Exposure to doxycycline increases risk of carrying a broad range of enteric antimicrobial resistance determinants in an elderly cohort.

OBJECTIVES: High rates of antibiotic prescription in residential aged care are likely to promote enteric carriage of antibiotic-resistant pathogens and increase the risk of antibiotic treatment failure. Despite their importance, relationships between antibiotic exposures and patterns of enteric resistance carriage in this population remain poorly understood. METHODS: We conducted a cross-sectional metagenomic cohort analysis of stool samples from residents of five long-term aged-care facilities in South Australia. Taxonomic composition was determined, and enteric carriage of antibiotic resistance genes (ARGs) was identified and quantified against the Comprehensive Antibiotic Resistance Database. Both the detection and abundance of stool taxa and ARGs were related to antibiotic exposures up to 12 months prior. Factors associated with the abundance of ARGs of high clinical concern were identified. RESULTS: Stool samples were provided by 164 participants (median age: 88 years, IQR 81-93; 72% female). Sixty-one percent (n = 100) of participants were prescribed antibiotics at least once in the prior 12 months (median prescriptions: 4, range: 1-52), most commonly a penicillin (n = 55, 33.5%), cephalosporin (n = 53, 32.3%), diaminopyrimidine (trimethoprim) (n = 36, 22%), or tetracycline (doxycycline) (n = 21, 12.8%). More than 1100 unique ARGs, conferring resistance to 38 antibiotic classes, were identified, including 20 ARGs of high clinical concern. Multivariate logistic regression showed doxycycline exposure to be the greatest risk factor for high ARG abundance (adjusted odds ratio [aOR]=14.8, q<0.001) and a significant contributor to inter-class selection, particularly for ARGs relating to penicillins (aOR=3.1, q=0.0004) and cephalosporins (aOR=3.4, q=0.003). High enteric ARG abundance was associated with the number of separate antibiotic exposures (aOR: 6.4, q<0.001), exposures within the prior 30 days (aOR: 4.6, q=0.008) and prior 30-100 days (aOR: 2.6, q=0.008), high duration of antibiotic exposure (aOR: 7.9, q<0.001), and exposure to 3 or more antibiotic classes (aOR: 7.4, q<0.001). Carriage of one or more ARGs of high clinical concern was identified in 99% of participants (n = 162, median: 3, IQR: 2-4), involving 11 ARGs conferring resistance to aminoglycosides, four to beta-lactams, one to glycopeptides, three to fluoroquinolones, and one to oxazolidinones. Carriage of ARGs of high clinical concern was positively associated with exposure to doxycycline (aminoglycoside, fluoroquinolone, and oxazolidinone ARGs) and trimethoprim (fluoroquinolone and beta-lactam ARGs). Analysis of doxycycline impact on microbiota composition suggested that observed resistome changes arose principally through direct ARG selection, rather than through the antibiotic depletion of sensitive bacterial populations. CONCLUSIONS: The gut microbiome of aged care residents is a major reservoir of antibiotic resistance. As a critical antibiotic in medical practice, a comprehensive understanding of the impact of doxycycline exposure on the gut resistome is paramount for informed antibiotic use, particularly in an evolving landscape of prophylactic applications. Near-universal asymptomatic carriage of clinically critical resistance determinants is highly concerning and reinforces the urgent need for improved management of antibiotic use in long-term aged care.

The impact of ageing-in-place reforms on the provision of home care packages for older Australians, 2008-21: a repeated cross-sectional study.

