Medical care of older persons in residential aged care facilities


The Silver Book
Depression
☰ Table of contents


Depressive disorders are common and disabling, particularly among older people who live in residential aged care or who have a comorbid illness.135 Prevalence estimates vary depending on the methodology used and the definition of depression.136 An Australian survey estimated that 51% of high care residents and 30% of low care residents without cognitive impairment had major depression based on the Geriatric Depression Scale.137

Depression in residents has been associated with recent bereavement, physical illness, cultural factors, quality of the home environment, existence of depression before admission, and the ways in which depression is treated.138

Depressive disorders include major and minor depression. Diagnostic criteria for major depression are shown in Table 8. Residents with minor depression (depressive symptoms without fulfilling DSM-IV criteria for major depression) may be just as distressed and functionally disabled by their symptoms as those with major depression.139

 

Table 8. DSM-IV criteria for major depression 140

DSM-IV criteria for major depression are five or more of the following symptoms persisting over a 2 week period causing clinically important distress or impairing work, social or personal functioning (with depressed mood or decreased interest or pleasure as one of the five):

  • Depressed mood most of the day, occurring most days(subjective or observed)
  • Markedly diminished interest or pleasure most of the day, nearly every day
  • Significant weight or appetite change
  • Insomnia or hypersomnia
  • Psychomotor agitation or retardation (observable by others)
  • Fatigue or loss of energy
  • Feelings of worthlessness or inappropriate guilt
  • Diminished ability to concentrate or make decisions
  • Recurring thoughts of death or suicide plans

 

Older people may have a recurrence of early onset depressive symptoms, or present with depression for the first time later in life (over 50 years of age). Early onset depressive disorders are likely to be associated with genetic risk and cognitive vulnerability to depression, and have an increased risk of developing coronary and cerebrovascular disease. Late onset depressive disorders are often associated with pre-existing physical illness, particularly cerebrovascular disease (eg. vascular depression and poststroke depression), heart disease, diabetes, cancer, Parkinson disease, dementia and cognitive impairment.141, 142 Depression may also occur in residents receiving palliative care.143

Vascular depression is characterised by a lack of family history of depression, subcortical neurological dysfunction, cognitive impairment and psychomotor change. Patients with vascular depression may later develop vascular dementia.144

Poststroke depression develops over months, with peak prevalence between 3-24 months, and is associated with poor functional and psychosocial outcome. Predictive factors are aphasia 3-12 months after stroke, older age, limited social supports and a previous history of psychiatric problems. It usually remits after 1-2 years, but some cases persist up to 3 years following stroke.145

Depression in residents may be unrecognised and untreated as older people may not report symptoms or may attribute symptoms to ageing or physical causes. Also, symptoms are more likely to be somatic or atypical.

 

Assessment


Assessment involves obtaining a history from residents and their relatives, the use of depression assessment scales and cognitive testing, physical examination, and investigations. The purpose of assessment is to:

  • confirm diagnosis and the severity of depression
  • differentiate depression from dementia and delirium
  • identify reversible causes
  • identify other conditions that may contribute to depression or be aggravated by depression assess the risk of self harm.

Clinical features of depression in older patients include:146

  • psychological-fluctuating depressed mood, loss of interest in activities, loss of motivation, irritability
  • somatic-loss of energy, fatigue, headache, pain and palpitations
  • cognitive-forgetfulness, poor concentration, psychomotor slowing
  • behavioural-social withdrawal, reduction in activity, disinhibition.

Patients with severe depression may also exhibit cognitive dysfunction, psychotic symptoms and melancholia. Symptoms of depression may be due to an underlying medical condition or cognitive impairment rather than an underlying mood disorder. Differential diagnoses include dementia, delirium, side effects of medications, sepsis and hypothermia.147

Table 6 (see Dementia) compares the clinical features of depression with dementia and delirium. Cognitive testing (eg. using the MMSE) can help differentiate between dementia and depression. There are several depression assessment tests available that have been validated in older populations. The Geriatric Depression Scale (see Tool 5) and the Cornell Scale for Depression in Dementia (see Tool 6) are recommended.148 The Geriatric Depression Scale is suitable for detecting major depression in older people without dementia. The Cornell Scale is designed for the assessment of depression in older people with dementia who can at least communicate basic needs. The Beck Depression Scale is recommended for patients poststroke, as it has low reliance on somatic symptoms and memory.149

