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Background: Pharmacist-led medication regimen simplification using a structured approach can reduce unnecessary medication regimen complexity in residential aged care facilities (RACFs), but no studies have investigated simplification by different health professionals, nor the extent to which simplification is recommended during comprehensive medication reviews., Objectives: To compare medication regimen simplification opportunities identified by pharmacists, general medical practitioners (GPs), and geriatricians and to determine if pharmacists identified simplification opportunities during routinely conducted comprehensive medication reviews in RACFs for these same residents., Methods: Three pharmacists, three GPs and three geriatricians independently applied the Medication Regimen Simplification Guide for Residential Aged CarE (MRS GRACE) to medication data for 83 residents taking medications at least twice daily. Interrater agreement was calculated using Fleiss's kappa. Pharmacist medication review reports for the same 83 residents were then examined to identify if the pharmacists conducting these reviews had recommended any of the simplification strategies., Results: Overall, 77 residents (92.8 %) taking medications at least twice daily could have their medication regimen simplified by at least one health professional. Pharmacists independently simplified 53.0-77.1 % of medication regimens (Κ = 0.60, 95%CI 0.46-0.75, indicating substantial agreement), while GPs simplified 74.7-89.2 % (Κ = 0.44, 95%CI 0.24-0.64, moderate agreement) and geriatricians simplified 41.0-66.3 % (Κ = 0.30, 95%CI 0.16-0.44, fair agreement). No simplification recommendations were included in the reports previously prepared by pharmacists as part of the comprehensive medication reviews undertaken for these residents., Conclusion: Pharmacists, GPs, and geriatricians can all identify medication regimen simplification opportunities, although these opportunities differ within and between professional groups. Although opportunities to simplify medication regimens during comprehensive medication reviews exist, simplification is not currently routinely recommended by pharmacists performing these reviews in Australian RACFs., Competing Interests: Declaration of competing interest JKS, WJW, and NS are accredited to perform comprehensive medication reviews in Australian RACFs. JKS is a non-executive director of Southern Cross Care SA, NT & VIC [aged care provider organization]. NS is a member of clinical governance committees for Estia, Eldercare, Anglicare, BUPA, Bolton Clarke, and Calvary Aged Care [aged care provider organizations] and is a non-executive director of the Pharmaceutical Society of Australia. NS and LC are employed by an organization providing pharmacist services to RACFs (Ward Medication Management) which provided data for this study, and JH and WJW were previously employed by this organization. JSB has received grant funding or consulting funds from the NHMRC, Victorian GovernmentDepartment of Health and Human Services, Dementia Australia Research Foundation, Yulgilbar Foundation, Aged Care Quality and Safety Commission, Dementia Centre for Research Collaboration, Pharmaceutical Society of Australia, Society of Hospital Pharmacists of Australia, GlaxoSmithKline Supported Studies Programme, Amgen, and several aged care provider organizations unrelated to this work (all grants and consulting funds were paid to the employing institution)., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

ObjectiveThis study aimed to examine the national variation in government-subsidised healthcare costs of residents in long-term care facilities (LTCFs) and costs differences by resident and facility characteristics.MethodsA retrospective population-based cohort study was conducted using linked national aged and healthcare data of older people (≥65years) living in 2112 LTCFs in Australia. Individuals' pharmaceutical, out-of-hospital, hospitalisation and emergency presentations direct costs were aggregated from the linked healthcare data. Average annual healthcare costs per resident were estimated using generalised linear models, adjusting for covariates. Cost estimates were compared by resident dementia status and facility characteristics (location, ownership type and size).ResultsOf the 75,142 residents examined, 70% (N=52,142) were women and 53.4% (N=40,137) were living with dementia. The average annual healthcare cost (all costs in $A) was $9233 (95% CI $9150-$9295) per resident, with hospitalisation accounting for 47.2% of the healthcare costs. Residents without dementia had higher healthcare costs ($11,097, 95% CI $10,995-$11,200) compared to those with dementia ($7561, 95% CI $7502-$7620). Residents living in for-profit LTCFs had higher adjusted average overall annual healthcare costs ($11,324, 95% CI $11,185-$11,463) compared to those living in not-for-profit ($11,017, 95% CI $10,895-$11,139) and government ($9731, 95% CI $9365-$10,099) facilities.ConclusionsThe healthcare costs incurred by residents of LTCFs varied by presence of dementia and facility ownership. The variation in costs may be associated with residents' care needs, care models and difference in quality of care across LTCFs. As hospitalisation is the biggest driver of the healthcare costs, strategies to reduce preventable hospitalisations may reduce downstream cost burden to the health system.

Objectives: Antipsychotics have been the focus of reforms for improving the appropriateness of psychotropic medicine use in residential aged care facilities (RACFs). Comprehensive evaluation of antidepressant use in RACFs is required to inform policy and practice initiatives targeting psychotropic medicines. This study examined national trends in antidepressant use among older people living in RACFs from 2006 to 2019., Design: National repeated cross-sectional study., Setting and Participants: Individuals aged 65 to 105 years who were permanent, long-term (≥100 days) residents of Australian RACFs between January 2006 and December 2019 were included., Methods: Annual age- and sex-adjusted antidepressant prevalence rates and defined daily doses (DDDs) supplied per 1000 resident-days from 2006 to 2019 were determined. Age- and sex-adjusted prevalence rate ratios (aRRs) and 95% confidence intervals (CIs) were estimated using Poisson and negative binomial regression models., Results: A total of 779,659 residents of 3371 RACFs were included (786,227,380 resident-days). Overall, antidepressant use increased from 46.1% (95% CI, 45.9-46.4) in 2006 to 58.5% (95% CI, 58.3-58.8) of residents in 2019 (aRR, 1.02; 95% CI, 1.02-1.02). Mirtazapine use increased from 8.4% (95% CI, 8.2-8.5) to 20.9% (95% CI, 20.7-21.1) from 2006 to 2019 (aRR, 1.07; 95% CI, 1.07-1.07). Antidepressant use increased from 350.3 (95% CI, 347.6-353.1) to 506.0 (95% CI, 502.8-509.3) DDDs/1000 resident-days (aRR, 1.03; 95% CI, 1.03-1.03), with mirtazapine utilization increasing by 6% annually (aRR, 1.06; 95% CI, 1.06-1.06)., Conclusions and Implications: This nationwide study identified a substantial increase in antidepressant use among residents of Australian RACFs, largely driven by mirtazapine. With nearly 3 in every 5 residents treated with an antidepressant in 2019, findings highlight potential off-label use and suggest that interventions to optimize care are urgently needed., Competing Interests: Disclosure J.K.S. is a non–executive director of Southern Cross Care SA, NT & VIC (an aged care provider organization). There are no other conflicts of interest to declare., (Copyright © 2024 AMDA – The Society for Post-Acute and Long-Term Care Medicine. All rights reserved.)

Objective The study examined emergency department (ED) presentations, unplanned hospitalisations and potentially preventable hospitalisations in older people receiving long-term care by type of care received (i.e. permanent residential aged care or home care packages in the community), in Australia in 2019. Methods A retrospective cohort study was conducted using the Registry of Senior Australians National Historical Cohort. Individuals were included if they resided in South Australia, Queensland, Victoria or New South Wales, received a home care package or permanent residential aged care in 2019 and were aged ≥65 years. The cumulative incidence of ED presentations, unplanned hospitalisations and potentially preventable hospitalisations in each of the long-term care service types were estimated during the year. Days in hospital per 1000 individuals were also calculated. Results The study included 203,278 individuals accessing permanent residential aged care (209,639 episodes) and 118,999 accessing home care packages in the community (127,893 episodes). A higher proportion of people accessing home care packages had an ED presentation (43.1% [95% confidence interval, 42.8-43.3], vs 37.8% [37.6-38.0]), unplanned hospitalisation (39.8% [39.6-40.1] vs 33.4% [33.2-33.6]) and potentially preventable hospitalisation (11.8% [11.6-12.0] vs 8.2% [8.1-8.4]) than people accessing permanent residential aged care. Individuals with home care packages had more days in hospital due to unplanned hospitalisations than those in residential care (7745 vs 3049 days/1000 individuals). Conclusions While a high proportion of older people in long-term care have ED presentations, unplanned hospitalisations and potentially preventable hospitalisations, people in the community with home care packages experience these events at a higher frequency.

