National Guide

Chapter 8 | The health of older people

Introduction







National Guide to preventive healthcare for Aboriginal and <br/>Torres Strait Islander people
Download PDF
      1. Introduction

Introduction

Dr Sylvia Nicholls    

Key messages

  • Older people and Elders contribute significantly to the wellbeing of their families and communities through strengthening of identity, cultural knowledge and social connectedness.1
  • Older peoples’ own priorities and goals should guide preventive health activities to support healthy ageing, consistent with person-centred care.2,3
  • Healthy ageing is supported by healthy living across the life course.4
  • Strengthening protective factors and addressing risk factors can prevent or delay the onset and progression of many chronic conditions.4
  • Aboriginal and Torres Strait Islander people may experience conditions associated with ageing at a younger age due to chronic disease and health inequities throughout the lifetime.5,6

Healthy ageing is supported by healthy living across the life course, and preventive health activities in older age (age 50 years and over) build on those of childhood and early adulthood.4 This is central to the vision of the National Aboriginal and Torres Strait Islander health plan 2013–2023, that ‘Aboriginal and Torres Strait Islander people enjoy long, healthy lives that are centred in culture, with access to services that are prevention-focused, culturally safe and responsive, equitable and free of racism’.7 Healthy ageing for Aboriginal and Torres Strait Islander people is best viewed through a holistic lens where the health of one individual is linked to the health of the whole community, and healthy ageing is seen as part of the cycle of life. 7 

Aboriginal and Torres Strait Islander communities tend to be younger than the wider population, reflecting both the higher birth rates and inequalities in life expectancy. However, with more Aboriginal and Torres Strait people living to an older age, the age structure is expected to rise, reflecting the wider trend of an ageing population in Australia.8 The number of Aboriginal and Torres Strait Islander people aged 45 years and above in 2016 was recorded as 167,259.8 This is projected to grow to 448,785 people over the next 30 years.8 This older (defined as age 45 years and above) adult cohort comprised 21% of the Aboriginal and Torres Strait Islander population in 2016, with projected growth to 26% in 2046.8 

For older Aboriginal and Torres Strait Islander adults, healthy ageing is characterised by engagement in community and culture including language, art, ceremonies and caring for Country.9 Elders’ own perspectives on ageing have been explored by researchers with the aim of providing culturally appropriate care.9–11 Aboriginal Elders saw healthy ageing ‘as more than just getting older, rather it was viewed as the ability to continue in key roles as cultural leaders and keepers of traditional knowledge’.9 Ongoing engagement with cultural practices, including preparation of traditional foods and passing on cultural knowledge, supports healthy ageing. In a study examining cultural safety in residential aged care, visiting the bush to collect plants was important: ‘go out for bush medicine, make it and take it to aged care and give it to the old people’.10 Cultural practices like this are consistently identified as fundamental to healthy ageing for indigenous peoples globally.12–14 

Elders are older people (age being a relative concept) who are respected for their knowledge and wisdom and who enact cultural roles and responsibilities within the community.12,13,15 Elders may be seen as role models, mentors and decision makers, and may be approached by family and community members in times of need.15,16 Cultural obligations may also extend across other roles (eg as traditional owners, senior custodians and/or family members). Older people and Elders contribute significantly to the wellbeing of their families and communities by strengthening identity, cultural knowledge and social connectedness.2,12,14,15 Gibson et al describe the ‘intersecting roles and responsibilities’ for older people in a study of 16 Elders on Wiradjuri country.2 The authors suggested that Eldership may be viewed in an occupational sense, encompassing leadership, teaching and learning, advocacy and activism.2 

Older adults often have caregiver roles within families, including the care of children and young people as part of kinship care practices. Older adults are central to healing activities within families and communities, including supporting people through bereavement, loss and trauma.2,15 By sharing language, knowledge and traditional stories with younger generations, cultural practices that were disrupted and suppressed through colonisation are revitalised. In a research project based in Tasmania, Elders conveyed the desire to ‘create a positive future’ and ‘create something good’ for the youth in the community.15 Caring for youth was also a major theme identified by Elders of other nations (Githabul/Bundjalung and Ngarabal).1 

These roles are maintained in the context of considerable adversity, and best practice preventive care for older adults is trauma informed. Older Aboriginal and Torres Strait Islander people who are alive now were born into a segregated society and subject to discriminatory government policies. Separation from family and ancestral lands, including living on missions and reserves, suppression of cultural practices and experiences of racism, are in the living memory of many older adults today. With unequal access to education, employment and housing opportunities, many Aboriginal and Torres Strait Islander families experience intergenerational economic hardship. Older Aboriginal and Torres Strait Islander people have likely experienced racism and discrimination, including from health providers, which can be an ongoing barrier to care.13 