Review medications to identify those with potential depressive effects(eg. anticonvulsants,acitretin, corticosteroids or progesterone). Investigations can help identify reversible causes of depression including vitamin B12 deficiency, hypothyroidism, delirium or sepsis.150 Look for conditions that could contribute to depression or affect treatment (eg. chronic insomnia, pain, incontinence, alcoholism, stroke, recent myocardial infarction, dementia, Parkinson disease). Neurological imaging may help assess dementia and cerebrovascular disease. Assess whether the patient is at risk of self harm (eg. by using the guide to assessment of suicide risk in the Psychotropic therapeutic guidelines).151

 

Management


Most older patients with depression will respond to treatment, with improvement in function and wellbeing. Overall, the prognosis for late onset depression is similar to that for younger patients.152

Treatment of depressive symptoms involves a combination of nonmedication therapies (eg. patient education, behavioural strategies, psychotherapy) and antidepressant medication.

Management also includes the treatment of reversible causes, change in medications or situations that are contributing to the depression, adequate treatment of associated medical conditions, and reduction of self harm risk.

Monitor progress regularly, and consider specialist referral for patients:153

  • with severe, melancholic or psychotic depression
  • who fail to respond to treatment
  • who are at significant risk of self harm
  • where the diagnosis is unclear
  • where specialist treatments are required, eg. electroconvulsive therapy.

 

Nonmedication therapy


Psychosocial management is the main treatment for mild depression related to loss, and provides additional support to antidepressant medication in major depression (eg. poststroke). Psychosocial management includes patient and family education, counselling, cognitive behavioural therapy, interpersonal therapy, re-establishment of sleep pattern, addressing functional difficulties, increasing social participation, diet, and regular exercise.154 Exercise is effective in relieving symptoms in mild to moderate depression, improving mobility, and reducing risks for vascular disease and falls. Exercise can involve a daily walk or resistance training.155

 

Medication


Antidepressants are effective in treating major depression, however there is limited evidence for their effectiveness in minor depression.156 Clinical trials demonstrate similar efficacy across the major medication classes of antidepressants for major depression. Combinations have not been shown to be more effective than monotherapy, and have a significant risk of serious adverse effects. When choosing medications, consider the patient`s history and previous response to antidepressants, adverse effect profiles, and the potential for medication interactions with current medications.157 Refer to guidelines for details of antidepressants, dosage regimens, adverse effects, interactions and discontinuation.158

The selective serotonin reuptake inhibitors (SSRIs) are first line antidepressants in the elderly as they have a safe side effect profile, a relatively quick onset of action of 7-10 days, and good anti-anxiolytic effects. Maximum benefit may take 6 weeks and treatment should be continued for at least 6 months. Most patients who have a relapse will respond to reinstated treatment. Monitor regularly for benefits and adverse effects, including falls and common effects of specific classes of medications.159 Adjunctive therapies with antipsychotics and electroconvulsive therapy are sometimes indicated for patients with severe depression.