OBJECTIVES: To assess changes following the 2013-21 Home Care Package (HCP) reforms in the rate of HCPs provided to Australians aged 65 years or older, the characteristics of people who have received HCPs, and the capacity of the program to meet demand for its services during 2018-21. STUDY DESIGN: Repeated cross-sectional population-based study; analysis of Australian Institute of Health and Welfare GEN Aged Care and Australian Department of Health Home Care Packages program data. SETTING, PARTICIPANTS: HCPs provided to non-Indigenous Australians aged 65 years or older, 2008-09 to 2020-21. MAIN OUTCOME MEASURES: Changes in age- and sex-standardised HCP rates (number per 1000 older people) and changes in proportions of recipients for selected characteristics, 2013-14 to 2020-21, overall and by care level; correspondence of proportional HCP supply and demand, 2018-19 to 2020-21, by care level. RESULTS: A total of 490 276 HCPs were provided during 2008-21. The age- and sex-standardised HCP rate rose from 9.23 per 1000 people aged 65 years or more in 2013-14 to 16.4 per 1000 older people in 2020-21. The increases in age- and sex-standardised HCP rate between 2013-14 and 2020-21 were greatest for level 1 (from 0.19 to 5.05 per 1000 older people) and level 3 HCPs (from 0.35 to 3.62 per 1000 older people); the rate for level 2 HCPs declined from 6.75 to 5.82 per 1000 older people, and that for level 4 HCPs did not change. The proportion of culturally and linguistically diverse recipients rose from 10.8% to 16.2%; the overall proportion of recipients living outside major cities rose slightly, from 28.1% to 28.7%, but declined for higher care level HCPs (level 3: from 30.8% to 27.8%; level 4: from 29.6% to 25.2%). During 2018-19 to 2020-21, the proportions of lower level (1 and 2) HCPs generally exceeded demand, while the supply of higher level (3 and 4) HCPs generally fell short of demand. CONCLUSIONS: Despite the increased overall availability of HCPs, the supply of higher care level HCPs is still lower than the demand, probably contributing to suboptimal support for the ageing-in-place preferences of older Australians, especially in regional and remote areas.

Health outcomes following provision of Home Medicines Reviews for older people receiving aged care services at home.

BACKGROUND: The impact of Home Medicines Reviews (HMRs) on long-term health outcomes among individuals receiving long-term in-home aged care services is unknown. OBJECTIVES: To examine associations between HMR provision and hospitalization, long-term care facility (LTCF) entry and mortality among older people receiving long-term in-home aged care services. METHODS: This retrospective cohort study included individuals aged 65-105 years from three Australian states who accessed in-home aged care services between 2013 and 2017. Using propensity score matching, HMR recipients (n = 1530) were matched to individuals who did not receive an HMR (n = 1530). Associations between HMR provision and outcomes were estimated using multivariable regression models. RESULTS: Over a median of 414 days (interquartile range 217-650) of follow-up, HMR provision was not associated with hospitalizations for unplanned events (subdistribution hazard ratio (sHR) 1.04, 95%CI 0.96-1.14), falls-related hospitalizations (sHR 0.97, 95%CI 0.83-1.13), LTCF entry (sHR 0.97, 95%CI 0.83-1.13), or all-cause mortality (adjusted HR 0.86, 95%CI 0.72-1.01). CONCLUSIONS: In a cohort of older people receiving long-term in-home aged care services, no differences in unplanned hospitalizations, falls, LTCF entry or mortality were observed those with HMRs compared to those that did not receive an HMR.

Association Between Pharmacologic Treatment of Depression and Patient-Reported Outcomes Following Total Hip and Knee Arthroplasty.

BACKGROUND: Depression is associated with inferior outcomes following hip or knee arthroplasty, though it remains unclear if this relationship is modifiable. This study examined the association between pharmacologic treatment of depression and patient-reported outcomes. METHODS: This retrospective cohort study of 1,651 total hip arthroplasty (THA) and 1,792 total knee arthroplasty (TKA) procedures between October 2012 and June 2019 used institutional registry data linked to nationwide pharmaceutical claims. The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) global score, with pain and function sub-scales assessed as secondary outcomes. The TKA and THA patients were analyzed separately via mixed-effect linear regression to compare patients who had depression treated with antidepressants (TKA, n = 210; THA, n = 150) to those who had untreated depression (TKA, n = 43; THA; n = 50), and those who did not have depression (TKA, n = 1,539; THA, n = 1,451). RESULTS: Among patients who had depression, not receiving preoperative antidepressant therapy was associated with smaller improvements in WOMAC global scores (TKA, adjusted mean difference [MD]: -13.1 points, 95% CI [confidence interval]: -21.4 to -4.8; THA, MD: -8.5 points, 95% CI: -15.7 to -1.2) at two years after surgery, but not at one year (TKA, MD: -5.4 points, 95% CI: -12.9 to 2.1; THA, MD: -6.3 points, 95% CI: -12.9 to 0.3). Those who did not have depression had similar improvements in WOMAC global scores to those who had treated depression at both one (TKA, MD: 0.8 points, 95% CI: -2.7 to 4.4; THA, MD: 1.8 points, 95% CI: -1.8 to 5.4) and two years (TKA, MD: -1.1 points, 95% CI: -4.9 to 2.7; THA, MD: -1.6 points, 95% CI: -5.6 to 2.3). The findings were consistent with secondary outcomes. CONCLUSION: Among patients who have depression, antidepressant therapy before TKA or THA is associated with improved outcomes. Additional studies are needed to establish the impact of interventions to address untreated depression before surgery.

