All the older people: where do they all belong?

RECENT times have seen a great deal of discussion and debate about older people and the poor conditions in residential aged care, their high risk of acquiring and dying from COVID-19 and the very long waiting lists for home care packages.

It is a narrative of our times, courtesy of some truly shocking headline stories emerging from the Royal Commission on Aged Care Quality and Safety, and fuelled by the general disruption of COVID 19 in Australian society at large and the poorly managed contagion and death rates in aged care services in particular (here and here).

It is indeed timely for us to reflect on the failures of our aged care system for older people. But when combined with the longer running society-wide trope of the threat posed by an ageing society, the “silver tsunami” of older people spreading across the land, we are in danger of forgetting who the majority of older people are and how they live their lives.

Older adults are an extremely heterogenous bunch. As very well placed concerns over the quality and adequacy of care being provided to older people who require assistance gain momentum, it is equally important to keep in mind the majority of older adults who do not fit stereotypical views of the “frail and disabled elderly”. And it is important for community-based doctors, nurses and allied health professionals to remember that the majority are not using any form of aged care service.

Only 4.4% of the 4 million people aged 65 and over live in residential aged care (here and here). When you look at the most recent numbers, 177 098 people aged 65 years and over were living in residential aged care, a further 104 189 were receiving home care packages, 9381 were in residential respite or transition care services and an estimated 735 892 receiving services from the Commonwealth Home Support Program (CHSP). The majority of older adults neither live in residential care, nor do they receive care packages or CHSP services. In fact, over 3 million older adults were not in receipt of government aged-care services (Figure 1).

Figure 1: Patterns of aged care use persons 65 years and over 2009 and 2019

Note: Author’s analysis of AIHW GEN aged care data. Point in time CHSP data are not available and were estimated for the purposes of this analysis at 90% of users over the 2008–09 and 2018–19 calendar years. This is likely to be an overestimate, as point in time data on home care package (HCP) client numbers were 65% and 69% of all users over the calendar year, resulting in a conservative estimate of the numbers of older Australians not using government-funded services.

Over the past decade, there has indeed been an increase in the number of people living in residential aged care facilities (24 800 more people). There have been larger increases in the number receiving home care packages (62 000 more people) and using CHSP services (an estimated 137 000 more people). The increasing number of service users is so commonly cited that it is easy to forget that the number of older adults not using aged care services has grown by almost 1 million.

Their health services will be provided predominantly through community-based GPs, community-based nurses and nurse practitioners, and community-based allied health professionals, making these professionals crucial to maintaining the health and wellbeing of older Australians. And it is important that those practitioners are thinking in terms of maximising functional health as well as in terms of diagnosis and management of disease.

These are the clinicians whose decisions have an impact on the lives of older people and their families on a regular basis. Functional health and wellbeing are important because they underpin the ability of older Australians to go about their daily lives and to function as full members of society — and participating as full members of society is where older people belong. The reciprocal relationship is equally true. The participation of older adults is important for the wellbeing of communities and the wider society: in the paid workforce, as volunteers, caring for friends and family members with a disability, and providing unpaid childcare.

According to 2016 census data, 53% of Australians aged 60–64 years were employed, 26% of those aged 65–69 years were employed, as were 13% of those aged 70–74 years. And the employment rate among older people has been growing steadily, more than doubling since 2004.

The sheer size of the older workforce is often underestimated.

In 2016, there were 1 091 046 employed persons aged 60 years and over, of whom 158 561 were aged 70 years and over. In the early stage of COVID-19 responses, it is salutary to consider when advice was given for older people to self-isolate that no thought was apparently given to their employment activity — it seemed to be assumed that they were not employed, and staying at home was without cost for the individual, their workplace and the local economy.

Older people also make a substantial contribution to society through unpaid work (Table 1).

Table 1. Percentage of persons 65 and overengaged in various activities 2016

Note: Author’s analysis of ABS 2016 census using TableBuilder

Around one in five is a volunteer up until age 80 years, when the proportion starts to decline. Even at age 90 years and over, one in 20 was still volunteering. At ages 60–64 years, around one in five is caring for a person with a disability, while at ages 80–89 years, it is one in ten. One in five people in their sixties is providing unpaid childcare, almost one in five at ages 70–74 years and one in ten at ages 75–79 years.

Except where these activities could be undertaken in the home and for co-residents, self-isolation is challenging for both older people and for those to whom they provide assistance, be that families, friends or members of the community.

Meanwhile, these same older people are likely to be looking after themselves, whether through shopping, gardening, exercise, hobbies, attending leisure and cultural events, or undertaking housework. As Table 1 indicates, around one in three spends 15 hours or more on housework every week up until age 80 years, when it drops to one in four, and then to one in ten for those aged 90 years and over.

The form of participation in society will vary with physical and mental health, with financial and housing resources, and with the age-friendliness of their community. Participation itself is a basic human right, it is part of the daily lives of older Australians and it requires support from health professionals who understand this level of engagement and activity is normal.

There is strong international evidence of a shortage of preventive and rehabilitation-focused care options for older populations across a wide range of mental and physical health conditions, including cardiology, oncology and stroke. Older people are also less likely to be referred for treatment for mental health issues, including suicidal ideation and self-harm (here, here and here). There is recent Australian evidence that GPs are less likely to prescribe physical exercise for hypertension management among patients aged 75 years and over.

The primary health care workforce is ideally placed to maximise the functional health of older people, whether by prevention, maintenance, rehabilitation or reablement. Government programs including Chronic Disease Management Plans and the Better Access initiative targeting mental health offer funding envelopes, as do services available through Medicare and private health insurance. Indeed, the new primary care model of accredited aged care general practices, recently advocated by Counsel Assisting the Royal Commission into Aged Care Quality and Safety (Recommendation 62) to provide proactive, coordinated and team-based approaches to health care for aged care recipients, could easily be applied to older adults who are currently not accessing aged care services.

The majority of older Australians belong in their homes, maintaining their independence in caring for themselves and their households. Many are active participants in their communities through both paid and unpaid work. Older people need health care that supports them to live their best possible lives and they need the support of health professionals who recognise their value to society and enable them to continue to participate and contribute to the level they desire. The “’90-year-old patient with macular degeneration” may also be the only organist in her local church — and she needs the appropriate specialist medical care to enable her to keep the music playing for her community.

Diane Gibson is Distinguished Professor of Health and Ageing at the Health Research Institute, Faculty of Health, University of Canberra.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.