  1. Flicker L. Clinical issues in aged care, managing the interface between acute, sub-acute, community and residential care. Aust Health Rev 2002;25:136-9.
  2. Lewis G, Pegram R. Residential aged care and general practice. Workforce demographic trends 1984-2001. Med J Aust 2002;177:84-6.
  3. Gray L, Woodward M, Scholes R, Fonda D, Busby W. Geriatric medicine: a pocket book for doctors, nurses, other health professionals and students. 2nd ed. Melbourne: Ausmed Publications, 2000.
  4. Aged Care Association Australia (ANHECA). Aged care Australia: the future challenges. Canberra: ANHECA, 2004.
  5. Aged Care Standards Agency (ACSA). Accreditation guide for residential aged care services. Canberra: ACSA Ltd., 2001.
  6. Australian Institute of Health and Welfare (AIHW). Residential aged care services in Australia 2000-1. A statistical overview. Canberra: AIHW, 2002.
  7. Carers Australia. Submission to the House of Representatives Standing Committee on Ageing: inquiry into long term strategies to address the ageing of the Australian population, 2004.  [Accessed 19 April 2005].
  8. Johnson N, Iddon P, Pierce G. Outside looking in: a resource kit on carer friendly practices in aged care facilities. Carers Victoria, 2003.
  9. Flicker L, op. cit.
  10. National Aged Care Alliance (NACA). NACA issues paper. The aged care - health care interface, 2003. [Accessed 19 April 2005].
  11. Saliba D, Solomon D, Rubenstein L, Young R, Schnelle J, Roth C, Wegner N. Quality indicators for the management of medical conditions in nursing home residents. J Am Med Dir Assoc 2004;5:297-309.
  12. Australian Nursing and Midwifery Council (ANMC). ANMC national competency standards for the enrolled nurse. [Accessed 01 August 2005].
  13. Healy J, Richardson S. Who cares for the elders? What we can and can't know from existing data. Adelaide: National Institute of Labour Studies, Flinders University, 2003.
  14. Australian Pharmaceutical Advisory Council (APAC). Guidelines for medication management in residential aged care facilities. 3rd ed. Canberra: APAC, Commonwealth of Australia, 2002.
  15. Health Professional Council of Australia. Membership and member organisations, 2005.  [Accessed 23 May 2005].
  16. Whitehead C, Penhall R. Australian Society for Geriatric Medicine. Position statement no. 8. Geriatric Assessment and Community Practice, 2000.  [Accessed 19 April 2005].
  17. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op. cit.
  18. Care Australia. A guide to palliative care service development: a population based approach, 2005.  [Accessed 19 April 2005].
  19. Ruth D, Wong R, Haesler E. General Practice in residential aged care, partnerships for 'round the clock' medical care. Melbourne: North West Melbourne Division of General Practice, 2004.  [Accessed 22 April 2005].
  20. Ibid.
  21. The Royal Australian College of General Practitioners (RACGP). Standards for general practices. 2nd ed. Melbourne: RACGP, 2000.
  22. RACGP and Committee of Presidents of Medical Colleges. Handbook for the management of health information in private medical practice, 2002. [Accessed 19 April 2005].
  23. Dorevitch M, Davis S, Andrews G. Guide for assessing older people in hospitals. Prepared for the Care of Older Australians Working Group and Department of Health and aged Care, May 2005 (in press).
  24. Gray LC, Newbury JW. Health assessment of elderly patients. Aust Fam Physician 2004;33:795-7.
  25. Siggins Miller Consultants and School of Population Health, University of Queensland. Executive summary. In: A report to the Brisbane North Division of General Practice (BNDGP). The residential care project. Queensland: BNDGP, 2002. [Accessed 26 April 2005]
  26. Dorevitch M, Davis S, Andrews G, op. cit.
  27. National Health Medical Research Council (NHMRC). Communicating with patients: advice for medical practitioners. Canberra: Commonwealth of Australia, NHMRC, 2004.
  28. Reuban DB, Herr KA, Pacala JT, et al. Geriatrics at your fingertips: 2005, 7th ed. New York: The American Geriatrics Society, 2005. [Accessed 17 June 2005].
  29. Ibid.
  30. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op. cit.
  31. Dorevitch M, Davis S, Andrews G, op. cit.
  32. Ibid.