Aged care service use by Aboriginal and Torres Strait Islander people after aged care eligibility assessments, 2017-2019: a population-based retrospective cohort study.

OBJECTIVE: To characterise the socio-demographic characteristics, aged and health care needs, and aged care services used by older Aboriginal and Torres Strait Islander people assessed for aged care service eligibility. STUDY DESIGN: Population-based retrospective cohort study; analysis of Registry of Senior Australians (ROSA) National Historical Cohort data. SETTING, PARTICIPANTS: Aboriginal and Torres Strait Islander people aged 50 years or older who were first assessed for aged care service eligibility (permanent residential aged care, home care package, respite care, or transition care) during 1 January 2017 - 31 December 2019. MAJOR OUTCOME MEASURES: Socio-demographic and aged care assessment characteristics; health conditions and functional limitations recorded at the time of the assessment; subsequent aged care service use. RESULTS: The median age of the 6209 people assessed for aged care service eligibility was 67 years (interquartile range [IQR], 60-75 years), 3626 were women (58.4%), and 4043 lived in regional to very remote areas of Australia (65.1%). Aboriginal health workers were involved in 655 eligibility assessments (10.5%). The median number of health conditions was six (IQR, 4-8); 6013 (96.9%) had two or more health conditions, and 2592 (41.8%) had seven or more. Comorbidity was most frequent among people with mental health conditions: 597 of 1136 people with anxiety (52.5%) and 1170 of 2416 people with depression (48.5%) had seven or more other medical conditions. Geriatric syndromes were recorded for 2265 people (36.5%); assistance with at least one functional activity was required by 6190 people (99.7%). A total of 6114 people (98.5%) were approved for at least one aged care service, 3218 of whom (52.6%) subsequently used these services; the first services used were most frequently home care packages (1660 people, 51.6%). CONCLUSION: Despite the high care needs of older Aboriginal and Torres Strait Islander people, only 52% used aged care services for which they were eligible. It is likely that the health and aged care needs of older Aboriginal and Torres Strait Islander people are not being adequately met.

Quality indicators to monitor the quality and safety of care for older people: a scoping review protocol.

OBJECTIVE: The objective of this review is to identify quality indicators used to monitor the quality and safety of care provided to older people (≥ 65 years old) in 8 care settings: primary care; hospital/acute care; aged care (including residential aged care and home or community care); palliative care; rehabilitation care; care transitions; dementia care; and care in rural areas. INTRODUCTION: There is a need for high-quality, holistic, person-centered aged and health care for older people. Older people receive care across multiple care settings, and population-level monitoring of quality and safety of care across settings represents a significant challenge. INCLUSION CRITERIA: National and international quality indicators used to monitor and evaluate quality and safety of care at the population level for older individuals in the 8 key care settings will be considered for inclusion. English-language quantitative and mixed method studies published from 2012 will be considered. METHODS: Academic (MEDLINE, Embase) and gray (government websites, clinical guidelines, Google) literature searches will be conducted. A standardized data extraction tool will be used to describe the identified quality indicators and associated tools. Quality indicators will be categorized by key domains (ie, pain, function, consumer experience, service delivery), quality indicator type (structure, process, outcome) and the Institute of Medicine's 6 dimensions of care quality (eg, efficiency, effectiveness, appropriateness, accessibility, acceptability/person-centered, safety). The scoping review will be conducted in accordance with the JBI methodology for scoping reviews and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). REVIEW REGISTRATION: Open Science Framework osf.io/8czun.