Background: Stratifying residents at increased risk for fractures in long-term care facilities (LTCFs) can potentially improve awareness and facilitate the delivery of targeted interventions to reduce risk. Although several fracture risk assessment tools exist, most are not suitable for individuals entering LTCF. Moreover, existing tools do not examine risk profiles of individuals at key periods in their aged care journey, specifically at entry into LTCFs., Purpose: Our objectives were to identify fracture predictors, develop a fracture risk prognostic model for new LTCF residents and compare its performance to the Fracture Risk Assessment in Long term care (FRAiL) model using the Registry of Senior Australians (ROSA) Historical National Cohort, which contains integrated health and aged care information for individuals receiving long term care services., Methods: Individuals aged ≥65 years old who entered 2079 facilities in three Australian states between 01/01/2009 and 31/12/2016 were examined. Fractures (any) within 365 days of LTCF entry were the outcome of interest. Individual, medication, health care, facility and system-related factors were examined as predictors. A fracture prognostic model was developed using elastic nets penalised regression and Fine-Gray models. Model discrimination was examined using area under the receiver operating characteristics curve (AUC) from the 20 % testing dataset. Model performance was compared to an existing risk model (i.e., FRAiL model)., Results: Of the 238,782 individuals studied, 62.3 % (N = 148,838) were women, 49.7 % (N = 118,598) had dementia and the median age was 84 (interquartile range 79-89). Within 365 days of LTCF entry, 7.2 % (N = 17,110) of individuals experienced a fracture. The strongest fracture predictors included: complex health care rating (no vs high care needs, sub-distribution hazard ratio (sHR) = 1.52, 95 % confidence interval (CI) 1.39-1.67), nutrition rating (moderate vs worst, sHR = 1.48, 95%CI 1.38-1.59), prior fractures (sHR ranging from 1.24 to 1.41 depending on fracture site/type), one year history of general practitioner attendances (≥16 attendances vs none, sHR = 1.35, 95%CI 1.18-1.54), use of dopa and dopa derivative antiparkinsonian medications (sHR = 1.28, 95%CI 1.19-1.38), history of osteoporosis (sHR = 1.22, 95%CI 1.16-1.27), dementia (sHR = 1.22, 95%CI 1.17-1.28) and falls (sHR = 1.21, 95%CI 1.17-1.25). The model AUC in the testing cohort was 0.62 (95%CI 0.61-0.63) and performed similar to the FRAiL model (AUC = 0.61, 95%CI 0.60-0.62)., Conclusions: Critical information captured during transition into LTCF can be effectively leveraged to inform fracture risk profiling. New fracture predictors including complex health care needs, recent emergency department encounters, general practitioner and consultant physician attendances, were identified., Competing Interests: Declaration of competing interest RV is a founding team member to a technological start-up, HealthyVibes.ai., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objectives: This study examined the effects of virtual reality (VR) among palliative care patients at an acute ward. Objectives included evaluating VR therapy benefits across three sessions, assessing its differential impact on emotional versus physical symptoms and determining the proportion of patients experiencing clinically meaningful improvements after each session., Methods: A mixed-methods design was employed. Sixteen palliative inpatients completed three personalised 20 min VR sessions. Symptom burden was assessed using the Edmonton Symptom Assessment Scale-Revised and quality of life with the Functional Assessment of Chronic Illness Therapy (FACIT-Pal-14). Standardised criteria assessed clinically meaningful changes. Quantitative data were analysed using linear mixed models., Results: Quality of life improved significantly pre-VR to post-VR with a large effect size (Cohen's d: 0.98). Total symptom burden decreased after 20 min VR sessions (Cohen's d: 0.75), with similar effect sizes for emotional (Cohen's d: 0.67) and physical symptoms (Cohen's d: 0.63). Over 50% of patients experienced clinically meaningful improvements per session, though substantial individual variability occurred., Conclusions: This study reveals the nuanced efficacy of personalised VR therapy in palliative care, with over half of the patients experiencing meaningful benefits in emotional and physical symptoms. The marked variability in responses underscores the need for realistic expectations when implementing VR therapy., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Although largely preventable, pressure injury is a major concern in individuals in permanent residential aged care (PRAC). Our study aimed to identify predictors and develop a prognostic model for risk of hospitalization with pressure injury (PI) using integrated Australian aged and health care data., Design: National retrospective cohort study., Setting and Participants: Individuals ≥65 years old (N = 206,540) who entered 1797 PRAC facilities between January 1, 2009, and December 31, 2016., Methods: PI, ascertained from hospitalization records, within 365 days of PRAC entry was the outcome of interest. Individual, medication, facility, system, and health care-related factors were examined as predictors. Prognostic models were developed using elastic nets penalized regression and Fine and Gray models. Area under the receiver operating characteristics curve (AUC) assessed model discrimination out-of-sample., Results: Within 365 days of PRAC entry, 4.3% (n = 8802) of individuals had a hospitalization with PI. The strongest predictors for PI risk include history of PIs [sub-distribution hazard ratio (sHR) 2.41; 95% CI 1.77-3.29]; numbers of prior hospitalizations (having ≥5 hospitalizations, sHR 1.95; 95% CI 1.74-2.19); history of traumatic amputation of toe, ankle, foot and leg (sHR 1.72; 95% CI 1.44-2.05); and history of skin disease (sHR 1.54; 95% CI 1.45-1.65). Lower care needs at PRAC entry with respect to mobility, complex health care, and medication assistance were associated with lower risk of PI. The risk prediction model had an AUC of 0.74 (95% CI 0.72-0.75)., Conclusions and Implications: Our prognostic model for risk of hospitalization with PI performed moderately well and can be used by health and aged care providers to implement risk-based prevention plans at PRAC entry., (Copyright © 2022 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To explore the perceptions of the Australian public regarding Australia's aged care workforce, including their willingness to pay more tax to fund better pay and conditions for aged care workers., Methods: An online survey was developed and administered to a representative sample of Australian adults (aged ≥18 years) by age group, gender and Australian state. Survey respondents completed a series of attitudinal statements to elicit their perceptions of the value of Australia's aged care workforce and were asked to indicate their willingness to pay additional tax to fund better pay and conditions for aged care workers. Those who gave a positive response were then asked to indicate what percentage of additional tax per year they would be willing to pay to ensure better pay and conditions for aged care workers., Results: A total of 2033 adult respondents completed the survey. A majority (78%) of respondents either 'agreed' or 'strongly agreed' that aged care workers should be paid more. Approximately half of the respondents (50.57%) expressed a willingness to pay more tax to ensure better pay and conditions for aged care workers. The mean willingness to pay was 1.31% additional tax overall, and mean percentage additional tax values were relatively consistent across key socio-demographic indicators., Conclusions: A majority of the Australian public are in favour of improving the wages and employment conditions of aged care workers. However, only one in two Australians is willing to pay more tax to ensure better pay and conditions for aged care workers., (© 2022 AJA Inc.)

Objective To describe patterns of use of the available Government-subsidised mental health services among people living in Australian residential aged care facilities. Methods A retrospective population-based trend analysis was conducted, including all non-Indigenous people living in an Australian facility between 2012 and 2017. Adjusted incidence proportions and trends were estimated for four groups of mental health services. Results The use of Medicare-subsidised mental health services was very low overall. The proportion of residents who accessed primary care mental health services increased from 1.3% in 2012/2013 to 2.4% in 2016/2017, while psychiatry service use increased from 1.9 to 2.3%. Claims for clinical psychology increased from 0.18 to 0.26%, and claims for a registered psychologist, occupational therapist or social worker rose from 0.45 to 1.2%. People with dementia were less likely than people without dementia to access all services aside from psychiatry services. Conclusions Less than 3% of residents accessed funding subsidies for mental health services and people with dementia experienced pronounced barriers to service access. Mental health care is a pillar of the publicly-funded health system in Australia, and low use of these services among aged care residents indicates a need for organisational and policy changes to improve access.

Objective: To assess the effectiveness of a pharmacist-led intervention using validated tools to reduce medicine-induced deterioration and adverse reactions., Design and Setting: Multicenter, open-label parallel randomised controlled trial involving 39 Australian aged-care facilities., Participants: Residents on ≥4 medicines or ≥1 anticholinergic or sedative medicine., Intervention: Pharmacist-led intervention using validated tools to detect signs and symptoms of medicine-induced deterioration which occurred every 8 weeks over 12 months., Comparator: Usual care (Residential Medication Management Review) provided by accredited pharmacists., Outcomes: Primary outcome was change in Frailty Index at 12 months. Secondary outcomes included changes in cognition, 24-hour movement behaviour by accelerometry, grip strength, weight, adverse events and quality of life., Results: 248 persons (median age 87 years) completed the study; 120 in the interventionand, 128 in control arms. In total 575 pharmacist, sessions were undertaken in the intervention arm. There was no statistically significant difference for change in frailty between groups (mean difference: 0.009, 95% CI: -0.028, 0.009, P = 0.320). A significant difference for cognition was observed, with a mean difference of 1.36 point change at 12 months (95% CI: 0.01, 2.72, P = 0.048). Changes in 24-hour movement behaviour, grip strength, adverse events and quality of life were not significantly different between groups. Point estimates favoured the intervention arm at 12 months for frailty, 24-hour movement behaviour and grip strength., Conclusions: The use of validated tools by pharmacists to detect signs of medicine-induced deterioration is a model of practice that requires further research, with promising results from this trial, particularly with regards to improved cognition., (© The Author(s) 2022. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objectives: Little is known about how prepared the aged care system is to meet the specific needs of Care Leavers and Forgotten Australians. We explored service provider and advocate perspectives about the barriers and facilitators for appropriate and safe care for this group., Methods: Three focus groups with sixteen professional stakeholders examined the ways aged care support is accessible and inaccessible for Forgotten Australians., Results: Participants noted structural and organisational features that act as barriers to best practice aged care. It was perceived that funding models and processes provide insufficient opportunity to develop trust with professionals and access tailored care. Once engaged with aged care services, the sector lacks the psychological literacy required to tailor care to manage the complex needs and preferences of Forgotten Australians., Conclusions: Systemic and organisational change that promotes increased flexibility, trauma-informed care and non-residential housing options will improve the safety and accessibility of aged care for Forgotten Australians., (© 2021 AJA Inc.)