  33. World Health Organisation (WHO). International classification of functioning, disability and health. Geneva: WHO, 2001.
  34. Mahoney FI, Bethel D. Functional evaluation: the Bethel Index. Maryland State Med Journal 1965;14:56-61.
  35. Dorevitch M, Davis S, Andrews G, op. cit.
  36. Pierce G, Nankervis J. Putting carers in the picture: Improving the focus on carer needs in aged care assessment. Melbourne: Carers Association Victoria, 1998.
  37. Doka DJ. Grief, loss and care giving. In: Doka KJ, Davidson JD, editors. Caregiving and loss. Washington, DC: Hospice Foundation of America, 2001;215-30.
  38. Boss P. Ambiguous loss: learning to live with unresolved grief. London: Harvard University Press, 2000.
  39. Darzins P, Molloy DW, Strang D, editors. Who can decide? The six step capacity assessment process. Adelaide: Memory Australia Press, 2000.
  40. Ibid.
  41. Ibid.
  42. Reuban DB, Herr KA, Pacala JT, et al, op. cit.
  43. Maas ML, Reed D, Myonghwa P, et al. Outcomes of family involvement in care intervention for caregivers of individuals with dementia nursing research. Nurs Res 2004;53:76-86.
  44. O'Shea M. An unrecognised grief: loss and grief issues for carers - a workers guide. Melbourne: Carers Association Victoria, 2001.
  45. Payda C, Draper B, Luscombe G, Erlich F, Maharja J. Stress in carers of the elderly - a controlled study of patients attending a Sydney medical practice. Aust Fam Physician 1999;28:233-7.
  46. Steinberg MA, Cartwright CM, Najman JM, MacDonald SM, Williams GM. Healthy ageing, health dying: community and health professional perspectives on end of life decision making: report to the Research and Development Grant Advisory Committee (RADGAC) of the Department of Human Services and Health. University of Queensland Department of Social and Preventive Medicine, February 1996.
  47. Cartwright CM, Parker MH. Advance care planning and end of life decision making. Aust Fam Physician 2004;33:815-9.
  48. Australian Medical Association (AMA) Committee on Care of Older People. Making decisions for later life: the medical profession's role. Working paper. AMA 2002.
  49. Ruth D, Wong R, Haesler E. General Practice in residential aged care: clinical information sheet: Advance care planning to improve end of life care, in Residential Aged Care Kit. Melbourne: North West Melbourne Division of General Practice, 2004. [Accessed 19 April 2005].
  50. Cartwright CM, Parker MH, op. cit.
  51. 51. World Health Organisation (WHO). National cancer control programmes: policies and managerial guidelines, 2nd ed. Geneva: WHO, 2002.
  52. Australian Government Department of Health and Ageing. Guidelines for a palliative approach in residential aged care. Canberra: Rural Health and Palliative Care Branch, Australian Government Department of Health and Ageing, 2004.  [Accessed 10 May 2005].
  53. WHO. National cancer control programmes: policies and managerial guidelines, op. cit.
  54. Rousseau P. Spirituality and the dying patient. J Clin Oncol 2003;21(9 Suppl):54-6.
  55. Murray SA, Kendall M, Boyd K, Sheikh, A. Illness trajectories and palliative care. BMJ 2005;330:1007-11.
  56. Australian Government Department of Health and Ageing 2004. Guidelines for a Palliative Approach in Residential Aged Care, op. cit.
  57. Taylor A, Box M. Palliative Care Australia: multicultural palliative care guidelines, 1999. Accessed 31 May 2005].
  58. Writing Group for Therapeutic Guidelines: Palliative Care. Therapeutic Guidelines: Palliative Care, version 1. Melbourne: Therapeutic Guidelines Ltd, 2001.
  59. Jones J, Willis D. In search of a good death: what is a good death? BMJ 2003;327:224.
  60. Age Health and Care Study Group. The future of health and care of older people: the best is yet to come. London: Age Concern, 1999.
  61. Ellershaw J, Wilkinson S, editors. Care of the dying - a pathway to excellence. New York: Oxford University Press, 2003.
  62. Ibid.
  63. Liverpool Care Pathway, 2005. [Accessed 10 May 2005].
  64. The RACGP. Clinical audit: what is a clinical audit? 2002. [Accessed 10 May 2005].
  65. ACSA, op. cit.
  66. Liverpool Care Pathway project. Beacon resource pack September 2002 - August 2003. [Accessed 10 May 2005].
  67. Australian Pharmaceutical Advisory Council (APAC), op. cit.
