July 2019| University of Exeter – Apathy: The forgotten symptom of dementia
Apathy is the most common neuropsychiatric symptom of dementia, with a bigger impact on function than memory loss – yet it is under-researched and often forgotten in care.
A new study has found that apathy is present nearly half of all people with dementia, with researchers finding it is often distinct from depression.
Although common, apathy is often ignored as it is less disruptive in settings such as care homes than symptoms like aggression. Defined by a loss of interest and emotions, it is extremely distressing for families and it is linked with more severe dementia and worse clinical symptoms.
Now, research led by the University of Exeter and presented at the Alzheimer’s Association International Conference in LA has analysed 4,320 people with Alzheimer’s disease from 20 cohort studies, to look at the prevalence of apathy over time.
At the start of the study, 45% presented with apathy, and 20% had persistent apathy over time. Researchers found that a proportion had apathy without depression, which suggests that the symptom might have its own unique clinical and biological profile when compared to apathy with depression and depression only.
Miguel de Silva Vasconcelos, PhD student at the University of Exeter and King’s College London, said : “Apathy is an under-researched and often ignored symptom of dementia. It can be overlooked because people with apathy seem less disruptive and less engaging, but it has a huge impact on the quality of life of people living with dementia, and their families. Where people withdraw from activities, it can accelerate cognitive decline and we know that there are higher mortality rates in people with apathy. It’s now time this symptom was recognised and prioritised in research and understanding.”
Professor Clive Ballard, of the University of Exeter Medical School, said: “Apathy is the forgotten symptom of dementia, yet it can have devastating consequences. Our research shows just how common apathy is in people with dementia, and we now need to understand it better so we can find effective new treatments. Our WHELD study to improve care home staff training through personalised care and social interaction included an exercise programme that improved apathy, so we know we can make a difference. This is a real opportunity for interventions that could significantly benefit thousands of people with dementia.”
The presentation was entitled ‘The Course of Apathy in People with Dementia’.
Aside from this criminal behaviour, Ms Hausler said the standards at her father’s aged care facility declined after a new operator reduced staffing levels and employed carers with little training. Call bells went unanswered, she said, and incontinence pads were rationed.
Ms Hausler has called for increased ratios of registered nurses in aged care facilities, and better training and registration for carers.
Under-staffing and inadequate training have long been problems in Australia’s aged care facilities, with aged care facilities employing fewer registered and enrolled nurses and more carers who have lower levels of training.
A registered nurse (RN) provides nursing leadership and clinical supervision in aged care facilities. They are skilled clinicians who can respond to medical emergencies and are qualified to carry out assessments.
An enrolled nurse (EN) conducts observations and assessments, and collaborates with and seeks assistance from the registered nurse in charge. Enrolled nurses are registered with AHPRA and undergo an 18-month diploma of nursing at TAFE.
Finally, care workers form the bulk of the aged care workforce and perform tasks such as showering, dressing and feeding residents. Titles for carers vary and include assistant in nursing, personal care worker, personal care attendant, and aged care worker, to name a few.
Care workers are required to complete a certificate III-level course, which can take up to six or seven months, but don’t require registration.
Carers cost less than nurses
There is no clear legislation requiring a certain number of registered nurses, enrolled nurses and carers to be on duty at certain point in time. The Aged Care Act 1997 is open to interpretation, so aged care providers are largely free to set their own staffing levels.
Research shows having a greater number of registered nurses increases patients’ well-being and safety. Better staffing levels allow nurses to spend more time caring for residents and reduces the likelihood that vital information is overlooked.
Employing skilled registered nurses in aged care facilities can also save the health system money by reducing the number of costly hospital admissions that arise because residents can’t be adequately cared for in their aged care facility.
Aged care residents often have mental health issues, face cognitive decline or dementia, take multiple medications each day, are physically frail, and often have multiple chronic conditions such as heart disease, diabetes, cancer, arthritis or asthma.
But it’s difficult to meet the needs of these patients with the current aged care staffing and skill levels.
More than 50% of the residents in a residential aged care facilities have some form of dementia, for example, yet more than 50% of aged care workers have no dementia training.
Substituting registered nurses with lesser skilled carers has meant tasks such as medication management have been assigned to carers in some aged care facilities, despite this being a high-risk task that requires a high level of skill and experience.
What are the solutions?
Carers currently make up around 70% of the aged care workforce. We need to reset aged care staffing levels and ensure we have the right skill sets, which industry bodies suggest is: 30% registered nurses, 20% enrolled nurses and 50% care workers.
Registration would clarify carers’ roles and allow only the delegation of tasks which are deemed safe for carers to carry out within their scope of practice. It would also ensure minimum training standards are met and that quality and safety is maintained.
The aim is not to vilify carers, who are the backbone of our aged care system, but rather to highlight the need for the right level of training, education and support to strengthen the aged care workforce and complement the care provided by registered and enrolled nurses.
Finally, we also need to increase the number of registered and enrolled nurses in the aged care workforce with guided pathways to attract and retain nurses. Well-structured graduate nurse programs, for instance, can provide support and guidance to the graduates who are considering a career in aged care.
April 2019 | University College London, Gower Street, London – Dementia more preventable in Asia and Latin America
Close to one in two cases of dementia could be preventable in low- to middle-income countries, finds a new UCL study.