The Stolen Generations refers to Aboriginal and Torres Strait Islander people who, as children, were forcibly removed from their families in the 20th century as part of protectionist and assimilationist government policies.17 The National Aboriginal and Torres Strait Islander Health Survey 2018–19 suggested that there were around 27,200 people aged 50 years and over who were Stolen Generation survivors, with an estimated 142,200 descendants.18 This means that one in five currently living Aboriginal and Torres Strait Islander people aged 50 years and over were removed from their families.18 This has wide-reaching implications for the physical and social and emotional wellbeing (SEWB) of individuals and their families. As well as the trauma and grief of separation, survivors described maltreatment and abuse, malnutrition and harsh living conditions.18
 
Compared with a reference group of other Aboriginal and Torres Strait Islander people aged 50 years and over, Stolen Generation survivors were more likely to experience further health and socioeconomic disadvantage.18 In 2018–19, of people of the Stolen Generations aged 50 years and over, 71% had government payments as the main source of income and 43% had days without money for basic living expenses.18 The AIHW report identifies that, compared with an Aboriginal and Torres Strait Islander reference group, Stolen Generation survivors were found to be 1.7-fold more likely to be a current smoker, 1.4-fold more likely to have a severe or profound disability and 1.4-fold more likely to have poor mental health.18

Multimorbidity increases as people age, and multimorbidity is higher for Aboriginal and Torres Strait Islander people in all age groups.19,20 For older Aboriginal and Torres Strait Islander people, cardiovascular disease, cancer and neurological disorders, including dementia, have emerged as leading contributors to the burden of disease.21 Respiratory diseases affect all age groups, with 3–13% of the total morbidity burden attributed to these conditions.21 This is similar to musculoskeletal conditions, which affect all age groups from the age of 5 years and account for 4–12% of the total burden of disease.21 The impact of chronic health conditions is a concern to older Aboriginal and Torres Strait Islander people, particularly when associated with a loss of independence, inability to work or social isolation.13,14 Some people felt they had become a burden to family during periods of illness.9 

Aboriginal and Torres Strait Islander people may experience conditions associated with ageing at a younger age due to chronic disease and health inequities throughout the lifetime. Therefore, Aboriginal and Torres Strait Islander people can access My Aged Care services from age 50 years, and screening for geriatric syndromes should occur at younger ages, particularly the risk of falls and cognitive impairment.5,6 There will be a significant difference between a person's health needs at age 50 years compared with 70 years, and clinical care should be patient centred.22 Cognitive impairment and dementia are not inevitable or expected parts of healthy ageing.5 Maintaining a healthy mind, both in terms of cognition and mental wellbeing, allows for greater independence and safety in older age, as well as cultural engagement.5 Cultural determinants of health, as well as social and emotional health are captured in the Good Spirit, Good Life tool. This holistic quality-of-life assessment tool has been developed and validated for use with and by Aboriginal people in urban and regional areas.23 

There are multiple opportunities for preventive health for older Aboriginal and Torres Strait Islander people. In 2018, 49% of the burden of disease experienced by Aboriginal and Torres Strait Islander people was potentially preventable, particularly disease due to tobacco use, alcohol use, overweight and obesity, illicit drug use and nutrition.21 Data suggest that fewer Aboriginal and Torres Strait Islander people participate in cancer screening activities. For example, in 2017, 21% of Aboriginal and Torres Strait Islander people completed the National Bowel Cancer Screening Program, compared with 43% of non-Indigenous Australians.19
 
A similar disparity was seen in the vaccination of adults against pneumococcal disease: in 2018–19, 32% of Aboriginal and Torres Strait Islander people aged 50 years and over and 46% of those aged 65 years and over were vaccinated for pneumococcal disease, compared with 54% of the wider population aged 65 years and over.19

In older age, key primary prevention activities include:

  • promoting healthy eating, physical activity and social and cultural connection
  • vaccinations for influenza, pneumococcal disease, herpes zoster virus (shingles) and COVID-19 to reduce the risk of communicable diseases
  • encouraging not ever smoking or stopping smoking
  • screening for bowel, breast and cervical cancer
  • cardiovascular risk assessment.

Preventive care for older people can be opportunistic and integrated into other primary care activities. Annual health checks provide a structured approach to asking questions and talking (yarning) about common health issues associated with ageing, such as:

  • SEWB and mental health
  • musculoskeletal health (including bone density) and falls
  • cognitive impairment and dementia
  • bladder and bowel health, including incontinence, and sexual health
  • adverse effects from medication
  • maintaining independence and care needs.

It is important that cultural safety is recognised by care providers, so that autonomy and self-determination is prioritised and preventive activities are not forced upon individuals and communities.9,12,14 Referral to culturally appropriate services is an important way to support engagement in healthcare. When considering the evidence base for preventive healthcare, it is mostly generated from a Western, biomedical perspective. Respectful communication is key to building trusting therapeutic relationships and to allow for patient- and family-centred care. In this way, clinicians may seek to recognise and respect how Aboriginal and Torres Strait Islander ways of thinking, being and doing contribute to health and wellbeing for Elders and older Aboriginal and Torres Strait Islander people.

