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RACGP aged care clinical guide (Silver Book)

Silver Book - Part B

Supporting independent living in older people

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Last revised: 13 Jan 2020

  • ‘Healthy ageing’ often includes the need for independence, autonomy, purposeful and meaningful existence, and the opportunity to participate and contribute in the community.
  • Achieving and maintaining independence requires a multidisciplinary approach that not only focuses on the physical and mental health statuses of the older person, but also on social, cultural and economic factors.
  • The independence of older people often diminishes because they are no longer able to care for themselves, often after an illness or injury.
  • General practitioners (GPs) can help promote the wellbeing and independence of older people by facilitating them to stay in their own homes for longer or assisting them in RACFs.
  • GPs should be aware of the older person’s emotional state, and recognise and acknowledge that the loss of independence can be hard for some to accept.
  • Respite care gives both the older person and their carers relief for a period of time.
  • The loss of function or ability to perform certain tasks does not necessarily mean that the patient has lost all function to perform all tasks.
  • Instead of focusing and highlighting the patient’s decline and what they cannot do, the focus should be
    re-aligned to highlight how the patient can participate in functional and social activities.
  • Avoid the use of generalised and stigmatising statements.

The common concepts of ‘healthy ageing’ often include the need for independence, autonomy, purposeful and meaningful existence, and the opportunity to participate and contribute in the community.1,2 Achieving and maintaining independence requires a multidisciplinary approach that not only focuses on the physical and mental health statuses of the older person, but also on social, cultural and economic factors.

The independence of older people often diminishes because they are no longer able to care for themselves, often after an illness or injury (eg fall). The level of independence lost can differ significantly, ranging from requiring help to hang the washing, to high-level dementia care in a residential aged care facility (RACF). As such, there is no ‘one size fits all’ model for supporting independence among older people. As advocated throughout the Silver Book, the most effective approach for achieving and maintaining independence is one that is person-centred, which focuses on the individual older person’s wants and needs.

General practitioners (GPs) can help promote the wellbeing and independence of older people by facilitating them to stay in their own homes for longer or assisting them in RACFs, or somewhere in between. GPs need to recognise the older person’s right to make choices and decisions; for example, recognising their right to take risks or lead a lifestyle that may be unhealthy.

Choosing between growing old in their own home and moving into an RACF is a complex decision for older people.3 Many older people would prefer to stay in their homes as they age; 4,5 however, physical disabilities and cognitive impairment may force them to face a housing decision. The advice that GPs give to the older person and their families can be an important deciding factor on whether the older person moves into an RACF.

Older people who choose to stay in their own home but require assistance to live independently can access support from the government through the Commonwealth Home Support Programme (CHSP) for basic assistance or the Home Care Packages Program (HCPP) for those who require greater assistance. However, it is important to note that the government does not always cover the full cost of the services required. Additionally, depending on the older person’s income, an out-of-pocket contribution may be required. Local councils and some charities may also offer in-home services (eg transport, social support, home maintenance) to older people.

In Australia, there are currently around 2700 RACFs in operation that cater to the different needs and interests of older people (eg specific cultural and linguistic group, dementia care). RACFs that are government funded must provide a certain level of service to receive accreditation, including:

  • continuing availability of staff to provide emergency assistance
  • assistance with personal care (eg toileting, showering, eating, dressing)
  • support with mobility and communication
  • help to access specialised therapy services or a health practitioner service
  • support for people with cognitive impairment (eg dementia).

However, the range of social and recreational activities available for older people in RACFs can vary significantly, and is significantly dependent on the provider. Out-of-pocket expenses above general fees may be required for access to these activities.

The complexities of housing decision often faced by older people are illustrated in Figure 1.

Factors influencing the housing decision of older adults

Figure 1.

Factors influencing the housing decision of older adults, classified by the meaning and experience of home dimensions
 
Reproduced with permission from Roy N, Dube R, Despres C, Freitas A, Legare F. Choosing between staying at home or moving: A systematic review of factors influencing housing decisions among frail older adults. PLoS One 2018;13(1):e0189266.


Respite care

Providing support and care for an older person is valuable and rewarding; however, it can be easy for the carer to forget about their own health and wellbeing (refer to Part B. Families and carers). Providing carers with a break from the caring role can help to relieve stress, which will undoubtedly benefit the older person too. Respite care gives both the older person and their carers relief for a period of time (eg a few hours, days or weeks).

