applied to annotate agitation symptoms from the unstructured EHRs of 40 Australian residential aged care facilities. The annotated corpus achieved an accuracy rate of 96%. This suggests that our proposed annotation workflow can be used in manual data processing to develop annotated training corpus for developing NLP algorithms.

Evaluation of an Infection surveillance program in residential aged care facilities in Victoria, Australia.

Infection surveillance is a key element of infection prevention and control activities in the aged care sector. In 2017, a standardised infection surveillance program was established for public residential aged care services in Victoria, Australia. This program will soon be expanded to a national level for all Australian residential aged care facilities. It has not been evaluated since its inception. The current study aimed to evaluate the Victorian Healthcare Associated Infection Surveillance System (VICNISS) Coordinating Centre Aged Care Infection Indicator Program (ACIIP), to understand its performance and functionality. A mixed methods evaluation was performed using the Updated Guidelines for Evaluating Public Health Surveillance Systems developed by the United States Centers for Disease Control and Prevention as a framework. VICNISS staff who coordinate and manage the ACIIP were invited to participate in interviews. Residential aged care staff who use the program were invited to participate in a survey. Document analysis was also performed. Four VICNISS staff participated in the interviews and 38 aged care staff participated in the survey. The ACIIP is stable and able to be adapted quickly to changing definitions for infections. Users found the system relatively easy to use but have difficulties after the long intervals between data entry year on year. VICNISS staff provide expert guidance which benefits users. Users appreciated the benefit of participating and many use the data for improving local practice. The ACIIP is a usessful state-wide infection surveillance program for aged care. Further development of data validation, IT system capacity and models for education and user support will be required to support future scalability.

Food, nutrition and the dining experience in aged care settings: Findings of a nationwide survey.

Previous research on food, nutrition and dining practices in Australian residential aged care (RAC) homes has been based on a limited sample of single-home or multiple-home providers, but a nationwide study has not been conducted. The aim of this study was to provide a preliminary overview of current food, nutrition and dining practices across Australian RAC facilities using a nationwide survey. A survey was distributed to Australian RAC homes in August-September 2020, as part of the National Congress on Food, Nutrition and the Dining Experience in Aged Care (February 2021). The survey, administered via an online portal, consisted of 38 semistructured questions including yes/no or multiple-choice responses, free text, frequency scales and number entry. Six key topics were explored, including 'food service system and environment', 'catering style', 'menu planning and evaluation', 'nutrition planning and requirements', 'nutrition-related screening and assessment' and 'training and additional information', which were informed by the Australian Government Department of Health and reflected the interests of the Congress. The final sample included 292 respondents (204 individual homes and 88 multiple-home proprietors) representing 1152 homes and 125,393 residents, encompassing approximately 43% of RAC homes (of a possible 2671) and 57% of residents (of a possible 219,965) in Australia. Survey respondents representing RAC homes included service managers, catering managers, Chief Executive Officers, cooks, chefs, dietitians or staff from other roles within homes. A number of potential areas of need were identified, included increasing the autonomy of residents to select the foods they desire, increasing the variety and choice (including timing) of meals, enhancing the dining environments in homes to stimulate food intake and increasing staff training and the number of trained chefs in homes, so that meals are prepared which address diverse nutritional needs of residents. This study provides insight into the food service and mealtime practices of over a third of Australian RAC homes. The findings of this survey may help to identify key targets for intervention to improve the food, nutrition and quality of life of aged care residents.

Pilot study to evaluate the need and implementation of a multifaceted nurse-led antimicrobial stewardship intervention in residential aged care.

To evaluate the need and feasibility of a nurse-led antimicrobial stewardship (AMS) programme in two Australian residential aged care homes (RACHs) to inform a stepped-wedged, cluster randomized controlled trial (SW-cRCT). A mixed-methods pilot study of a nurse-led AMS programme was performed in two RACHs in Victoria, Australia (July-December 2019). The AMS programme comprised education, infection assessment and management guidelines, and documentation to support appropriate antimicrobial use in urinary, lower respiratory and skin/soft tissue infections. The programme was implemented over three phases: (i) pre-implementation education and integration (1 month); (ii) implementation of the intervention (3 months); and (iii) post-intervention evaluation (1 month). Baseline RACH and resident data and weekly infection and antimicrobial usage were collected and analysed descriptively to evaluate the need for AMS strategies. Feedback on intervention resources and implementation barriers were identified from semi-structured interviews, an online staff questionnaire and researcher field notes. Six key barriers to implementation of the intervention were identified and used to refine the intervention: aged care staffing and capacity; access to education; resistance to practice change; role of staff in AMS; leadership and ownership of the intervention at the RACH and organization level; and family expectations. A total of 61 antimicrobials were prescribed for 40 residents over the 3 month intervention. Overall, 48% of antibiotics did not meet minimum criteria for appropriate initiation (respiratory: 73%; urinary: 54%; skin/soft tissue: 0%). Several barriers and opportunities to improve implementation of AMS in RACHs were identified. Findings were used to inform a revised intervention to be evaluated in a larger SW-cRCT.