Background: This paper describes the collection and integration of mixed methods data to facilitate the final selection of items for the Quality of Life - Aged Care Consumers (QOL-ACC) instrument. The aim of the wider project is to develop a preference-based quality of life instrument that can be used for quality assessment and economic evaluation. Older people have been involved at every stage of the development of the QOL-ACC to ensure that the final instrument captures their perspectives and preferences., Methods: Mixed methods data was collected on draft items for the QOL-ACC instrument across six key quality of life dimensions (mobility, pain management, emotional well-being, independence, social connections, and activities). Qualitative face validity data was collected from older people (aged 66 to 100 years) living in the community and in residential aged care via semi-structured interviews (n = 59). Quantitative data was collected from older people (aged 65 to 91 years) receiving aged care services in the community via an online survey (n = 313). A traffic light pictorial approach was adopted as a practical and systematic way to categorise and present data in a meaningful way that was easy for non-academic workshop members to understand and to be able to discuss the relative merits of each draft item., Results: The traffic light approach supported the involvement of consumer and aged care provider representatives in the selection of the final items. Six items were selected for the QOL-ACC instrument with one item representing each of the six dimensions., Conclusions: This methodological approach has ensured that the final instrument is psychometrically robust as well as meaningful, relevant and acceptable to aged care consumers and providers., (© 2021. The Author(s).)

Background: Entering permanent residential aged care (PRAC) is a vulnerable time for individuals. While falls risk assessment tools exist, these have not leveraged routinely collected and integrated information from the Australian aged and health care sectors. Our study examined individual, system, medication, and health care related factors at PRAC entry that are predictors of fall-related hospitalisations and developed a risk assessment tool using integrated aged and health care data., Methods: A retrospective cohort study was conducted on N = 32,316 individuals ≥65 years old who entered a PRAC facility (01/01/2009-31/12/2016). Fall-related hospitalisations within 90 or 365 days were the outcomes of interest. Individual, system, medication, and health care-related factors were examined as predictors. Risk prediction models were developed using elastic nets penalised regression and Fine and Gray models. Area under the receiver operating characteristics curve (AUC) assessed model discrimination., Results: 64.2% (N = 20,757) of the cohort were women and the median age was 85 years old (interquartile range 80-89). After PRAC entry, 3.7% (N = 1209) had a fall-related hospitalisation within 90 days and 9.8% (N = 3156) within 365 days. Twenty variables contributed to fall-related hospitalisation prediction within 90 days and the strongest predictors included fracture history (sub-distribution hazard ratio (sHR) = 1.87, 95% confidence interval (CI) 1.63-2.15), falls history (sHR = 1.41, 95%CI 1.21-2.15), and dementia (sHR = 1.39, 95%CI 1.22-1.57). Twenty-seven predictors of fall-related hospitalisation within 365 days were identified, the strongest predictors included dementia (sHR = 1.36, 95%CI 1.24-1.50), history of falls (sHR = 1.30, 95%CI 1.20-1.42) and fractures (sHR = 1.28, 95%CI 1.15-1.41). The risk prediction models had an AUC of 0.71 (95%CI 0.68-0.74) for fall-related hospitalisations within 90 days and 0.64 (95%CI 0.62-0.67) for within 365 days., Conclusion: Routinely collected aged and health care data, when integrated at a clear point of action such as entry into PRAC, can identify residents at risk of fall-related hospitalisations, providing an opportunity for better targeting risk mitigation strategies., (© 2021. The Author(s).)

Background: Apathy is a frequent and underrecognized neurological disorder symptom. Reduced goal-directed behavior caused by apathy is associated with poor outcomes for older adults in residential aged care. Recommended nonpharmacological treatments include person-centered therapy using information and communication technology. Virtual reality (VR) in the form of head-mounted displays (HMDs) is a fully immersive technology that provides access to a wide range of freely available content. The use of VR as a therapy tool has demonstrated promise in the treatment of posttraumatic stress disorder and anxiety. In addition, VR has been used to improve conditions including depression, anxiety, cognitive function, and balance in older adults with memory deficits, Alzheimer disease, and Parkinson disease. Research using VR for the symptoms of apathy in older adults living in residential aged care facilities is limited., Objective: This study aims to examine whether using HMDs as a tool for reminiscence therapy improves the symptoms of apathy compared with using a laptop computer and physical items with older adults living in residential aged care., Methods: In this multisite trial, 43 participants were allocated to one of three groups: reminiscence therapy intervention using VR in the form of HMDs, reminiscence therapy using a laptop computer supplemented by physical items if required (active control), and a usual care (passive control) group. The primary outcome was apathy, and the secondary outcomes included cognition and depression. The side effects of using HMDs were also measured in the VR group., Results: Mixed model analyses revealed no significant group interaction over time in outcomes between the VR and laptop groups (estimate=-2.24, SE 1.89; t 40 =-1.18; P=.24). Pooled apathy scores in the two intervention groups compared with the passive control group also revealed no significant group interaction over time (estimate=-0.26, SE 1.66; t 40 =-0.16; P=.88). There were no significant secondary outcomes. Most participants in the VR group stated that they would prefer to watch content in VR than on a flat screen (Χ 2 2 =11.2; P=.004), side effects from HMD use were negligible to minimal according to the Simulator Sickness Questionnaire cutoff scores., Conclusions: Although there were no significant results in outcome measures, this study found that participants engaged in the research and enjoyed the process of reminiscing using both forms of technology. It was found that VR can be implemented in an aged care setting with correct protocols in place. Providing residents in aged care with a choice of technology may assist in increasing participation in activities. We cannot dismiss the importance of immediate effects while the therapy was in progress, and this is an avenue for future research., Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12619001510134; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378564., International Registered Report Identifier (irrid): RR2-DOI: 10.1136/bmjopen-2020-046030., (©Dimitrios Saredakis, Hannah AD Keage, Megan Corlis, Erica S Ghezzi, Helen Loffler, Tobias Loetscher. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 20.09.2021.)

Background: SARS-CoV-2 poses a considerable threat to those living in residential aged care facilities (RACF). RACF COVID-19 outbreaks have been characterised by the rapid spread of infection and high rates of severe disease and associated mortality. Despite a growing body of evidence supporting airborne transmission of SARS-CoV-2, current infection control measures in RACF including hand hygiene, social distancing, and sterilisation of surfaces, focus on contact and droplet transmission. Germicidal ultraviolet (GUV) light has been used widely to prevent airborne pathogen transmission. Our aim is to investigate the efficacy of GUV technology in reducing the risk of SARS-CoV-2 infection in RACF., Methods: A multicentre, two-arm double-crossover, randomised controlled trial will be conducted to determine the efficacy of GUV devices to reduce respiratory viral transmission in RACF, as an adjunct to existing infection control measures. The study will be conducted in partnership with three aged care providers in metropolitan and regional South Australia. RACF will be separated into paired within-site zones, then randomised to intervention order (GUV or control). The initial 6-week period will be followed by a 2-week washout before crossover to the second 6-week period. After accounting for estimated within-zone and within-facility correlations of infection, and baseline infection rates (10 per 100 person-days), a sample size of n = 8 zones (n = 40 residents/zone) will provide 89% power to detect a 50% reduction in symptomatic infection rate. The primary outcome will be the incidence rate ratio of combined symptomatic respiratory infections for intervention versus control. Secondary outcomes include incidence rates of hospitalisation for complications associated with respiratory infection; respiratory virus detection in facility air and fomite samples; rates of laboratory confirmed respiratory illnesses and genomic characteristics., Discussion: Measures that can be deployed rapidly into RACF, that avoid the requirement for changes in resident and staff behaviour, and that are effective in reducing the risk of airborne SARS-CoV-2 transmission, would provide considerable benefit in safeguarding a highly vulnerable population. In addition, such measures might substantially reduce rates of other respiratory viruses, which contribute considerably to resident morbidity and mortality. Trial registration Australian and New Zealand Clinical Trials Registry ACTRN12621000567820 (registered on 14th May, 2021)., (© 2021. The Author(s).)

