Estimating potential palliative care needs for residential aged care: A population-based retrospective cohort study.

OBJECTIVE: Population-based data on the required needs for palliative care in residential aged care have been highlighted as a key information gap. This study aimed to provide a comprehensive estimate of palliative care needs among Australia's residential aged care population using a validated algorithm based on causes of death. METHODS: A population-based retrospective cohort study was conducted using data from the Registry of Senior Australians of non-Indigenous residents of residential aged care services in New South Wales, Victoria, and South Australia aged older than 65 years, who died between 2016 and 2017 (n = 71,677). An internationally validated algorithm was used to estimate and characterise potential palliative care needs based on causes of death. This estimate was compared to palliative care needs identified from funding-based care needs assessment data. RESULTS: Ninety two per cent (n = 65,949) were estimated to have had potential palliative care needs prior to their death. Of these, 19% (n = 12,467) were assigned an end-of-life trajectory related to cancer, 61% (n = 40,511) to organ failure and 20% (n = 12,971) to frailty and dementia. By comparison, only 6% (n = 4430) of residents were assessed as needing palliative care by the funding-based care needs assessment. CONCLUSIONS: Over 90% of individuals dying in residential aged care may have benefited from a palliative approach to care. This need is substantially underestimated by the funding-based care needs assessment, which utilises a narrow definition of palliative care when death is imminent. There is a clear imperative to distinguish between palliative and end-of-life care needs within residential aged care to ensure appropriate and equitable access to palliative care.

Quantifying the effects of sleep on sensor-derived variables from upper limb accelerometry in people with and without upper limb impairment.

BACKGROUND: Despite the promise of wearable sensors for both rehabilitation research and clinical care, these technologies pose significant burden on data collectors and analysts. Investigations of factors that may influence the wearable sensor data processing pipeline are needed to support continued use of these technologies in rehabilitation research and integration into clinical care settings. The purpose of this study was to investigate the effect of one such factor, sleep, on sensor-derived variables from upper limb accelerometry in people with and without upper limb impairment and across a two-day wearing period. METHODS: This was a secondary analysis of data collected during a prospective, longitudinal cohort study (n = 127 individuals, 62 with upper limb impairment and 65 without). Participants wore a wearable sensor on each wrist for 48 h. Five upper limb sensor variables were calculated over the full wear period (sleep included) and with sleep time removed (sleep excluded): preferred time, non-preferred time, use ratio, non-preferred magnitude and its standard deviation. Linear mixed effects regression was used to quantify the effect of sleep on each sensor variable and determine if the effect differed between people with and without upper limb impairment and across a two-day wearing period. RESULTS: There were significant differences between sleep included and excluded for the variables preferred time (p < 0.001), non-preferred time (p < 0.001), and non-preferred magnitude standard deviation (p = 0.001). The effect of sleep was significantly different between people with and without upper limb impairment for one variable, non-preferred magnitude (p = 0.02). The effect of sleep was not substantially different across wearing days for any of the variables. CONCLUSIONS: Overall, the effects of sleep on sensor-derived variables of upper limb accelerometry are small, similar between people with and without upper limb impairment and across a two-day wearing period, and can likely be ignored in most contexts. Ignoring the effect of sleep would simplify the data processing pipeline, facilitating the use of wearable sensors in both research and clinical practice.

Trends in mental health service utilisation by Australia's older population.

