LO: Understand the personal, family and social implications of
the frailties and illnesses of ageing
1. Reactions to separations and losses of life partner, home, friends,
independence
Australian studies have revealed that primary values of the elderly (over 65 yrs) were:
 The elderly persons own health
 The persons family relationships (in a narrow circle – children and
spouse/husband)
 Their economic security
So any changes or issues which affect these values have a great impact on the elderly. Added
to this the accumulation and gradual progression of multiple chronic illnesses contribute to
adverse reactions by the elderly.
Generally elderly persons are more vulnerable to physical and psychological stress.
Depression in particular is the most common psychological reaction to stressful life events of
the elderly. 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
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 (refer below).
 Increasing evidence that depression in the elderly commonly goes undiagnosed or
is not recognized by health care professionals as it is frequently dismissed as
simply ‘getting old’ or a normal part of the ageing process.
 Signs of depression in the elderly are:
 Depressed mood most of the day, occurring most days
 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
 Most older patients with depression will respond to treatment, with improvement
in function and wellbeing.
Other reactions that commonly occur in the elderly are:
 An increased sense of dissatisfaction at insufficient care and consideration (not
what they are used to) and there is increased worry about maintaining the status
they achieved in the family and community during the course of life.
 There may be intergenerational problems i.e. with their children and families thus
contribute to feelings of isolation and depression.
 Urbanisation and modernisation and the economic fluctuations may contribute to a
sense of devaluation of the elderly regarding his/her role and social status.
These problems often invoke feelings of insecurity, anxiety and inferiority
2. Fears of and resistance to displacement, relocation and institutional
placement.
The majority of the resistance to displacement and relocation to an aged care facility can be
derived from:
 Lack of understanding of what an aged care facility is and what they provide
 Sense of fear of an unknown/unfamiliar environment. This includes unfamiliar
surroundings and changes in diet and lifestyle habits.
 Loss of social interaction with family and friends. Fear of social isolation and
feelings of abandonment.
 Cost of relocation and institutional. This includes selling the family home or the
economic burden placed on the family to provide aged care facilities.
 Fear of being mistreated and neglected.
 Fear of institution being regimented thus a loss of their freedom of choice and the
routine they are used to.
3. Issues of autonomy, competence, self-determination related to dementing
and related illnesses; the distinction between autonomy and independence.
Autonomy: refers to the capability and right of patients to control the course of their own
medical treatment and participate in the treatment decision-making process.
 Patient autonomy does allow for health care providers to educate the patient but does not
allow the health care provider to make the decision for the patient.
 Older people are entitled to be treated in the same way as younger people and to be seen
as individuals with their own needs, preferences and life stories.
 Respect for autonomy may be challenged when the elderly person is moderately to
severely demented. Where the patients awareness of self, their belief and values system,
their own interests and their ability to think rationally are compromised.
 This brings up the issue of competence.
Competence: describes competence as a set of patient’s values and goals, the ability of the
patient to communicate and understand information, and the capacity to reason.
The patient must be able to:
 Comprehend information
 Repeat information
 Assess benefits v risks
 Communicate preference
 Justify preference
Competence is typically called into question when elderly patients refuse to consent to
recommended surgical procedures, medication, hospitalization and most commonly nursing
home placement.
A demented patient has a reduced capacity to make competent decisions regarding their
healthcare.
Care must be taken as doctors are held responsible for eliciting a judgment of competence
before proceeding with treatment yet it is difficult to determine competence as there are no
clear standards to determine patients' decision-making capabilities.
Self-determination: is defined as a free choice of one’s own acts without external
compulsion (in the case of the elderly patient it is the freedom of choice without compulsion
from a health care provider or relative).
 Similar concept to autonomy.
 Self determination can be at significant risk in the demented elderly patient.
Independence: is the ability to perform activities without requiring assistance from another
person.
 Not only refers to independence with decision making but also concerns with functional
aspects of life such as cooking, cleaning, getting dressed, mobility, transportation.
 The elderly value their independence highly and loss of independence has a significant
impact on physical and psychological health.
Although there are clearly limits to personal autonomy, especially when it comes to
vulnerable older people, physicians need to work with competent older patients and their
families to maximize patient safety and quality of life wherever the patient chooses to live.