There is never a ‘best time’ for respite care, and it is important to emphasise that carers should not wait until they are too overwhelmed with the responsibilities of caring before considering respite care. It is vital that the carer look after themselves so they can continue to provide care for the older person.

There are several types of respite care available to older people and their carers:

  • In-home respite – the care worker comes to the older person’s home to provide care (requires assessment by the Regional Assessment Service [RAS]).
  • Overnight or weekend respite – the care worker comes to the older person’s home to stay overnight or several days.
  • Community access respite – the care worker assists the older person to attend social activities for a couple of hours during the day.
  • Residential respite – the older person moves into an RACF for a short stay (requires assessment by the Aged Care Assessment Team [ACAT]).
  • Emergency respite – Commonwealth Respite and Carelink Centre
    • 1800 052 222 during business hours
    • 1800 059 059 for emergency respite after hours.

GPs should be aware of the older person’s emotional state, and recognise and acknowledge that the loss of independence can be hard for some to accept. The focus should be on restorative care (including improving independence and function in addition to social function) and reablement (supporting the person to maximise their independence).6

The loss of function or ability to perform certain tasks does not necessarily mean that the patient has lost all function to perform all tasks. For example, just because a patient is physically incapacitated does not mean that they do not have an opinion or are unable to make their own decisions.

Instead of focusing and highlighting the patient’s decline and what they cannot do, the focus should be re-aligned to highlight how the patient can participate in functional and social activities. Engage in strategies and establish a management plan that will help the patient regain physical and cognitive functions. This may include participation in activities in an RACF, or accessing support for domestic duties at home.

GPs can play an important role in supporting older people’s independence during consultations and as an advocate for older people’s independence in the public arena. Examples of advice to give older people for supporting healthy ageing during general practice or RACF consultations are listed in Box 1.

Box 1. Advice for supporting healthy ageing during the consultation7

  • Most older people are aware of lifestyle changes that can benefit their health, but require encouragement to adopt and motivation to sustain them – the GP has a key role in this regard.
  • There may be technical or health literacy reasons for not making lifestyle changes. To address these, consider referring the older person to an allied health professional or other medical specialist (eg exercise physiologist, psychologist, dentist, dietitian).
  • Volunteering and special interest groups can ameliorate loneliness and social isolation and promote physical, mental and social health. Older people can be encouraged to get involved with social groups in their community and/or online.
  • Local councils can provide information on recreational activities, run by groups such as COTA, National Seniors, Probus, U3A and Active Ageing Australia.
  • Access (eg cost, transport, waiting lists) is a common concern for older people. The GP cannot be expected to know about all services available in the community, but should be aware of a selection of accessible services.
Adapted with permission from Sims J. Healthy ageing. Aust Fam Physician 2017;46(1–2):26–29.[Accessed 26 June 2019].
 

Avoid the use of generalised and stigmatising statements (eg ‘You’re getting old now, you can’t do that anymore’, ‘You can’t do it alone, you need to wait for help’). Instead, focus on language that can help the older person retain dignity and choice, and that enables a sense of achievement, albeit limited (eg ‘What do you think about …’, ‘How about we try …’).

  1. Rowe J, Kahn RL. Human aging: Usual and successful. Science 1987;48(237):143–49.
  2. Baltes P. On the incomplete architecture of human ontogeny. Selection, optimization, and compensation as foundation of developmental theory. Am Psychol 1997;52(4):366–80.
  3. Roy N, Dube R, Despres C, Freitas A, Legare F. Choosing between staying at home or moving: A systematic review of factors influencing housing decisions among frail older adults. PLoS One 2018;13(1):e0189266.
  4. Caron CD, Ducharme F, Griffith J. Deciding on institutionalization for a relative with dementia: The most difficult decision for caregivers. Canadian Journal of Aging 2006;25(2):193–205.
  5. Canadian Institute for Health Information. Health care in Canada, 2011: A focus on seniors and aging. Ottawa: CIHI, 2011.
  6. O’Connor CM, Poulos CJ, Gresham M, Poulos RG. Supporting independence and function in people living with dementia, A technical guide to the evidence supporting reablement interventions. 2nd edn. Sydney: HammondCare, 2019. [Accessed 15 October 2019].
  7. Sims J. Healthy ageing. Aust Fam Physician 2017;46(1–2):26–29. [Accessed 26 June 2019].