OBJECTIVES: To examine the incidence, trends, and differences between age groups and sex in Medicare Benefits Schedule (MBS)-subsidised mental health service utilisation by older Australians over the past 10 years. METHODS: A cross-sectional cohort study between 1 July 2009 and 30 June 2019 was conducted using publicly available MBS data for older individuals aged ≥65 years. Age- and sex-standardised yearly incidence rates of psychological therapy (MBS M06), GP mental health treatments (MBS A20), focussed psychological strategy (MBS M07), and psychiatric attendances (MBS A08) and incidence rate ratios (IRR) estimated using Poisson regression were calculated. RESULTS: Overall, the rate of utilisation of primary care mental health services by the older population increased over the study period, with psychological therapy claims increasing the greatest from 14.4/1000 older persons in 2009/10 to 38.5/1000 in 2018/19 (IRR 1.11, 95% CI 1.09-1.13), followed by GP mental health treatments increasing from 43.7/1000 (95% CI 43.4-43.9) in 2009/10 to 81.0/1000 (95% CI 80.7-81.3) in 2018/19 (IRR 1.07/year, 95% CI 1.06-1.09). Females aged 65-74 years had the highest use of GP mental health treatments at 123.8/1000 compared to 63.6/1000 in males in 2018/2019. CONCLUSIONS: While utilisation of mental health services by the older population in Australia has increased over the study period, it is important that policymakers and service providers continue to support access and use of these services, which may facilitate well-being and quality of life in the older population.

Government-subsidised mental health services are underused in Australian residential aged care facilities.

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.

Utilisation of general practice health assessments around an aged care assessment is associated with lower mortality risk in older Australians.

OBJECTIVE: (i) to describe the general practitioner utilisation of health assessments, management plans, coordination of team care arrangements and medication review item numbers within 6 months of an aged care eligibility assessment for home care packages (HCP) and (ii) investigate the impact of health assessments on the risk of mortality and entry into permanent residential aged care (PRAC) of individuals accessing HCP. DESIGN AND SETTING: retrospective cohort study utilising data from the Registry of Senior Australians (ROSA) was conducted. SUBJECTS: 75,172 individuals aged ≥75 years who received HCP between 2011 and 2015. OUTCOME MEASURE: for objective 1: the use of comprehensive assessments (Medicare Benefits Schedule (MBS) items 705 or 707), management plans (MBS 721), coordination of team care arrangements (MBS 723), and medication reviews (MBS 900). For objective 2: time to death and entry into PRAC. RESULTS: of the 75,172 individuals, 28.2% (95% confidence interval (CI): 27.8-8.5%) had comprehensive assessments, 36.7% (95% CI: 36.3-37.0%) had management plans, 33.0% (95% CI: 32.7-33.3%) received coordination of team care arrangements and 5.4% (95% CI: 5.2-5.5%) had medication reviews. Individuals with a comprehensive assessment had a 5% lower risk of mortality (adjusted hazard ratio (aHR), 95% CI = 0.95, 0.92-0.98) but 5% higher risk of transition to PRAC (adjusted subdistribution HRs, 95% CI = 1.05, 1.02-1.08) compared to those who did not have these services. CONCLUSION: the utilisation of health assessments was associated with a lower risk of mortality. There is an opportunity for increased use of item numbers in frailer individuals.

Association of Age-Related Cataract With Skin Cancer in an Australian Population.

Purpose: Ultraviolet radiation from sunlight contributes to age-related cataract and skin cancer. The EPHA2 gene is implicated in both these diseases. The purpose of this study was to determine whether age-related cataract and skin cancer are associated in a cohort of older Australians. Methods: A cross-sectional study was performed using the Historical Cohort of the Registry of Senior Australians. Individuals aged ≥65 years or aged ≥50 years and of Aboriginal or Torres Strait Islander descent, who had an aged care eligibility assessment between July 2005 and June 2015, and had a history of cataract surgery and/or skin cancer according to the Australian Government Medicare Benefits Schedule dataset, during the 3-year period prior, were evaluated (N = 599,316). A multivariable logistic regression model was used to determine association and multiple hypothesis correction was employed. Results: Of the evaluated individuals, 87,097 (14.5%) had a history of cataract and 170,251 (28.4%) a history of skin cancer. Among those with a history of cataract, 20,497 (23.5%), 1127 (1.3%), and 14,730 (16.9%) individuals had a concurrent history of keratinocyte, melanoma, and premalignant/solar keratosis, respectively. Those with a history of cataract were 19% more likely to have a history of skin cancer (odds ratio [OR], 1.19; 95% confidence interval [CI], (1.17-1.21). Co-occurrence of keratinocyte skin cancer was 16% (OR, 1.16; 95% CI, 1.14-1.18), melanoma 21% (OR, 1.21; 95% CI, 1.13-1.29), and premalignant/solar keratosis 19% (OR, 1.19; 95% CI, 1.17-1.22) more in the presence than absence of history of cataract. Conclusions: Age-related cataract is positively associated with skin cancer and its subtypes, including premalignant lesions in an older Australian population.