4. Issues in and structures for substituted decision-making
Substituted decision making: when a patient is deemed incompetent and cannot make
decisions regarding his/her health status and medical intervention.
Determination of a patient’s capacity to make decisions is an important role of the doctor.
This may apply in one of three situations:
 consent for medical treatment (may be compromised in demented patients)
 Arranging enduring guardianship or giving an advance care directive.
 Making a will or giving power of attorney.
The patient’s capacity to make decisions about matters such as consent to treatment, living
circumstances and financial arrangements needs to be determined
Capacity to arrange Enduring Guardianship or advance care directives
 Advanced care directives also called ‘living wills’ is a written document that describes
ones future preferences for medical treatment in the anticipation of a time when one is
unable to express those preferences because of injury or illness.
 Enduring guardian: an enduring guardian can make personal decisions on the patients’
behalf, such as what medical treatment and services they should receive. A guardian is
appointed by the guardianship tribunal for those who are unable to make decisions for
themselves due to dementia (and other disabilities). Guardianship is different from power
of attorney in that a guardian is appointed by a third party rather than being nominated by
the patient. It is governed by the NSW legislation under the Guardianship Act 198.
 Power of attorney: Is a deed giving the person appointed (nominated attorney) the power
to do anything legally or financially on your behalf (e.g. pay bills, buy and sell real estate,
open and operate bank accounts, enter nursing home and hostel contracts). To make a
power of attorney the patient must be of sound mind. However if the patient has not
appointed an enduring power of attorney and they are diagnosed with dementia, they are
advised to appoint one as soon as possible. Governed by the NSW legislation under the
Powers of Attorney Act 2003
 Enduring power of attorney: the power of attorney stays in effect if the patient looses
mental capacity after they have appointed someone.
In making such arrangements the patient must understand that:
 the choices being made are for the future
 it will be used only if the patient has become incapable
 some choices are about future treatment

some choices are about who will then decide

the choices made could threaten life
 coma or dementia means that no choice in the future will be possible
 choices may change over time
 directives should be updated and changed if necessary each year
 choices made in the directive override later choices if the patient has become incapable.
5. Changes in the provision of institutional care for the elderly.
The lifetime risk of requiring aged care home care in Australia is estimated to be 20% for
men and 34% for women. Approximately 6% of people aged over 65 years (and 30% of
people aged over 85 years) live in aged care facilities. There are equal proportions of men
and women aged 65-74 years; but by age 85 years, residents are predominantly women.
The residential aged care population includes groups with special needs such as Aboriginal
and Torres Strait Islander peoples, people from culturally and linguistically diverse
backgrounds, and people with physical and intellectual disabilities. Residential aged care
facilities provide accommodation, personal care and other support services such as pharmacy,
allied health, social services, specialist services or respite care. Facilities can be owned and
managed by charitable not for profit, private for profit, or government organisations.
Residential aged care is regulated under The Aged Care Act 1997 (Commonwealth) and
accredited via the Aged Care Standards and Accreditation Agency. There is an expectation of
continuous improvement to services, and facilities must be accredited to receive subsidies.
The Australian Government Department of Health and Ageing regularly audits facilities and
residential care claims. Facilities provide accommodation and high care and/or low care to
eligible older people who are assessed by an Aged Care Assessment Team (ACAT).
The Resident Classification Scale (RCS) is used to assess the level of care and support needs
of the individual. Based on this, an Australian Government subsidy is paid per resident per
day. People entering are income tested with some residents expected to pay additional fees.
An accommodation payment may also apply. Overall, there are about 140 000 government
subsidised beds comprising 74 000 high care (formerly aged care home care) and 66 000 low
care (formerly hostel care). Ageing taking place in facilities enable residents to remain in the
same facility as their care needs increase from low to high care. There are increasing
demands for residential care as the population ages, and as informal care by family members
becomes a less viable option due to shifting work patterns and higher levels of family
mobility.
Carer allowance: an individual is eligible for a carers allowance if the carer is looking after an
adult with a severe disability or medical condition who needs a lot of additional care and
attention, and they provide care for an adult in either their home or the home of the person
they care for, and the person they are caring for are Australian residents.
 To qualify the carers need a health professional's report.
 Carers receive an allowance of $100.80 for themselves (which is not means tested) and a
$546.80 payment for the person they care for (means tested).