  68. Australian Medicines Handbook. Australian Medicines Handbook: medication choice companion: aged care. Adelaide: Australian Medicine Handbook, 2003.
  69. Ibid.
  70. Wagerty D, Brickley R. American Medical Directors Association and American Society of Consultant Pharmacists joint position statement on the Beers List of Potentially Inappropriate Medications in Older Adults, 2005.  [Accessed 26 April 2005].
  71. Australian Medicines Handbook, op. cit.
  72. Swagerty D, Brickley R, op. cit.
  73. APAC. APAC national guidelines to achieve the continuum of quality use of medicines between hospital and community. Canberra: APAC, Commonwealth of Australia, 1998.
  74. Pharmaceutical Society of Australia (PSA). Professional practice standards. Pharmacy services to residential care facilities, in Australia Pharmaceutical Formulary and Handbook. 19th ed. Canberra: PSA, 2004.
  75. Brown TM, Boyle MF. Clinical review ABC of psychological medicine: delirium. BMJ 2002;325:644-7.
  76. Writing Group for Therapeutic Guidelines: Psychotropic. Therapeutic Guidelines: Psychotropic, version 5. Melbourne: Therapeutic Guidelines Limited, 2003.
  77. Ibid.
  78. Australian Medicines Handbook, op. cit.
  79. Innouye SK, Charpentier PA. Precipitating factors for delirium in hospitalised elderly persons: predictive model and interrelationship with baseline vulnerability. JAMA 1996;275:852-7.
  80. Ibid.
  81. Writing Group for Therapeutic Guidelines: Psychotropic, op. cit.
  82. Ibid.
  83. Australian Medicines Handbook, op. cit.
  84. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op cit.
  85. Brodaty H, Draper BM, Low LF. Behavioural and psychological symptoms of dementia: a seven tiered model of service delivery. Med J Aust 2003;178:231-4. [Accessed 29 April 2005].
  86. Alzheimer's Australia and Access Economics. Dementia estimates and projections: Australian states and territories. Report by Access Economics for Alzheimer's Australia, 2005.  [Accessed 29 April 2005].
  87. Scherer S. Getting ACROSS Dementia: A dementia management resource for general practice. Melbourne: Southcity GP Services and Alzheimer's Association Victoria, 2003.
  88. Bridges-Webb C, Wolk J. Care of patients with dementia in general practice guidelines. Sydney: The Royal Australian College of General Practitioners and NSW Health, 2003.  [Accessed 29 April 2005].
  89. Ibid.
  90. Pond D, Brodaty H. Diagnosis and management of dementia in general practice. Aust Fam Physician 2004;33:789-93.
  91. Folstein MF, Folstein S, McHugh PR. Mini-Mental State a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-98.
  92. Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing 1972;1:233-8.
  93. Dorevitch M, Davis S, Andrews G, op. cit.
  94. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op. cit
  95. Australian Medicines Handbook, op. cit.
  96. Scott E, Pesiah C, Hickie I, Ricci C, Davenport T. A depression management program for older patients and their general practitioners. Melbourne: SPHERE: A national mental health project, 1995. 
  97. Scott E, Pesiah C, Hickie I, Ricci C, Davenport T, op. cit.
  98. Juby A, Tench S, Baker V. The value of clock drawing in identifying executive cognitive dysfunction in people with a normal Mini-Mental State Examination score. CMAJ 2002;167:859-64.
  99. Bridges-Webb C, Wolk J, op. cit.
  100. Ibid.
  101. Scherer S, op. cit.
  102. Bridges-Webb C, Wolk J, op. cit.
  103. Kane RL, Ouslander JG, Abrass IB. Essentials of clinical geriatrics. 4th ed. New York: McGraw-Hill, 1999.
  104. Maas ML, Reed D, Myonghwa P, et al, op. cit.
  105. Rosen J, Mittal V, Mulsant BH, Degenholsz H, Castle N, Fox D. Educating the families of nursing home residents: a pilot study using a computer-based system. J Am Med Dir Assoc 2003;4:128-34.
  106. Scherer S, op. cit.
  107. Van Doorn C, Gruber-Baldini AL, Zimmerman S, et al. Dementia as a risk factor for falls and fall injuries among nursing home residents. J Am Geriatr Soc 2003;51:1213-8.
  108. Ouslander JG, Simmons S, Schnelle J, Uman G, Fingold S. Effects of prompted voiding on fecal continence among nursing home residents. J Am Geriatr Soc 1996;44:424-8.
  109. Ostaszkiewicz J, Johnston L, Roe B. Timed voiding for the management of urinary incontinence in adults (Cochrane Review). In: The Cochrane Library, Issue 1, 2004. Chichester: Wiley.