Introduction: Pediatric integrated care is well-positioned to play a substantial role in crisis intervention; however, few studies have investigated the impact of these services., Method: We investigated differences in service utilization for youth experiencing a crisis in a large, predominantly rural health system by comparing outcomes for 171 youth who received a crisis evaluation in a primary care behavioral health (PCBH) setting to 171 youth presenting to the emergency department at the main hospital campus using a retrospective cohort study design., Results: PCBH patients were less likely to be male, more likely to be diagnosed with an Adjustment Disorder and less likely to be diagnosed with Autism Spectrum Disorder. Youth evaluated in PCBH were more likely to receive a psychiatric admission, had a shorter latency to the next BH appointment, and had higher rates of completing at least 1 visit in the year following the evaluation. A statistically nonsignificant reduction in frequency of psychiatric admission was observed in the year after the index date, with 3 integrated care patients (vs. 18 on index date) and 5 ED patients (vs. 6 on index date) admitted., Discussion: Opportunities for future research on cost-effectiveness of care and continuous improvement aligned with quadruple aim outcomes are discussed. Overall, this study is among few others investigating the potential for pediatric integrated care models to contribute to youth suicide prevention and the study demonstrated promising increases in access and engagement with timely behavioral health care. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

There is a well-established relationship between child maltreatment and delinquency, indicating that maltreated youth are at a heightened risk for later delinquency. However, the literature is unclear as to why some maltreated youth proceed to engage in delinquent behaviors, whereas others do not. The present study examined whether parental or family factors moderated the relation between a history of maltreatment and engagement in delinquent behavior during adolescence. Parental and family moderators included parental monitoring, parental emotional distress (depression and everyday stressors), parent-child relationship quality, family community and religious disengagement, poverty, and negative life events. This study utilized data on 1,149 children from the Longitudinal Studies of Child Abuse and Neglect (LONGSCAN), a collaborative effort across research sites that collected data regarding the risk factors and consequences of child maltreatment. For the purposes of this study, we utilized adolescent self-reports of delinquency, caregiver reports of parental and family variables, and administrative data on child maltreatment. Community and religious disengagement was the only variable that moderated the relation between maltreatment and delinquency. The effects of community and religious disengagement varied by maltreatment group such that greater community and religious disengagement was related to increased delinquent involvement for those in the no maltreatment, childhood-only maltreatment, and persistent maltreatment groups. Child maltreatment was not a significant predictor of delinquency over and above the effect of parenting and family variables that were measured during adolescence. Findings point to the importance of considering proximal parenting and family factors in understanding the maltreatment-delinquency relationship.

Background: Little is known about changes in pro re nata (PRN) medication prescribing and administration in residential aged care facilities (RACFs) over time., Objective: To determine the prevalence and factors associated with PRN medication administration in RACFs and examine changes over 12-months., Methods: Secondary analyses utilizing data from the SIMPLER randomized controlled trial (n = 242 residents, 8 RACFs) was undertaken. PRN medication data were extracted from RACF medication charts. Factors associated with PRN medication administration in the preceding week were explored using multivariable logistic regression., Results: At baseline, 211 residents (87.2%) were prescribed ≥1 PRN medication, with 77 (36.5%) administered PRN medication in the preceding week. PRN administration was more likely in non-metropolitan areas, and less likely among residents with more severe dementia symptoms and greater dependence with activities of daily living. No significant differences in overall PRN prescribing or administration in 162 residents alive at 12-month follow-up were observed., Conclusions: Despite being frequently prescribed, the contribution of PRNs to overall medication use in RACFs is small. PRN prescribing and administration was relatively static over 12-months despite likely changes in resident health status over this period, suggesting further exploration of PRN prescribing in relation to resident care needs may be warranted., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: To explore perceptions and expectations regarding aged care among older Forgotten Australians, informing better ways of delivering safe and inclusive care for this group., Methods: In-depth interviews were undertaken with sixteen Forgotten Australians to understand their perspectives, hopes and perceived barriers to receiving appropriate aged care. Qualitative data were analysed using Ritchie and Spencer's framework approach., Results: Participants were highly averse to receiving aged care in residential settings, particularly where delivered by religious organisations. Limited perceived opportunities to develop trust and maintain control and independence while managing re-traumatising situations shaped Forgotten Australians negative perceptions of the aged care system. Participants also spoke of how their lifelong marginalisation could limit their access to choice and quality in aged care., Conclusion: The aged care industry could provide safe and inclusive care by adopting a person-centred and trauma-informed model that recognises and addresses the specific needs and challenges of Forgotten Australians., (© 2020 AJA Inc.)

Objective: To evaluate the cost-effectiveness of a 12-week Exercise Physiology (EP) program for people living in a residential aged care facility., Methods: A within-study pre- and postintervention design to calculate incremental cost-effectiveness ratios per quality-adjusted life years gained. A health service provider perspective was used., Results: Fifty-nine participants enrolled in a 12-week program. The program cost was A$514.30 per resident. At a willingness-to-pay threshold of A$64 000, the likelihood of being cost-effective of the program is approximately 60%, due to a small increase in participants' quality of life, as reported by care staff. The model showed great variance, depending on who rated the participants' quality of life outcomes., Conclusion: It is uncertain that a 12-week EP program is cost-effective based on the evidence of the current trial. However, it appears that a low-cost program can produce small improvements for residents in care facilities., (© 2020 AJA Inc.)

Complex medication regimens are highly prevalent, burdensome for residents and staff, and associated with poor health outcomes in residential aged care facilities (RACFs). The SIMPLER study was a non-blinded, matched-pair, cluster randomized controlled trial in eight Australian RACFs that investigated the one-off application of a structured 5-step implicit process to simplify medication regimens. The aim of this study was to explore the processes underpinning study implementation and uptake of the medication simplification intervention. A mixed methods process evaluation with an explanatory design was undertaken in parallel with the main outcome evaluation of the SIMPLER study and was guided by an established 8-domain framework. The qualitative component included a document analysis and semi-structured interviews with 25 stakeholders (residents, family, research nurses, pharmacists, RACF staff, and a general medical practitioner). Interviews were transcribed verbatim and reflexively thematically content analyzed. Descriptive statistics were used to summarize quantitative data extracted from key research documents. The SIMPLER recruitment rates at the eight RACFs ranged from 18.9% to 48.6% of eligible residents (38.4% overall). Participation decisions were influenced by altruism, opinions of trusted persons, willingness to change a medication regimen, and third-party hesitation regarding potential resident distress. Intervention delivery was generally consistent with the study protocol. Stakeholders perceived regimen simplification was beneficial and low risk if the simplification recommendations were individualized. Implementation of the simplification recommendations varied between the four intervention RACFs, with simplification implemented at 4-month follow-up for between 25% and 86% of residents for whom simplification was possible. Good working relationships between stakeholders and new remunerated models of medication management were perceived facilitators to wider implementation. In conclusion, the one-off implicit medication simplification intervention was feasible and generally delivered according to the protocol to a representative sample of residents. Despite variable implementation, recommendations to simplify complex regimens were valued by stakeholders, who also supported wider implementation of medication simplification in RACFs.

Background: Understanding the health profile, service and medicine use of Australians in the aged care sector will help inform appropriate service provision for our ageing population., Aims: To examine the 2006-2015 trends in (i) comorbidities and frailty of individuals accessing aged care, and (ii) health services, medicine use and mortality after entry into long-term care., Methods: Cross-sectional and population-based trend analyses were conducted using the Registry of Senior Australians., Results: From 2006 to 2015, 509 944 individuals accessed permanent residential care, 206 394 home care, 283 014 respite and 124 943 transition care. Over this time, the proportion of individuals accessing permanent residential care with high frailty scores (≥0.3) increased (19.7-49.7%), as did the proportion with 5-9 comorbidities (46.4-54.5%), with similar trends observed for those accessing other services. The median number of medicines dispensed in the year after entering permanent residential care increased from 9 (interquartile range (IQR) 6-12) to 10 (IQR 7-14), while remaining stable in home care (2006: 9, IQR 5-12, 2015: 9, IQR 6-13). Short-term (within 100 days) mortality in those accessing permanent care was higher in 2006 (15.6%, 95% CI 15.2-16.0) than 2015 (14.6%, 95% CI 14.3-14.9). Longer term (101-1095 days, 2006: 44.3%, 95% CI 43.7-45.0, 2015: 46.4%, 95% CI 45.8-46.9) mortality was higher in 2015 compared to 2006. Mortality in individuals accessing home care did not change., Conclusion: The health of older Australians accessing aged care programmes has declined while frailty increased, with an increasing use of medicine and worse long-term mortality in some. Funding and care models need to adapt to this changing profile., (© 2020 The Authors. Internal Medicine Journal by Wiley Publishing Asia Pty Ltd on behalf of Royal Australasian College of Physicians.)