Radiological changes on CT after stereotactic body radiation therapy to non-spine bone metastases: a descriptive series.

BACKGROUND: In recent years, stereotactic body radiation therapy (SBRT) has become increasingly used for the management of non-spine bone metastases. Few studies have examined the radiological changes in bone metastases after treatment with SBRT and there is no consensus about what constitutes radiologic response to therapy. This article describes various changes on CT after SBRT to non-spine bone metastases in eight selected cases. METHODS: A retrospective review was conducted for patients treated with SBRT to non-spine bone metastases between November 2011 and April 2014 at Sunnybrook Health Sciences Centre. A musculoskeletal radiologist identified eight illustrative cases of interest and provided a description of the findings. RESULTS: Different radiological changes following SBRT were described, including: remineralization of lytic bone metastases, demineralization of sclerotic bone metastases, pathologic fracture, size progression and response in different lesions, as well as lung fibrosis after SBRT to a rib metastasis. CONCLUSIONS: We reviewed the radiological images of eight selected cases after SBRT to nonspine bone metastases and a number of characteristic findings were highlighted. We recommend future studies to correlate radiologic changes with clinical outcomes including pain relief, toxicity and long-term local control.

Computed Tomography Evaluation of Density Following Stereotactic Body Radiation Therapy of Nonspine Bone Metastases.

INTRODUCTION: Stereotactic body radiation therapy allows for the precise delivery of high-dose radiation to disease sites and is becoming increasingly used to treat nonspine bone metastases. Previous studies have shown that remineralization of lytic bone metastases follows after conventional radiotherapy. The objective of this study was to investigate changes in bone density in nonspine bone metastases following stereotactic body radiation therapy. METHODS: A retrospective review was conducted for all patients treated with stereotactic body radiation therapy to nonspine bone metastases between May 2011 and April 2014. A minimum of 1 pretreatment and 1 posttreatment computed tomography scan was required. An independent musculoskeletal radiologist contoured the lesions on the most representative computed tomography slices. Density was measured in Hounsfield units and analyzed using pretreatment and posttreatment ratios. RESULTS: Forty sites were treated (55% lytic, 30% sclerotic, and 15% mixed). The median follow-up duration was 7 months. Lytic osseous metastases from renal cell carcinoma progressed during initial follow-up imaging and then returned to baseline. Of 9 lytic lesions not from renal cell carcinoma, 6 showed an immediate increase in density and 2 remained stable. Six of 7 sclerotic lesions from prostate cancer showed decreased density throughout all follow-ups. CONCLUSION: Stereotactic body radiation therapy is efficacious in the remineralization of lytic and demineralization of sclerotic nonspine bone metastases.

Tumor Response After Stereotactic Body Radiation Therapy to Nonspine Bone Metastases: An Evaluation of Response Criteria.