  110. Scherer S, op. cit.
  111. Brodaty H, Draper BM, Low LF, op. cit.
  112. National Dementia Behaviour Advisory Service (Alzheimer's Australia). ReBOC: reducing behaviours of concern: a hands on guide. Canberra: Australian Government Department of Health and Ageing, 2003.
  113. Popplewell P, Phillips P. Is it dementia? Which one? Aust Fam Physician 2002;31:319-21.
  114. National Prescribing Service. Galantamine (Reminyl) prolonged release capsules for dementia in Alzheimer's disease. NPS RADAR Review, December 2004. [Accessed 16 May 2005].
  115. Neal M, Briggs M. Validation therapy for dementia (Cochrane Review). In: The Cochrane Library, Issue 3, 2003. Chichester: Wiley.
  116. Australian Government Department of Health and Ageing. Decision making tool: responding to issues of restraint in aged care. Canberra: Australian Government Department of Health and Ageing, 2004.  [Accessed 10 May 2005].
  117. Writing Group for Therapeutic Guidelines: Psychotropic, op. cit.
  118. Scott E, Pesiah C, Hickie I, Ricci C, Davenport T, op. cit.
  119. National Prescribing Service. Galantamine (Reminyl) prolonged release capsules for dementia in Alzheimer's disease, op. cit.
  120. Writing Group for Therapeutic Guidelines: Psychotropic, op. cit.
  121. Scott E, Pesiah C, Hickie I, Ricci C, Davenport T, op. cit.
  122. Australian Medicines Handbook, op. cit, 5-8.
  123. Writing Group for Therapeutic Guidelines: Psychotropic, op. cit.
  124. Ibid.
  125. Brodaty H, Draper BM, Low LF, op. cit.
  126. Australian Medicines Handbook, op. cit, 5-8.
  127. Scherer S, op. cit.
  128. Writing Group for Therapeutic Guidelines: Psychotropic, op. cit.
  129. Australian Medicines Handbook, op. cit, p.5-8.
  130. Writing Group for Therapeutic Guidelines: Psychotropic, op. cit.
  131. National Prescribing Service. Resperidone (Risperdal) for behavioural disturbances in dementia. NPS RADAR Review, April 2005.   [Accessed 16 May 2005].
  132. Ibid.
  133. Australian Medicines Handbook, op. cit, 5-8.
  134. Ibid.
  135. Katona CLE, Livingstone G. Functional psychiatric illness in old age. In: Tallis RC, Fillit HM, editors. Brocklehurst''s Textbook of Geriatric Medicine and Gerontology, 6th ed. London: Churchill Livingstone, 2002.
  136. Teresi J, Holmes D, Ramirez M, Eimicke J. Prevalence of depression and depression recognition in nursing homes. Soc Psychiatry, Psychiatr Epidemiol 2001;36:613-20.
  137. Fleming R, editor. Challenge depression: a manual to help staff identify and reduce depression in aged care facilities. Sydney: The Hammond Care Group, 2001.
  138. Fleming R, op. cit.
  139. Snowdon J. Late-life depression: what can be done? Aust Prescr 2001;24:65-7.
  140. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-IV). 4th ed. Washington DC: American Psychiatric Association Press, 1994.
  141. Scott E, Pesiah C, Hickie I, Ricci C, Davenport T, op. cit.
  142. Fleming R, op. cit.
  143. Writing Group for Therapeutic Guidelines: Antibiotic, op. cit.
  144. Scott E, Pesiah C, Hickie I, Ricci C, Davenport T, op. cit.
  145. Khan F. Poststroke depression. Aust Fam Physician 2004;33:831-4.
  146. Scott E, Pesiah C, Hickie I, Ricci C, Davenport T, op. cit.
  147. Khan F, op. cit.
  148. Fleming R, op. cit.
  149. Khan F, op. cit.
  150. Australian Medicines Handbook, op. cit.
  151. Writing Group for Therapeutic Guidelines: Psychotropic, op. cit.
  152. Snowdon J, op. cit.
  153. Scott E, Pesiah C, Hickie I, Ricci C, Davenport T, op. cit.
  154. Khan F, op. cit.
  155. Bird MJ, Parslow RA. Potential for community programs to prevent depression in older people. Med J Aust 2002;177:S107-110.
  156. Snowdon J, op. cit.
  157. Writing Group for Therapeutic Guidelines: Psychotropic, op. cit.
  158. Ibid.
  159. Australian Medicines Handbook, op. cit.
  160. Chan D, Phoon S, Yeoh E. Australian Society for Geriatric Medicine. Position statement no. 12. Dysphagia and aspiration in older people. Australas J Ageing 2004;23:198-202.  [Accessed 19 April 2005].
  161. Martino R, Pron G, Diamant N. Screening for oropharyngeal dysphagia in stroke: insufficient evidence for guidelines. Dysphagia 2000;15:19-30.
  162. Australian Medicines Handbook, op. cit.
  163. Chan D, Phoon S, Yeoh E, op. cit.
  164. Australian Medicines Handbook, op. cit.