In the SImplification of Medications Prescribed to Long-tErm care Residents (SIMPLER) cluster-randomized controlled trial, we investigated the impact of a structured medication regimen simplification intervention on medication incidents in residential aged care facilities (RACFs) over a 12-month follow-up. A clinical pharmacist applied the validated 5-step Medication Regimen Simplification Guide for Residential Aged CarE (MRS GRACE) for 96 of the 99 participating residents in the four intervention RACFs. The 143 participating residents in the comparison RACFs received usual care. Over 12 months, medication incident rates were 95 and 66 per 100 resident-years in the intervention and comparison groups, respectively (adjusted incident rate ratio (IRR) 1.13; 95% confidence interval (CI) 0.53-2.38). The 12-month pre/post incident rate almost halved among participants in the intervention group (adjusted IRR 0.56; 95%CI 0.38-0.80). A significant reduction in 12-month pre/post incident rate was also observed in the comparison group (adjusted IRR 0.67, 95%CI 0.50-0.90). Medication incidents over 12 months were often minor in severity. Declines in 12-month pre/post incident rates were observed in both study arms; however, rates were not significantly different among residents who received and did not receive a one-off structured medication regimen simplification intervention.

Introduction: Apathy is a prevalent neuropsychiatric symptom for older adults residing in aged care. Left untreated, apathy has been associated with accelerated cognitive decline and increased risk of mortality. Reminiscence therapy is commonly used in aged care and has demonstrated to reduce apathy. Traditional methods of reminiscence use physical objects and more recently technology including tablets and laptop computers have demonstrated potential. Virtual reality (VR) has successfully been used to treat psychological disorders; however, there is little evidence on using VR for behavioural symptoms such as apathy in older adults. Using VR to deliver reminiscence therapy provides an immersive experience, and readily available applications provide access to a large range of content allowing easier delivery of therapy over traditional forms of therapy. This study aims to identify changes in apathy after a reminiscence therapy intervention using head-mounted displays (HMDs)., Methods and Analysis: Participants will be allocated to one of three groups; reminiscence therapy using VR; an active control using a laptop computer or physical items and a passive control. A total of 45 participants will be recruited from residential aged care (15 in each group). The three groups will be compared at baseline and follow-up. The primary outcome is apathy, and secondary outcomes include cognition and depression. Side effects from using HMDs will also be examined in the VR group. Primary and secondary outcomes at baseline and follow-up will be analysed using linear mixed modelling., Ethics and Dissemination: Ethics approval was obtained from the University of South Australia Human Research Ethics Committee. The results from this study will be disseminated through manuscript publications and national/international conferences., Trial Registration Number: ACTRN12619001510134., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Rationale/aim: Medication administration is a complex and time-consuming task in residential aged care facilities (RACFs). Understanding the time associated with each administration step may help identify opportunities to optimize medication management in RACFs. This study aimed to investigate the time taken to administer medications to residents, including those with complex care needs such as cognitive impairment and swallowing difficulties., Method: A time-and-motion study was conducted in three South Australian RACFs. A representative sample of 57 scheduled medication administration rounds in 14 units were observed by a single investigator. The rounds were sampled to include different times of day, memory support units for residents living with dementia and standard units, and medication administration by registered and enrolled nurses. Medications were administered from pre-prepared medication strip packaging. The validated Work Observation Method By Activity Timing (WOMBAT) software was used to record observations., Results: Thirty nurses were observed. The average time spent on scheduled medication administration rounds was 5.2 h/unit of average 22 residents/day. The breakfast medication round had the longest duration (1.92 h/unit). Resident preparation, medication preparation and provision, documentation, transit, communication, and cleaning took an average of 5 minutes per resident per round. Medication preparation and provision comprised 60% of overall medication round time and took significantly longer in memory support than in standard units (66 vs 49 seconds per resident per round for preparation, 79 vs 58 for provision; P < .001 for both). Almost half (42%) of tablets/capsules were crushed in memory support units. The time taken for medication administration was not significantly different among registered and enrolled nurses., Conclusions: Nurses took an average of 5 minutes to administer medications per resident per medication round. Medication administration in memory support units took an additional minute per resident per round, with almost half of tablets and capsules needing to be crushed., (© 2020 John Wiley & Sons, Ltd.)

Background: There is a high burden of antipsychotic use in residential aged care facilities (RACFs) and there is concern regarding potential inappropriate prescribing of antipsychotics in response to mild behavioural symptoms. Antipsychotic use has been associated with a higher risk of mortality in community-dwelling older adults with dementia, but few studies have examined associations upon RACF entry., Aims: To examine associations between incident antipsychotic use and risk of mortality for people with and without diagnosed dementia in RACFs., Methods: A retrospective cohort study, employing a new-user design (individuals did not receive an antipsychotic 6 months before enrolment) of 265,820 people who accessed RACFs in Australia between 1/4/2008 and 30/6/2015 was conducted. Cox regression models were used to examine adjusted associations between antipsychotic use in the first 100 days of RACF entry and mortality., Results: In the 100 days after entering care, 29,455 residents (11.1%) were dispensed an antipsychotic. 180,956 (68.1%) residents died [38,249 (14.4%) were related to cerebrovascular causes] over a median 2.1 years (interquartile range 1.0-3.6) follow-up. Of the residents included, 119,665 (45.0%) had a diagnosis of dementia. Incident antipsychotic use was associated with higher risk of mortality in residents with dementia (adjusted hazard ratio 1.20, 95% confidence interval 1.18-1.22) and without dementia (1.28, 1.24-1.31)., Conclusion: Initiation of antipsychotics after moving to RACFs is associated with a higher risk of mortality. Careful consideration of the potential benefits and harms should be given when starting a new prescription for antipsychotics for people moving to RACFs.

Objectives: Residential medication management reviews (RMMRs) are comprehensive medication reviews conducted by clinical pharmacists and general medical practitioners. RMMRs are the primary government-funded service to optimize medication management in Australian residential aged care facilities (RACFs) and are recommended for all new residents. This study investigated resident characteristics associated with timely RMMR provision within 90 days of RACF entry and national intrafacility variation in timely RMMR provision., Design: National retrospective cohort study., Setting and Participants: Individuals aged ≥65 years who first entered permanent residential aged care in Australia between January 1, 2012, and December 31, 2015, received at least 1 medication in the previous year, and were alive at 90 days post-RACF entry., Methods: Resident characteristics associated with timely RMMR provision were determined using multivariate logistic regression. Crude and risk-adjusted funnel plots were used to examine intrafacility variation in timely RMMR provision., Results: Of the 143,676 residents from 2799 RACFs included, 30,883 (21.5%) received an RMMR within 90 days. Resident characteristics associated with timely provision included dementia (adjusted odds ratio [aOR] 1.05, 95% confidence interval [CI] 1.02-1.08), primary language other than English (aOR 1.04, 95% CI 1.01-1.09), number of unique prescriptions dispensed in the previous year (aOR [per additional 5 prescriptions] 1.02, 95% CI 1.01-1.03), need for medication administration assistance (aORs ranged from 1.35 to 1.42, compared with residents self-managing) and facility remoteness (aORs ranged from 0.67 to 0.75 for residents outside major cities). The proportion of new residents receiving a timely RMMR ranged from 0% (n = 303 RACFs) to 100% (n = 4 RACFs). There were 174 RACFs (6.2%) in which ≥50% of new residents received a timely RMMR., Conclusions and Implications: Although there was some evidence that RMMRs are targeted to individuals with a greater burden of medication use and those living with dementia, considerable variation in provision exists nationally. This flagship medication review service is generally underutilized among residents of Australian RACFs., (Copyright © 2020 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: Mental health disorders are a major health concern in older people and are associated with a higher risk of disability, frailty and early mortality. This study aimed to conduct a contemporary population-based assessment of the prevalence, trends and factors associated with mental health disorders in individuals who are living in permanent residential aged care (PRAC) in Australia., Methods: A retrospective cross-sectional study was conducted using national data from the Registry of Senior Australians, a national cohort of older Australians who had aged care eligibility assessment and entered PRAC between 2008 and 2016. Stepwise multivariate logistic regression modeling was applied to identify factors associated with mental health disorders., Results: Of 430,862 individuals included in this study, 57.8% had at least one mental health disorder. The prevalence of depression, phobia/anxiety and psychosis were as follows: 46.2% (95% confidence interval = [46.0%, 46.3%]), 14.9% (95% confidence interval = [14.8%, 15.0%]) and 9.7% (95% confidence interval = [9.6%, 9.8%]), respectively. The likelihood of having a mental health disorder was higher for those who were (adjusted odds ratio [95% confidence interval]) relatively younger, specifically for every 10-year increment in age, the odds of having mental health disorders was 44.0% lower (0.56, [0.55, 0.56]); female (1.33 [1.32, 1.35]); having increasing numbers of physical health comorbidities, 6-10 (1.26 [1.24, 1.29]) or 11-15 (1.48 [1.45, 1.51]) or more than 15 (1.64 [1.58, 1.71]) compared to people having less than five comorbidities; having limitations related to health care tasks (1.05 [1.04, 1.07]), meals (1.04 [1.02, 1.05]) or social and community participation (1.10 [1.08, 1.12])., Conclusion: The burden of mental health disorders in older Australians living in PRAC was high and individuals with these conditions tend to be younger, with several physical comorbidities and/or functional limitations. Understanding the profile of individuals with mental health disorders at entry into PRAC can be used as evidence for baseline resource allocation for this population and evaluation of future needs of mental health services.