PURPOSE: To evaluate the applicability of the Response Evaluation Criteria in Solid Tumors (RECIST 1.1) and University of Texas MD Anderson (MDA) Cancer Center criteria in the setting of stereotactic body radiation therapy (SBRT) to nonspine bone metastases. METHODS: Patients who were treated with SBRT to nonspine bone metastases were identified by retrospective chart review. An independent musculoskeletal radiologist evaluated response to treatment using computed tomography (CT) scans. RESULTS: Thirty-three patients were treated to 42 nonspine bone metastases. The most common primary cancer cites were renal cell carcinoma (RCC) (33.3%), lung (24.2%), and prostate (18.2%). Bone metastases were either mainly lytic (57.1%), mainly sclerotic (28.6%), or mixed (14.3%). When lytic and sclerotic lesions were evaluated according to RECIST 1.1, local control (LC) was 83%, 85%, 88%, and 80% for those with CT imaging between months 1 to 3, 4 to 6, 7 to 9, and 10 to 12, respectively. When evaluated by the MDA criteria by density, LC within each time period was slightly greater. Overall LC decreased considerably when evaluated by MDA in terms of size. CONCLUSIONS: Consensus definitions of response are required as they have implications on clinical trials and disease management. Without consistent response criteria, outcomes from clinical trials cannot be compared and treatment efficacy remains undetermined.

Combining d-cycloserine with motor training does not result in improved general motor learning in neurologically intact people or in people with stroke.

Neurological rehabilitation involving motor training has resulted in clinically meaningful improvements in function but is unable to eliminate many of the impairments associated with neurological injury. Thus there is a growing need for interventions that facilitate motor learning during rehabilitation therapy, to optimize recovery. d-Cycloserine (DCS), a partial N-methyl-d-aspartate (NMDA) receptor agonist that enhances neurotransmission throughout the central nervous system (Ressler KJ, Rothbaum BO, Tannenbaum L, Anderson P, Graap K, Zimand E, Hodges L, Davis M. Arch Gen Psychiatry 61: 1136-1144, 2004), has been shown to facilitate declarative and emotional learning. We therefore tested whether combining DCS with motor training facilitates motor learning after stroke in a series of two experiments. Forty-one healthy adults participated in experiment I, and twenty adults with stroke participated in experiment II of this two-session, double-blind study. Session one consisted of baseline assessment, subject randomization, and oral administration of DCS or placebo (250 mg). Subjects then participated in training on a balancing task, a simulated feeding task, and a cognitive task. Subjects returned 1-3 days later for posttest assessment. We found that all subjects had improved performance from pretest to posttest on the balancing task, the simulated feeding task, and the cognitive task. Subjects who were given DCS before motor training, however, did not show enhanced learning on the balancing task, the simulated feeding task, or the associative recognition task compared with subjects given placebo. Moreover, training on the balancing task did not generalize to a similar, untrained balance task. Our findings suggest that DCS does not enhance motor learning or motor skill generalization in neurologically intact adults or in adults with stroke.

International guidelines for effective control of head louse infestations.

Head louse infestations are increasing or remain high in most countries. In order to reduce the proportion of children infested with head lice and slow down the emergence of strains of lice resistant to pediculicides, more active involvement of health and educational authorities, as well as parents, is of paramount importance. We suggest that health authorities should introduce more efficient methods for evaluating pediculicides and more stringent regulations for adoption of new anti-louse products. Baseline studies are also essential for new pediculicides. Children should be properly screened, especially in problematic areas. The media should be used to educate parents on louse control. Health providers need to be aware of which anti-louse remedies are demonstrably effective and be capable of assisting families with louse control. Academic institutions should conduct baseline and efficacy studies on pediculicides and other treatment modalities, as well as research on the biology and epidemiology of lice. Parents should regularly inspect their children, treat as necessary, and try to avoid creating stigmas and emotional problems for the child. The pharmaceutical industry should aim to introduce pediculicides based on new chemical compounds, especially natural products. Companies should develop effective and safe repellents and nit removal remedies. General recommendations are given on how to diagnose and treat louse infestations with chemicals, biological agents, and louse combs and how to protect children from infestations. The no-nit policy, based on the persistence of empty egg cases, is not justified and does more harm than good; therefore, we recommend that it be immediately halted.