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.

Medication management in long-term care: using evidence generated from real-world data to effect policy change in the Australian setting.

Older individuals residing in long-term care facilities (LTCFs) are often living with multimorbidity and exposed to polypharmacy, and many experience medication-related problems. Because randomized controlled trials seldom include individuals in LTCFs, pharmacoepidemiological studies using real-world data are essential sources of new knowledge on the utilization, safety and effectiveness of pharmacotherapies and related health outcomes in this population. In this commentary, we discuss recent pharmacoepidemiological research undertaken to support the investigations and recommendations of a landmark public inquiry into the quality and safety of care provided in the approximately 3,000 Australian LTCFs which house over 240,000 residents annually and informed subsequent national medication-related policy reforms. Suitable sources of real-world data for pharmacoepidemiological studies in long-term care cohorts and methodological considerations are also discussed.

Predictors of mortality shortly after entering a long-term care facility.

OBJECTIVE: Moving into a long-term care facility (LTCF) requires substantial personal, societal and financial investment. Identifying those at high risk of short-term mortality after LTCF entry can help with care planning and risk factor management. This study aimed to: (i) examine individual-, facility-, medication-, system- and healthcare-related predictors for 90-day mortality at entry into an LTCF and (ii) create risk profiles for this outcome. DESIGN: Retrospective cohort study using data from the Registry of Senior Australians. SUBJECTS: Individuals aged ≥ 65 years old with first-time permanent entry into an LTCF in three Australian states between 01 January 2013 and 31 December 2016. METHODS: A prediction model for 90-day mortality was developed using Cox regression with the purposeful variable selection approach. Individual-, medication-, system- and healthcare-related factors known at entry into an LTCF were examined as predictors. Harrell's C-index assessed the predictive ability of our risk models. RESULTS: 116,192 individuals who entered 1,967 facilities, of which 9.4% (N = 10,910) died within 90 days, were studied. We identified 51 predictors of mortality, five of which were effect modifiers. The strongest predictors included activities of daily living category (hazard ratio [HR] = 5.41, 95% confidence interval [CI] = 4.99-5.88 for high vs low), high level of complex health conditions (HR = 1.67, 95% CI = 1.58-1.77 for high vs low), several medication classes and male sex (HR = 1.59, 95% CI = 1.53-1.65). The model out-of-sample Harrell's C-index was 0.773. CONCLUSIONS: Our mortality prediction model, which includes several strongly associated factors, can moderately well identify individuals at high risk of mortality upon LTCF entry.

National trends in utilisation of glucose lowering medicines by older people with diabetes in long-term care facilities.

AIMS: To examine national trends in glucose lowering medicine (GLM) use among older people with diabetes in long-term care facilities (LTCFs) during 2009-2019. METHODS: A repeated cross-sectional study of individuals ≥65 years with diabetes in Australian LTCFs (n = 140,322) was conducted. Annual age-sex standardised prevalence of GLM use and number of defined daily doses (DDDs)/1000 resident-days were estimated. Multivariable Poisson or Negative binomial regression models were used to estimate adjusted rate ratios (aRRs) and 95 % confidence intervals (CIs). RESULTS: Prevalence of GLM use remained steady between 2009 (63.9%, 95 %CI 63.3-64.4) and 2019 (64.3%, 95 %CI 63.9-64.8) (aRR 1.00, 95 %CI 1.00-1.00). The percentage of residents receiving metformin increased from 36.0% (95 %CI 35.3-36.7) to 43.5% (95 %CI 42.9-44.1) (aRR 1.01, 95 %CI 1.01-1.01). Insulin use also increased from 21.5% (95 %CI 21.0-22.0) to 27.0% (95 %CI 26.5-27.5) (aRR 1.02, 95 %CI 1.02-1.02). Dipeptidyl peptidase-4 inhibitor use increased from 1.0% (95 %CI 0.9-1.1) to 21.1% (95 %CI 20.7-21.5) (aRR 1.24, 95 %CI 1.24-1.25), while sulfonylurea use decreased from 34.4% (95 %CI 33.8-35.1) to 19.3% (95 %CI 18.9-19.7) (aRR 0.93, 95 %CI 0.93-0.94). Similar trends were observed in DDDs/1000 resident days. CONCLUSIONS: The increasing use of insulin and ongoing use of sulfonylureas suggests a need to implement evidence-based strategies to optimise diabetes care in LTCFs.

