Since commencing in December 2018, the Royal Commission into Aged Care Quality and Safety has highlighted extensive issues surrounding the quality and regulation of care in Australian residential aged care facilities.
As hearings for the commission continue around the nation, the public are being reminded that it is not only the physical wellbeing of aged care residents that need improving; it is also their mental health.
Research in 2017 from the Australian Institute of Health and Welfare found that 47 per cent of people living in permanent residential aged care have depression.
While that is a problem in itself, a clinical review of depression in older adults in 2011 by Joanna Rodda and Janet Carter for medical research journal BMJ found that depression in later life was associated with disability, increased mortality, and poorer outcomes from physical illness.
The review also found that older adults with depression were at increased risk of suicide.
This was backed by World Health Organisation (WHO) data published in 2014 that showed adults over 65 had one of the highest suicide rates of all age groups.
Dr Briony Jain is a leading expert in the epidemiology and prevention of suicide among nursing home residents.
Dr Jain conducted the first comprehensive Australian study of intentional deaths from suicide among nursing home residents as part of her PhD with the Department of Forensic Medicine at Monash University.
This research, which was published in 2018, examined 141 suicides among nursing home residents between 2000 and 2013, and found that more than half the residents who died from suicide had a diagnosis of depression.
“The important thing to note about the findings is that these were diagnosed cases, so a GP or psychiatrist had made that diagnosis,” Dr Jain said.
“Whereas there would have [potentially] been a lot of people who were perhaps exhibiting signs of depression and it hadn’t been diagnosed,” she said.
“[Depression] can be quite difficult to recognise because the symptoms can be quite similar to just getting older.”
“But then there’s some misconception that depression in old age is ‘normal’, that it’s quite normal to be sad… it’s a really complex issue.”
According to a report by the Australian Institute for Health and Welfare that focused on depression, there is a link between depression and suicide at all ages.
Dr Jain said in order to prevent suicide and improve the mental health of residents, it was necessary to first understand what was at the root of the problem in aged care.
“That’s everything that the royal commission are really struggling with at the moment and really struggling to figure out: ‘What is the problem?’” she said.
“I think what is going to come out of it and what most people in my field have been talking about for the last year, is understaffing is such a big issue.”
“We need more people to be able to care for the growing number of older people who need long term care.”
“And we need them to be better trained and better equipped to deal with the things they need to deal with.”
National mental health charity, SANE Australia, published a report on mental health care for older Australians in 2013, recommending mandatory mental health training for staff working in the aged care and community support sectors.
Meanwhile, Leading Age Services Australia (LASA) stated in their 2018 report on improving access to psychological services in residential care, that the majority of staff were personal care workers who did not have the training or skills to identify mental health issues.
Tia-Jade Lavin began working in aged care facilities on the Gold Coast as an Assistant in Nursing (AIN) when she was only 16, after completing a Certificate III in Healthcare.
Ms Lavin said she received limited training on mental health issues during her studies, and said she believed carers at all levels needed to be made aware of how to understand and respond to the mental health concerns of residents, and not just focus on their physical care.
“If I ever saw anything like [mental health issues] I was always just passing it up the ladder to the registered nurse,” Ms Lavin said.
“But it’s really all about the AINs noticing it, which means they really do need to be taught in that expertise.”
“I think that’s why a lot of the AINs feel they are underpaid, because you do walk into an aged care home, you spend half a day there, you will realise that AINs do run that place… AINs are everywhere with the residents, everywhere, constantly.”
As well as a diagnosis of depression, Dr Briony Jain’s research found more than half of the residents who had died of suicide had resided in the aged care facility for less than 12 months.
She explained that this highlighted another complexity in understanding suicide risks and mental health issues in aged care.
“With my research, we found that people living there for less than 12 months had a higher risk, and I think that might be contributory from that transition period, that they hadn’t really adjusted to nursing home life,” Dr Jain said.
Included in some of the coronial reports Dr Jain examined during her research were letters and notes from residents who had committed suicide.
While not published, the information contained in these notes gave insight into the factors that contributed to suicide for some residents.
“I could see what people were thinking at the time and a lot of it was ‘I just can’t live like this’, and they were used to being independent and all of a sudden [they were] not having any decisions for themselves and [having] things happening to them, and it was just a bit tough for them to take.”
Dr Jain said there were always multiple reasons for the suicide, not just a single reason.
“Something was going on with the family, plus they’d transitioned, or depression plus something else.”
“It’s always a combination of factors, it’s never just one thing you can point your finger at, which is why I think it’s really important for us to address some of the overarching issues with aged care,” she said.
NSW-based occupational therapist Erin Mulvihill regularly works with elderly patients in hospitals, and often has to assess whether they are fit to return home or if they need to be moved into care.
Ms Mulvihill said many of her patients had a difficult time entering nursing homes because of their perceptions of aged care facilities, and they struggled with mental health issues as a result.
“They [can] see it as a very confronting thing because of past experience, because they know other people who have died, and they see it as being kind of like one step before your funeral, and there’s no quality of life,” Ms Mulvihill said.
“I think sometimes it’s about educating people about the nursing home that they’re choosing and getting them to ask the questions about what they’re worried about,” she said.
“A lot of people feel like that’s all done without their involvement.”
“Getting them to ask those questions and know that it’s OK to choose things, and let them know they can even change between nursing homes if they’re not happy, can even be reassuring.”
In less than two months, the Royal Commission into Aged Care Quality and Safety will stop taking public submissions, with an interim report to be delivered by the end of October 2019.
It reinforces the urgent need to consider all aspects of aged care that need improving, including providing access to mental health services and supporting individuals who are transitioning into care.
Dr Jain said even though there were changes underway, these were important conversations that needed to continue in order to see real change.
“I think it’s all incremental; we’re talking more about aging issues and it’s because people are getting a bit more concerned and want a better quality of life, not only for their parents, but for themselves,” she said.
“A lot of people don’t want to talk about nursing homes because it’s depressing.
“And that’s the problem right there, if we don’t even want to talk about it because it’s depressing, why are we OK to put our older people in these facilities and not worry about their quality of care?”