Objectives: To introduce the Registry of Senior Australians (ROSA) Outcome Monitoring System, which can monitor the quality and safety of care provided to individuals accessing residential aged care. Development and examination of 12 quality and safety indicators of care and their 2016 prevalence estimates are presented., Design: Retrospective., Setting: 2690 national and 254 South Australian (SA) aged care facilities., Participants: 208 355 unique residents nationally and 18 956 in SA., Main Outcome Measures: Risk-adjusted prevalence of high sedative load, antipsychotic use, chronic opioid use, antibiotic use, premature mortality, falls, fractures, medication-related adverse events, weight loss/malnutrition, delirium and/or dementia hospitalisations, emergency department presentations, and pressure injuries., Results: Five indicators were estimated nationally; antibiotic use (67.5%, 95% confidence interval (CI): 67.3-67.7%) had the highest prevalence, followed by high sedative load (48.1%, 95% CI: 47.9-48.3%), chronic opioid use (26.8%, 95% CI: 26.6-26.9%), antipsychotic use (23.5%, 95% CI: 23.4-23.7%) and premature mortality (0.6%, 95% CI: 0.6-0.7%). Seven indicators were estimated in SA; emergency department presentations (19.1%, 95% CI: 18.3-20.0%) had the highest prevalence, followed by falls (10.1%, 95% CI: 9.7-10.4%), fractures (4.8%, 95% CI: 4.6-5.1%), pressure injuries (2.9%, 95% CI: 2.7-3.1%), delirium and/or dementia related hospitalisations (2.3%, 95% CI: 2.1-2.6%), weight loss/malnutrition (0.7%, 95% CI: 0.6-0.8%) and medication-related events (0.6%, 95% CI: 0.5-0.7%)., Conclusions: Twelve quality and safety indicators were developed to monitor aged care provided to older Australians based on the synthesis of existing literature and expert advisory input. These indicators rely on existing data within the aged care and healthcare sectors, therefore creating a pragmatic tool to examine quality and unwarranted care variation., (© The Author(s) 2020. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

As we age, maintaining physical functionality is important with respect to wellbeing and healthy ageing. For older adults with dementia this may be difficult, particularly in the residential aged care environment. This article reports the qualitative examination of an Exercise Physiologist-delivered exercise programme for residents with dementia. Perspectives related to the perceived impact and acceptability of the programme, as well as barriers to implementation, and delivery of exercise to residents, were sought from family members and care staff through semi-structured interviews. Benefits related to physical and social factors were identified, and perceptions related to who might benefit from exercise were changed as a result of observing residents participate in the programme. These findings support the notion that an Exercise Physiologist-delivered exercise programme, with a person-centred approach, can contribute to improved functionality for residents with dementia.

Objective: To evaluate the access of approved aged care services and factors associated with accessing these services., Methods: A retrospective cohort study was conducted (1/7/2003-30/6/2013). The incidence of accessing permanent residential, home and respite care services within one year or transition care within 28 days of approval was evaluated. The association of participants' socio-demographic characteristics, limitations, health conditions and assessment characteristics with service use was evaluated., Results: In 799 750 older Australians, the incidence of accessing approved permanent residential care within one year was 70.9% (95% confidence interval [CI] 70.8%-71.0%), home care 49.5% (95% CI 49.3%-49.7%) and respite 41.8% (95% CI 41.7%-41.9%). The incidence of accessing transition care at 28 days was 78.5% (95% CI 78.2%-78.7%). Aged care seekers', assessments' and assessors' characteristics are associated with service access., Conclusion: Monitoring the use of aged care service approvals is necessary for the identification of service access barriers to support evidence-based policy changes., (© 2019 The Authors. Australasian Journal on Ageing published by John Wiley & Sons Australia, Ltd on behalf of AJA Inc.)

Objective: To assess the application of a structured process to consolidate the number of medication administration times for residents of aged care facilities., Design: A nonblinded, matched-pair, cluster randomized controlled trial., Setting and Participants: Permanent residents who were English-speaking and taking at least 1 regular medication, recruited from 8 South Australian residential aged care facilities (RACFs)., Methods: The intervention involved a clinical pharmacist applying a validated 5-step tool to identify opportunities to reduce medication complexity (eg, by administering medications at the same time or through use of longer-acting or combination formulations). Residents in the comparison group received routine care. The primary outcome at 4-month follow-up was the number of administration times per day for medications charted regularly. Resident satisfaction and quality of life were secondary outcomes. Harms included falls, medication incidents, hospitalizations, and mortality. The association between the intervention and primary outcome was estimated using linear mixed models., Results: Overall, 99 residents participated in the intervention arm and 143 in the comparison arm. At baseline, the mean resident age was 86 years, 74% were female, and medications were taken an average of 4 times daily. Medication simplification was possible for 62 (65%) residents in the intervention arm, with 57 (62%) of 92 simplification recommendations implemented at follow-up. The mean number of administration times at follow-up was reduced in the intervention arm in comparison to usual care (-0.36, 95% confidence interval -0.63 to -0.09, P = .01). No significant changes in secondary outcomes or harms were observed., Conclusions and Implications: One-off application of a structured tool to reduce regimen complexity is a low-risk intervention to reduce the burden of medication administration in RACFs and may enable staff to shift time to other resident care activities., (Copyright © 2020 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: Medications with anticholinergic or sedative effects are frequently used by older people but can increase risk of falls and adverse events; however, less is known about their effect on movement behaviour. Here we examine the cross-sectional association between medication use and movement behaviour in older adults living in residential aged care., Materials and Methods: Twenty-eight older adults living in residential aged care in metropolitan Australia participated. Medication data were collected from participants' medical charts and sedative load and anticholinergic burden were determined. Seven-day movement behaviour was objectively assessed by a wrist-worn triaxial accelerometer. Raw accelerations were converted to sleep, sedentary time, and time in light, moderate, and moderate-to-vigorous physical activity. To explore the relationship between medication and movement behaviour, Spearman's Rho correlations were conducted, as the data were not normally distributed., Results: Analyses indicated that while anticholinergic burden was not associated with movement behaviour, sedative load was negatively correlated with a number of variables, accounting for 14% variance in moderate-to-vigorous physical activity (MVPA), and 17% in the bout length of MVPA ( p  < .02)., Conclusion: The findings of this study showed a negative association between sedative load, due to medicines, and an individual's movement behaviour. The impact of this could be a reduction in the ability of this population to maintain or improve their functional mobility, which may overshadow any benefits of the medicine in some circumstances., Competing Interests: Alison Penington and Megan Corlis were employed by Helping Hand Organisation at the time of the study., (©2020 Parfitt et al.)

Background: Apathy is a common symptom in neurological disorders, including dementia, and is associated with a faster rate of cognitive decline, reduced quality of life, and high caregiver burden. There is a lack of effective pharmacological treatments for apathy, and nonpharmacological interventions are a preferred first-line approach to treatment. Virtual reality (VR) using head-mounted displays (HMDs) is being successfully used in exposure- and distraction-based therapies; however, there is limited research on using HMDs for symptoms of neurological disorders., Objective: This feasibility study aimed to assess whether VR using HMDs could be used to deliver tailored reminiscence therapy and examine the willingness to participate, response rates to measures, time taken to create tailored content, and technical problems. In addition, this study aimed to explore the immediate effects between verbal fluency and apathy after exposure to VR., Methods: A mixed methods study was conducted in a sample of older adults residing in aged care, and 17 participants were recruited. Apathy was measured using the Apathy Evaluation Scale (AES), and verbal fluency was used as a proxy measure of improvements in apathy and debriefing interviews to assess feedback from participants. Side effects that can occur from using HMDs were also measured., Results: We recruited participants from a high socioeconomic status setting with a high education level, and the participation rate was 85% (17/20); most responses to measures were positive. Access to a wide range of freely available content and the absence of technical difficulties made the delivery of a VR reminiscence intervention highly feasible. Participants had improved semantic scores (t 14 =-3.27; P=.006) but not phonemic fluency scores (t 14 =0.55; P=.59) immediately after the intervention. Those with higher levels of apathy demonstrated the greatest cognitive improvements after a VR reminiscence experience, which was indicated by a strong positive relationship between the AES and semantic verbal fluency change scores postminus pre-VR (r=0.719; 95% CI 0.327 to 0.900; P=.003). All participants enjoyed the experience despite 35% (6/17) of participants experiencing temporary side effects., Conclusions: This study provides initial evidence that it is feasible to use VR with HMDs for therapy to treat symptoms of apathy in older adults in residential aged care. However, there is a need to closely monitor the side effects of HMD use in older adults. Further research is needed using an active control group to compare the use of VR with traditional forms of reminiscence therapy., (©Dimitrios Saredakis, Hannah AD Keage, Megan Corlis, Tobias Loetscher. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 26.06.2020.)