National surveillance using a clinical quality indicator for prolonged antipsychotic use among older Australians with dementia who access aged care services.

OBJECTIVES: Dementia guidelines recommend antipsychotics are only used for behavioral and psychological symptoms when non-drug interventions fail, and to regularly review use. Population-level clinical quality indicators (CQIs) for dementia care in permanent residential aged care (PRAC) typically monitor prevalence of antipsychotic use but not prolonged use. This study aimed to develop a CQI for antipsychotic use >90 days and examine trends, associated factors, and variation in CQI incidence; and examine duration of the first episode of use among individuals with dementia accessing home care packages (HCPs) or PRAC. METHODS: Retrospective cohort study, including older individuals with dementia who accessed HCPs (n = 50,257) or PRAC (n = 250,196). Trends in annual CQI incidence (2011-12 to 2015-16) and associated factors were determined using Poisson regression. Funnel plots examined geographical and facility variation. Time to antipsychotic discontinuation was estimated among new antipsychotic users accessing HCP (n = 2367) and PRAC (n = 15,597) using the cumulative incidence function. RESULTS: Between 2011-12 and 2015-16, antipsychotic use for >90 days decreased in HCP recipients from 10.7% (95% CI 10.2-11.1) to 10.1% (95% CI 9.6-10.5, adjusted incidence rate ratio (aIRR) 0.97 (95% CI 0.95-0.98)), and in PRAC residents from 24.5% (95% CI 24.2-24.7) to 21.8% (95% CI 21.5-22.0, aIRR 0.97 (95% CI 0.96-0.98)). Prior antipsychotic use (both cohorts) and being male and greater socioeconomic disadvantage (PRAC cohort) were associated with higher CQI incidence. Little geographical/facility variation was observed. Median treatment duration in HCP and PRAC was 334 (interquartile range [IQR] 108-958) and 555 (IQR 197-1239) days, respectively. CONCLUSIONS: While small decreases in antipsychotic use >90 days were observed between 2011-12 and 2015-16, findings suggest antipsychotic use among aged care recipients with dementia can be further minimized.

Primary, allied health, selected specialists, and mental health service utilisation by home care recipients in Australia before and after accessing the care, 2017-2019.

OBJECTIVES: To examine changes in primary, allied health, selected specialists, and mental health service utilisation by older people in the year before and after accessing home care package (HCP) services. METHODS: A retrospective cohort study using the Registry of Senior Australians Historical National Cohort (≥ 65 years old), including individuals accessing HCP services between 2017 and 2019 (N = 109,558), was conducted. The utilisation of general practice (GP) attendances, health assessments, chronic disease management plans, allied health services, geriatric, pain, palliative, and mental health services, subsidised by the Australian Government Medicare Benefits Schedule, was assessed in the 12 months before and after HCP access, stratified by HCP level (1-2 vs. 3-4, i.e., lower vs. higher care needs). Relative changes in service utilisation 12 months before and after HCP access were estimated using adjusted risk ratios (aRR) from Generalised Estimating Equation Poisson models. RESULTS: Utilisation of health assessments (7-10.2%), chronic disease management plans (19.7-28.2%), and geriatric, pain, palliative, and mental health services (all ≤ 2.5%) remained low, before and after HCP access. Compared to 12 months prior to HCP access, 12 months after, GP after-hours attendances increased (HCP 1-2 from 6.95 to 7.5%, aRR = 1.07, 95% CI 1.03-1.11; HCP 3-4 from 7.76 to 9.32%, aRR = 1.20, 95%CI 1.13-1.28) and allied health services decreased (HCP 1-2 from 34.8 to 30.7%, aRR = 0.88, 95%CI 0.87-0.90; HCP levels 3-4 from 30.5 to 24.3%, aRR = 0.80, 95%CI 0.77-0.82). CONCLUSIONS: Most MBS subsidised preventive, management and specialist services are underutilised by older people, both before and after HCP access and small changes are observed after they access HCP.