Seeing people living with dementia through the lens of technology: pain assessment and clinical impact

Objective:Due to communication difficulties, pain assessment in people living with dementia (PLWD) is challenging. In this study we explore vocalisations and facial expressions during assessment of pain and provide evidence in regards to clinical impact of pain assessment, as part of a targeted care program.Methods:In order to determine key facial and vocalisation features and their relationship with pain we analysed a total of 22,194 pain assessments in PLWD (n = 3,144) from 34 different Australian residential aged care homes. Pain assessments were conducted using PainChek, which is a technology-based system comprised of three key components: point-of-care AI-powered application, training and digital analytics. Additionally, we examine the 6-months clinical impact of introducing this system, as part of a wider psychosocial care intervention (i.e., the Reconnect program) in the UK care home setting. Here we focus on how this pain assessment system contributed to the use of psychotropics and issues such as safeguarding.Results:Likelihood of vocalization feature presence varied based on the intensity of pain. In this regard, sighing and screaming were more likely during experience of higher pain (eight times). During experience of severe pain eyelid tightening was the most frequent facial expression (48.6%) whereas higher pain levels were mostly predicted by horizontal mouth stretch feature. Use of PainChek system as part of the Reconnect program contributed to a more consistent pain management approach, benzodiazepine reduction (29%) and cessation (46%) and reduction of antipsychotic prescribing (22%). Compared to the 6 monthly period from the year prior to implementation of the Reconnect program, a 92% reduction in safeguarding events was reported.Conclusion:In this study we demonstrate the potential to digitally phenotype key pain behaviours such as vocalizations and facial expressions using the PainChek system. We also evidence the positive impact of pain assessment combined with psychosocial care, on use of psychotropics and safeguarding incidents.

Sustaining and expanding telehealth activity: Training requirements for Australian residential aged care front-line staff.

To identify the training needs of front-line aged care staff as perceived by senior clinicians and managers at selected residential aged care facilities (RACFs). A qualitative explorative designed study using semi-structured interviews with a convenience sample of RACF senior managers and nurses. A hybrid analysis approach using a framework deductive analysis followed by inductive analysis for sub-themes. Four sub-themes emerged to sustain increased telehealth activity: technology knowledge and digital literacy skills, including understanding telehealth ecosystems and technical skills; evidence-based reviews and clinical frameworks for telehealth consultations to identify appropriate consultations and successful use cases; telehealth best practice guidelines and workflows including telehealth consultations protocols, communicating by videoconferencing, how to support families in attending telehealth consultations and optimal training models; and telehealth policy and legal guidance. Staff require comprehensive training to sustain and expand telehealth use in RACFs. Training should focus on knowledge, skills and competencies in using telehealth as well as the broad factors of policies and understanding ICT systems to support staffs' abilities and confidence. This study provides innovative findings that identify key components and associated activities and resources for training RACF staff to ensure they have sufficient knowledge, competency, skills and confidence to integrate telehealth into care provision.

Measures that matter should define accountability and governance frameworks.

While the Royal Commission into Aged Care Quality and Safety has clearly identified the issues with our Australian residential aged care system, its recommendations-so far-have not been translated into policies that will ensure a framework in which nursing home operators and care staff are empowered to focus on what matters-ensuring vulnerable residents receive care that meets their needs and preserves their dignity. For this to be achievable the system requires measures that in the first instance reflect the system's purpose, and that all stakeholders can use to improve care. Such measures need to be easy to understand and implement, and most importantly reduce bureaucratic burden.