Purpose: Being able to manage a complex medication regimen is key to older people continuing to live at home. This study determined the feasibility of a multi-component intervention to simplify medication regimens for people receiving community-based home care services., Patients and Methods: Research nurses recruited people receiving community-based home care services to participate in this non-randomized pilot and feasibility study (Australian New Zealand Clinical Trials Registry ACTRN12618001130257). Participants received a one-off clinical pharmacist intervention comprising medication reconciliation, assessment of capacity to self-manage medications, and application of a structured 5-step tool to identify medication simplification opportunities. A mixed-methods feasibility assessment with an explanatory design was undertaken to assess recruitment, protocol adherence and stakeholder acceptability. Data from interviews with 12 stakeholders were thematically analyzed. Secondary outcome measures, including medication discrepancies, and changes in number of medication administration times per day, quality of life, medication adherence and health service utilization, were determined over a 4-month follow-up., Results: Twenty-five out of the target 50 participants were recruited. Initial recruitment was impacted by apparent uncertain role responsibilities in medication management, with some clients who declined to participate perceiving they would be unlikely to benefit or being reluctant to change regimens. However, with few exceptions, participants who received intervention did so with a high degree of protocol adherence and acceptability. Stakeholders valued the intervention and supported wider implementation. Discrepancies between the baseline medication history from the general medical practitioner and the pharmacist-compiled "best possible medication history" were identified for all participants' regimens (median of 6 per participant), with one-third resolved at follow-up. Simplification was possible for 14 participants (56%) and implemented for 7 (50%) at follow-up. No significant changes in other secondary outcomes were observed., Conclusion: The intervention was delivered as planned, and valued by stakeholders. Recruitment barriers should be addressed before wider implementation., Competing Interests: This study was funded through the NHMRC CDPC and the community-based home care provider organization involved in this research is one of the NHMRC CDPC funding partners. The authors report grants from the National Health and Medical Research Council Cognitive Decline Partnership Centre, during the conduct of the study. JKS is supported by an NHMRC Early Career Fellowship. JSB is supported by an NHMRC Dementia Leadership Fellowship. MC, JVE, MH and TC are employed by the organization providing the community-based home care services., (© 2020 Sluggett et al.)

Aim: It is important for older adults to maintain the ability to be physically active, and to experience the benefits that physical activity brings. This study evaluates a 12-week Accredited Exercise Physiologist-led exercise program for vulnerable older adults living with dementia, delivered in a residential aged care facility in South Australia. The value of the program was also evaluated from the perspective of partners-in-care (family members and care staff)., Methods: Participants (n = 59) were randomized to either an intervention or control group, based on their functional and cognitive status. Physical function, cognitive function and habitual physical activity were assessed at baseline and post-intervention. In total, 51 family members and 44 care staff completed surveys or participated to understand their perspectives of residents' capacity to exercise, as well as their perceptions of the impact of the program., Results: Repeated measures ANOVA identified evidence for maintenance of physical function (timed-up-and-go [ɳ 2 = 0.19], handgrip strength [ɳ 2 = 0.13]); however, there were no differences for objectively measured habitual activity or cognitive function. Evidence for a dose effect was demonstrated for the 2-min walk and timed-up-and-go associated with the number of individual sessions attended by a participant. Partners-in-care perceived greater improvement compared with deterioration across all measured factors [(P < 0.01, partial eta 2 (ɳ 2 ) =0.19] ranged from 0.35 to 0.78) post-intervention. Perceptions and expectations of who could benefit from participation were changed (P < 0.05) and indicated that all but the most severely declined residents would be likely to benefit., Conclusions: Data supporting the maintenance for some physical functions suggest that this type of program should be considered for older adults living with dementia in residential aged care facilities. Geriatr Gerontol Int 2020; ••: ••-••., (© 2020 Japan Geriatrics Society.)

Objectives: To examine the use of residential respite care and determine associations between respite care and total days spent in residential care (respite days plus long-term care days)., Design: A retrospective cohort study of individuals accessing aged care services in Australia using the National Historical Cohort of the Registry of Senior Australians was conducted., Setting: Residential respite care (short stays in residential aged care homes) and long-term residential care accessed in all government-subsidized residential aged care homes in Australia., Participants: This study included people who were approved for government-subsidized residential respite care between January 2005 and June 2012 (n = 480,862) and included a 2-year follow-up period., Methods: Poisson regression models were used to examine associations between use of residential respite care and number of days spent in residential care., Results: Of people approved for residential respite care, 36.9% used their approval within 12 months (32.0% used respite once and went directly to long-term care without returning home, 40.7% used respite once and did not go directly to long-term care, and 27.3% used respite ≥2 times). Compared with people who did not use respite care, using respite care once and not going directly to long-term care was associated with less total days in residential care [incidence rate ratio (IRR) 0.68, 95% confidence interval (CI) 0.67-0.69; P < .001] and using respite care ≥2 times was also associated with fewer days (IRR 0.86, 95% CI 0.84-0.87, P < .001). Using respite care once and going directly to long-term care was associated with more days in residential care (IRR 1.11, 95% CI 1.10-1.12, P < .001)., Conclusions and Implications: Using residential respite care was associated with fewer days spent in residential care when people returned home after using respite. The findings suggest that using residential respite as intended by returning home after use achieves the goal of helping people stay living at home longer., (Copyright © 2019 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Many medicines have adverse effects which are difficult to detect and frequently go unrecognised. Pharmacist monitoring of changes in signs and symptoms of these adverse effects, which we describe as medicine-induced deterioration, may reduce the risk of developing frailty. The aim of this trial is to determine the effectiveness of a 12-month pharmacist service compared with usual care in reducing medicine-induced deterioration, frailty and adverse reactions in older people living in aged-care facilities in Australia., Methods and Analysis: The reducing medicine-induced deterioration and adverse reactions trial is a multicentre, open-label randomised controlled trial. Participants will be recruited from 39 facilities in South Australia and Tasmania. Residents will be included if they are using four or more medicines at the time of recruitment, or taking more than one medicine with anticholinergic or sedative properties. The intervention group will receive a pharmacist assessment which occurs every 8 weeks. The pharmacists will liaise with the participants' general practitioners when medicine-induced deterioration is evident or adverse events are considered serious. The primary outcome is a reduction in medicine-induced deterioration from baseline to 6 and 12 months, as measured by change in frailty index. The secondary outcomes are changes in cognition scores, 24-hour movement behaviour, grip strength, weight, percentage robust, pre-frail and frail classification, rate of adverse medicine events, health-related quality of life and health resource use. The statistical analysis will use mixed-models adjusted for baseline to account for repeated outcome measures. A health economic evaluation will be conducted following trial completion using data collected during the trial., Ethics and Dissemination: Ethics approvals have been obtained from the Human Research Ethics Committee of University of South Australia (ID:0000036440) and University of Tasmania (ID:H0017022). A copy of the final report will be provided to the Australian Government Department of Health., Trial Registration Number: Australian and New Zealand Trials Registry ACTRN12618000766213., Competing Interests: Competing interests: The reducing medicine-induced deterioration and adverse reactions (ReMInDAR) trial is by the Australian Government. ACK is employed as a research assistant of the ReMInDAR trial. RB is employed as the ReMInDAR partnership engagement and trial manager to oversee the operations management for the trial., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

In the SImplification of Medications Prescribed to Long-tErm care Residents (SIMPLER) cluster-randomized controlled trial, we evaluated the impact of structured medication regimen simplification on medication administration times, falls, hospitalization, and mortality at 8 residential aged care facilities (RACFs) at 12 month follow up. In total, 242 residents taking ≥1 medication regularly were included. Opportunities for simplification among participants at 4 RACFs were identified using the validated Medication Regimen Simplification Guide for Residential Aged CarE (MRS GRACE). Simplification was possible for 62 of 99 residents in the intervention arm. Significant reductions in the mean number of daily medication administration times were observed at 8 months (-0.38, 95% confidence intervals (CI) -0.69 to -0.07) and 12 months (-0.47, 95%CI -0.84 to -0.09) in the intervention compared to the comparison arm. A higher incidence of falls was observed in the intervention arm (incidence rate ratio (IRR) 2.20, 95%CI 1.33 to 3.63) over 12-months, which was primarily driven by a high falls rate in one intervention RACF and a simultaneous decrease in comparison RACFs. No significant differences in hospitalizations (IRR 1.78, 95%CI 0.57-5.53) or mortality (relative risk 0.81, 95%CI 0.48-1.38) over 12 months were observed. Medication simplification achieves sustained reductions in medication administration times and should be implemented using a structured resident-centered approach that incorporates clinical judgement.