Hospitalisations and emergency department presentations by older individuals accessing long-term aged care in Australia.

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.

National Trends in Antidepressant Use in Australian Residential Aged Care Facilities (2006-2019).

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.

Historical Trends and Future Projections of Demand for Permanent Residential Aged Care for Older People in Australia, 2008-2052.

OBJECTIVES: To examine the historical trends and predict the future rates and total volumes of permanent residential aged care (PRAC) service utilization in Australia. DESIGN: A population-based repeated cross-sectional and projection study of non-indigenous older people (≥65 years) accessing PRAC in Australia was conducted. SETTING AND PARTICIPANTS: Publicly available aged care admissions from the Australian Institute of Health and Welfare and population estimates from the Australian Bureau of Statistics were used. METHODS: Historical incidence rates (per 1000 people), incidence rate ratios (IRRs) and 95% CIs of PRAC admission from 2008-2009 to 2020-2021 were estimated using negative binomial regression models. The future incidence and prediction intervals (PIs) of PRAC admission between 2021-2022 and 2051-2052 were projected using a generalized additive model-negative binomial regression. All estimates were adjusted or standardized by sex and age. RESULTS: Between 2008-2009 and 2020-2021, the adjusted admission to PRAC decreased (from 23.6/1000 people to 15.7/1000 people with an IRR = 0.97/year, 95% CI 0.97-0.98). The projected PRAC admission rate will decrease to 12.1/1000 (95%PI 10.8-13.3) by 2037-2038 and 9.0/1000 (95%PI 7.6-10.4) by 2051-2052. The projected volume of PRAC admission will be 73,988 (95%PI 65,960-81,425) at its highest point in 2037-2038 and 64,579 (95%PI 54,258-74,543) in 2051-2052. CONCLUSIONS AND IMPLICATIONS: The utilization of PRAC has decreased in the past decade, and a predicted decrease in PRAC use in future years is estimated. However, the volume of PRAC utilization will still increase for the next 15 years (until 2037-2038) due to our increasingly older population. These findings can inform service planning of PRAC access in Australia.

Excess mortality in residents of aged care facilities during COVID-19 in Australia, 2019-22.

BACKGROUND: To date, the excess mortality experienced by residential aged care facility (RACF) residents related to COVID-19 has not been estimated in Australia. This study examined (i) the historical mortality trends (2008-09 to 2021-22) and (ii) the excess mortality (2019-20 to 2021-22) of Australian RACF residents. METHODS: A retrospective population-based study was conducted using the Australian Institute of Health and Welfare's GEN website data (publicly available aged care services information). Non-Aboriginal, older (≥65 years old) RACF residents between 2008-09 and 2021-22 were evaluated. The observed mortality rate was estimated from RACF exits compared with the RACF cohort yearly. Direct standardization was employed to estimate age-standardized mortality rates and 95% CIs. Excess mortality and 95% prediction intervals (PIs) for 2019-20 to 2021-22 were estimated using four negative binomial (NB) and NB generalized additive models and compared. RESULTS: The age-standardized mortality rate in 2018-19 was 23 061/100 000 residents (95% CI, 22 711-23 412). This rate remained similar in 2019-20 (23 023/100 000; 95% CI, 22 674-23 372), decreased in 2020-21 (22 559/100 000; 95% CI, 22 210-22 909) and increased in 2021-22 (24 885/100 000; 95% CI, 24 543-25 227). The mortality rate increase between 2020-21 and 2021-22 was observed in all age and sex groups. All models yielded excess mortality in 2021-22. Using the best-performing model (NB), the excess mortality for 2019-20 was -160 (95% PI, -418 to 98), -958 (95% PI, -1279 to -637) for 2020-21 and 4896 (95% PI, 4503-5288) for 2021-22. CONCLUSIONS: In 2021-22, RACF residents, who represented <1% of the population, experienced 21% of the Australian national excess mortality (4896/22 886). As Australia adjusts to COVID-19, RACF residents remain a population vulnerable to COVID-19.