  165. Jonsen AR, Siegler M, Winslade WJ. Clinical ethics: a practical approach to ethical decisions in clinical medicine, 5th ed. New York: McGraw-Hill, 2002.
  166. Scherer S, Jennings C, Smeaton M, Thompson P, Stein M. A multi-disciplinary practice guideline for hip fracture prevention. Australas J Ageing 2002 21:203-10.
  167. Australian Council for Safety and Quality in Health Care. Preventing falls and harm from falls. Best practice guidelines for Australian hospitals and residential aged care facilities. Canberra, ACT: Australian Government Department of Health and Ageing, 2005; in press.
  168. Ibid.
  169. Ibid.
  170. Ibid.
  171. Guideline for the prevention of falls in older persons. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. J Am Geriatr Soc 2001;49:664-72.
  172. Australian Council for Safety and Quality in Health Care, op. cit.
  173. Writing Group for Therapeutic Guidelines: Therapeutic Guidelines: endocrinology, version 4. Melbourne: Therapeutic Guidelines Limited, 2004.
  174. Australian Council for Safety and Quality in Health Care, op. cit.
  175. Fonda D. Improving management of urinary incontinence in geriatric centres and nursing homes. Victorian Geriatric Peer Review Group. Aust Clin Rev 1990;10:66-71.
  176. Gardner J. Promoting continence in nursing homes: a national project. Urol Nurs 1992;12(2):83.
  177. Reuban DB, Herr KA, Pacala JT, et al, op. cit.
  178. The RACGP (West Australian Research Unit). Managing incontinence in general practice. Clinical practice guidelines. Perth: RACGP, 2002.  [Accessed 6 June 2005].
  179. Australian Medicines Handbook, op. cit.
  180. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op. cit.
  181. Ibid.
  182. Australian Medicines Handbook, op. cit.
  183. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op. cit.
  184. Australian Medicines Handbook, op. cit.
  185. Ibid.
  186. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op. cit.
  187. Sapsford R. Physiotherapy for pelvic floor dysfunction in the aged care setting. In: Nitz JC, Hourigan SR, editors. Physiotherapy practice in residential aged care. Edinburgh: Butterworth Heinemann, 2004.
  188. The RACGP (West Australian Research Unit), op. cit.
  189. Kalantar JS, Howell S, Tally MJ. Prevalence of faecal incontinence and associated risk factors: an underdiagnosed problem in the Australian community? Med J Aust 2002;176:54-7.
  190. Reuban DB, Herr KA, Pacala JT, et al, op. cit.
  191. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op. cit.
  192. Australian Medicines Handbook, op. cit.
  193. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op. cit.
  194. Reuban DB, Herr KA, Pacala JT, et al, op. cit.
  195. Ibid.
  196. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op. cit.
  197. Kamm MA. Faecal incontinence: common and treatable Med J Aust 2002;176:47-8.
  198. The RACGP (West Australian Research Unit), op. cit.
  199. Australian Government Department of Health and Ageing. Infection control guidelines for the prevention of transmission of infectious diseases in the health care setting, 2004.  [Accessed 19 April 2005].
  200. Ibid.
  201. Writing Group for Therapeutic Guidelines: Antibiotic, op. cit.
  202. Australian Government Department of Health and Ageing. Infection control guidelines for the prevention of transmission of infectious diseases in the health care setting, op. cit.
  203. Writing Group for Therapeutic Guidelines: Antibiotic, op. cit.
  204. Australian Medicines Handbook, op. cit.
  205. National Health and Medical Research Council. The Australian immunisation handbook. 8th ed. Canberra: Commonwealth of Australia, 2003.
  206. Ruth D, Wong R, Haesler E. General practice in residential aged care: clinical information sheet: Urinary tract infections. In: Residential Aged Care Kit. Melbourne: North West Melbourne Division of General Practice, 2004. [Accessed 19 April 2005]
  207. Ibid.
  208. Australian Government Department of Health and Ageing. Guidelines for a palliative approach in residential aged care, op. cit.
  209. Ruth D, Wong R, Haesler E, op. cit.
  210. Mater Hospital (Oncology and Palliative Care Wards). Authorised opioid conversion chart. Brisbane: Mater Hospital, 2005.