Objective: To examine the prevalence of psychotropic medicine dispensing before and after older people enter residential care., Design: Retrospective national cohort study; analysis of Registry of Senior Australians (ROSA) data., Setting, Participants: All concession card-holding residents of government-subsidised residential aged care facilities in Australia who entered residential care for at least three months between 1 April 2008 and 30 June 2015., Main Outcome Measures: Proportions of residents dispensed antipsychotic, benzodiazepine, or antidepressant medicines during the year preceding and the year after commencing residential care, by quarter., Results: Of 322 120 included aged care residents, 68 483 received at least one antipsychotic (21.3%; 95% CI, 21.1-21.4%), 98 315 at least one benzodiazepine (30.5%; 95% CI, 30.4-30.7%), and 122 224 residents at least one antidepressant (37.9%; 95% CI, 37.8-38.1%) during their first three months of residential care; 31 326 of those dispensed antipsychotics (45.7%), 38 529 of those dispensed benzodiazepines (39.2%), and 25 259 residents dispensed antidepressants (19.8%) had not received them in the year preceding their entry into care. During the first three months of residential care, the prevalence of antipsychotic (prevalence ratio [PR], 3.37; 95% CI, 3.31-3.43) and antidepressant dispensing (PR, 1.05; 95% CI, 1.04-1.07) were each higher for residents with than for those without dementia; benzodiazepine dispensing was similar for both groups (PR, 1.01; 95% CI, 0.99-1.02)., Conclusions: Dispensing of psychotropic medicines to older Australians is high before they enter residential care but increases markedly soon after entry into care. Non-pharmacological behavioural management strategies are important for limiting the prescribing of psychotropic medicines for older people in the community or in residential care., (© 2020 AMPCo Pty Ltd.)

Objectives: Regular physical activity for older adults as they age is important for maintaining not only physical function but also independence and self-worth. To be able to monitor changes in physical function, appropriate validated measures are required. Reliability of measures such as the timed-up-and-go, five-repetition sit-to-stand, handgrip strength, two-minute walk, 30-second sit-to-stand, and four-metre walk has been demonstrated; however, the appropriateness of such measures in a population of adults living with dementia, who may be unable to follow instructions or have diminished physical capacity, is not as well quantified. This study sought to test modified standard protocols for these measures., Methods: Modification to the standard protocols of the timed-up-and-go, five-repetition sit-to-stand, handgrip strength, two-minute walk, 30-second sit-to-stand, and four-metre walk was trialled. This occurred through modification of procedural components of the assessment, such as encouraging participants to use their hands to raise themselves from a seated position, or the incorporation of staged verbal cueing, demonstration, or physical guidance where required. The test-retest reliability of the modified protocols was assessed using Pearson's correlation, and performance variances were assessed using the %coefficient of variation. Intraclass correlations were included for comparisons to previous research and to examine measurement consistency within three trials., Results: At least 64% of the population were able to complete all measures. Good test-retest reliability was indicated for the modified measures (timed-up-and-go = 0.87; five-repetition sit-to-stand = 0.75; handgrip strength = 0.94; two-minute walk = 0.87; the 30-second sit-to-stand = 0.93; and the four-metre walk = 0.83), and the %coefficient of variation (7.2%-14.8%) and intraclass correlation (0.77-0.98) were acceptable to good., Conclusion: This article describes the methodology of the modified assessments, presents the test-retest statistics, and reports how modification of the current protocols for common measures of physical function enabled more older adults living with dementia in a residential aged care facility to participate in assessments, with high reliability demonstrated for the measures., Competing Interests: Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2020.)

Objective: This study examined CPS involvement of children surviving the CMF of a sibling as well as predictors of subsequent CPS reports., Method: Department of Human Services and Child Death Review Board data about children who died from a CMF during 1993-2003 ( n = 416) and their siblings in the state of Oklahoma were used to examine CPS involvement and predictors of subsequent CPS reports for surviving siblings., Results: Surviving siblings of a victim of a CMF experienced substantial CPS involvement; 81% of the original victims had siblings who were subsequently reported to CPS ( n = 1,840). Original victim and family characteristics that predicted a greater rate of siblings' subsequent reports to CPS included younger original victim age, greater number of children in the original victim's home, and more previous reports of the original victim to CPS., Discussion: A large portion of families with a CMF struggle to adequately care for their surviving children. Such families may need additional support after a CMF.

Objective: To explore variation in medication regimen complexity in residential aged care facilities (RACFs) according to resident age, length of stay, comorbidity, dementia severity, frailty, and dependence in activities of daily living (ADLs), and compare number of daily administration times and Medication Regimen Complexity Index (MRCI) as measures of regimen complexity., Methods: This study was a cross-sectional analysis of baseline data from the SImplification of Medications Prescribed to Long-tErm care Residents (SIMPLER) cluster-randomized controlled trial. The SIMPLER study recruited 242 residents with at least one medication charted for regular administration from 8 RACFs in South Australia. Comorbidity was assessed using the Charlson Comorbidity Index (CCI). Dementia severity was assessed using the Dementia Severity Rating Scale. Frailty was assessed using the FRAIL-NH scale. Dependence in ADLs was assessed using the Katz ADL scale., Results: The median age of participants was 87 years (interquartile range 81-92). Over one-third of participants (n=86, 36%) had 5 or more daily medication administration times. The number of daily administration times and MRCI scores were positively correlated with resident length of stay (r s =0.19; 0.27), FRAIL-NH score (r s =0.23; 0.34) and dependence in ADLs (r s =-0.21; -0.33) (all p<0.01). MRCI was weakly negatively correlated with CCI score (r s =-0.16; p=0.013). Neither number of daily administration times nor MRCI score were correlated with age or dementia severity. In multivariate analysis, frailty was associated with number of daily administration times (OR: 1.13, 95% CI: 1.03-1.24) and MRCI score (OR: 1.26, 95% CI: 1.13-1.41). Dementia severity was inversely associated with both multiple medication administration times (OR: 0.97, 95% CI: 0.94-0.99) and high MRCI score (OR: 0.95, 95% CI: 0.92-0.98)., Conclusion: Residents with longer lengths of stay, more dependent in ADLs and most frail had the most complex medication regimens and, therefore, may benefit from targeted strategies to reduce medication regimen complexity., Competing Interests: This work was supported by the NHMRC Cognitive Decline Partnership Centre (grant number GNT9100000). The Cognitive Decline Partnership Centre receives support from the NHMRC and funding partners including Helping Hand Aged Care, HammondCare, Brightwater and Dementia Australia. The contents of the published materials are solely the responsibility of the individual authors identified, and do not reflect the views of the NHMRC and any other funding bodies or the funding partners. EYHC was supported by a postgraduate research scholarship funded by the Cognitive Decline Partnership Centre and the Monash University Faculty of Pharmacy and Pharmaceutical Sciences. JSB was supported by an NHMRC Dementia Research Leadership Fellowship. MC, MH and JvE are employed by Helping Hand Aged Care. JKS and JI were supported by NHMRC Early Career Fellowships. The authors report no other conflicts of interest in this work., (© 2019 Chen et al.)

Objective: To describe the co-design process in a project that "evaluated how the key worker role can best support people living with dementia in the community setting.", Methods: People with dementia, care-partners, aged-care service experts, policymakers and academics utilised a co-design process to undertake a systematic literature review and a qualitative evaluation study., Results: The development of a successful co-design process that includes people living with dementia and their care-partners ("consumers") at all stages of the research process and addresses their individual needs., Conclusions: The co-design approach utilised in this project provided support, for consumers living in the community to be fully involved in the research design, conduct and plans for dissemination and implementation of the findings. Consequently, the research outcomes are based on solid evidence and consumer need. Additionally, a successful model for supporting consumers to facilitate their involvement in all aspects of the research process, was developed., (© 2019 The Authors. Australasian Journal on Ageing published by John Wiley & Sons Australia, Ltd on behalf of AJA Inc.)

Objective: To systematically review literature reporting processes, impact and outcomes of medication review and reconciliation in Australian residential aged care facilities (RACFs)., Methods: PubMed/MEDLINE, EMBASE, CINAHL, Informit Health and grey literature were searched from 1995 to July 2018. Studies reporting outcomes of a stand-alone medication review or reconciliation interventions in Australian RACFs were included., Results: Thirteen studies investigated medication review, eight of which studied Residential Medication Management Reviews (RMMRs). Five studies reported that medication reviews identified an average of 2.7-3.9 medication-related problems (MRPs) per resident. One study reported medication reviews had no impact on quality of life, hospitalisation or mortality, but was not powered to assess these. Three studies reported general practitioners' acceptance of pharmacists' recommendations to resolve MRPs, ranging between 45 and 84%., Conclusions: Medication review may be a useful strategy to identify and prompt resolution of MRPs. However, the impact on clinical and resident-centred outcomes remains unclear., (© 2019 The Authors. Australasian Journal on Ageing published by John Wiley & Sons Australia, Ltd on behalf of AJA Inc.)