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It is this last statistic which best represents the growing need for services for older people, as people aged over 80 years are disproportionate consumers of the major support systems — 68% of people in nursing homes are aged over 80 years.¹ Despite the use of federal targets for residential care based on population ratios and increased funding for home support services, there is pressure on all parts of the aged care system, including residential care.² What measures can the Australian community initiate to both increase the quality of life for older Australians and decrease the expenditure requirement for the more costly items of care?

Over the past 15 years the policy of the State and Federal governments has been to provide services to allow individuals to remain in their own homes for as long as possible. This policy of support for home care has intrinsic appeal and there have been substantial real increases in funding. Federal expenditure on Home and Community Care (HACC) has increased in inflation-adjusted terms from 561 million dollars in 1991-92 to 799 million dollars in 1997-98.¹ In addition, the Federal Government spent $2.8 billion dollars, or approximately 0.5% of GDP, on residential care in 1997-98.¹

So, if expenditure has grown, why do we have increasing numbers of older people in acute hospital beds awaiting residential care placement, and long waiting times for community care?² Answers to these questions lie in the interplay of the total health and welfare systems. Over the past 15 years there has been a relative decrease in the number of beds in the nursing home sector and a small increase in hostel beds, which is almost entirely consumed by people who have been assessed as requiring high-level care.² Also, because the provision of residential care is based on the number of people aged over 70 years, and an increasing proportion of these will be aged over 80 years, there is an expected decrease in the number of beds relative to the number of people who need them the most. More insidiously, State governments have effectively capped their expenditure on assessment and rehabilitation services, as well as opting out of the residential care sector (the public nursing home sector frequently supplied special-needs residential care as well as slow-stream rehabilitation beds). Thus, the availability of assessment, rehabilitation and specialised residential care beds has decreased at a time when it is needed most.

It has been suggested that there should be more emphasis on home-based rehabilitation, as a broad range of rehabilitation services in the home can be streamlined and individualised, based on the individual's abilities and condition, and using the family to supplement care.^3,4 Rehabilitation attempts to help individuals regain freedom of movement and functional independence, and to reintegrate as fully as possible into community life. Although different settings for individuals will be appropriate at certain stages, the development of community-based rehabilitation by multidisciplinary teams can be effective in promoting the independence of patients and reducing their demand for other community services.⁵

Home rehabilitation programs can emphasise a task-and-context-oriented approach, educate patients, and apply information in practical situations to solve problems in the home. These programs are usually short-term, providing interventions to individuals who are experiencing or at risk of some degree of functional decline.

In this issue of the Journal, Wang and colleagues identify factors that are associated with an increased risk for needing nursing home care in the future.⁶ With each five-year increase in age there is a doubling of the likelihood of admission to nursing home care. This risk reaches a peak of 35% in the group aged 85 and over. The doubling of risk every five years is similar to the changes in incidence of a number of important conditions known to produce high rates of disability, such as dementia and hip fracture. Although dementia is the commonest condition found in people in residential care,⁷ cognition was not measured at baseline in the study of Wang et al. However, other disabilities, such as special sensory impairment, arthritis and walking difficulty, were strongly associated with subsequent nursing home admission. As Wang et al point out, these factors are often modifiable, and older people may benefit from community-based rehabilitation programs to improve mobility and independence. Falls may contribute to the need for nursing home admissions, and research has suggested that most are potentially preventable,⁸ although the effects of intervention are not as dramatic as might be expected.⁹ Falls-prevention programs with a multi-intervention approach, either clinic-based or through home visits, are effective in meeting the needs of a large number of older people at risk of falls.⁹ Specific other problems associated with nursing home placement, such as undernutrition and incontinence, are also potentially remediable.

Directing further funds to a plethora of HACC agencies providing untargeted maintenance services for some of the personal-care needs of frail older people is unlikely to markedly decrease the need for residential care. Revolutionary changes in either information technology¹⁰ or biotechnology¹¹ may produce dramatic benefits, although this can only be speculative at this stage. For now, a focus on targeted assessment and rehabilitation strategies may both give older people a better quality of life and reduce the demand for residential care. An example of this would be providing home-based physiotherapy to an older person who was experiencing decreased mobility and falls, rather than just delivering meals and providing home help. Community rehabilitation teams that work with the acute care sector, HACC services and primary care offer some prospect of improvement in services for older people.

R Arthur Criddle
Physician, Department of Geriatric Services
Sir Charles Gairdner Hospital, Nedlands, WA

Leon Flicker
Professor, Department of Medicine — Geriatric Medicine
University of Western Australia, Royal Perth Hospital, Perth, WA

Acknowledgements: The authors would like to thank Caroline Reberger for helpful comments and criticism.

1. Gibson D, Benham C, Racic L, editors. Older Australia at a glance. Canberra: Australian Institute of Health and Welfare, 1999 (Catalogue no. AGE 12).
2. Flicker L. Health care for older people in residential care — who cares? Med J Aust 2000; 173: 77-79.
3. Brocklehurst JC, Morris P, Andrews K, et al. Social effects of stroke. Soc Sci Med 1981; 15: 35-39.
4. Young J. Rehabilitation and older people. BMJ 1996; 313: 677-681.
5. Evans RL, Connis RT, Hendricks RD, Haselkorn JK. Multidisciplinary rehabilitation versus medical care: a meta-analysis. Soc Sci Med 1995; 40: 1699-1706.
6. Wang JJ, Mitchell P, Smith W, et al. Incidence of nursing home placement in a defined community. Med J Aust 2001; 174: 271-275.
7. Rosewarne R, Opie J, Bruce A, et al. Care needs of people with dementia and challenging behaviour living in residential facilities. Canberra: AGPS, 1997.
8. Clemson L, Cumming RG, Roland M. Case-control study of hazards in the home and risk of falls and hip fractures. Age Ageing 1996; 25: 97-101.
9. Gillespie LD, Gillespie WJ, Cumming R, et al. Interventions for preventing falls in the elderly (Cochrane Review). In: The Cochrane Library, Issue 4. Oxford: Update Software, 2000.
10. Celler BG, Lovell NH, Chan DKY. The potential impact of home telecare on clinical practice. Med J Aust 1999; 171: 518-521.
11. Schenk D, Barbour R, Dunn W, et al. Immunization with amyloid-beta attenuates Alzheimer-disease-like pathology in the PDAPP mouse. Nature 1999; 400: 173-177.

©MJA 2001
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