  211. Writing Group for Therapeutic Guidelines: Analgesic: Therapeutic Guidelines: Analgesic, version 4. Melbourne: Therapeutic Guidelines Limited, 2002.
  212. Ibid.
  213. Joanna Briggs Institute. Pressure sores - part 1: prevention of pressure related damage. Best Practice 1997;1:1-6.  [Accessed 6 June 2005].
  214. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op. cit.
  215. Stacey MC. Preventing pressure ulcers [editorial]. Med J Aust 2004;180:316.
  216. Prentice JL, Stacey MC. Pressure ulcers: the case for improving prevention and management in Australian health care settings. Primary Intention 2001;9:111-20.
  217. Australian Wound Management Association. Clinical practice guidelines for prediction and prevention of pressure ulcers. Perth: Cambridge Media, 2001.
  218. Queensland Health. Pressure ulcer prevention and management resource guidelines. Brisbane: Queensland Health, 2004.  [Accessed 6 June 2005].
  219. Ibid.
  220. Stacey MC, op. cit.
  221. Norton D, Exton-Smith AN, McLaren R. An investigation of geriatric nursing problems in hospitals. London: Churchill Livingstone. National Corporation for Care of Old People, 1975.
  222. Bergstrom N. A clinical trial of the Braden Scale for predicting pressure score risk. Nurs Clin North Am 1987;22:417-28.
  223. Waterlow J. Pressure sores: a risk assessment card. Nurs Times 1985;81:49-55.
  224. Joanna Briggs Institute. Pressure sores - part 1: prevention of pressure related damage. Best Practice 1997;1:1-6. [Accessed 6 June 2005].
  225. Dorevitch M, Davis S, Andrews G, op. cit.
  226. Norton D, Exton-Smith AN, McLaren R, op. cit.
  227. Queensland Health, op. cit
  228. Australian Wound Management Association, op. cit.
  229. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op. cit.
  230. Ibid.
  231. Reuban DB, Herr KA, Pacala JT, et al, op. cit.
  232. Queensland Health, op. cit.
  233. Ibid.
  234. Ibid.
  235. Guy RJ, Di Natale R, Kelly HA, et al. Influenza outbreaks in aged-care facilities: staff vaccination and the emerging use of antiviral therapy. Med J Aust 2004;180:640-2.
  236. Australian Medicines Handbook, op. cit.
  237. Writing Group for Therapeutic Guidelines: Antibiotic, op. cit.
  238. Guy RJ et al., op. cit.
  239. Australian Medicines Handbook, op. cit.
  240. Ibid.
  241. National Health and Medical Research Council, op. cit.
  242. Writing Group for Therapeutic Guidelines: Antibiotic, op. cit.
  243. Ibid.
  244. Australian Medicines Handbook, op. cit.
  245. Ruth D, Wong R, Haesler E. General practice in residential aged care: clinical information sheet: Urinary Tract Infections, op. cit.
  246. Australian Medicines Handbook, op. cit, 5-8.
  247. Ruth D, Wong R, Haesler E. General practice in residential aged care: clinical information sheet: Urinary tract infections, op. cit.
  248. Ibid.
  249. Australian Medicines Handbook, op. cit, 5-8.
  250. Ruth D, Wong R, Haesler E. General practice in residential aged care: clinical information sheet: Urinary tract infections, op. cit.
  251. Australian Medicines Handbook, op. cit, 5-8.
  252. Writing Group for Therapeutic Guidelines: Antibiotic, op. cit.
  253. Australian Medicines Handbook, op. cit, 5-8.
  254. Ruth D, Wong R, Haesler E. General practice in residential aged care: clinical information sheet: Urinary tract infections, op. cit.
  255. Ibid.
  256. Writing Group for Therapeutic Guidelines: Antibiotic, op. cit.
  257. Australian Medicines Handbook, op. cit, 5-8.
  258. Ruth D, Wong R, Haesler E. General Practice in residential aged care, partnerships for 'round the clock' medical care, op. cit.
  259. Australian Government Department of Health and Ageing. Medicare Benefits Schedule, 2005. Available atwww7.health.gov.au/pubs/mbs/index.htm [Accessed 10 May 2005].
  260. Aged Care Standards Agency. Continuous improvement for residential aged care: an education package, 2001.  [Accessed 10 May 2005].
  261. NSW Health Department. Easy guide to clinical practice improvement. A guide for health care professionals, 2002. [Accessed 10 May 2005].
  262. Dorevitch M, Davis S, Andrews G, op. cit.
  263. Flicker l, Loguidice D, Carlin JB, Ames D. The predictive value of dementia screening in clinical populations. Int J Geriatric Psychiatry 1997;12:203-9.
  264. Dorevitch M, Davis S, Andrews G, op. cit.