Afterhours telehealth in Australian residential aged care facilities: a mixed methods evaluation

BackgroundThe aged care system in Australia is under pressure. Residential aged care facilities (RACFs) and general practitioners (GPs) have difficulty providing the care needed by their residents, particularly after hours. Many residents are given ambulance support and transferred to hospital emergency departments (EDs) for care that could be provided at RACFs. The MyEmergencyDoctor (MED) service was commissioned in a 12-month program (February 2020-February 2021) using ED physicians to provide afterhours telehealth care in six RACFs.MethodsUsing the NASSS framework, we synthesised descriptive analyses of statistical data from the MED service, RACFs and the ambulance service and a thematic analysis of interview data collected from GPs, RACF and MED service staff, and family members of residents.ResultsMost calls to MED (179/209) were resolved with in-house treatment thereby reducing ambulance usage and hospital admissions. Interviews further revealed that MED enabled timely care for residents who were unwell but did not need hospital transfer. Technology, training, and rapid access to MED assisted RACF staff and complemented usual GP care. MED potentially reduced GP burnout. Refresher training was considered important especially in RACFs with high staff turnover, as was greater afterhours access to medications.ConclusionsThe afterhours telehealth model provided in-house care and reduced ambulance transfers, and GPs and RACF staff generally felt supported. The service was easy to use and fostered good communications with GPs and RACF staff. Some GPs preferred to provide their own care, commenting on the need for a good understanding of patient and family needs and of the local context. Other stakeholders suggested this model could be extended to palliative care settings and to normal business hours when GPs were unavailable. The reduced ambulance and hospital use suggested benefits to wider health systems, however policies and funding that remunerate GPs, support community-based care and provide additional staffing in RACFs are needed to sustain afterhours telehealth in RACFs. Use of the NASSS (non-adoption, abandonment, scale-up, spread, and sustainability) Framework provided a valuable explanatory lens for our analyses.

Identifying barriers and enablers to participation in infection surveillance in Australian residential aged care facilities

BackgroundInfection surveillance is a vital part of infection prevention and control activities for the aged care sector. In Australia there are two currently available infection and antimicrobial use surveillance programs for residential aged care facilities. These programs are not mandated nor available to all facilities. Development of a new surveillance program will provide standardised surveillance for all facilities in Australia.MethodsThis study aimed to assess barriers and enablers to participation in the two existing infection and antimicrobial use surveillance programs, to improve development and implementation of a new program. A mixed-methods study was performed. Aged Care staff involved in infection surveillance were invited to participate in focus groups and complete an online survey comprising 17 items. Interviews were transcribed and analysed using the COM-B framework.ResultsTwenty-nine staff took part in the focus groups and two hundred took part in the survey. Barriers to participating in aged care infection surveillance programs were the time needed to collect and enter data, competing priority tasks, limited understanding of surveillance from some staff, difficulty engaging clinicians, and staff fatigue after the COVID-19 pandemic. Factors that enabled participation were previous experience with surveillance, and sharing responsibilities, educational materials and using data for benchmarking and to improve practice.ConclusionStreamlined and simple data entry methods will reduce the burden of surveillance on staff. Education materials will be vital for the implementation of a new surveillance program. These materials must be tailored to different aged care workers, specific to the aged care context and provide guidance on how to use surveillance results to improve practice.

An evaluation of influenza, pneumococcal and herpes zoster vaccination coverage in Australian aged care residents, 2018 to 2022.

For older persons, vaccination mitigates the harmful impact of vaccine preventable infections. Our study objectives were to evaluate in the Victorian public sector residential aged care services (PSRACS) (1) the existence of local vaccination policies and admission assessment practices, (2) the current documented status of resident influenza, pneumococcal and herpes zoster vaccination uptake and (3) changes in documented resident vaccination uptake over time. Standardised data were annually reported by all PSRACS between 2018 and 2022. The influenza, pneumococcal and herpes zoster vaccination status of each resident was classified as vaccinated, declined, contraindicated or unknown. Annual trends in vaccination status were assessed using Spearman's correlation. In 2022, most PSRACS reported an influenza immunisation policy existed (87.1%) and new residents were assessed for their influenza vaccination status (97.2%); fewer PSRACS reported the same for pneumococcal disease (73.1% and 78.9%) and herpes zoster (69.3% and 75.6%). The median resident influenza, pneumococcal and herpes zoster (70-79 years old) vaccination uptake was 86.8%, 32.8% and 19.3% respectively. The median unknown status was 6.9%, 63.0% and 76.0% respectively. Statistical evidence of an increase in annual uptake was observed for the herpes zoster (all resident) surveillance module (rs=0.900, p=0.037). Our study showed local influenza vaccination policies and practices exist and influenza vaccination uptake was consistently high. Pneumococcal and herpes zoster vaccination uptake were lower. Quality improvement strategies that at least determine the status of those residents classified as unknown are required.