  1. Busija L, Cinelli R, Toombs MR, et al. The role of Elders in the wellbeing of a contemporary Australian Indigenous community. Gerontologist 2020;60(3):513–24. doi: 10.1093/geront/gny140.
  2. Gibson C, Dudgeon P, Crockett J. Listen, look and learn: Exploring cultural obligations of Elders and older Aboriginal people. J Occup Sci 2020;27(2):193–203. doi: 10.1080/14427591.2020.1732228.
  3. Gibson C, Crockett J, Dudgeon P, Bernoth M, Lincoln M. Sharing and valuing older Aboriginal people’s voices about social and emotional wellbeing services: A strength-based approach for service providers. Aging Ment Health 2020;24(3):481–88. doi: 10.1080/13607863.2018.1544220.
  4. Livingston G, Huntley J, Sommerlad A, et al. Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. Lancet 2020;396(10248):413–46. doi: 10.1016/S0140-6736(20)30367-6.
  5. Belfrage M, Hughson J, Gouglas H, LoGiudice D. Best-practice guide to cognitive impairment and dementia care for Aboriginal and Torres Strait Islander people attending primary care. The University of Melbourne, 2022 [Accessed 10 May 2024].
  6. LoGiudice D. The health of older Aboriginal and Torres Strait Islander peoples. Australas J Ageing 2016;35(2):82–85. doi: 10.1111/ajag.12332.
  7. Department of Health. National Aboriginal and Torres Strait Islander Health Plan 2021–2031. Australian Government, 2021 [Accessed 10 May 2024].
  8. Temple JB, Wilson T, Taylor A, Kelaher M, Eades S. Ageing of the Aboriginal and Torres Strait Islander population: Numerical, structural, timing and spatial aspects. Aust N Z J Public Health 2020;44(4):271–78. doi: 10.1111/1753-6405.13001.
  9. Coombes J, Lukaszyk C, Sherrington C, et al. First Nation Elders' perspectives on healthy ageing in NSW, Australia. Aust N Z J Public Health 2018;42(4):361–64. doi: 10.1111/1753-6405.12796 .
  10. Parrella A, Pearson O, Davy C, et al. Understanding culturally safe aged care from the perspectives of older Aboriginal Australians in rural and remote communities. Health Promot J Austr 2022;33(3):566–75. doi: 10.1002/hpja.541.
  11. Wettasinghe PM, Allan W, Garvey G, et al. Older Aboriginal Australians’ health concerns and preferences for healthy ageing programs. Int J Environ Res Public Health 2020;17(20):7390. doi: 10.3390/ijerph17207390.
  12. Quigley R, Russell SG, Larkins S, et al. Aging well for Indigenous peoples: A scoping review. Front Public Health 2022;10:780898. doi: 10.3389/fpubh.2022.780898.
  13. Yashadhana A, Howie A, Veber M, et al. Experiences and perceptions of ageing among older First Nations Australians: A rapid review. Australas J Ageing 2022;41(1):8–19. doi: 10.1111/ajag.13031.
  14. Davy C, Kite E, Aitken G, et al. What keeps you strong? A systematic review identifying how primary health-care and aged-care services can support the well-being of older Indigenous peoples. Australas J Ageing 2016;35(2):90-97. doi: 10.1111/ajag.12311 .
  15. Cox T, Mond J, Hoang H. ‘We’re also healers’: Elders leading the way in Aboriginal community healing. Aust J Prim Health 2022;28(4):283–88. doi: 10.1071/PY21289.
  16. Eades O, Toombs MR, Cinelli R, et al. The path to Eldership: Results from a contemporary Indigenous Australian community. Gerontologist 2022;62(4):607–15. doi: 10.1093/geront/gnab062.
  17. Human Rights and Equal Opportunity Commission. Bringing them home. Commonwealth of Australia, 1997 [Accessed 10 May 2024].
  18. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Stolen Generations aged 50 and over: Updated analysis for 2018–19. AIHW, 2021 [Accessed 10 May 2024].
  19. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander health performance framework – summary report 2024. AIHW, 2024 [Accessed 10 May 2024].
  20. Carman W, Ishida M, Trounson JS, et al. Epidemiology of physical–mental multimorbidity and its impact among Aboriginal and Torres Strait Islander in Australia: A cross-sectional analysis of a nationally representative sample. BMJ Open 2022;12(10):1–9. doi: 10.1136/bmjopen-2021-054999.
  21. Australian Institute of Health And Welfare (AIHW). Australian burden of disease study: Impact and causes of illness and death in Aboriginal and Torres Strat Islander people 2018. AIHW, 2022 [Accessed 10 May 2024].
  22. Australian and New Zealand Society for Geriatric Medicine (ANZSGM). Aboriginal and Torres Strait Islander Ageing in Australia. [Position Statement] ANZSGM, 2016 [Accessed 7 May 2023].
  23. Gilchrist L, Hyde Z, Petersen C, et al. Validation of the Good Spirit, Good Life quality-of-life tool for older Aboriginal Australians. Australas J Ageing 2023;42(2):302–10. doi: 10.1111/ajag.13128.




 

Advertising