Dancing in Peru
The findings, published in The Lancet Global Health, found how improving childhood education and other health outcomes throughout life could reduce the risk of dementia.
“After our previous research finding that one in three cases of dementia could be preventable, we realised that the evidence was skewed towards higher-income countries,” said the study’s lead author, Dr Naaheed Mukadam (UCL Psychiatry).
“We have now found that in low- to middle-income countries in Asia and Latin America, dementia may be even more preventable than it is in more wealthy countries. If life-course risk factors such as low levels of education in early life and hearing loss, obesity and low physical activity in mid-life to old age are addressed, these countries could see large improvements in their dementia rates.”
While the number of people with dementia is increasing globally, particularly in low- to middle-income countries, there have been modest reductions in age-specific dementia rates in many high-income countries over the last two decades.* The researchers say this could be due to improvements in health outcomes throughout life that affect dementia risk.
The research team built on their previous work for the Lancet Commission on dementia prevention, intervention, and care, published in 2017, which found that 35% of dementia is attributable to nine risk factors: low levels of childhood education, hearing loss, smoking, hypertension, obesity, physical inactivity, social isolation, depression, and diabetes.*
To understand whether the commission’s findings would apply equally to global regions that were underrepresented in the report, a team of UCL researchers sought out data from China, India and Latin America. They drew from the research collective 10/66 Dementia Research Group’s data, which used similar methodology to gauge prevalence of the nine risk factors in those countries, with sample sizes of 1,000 to 3,000 in each country.
The researchers found even more potential for preventing dementia across the globe, as the proportion of dementia linked to the nine modifiable risk factors was 40% in China, 41% in India and 56% in Latin America.
A major factor in that difference is the lower levels of educational attainment in low- to middle-income countries, which the researchers say signals hope for the future, as education levels rise.
“People growing up in Asia and Latin America today are more likely to have completed schooling than their parents and grandparents were, meaning they should be less at risk of dementia later in life than people who are already over 65. Continuing to improve access to education could reap great benefits for dementia rates in years to come,” Dr Mukadam said.
On the other hand, social isolation is a major risk factor of dementia in higher income countries, but much less so in China and Latin America. The researchers say that public health officials in countries such as the UK could learn from China and Latin America in efforts to build more connected communities to buffer against the dementia risk tied to social isolation.
Obesity and hearing loss in mid-life, and physical activity in later life, were also strongly linked to dementia risk in the study area, as well as mid-life hypertension in China and Latin America and smoking in later-life in India.
“Reducing the prevalence of all of these risk factors clearly has numerous health benefits, so here we’ve identified an added incentive to support public health interventions that could also reduce dementia rates. The growing global health burden of dementia is an urgent priority, so anything that could reduce dementia risk could have immense social and economic benefit,” Dr Mukadam said.
Senior author Professor Gill Livingston (UCL Psychiatry) added: “A lot of the findings of health and medical research derive primarily from higher income countries such as in Western Europe and North America, so ensuring that research is inclusive is vital to the development of global public health strategies.”
“While we don’t expect these risk factors to be eliminated entirely, even modest improvements could have immense impact on dementia rates. Delaying the onset of dementia by just five years would halve its prevalence*,” she said.
The researchers are supported by the National Institute for Health Research UCLH Biomedical Research Centre, Wellcome, NIHR, Economic and Social Research Council, and NIHR Collaboration for Leadership in Applied Health Research and Care North Thames.
Research paper in The Lancet Global Health
Dr Naaheed Mukadam’s academic profile
* The Lancet Commission on dementia, prevention, intervention and care
People dancing in Peru. Credit: Alex Proimos, Source: Flickr
tel: +44 20 7679 9222
Dementia is a cruel disease that robs people of their memory, their judgement and their identity. Unfortunately, there is no cure, and in the past few years a number of clinical trials for new dementia drugs have failed – the latest being Biogen’s drug aducanumab. Without any effective treatments on the horizon, most people’s best hope is to avoid getting dementia in the first place.
One of the hallmarks of dementia is cognitive decline. There are several lifestyle changes that may slow cognitive decline, such as doing mentally stimulating activities (crossword puzzles, learning a new language), getting plenty of exercise and maintaining a healthy diet – especially one low in saturated fats, refined carbohydrates and sugar.
Of these, diet is a favourite among health reporters, perhaps because the message can be delivered clearly and succinctly. The latest such story comes from the Daily Mirror which claims that eating just two teaspoons of nuts a day “boosts brain function by 60%”. If the claim is true, we should all be rushing out to buy a bag of nuts, but is this what the study actually says?
The article is based on an observational study published in the Journal of Nutrition Health and Aging. After assessing the diets of nearly 5,000 adults in China (aged 55 and older) over a period of nine years, the researchers found an inverse relationship between the amount of nuts people ate and the degree of cognitive decline they experienced. Those who consumed more than 10g of nuts and seeds a day were less likely to show a fall in their cognitive function compared with those who consumed less than 10g a day.
Out of the 4,822 participants in the study, 67% had their cognitive ability tested twice (only 16% were tested more than twice over the course of the study). Where more than one cognitive measurement was made, cognitive performance decreased over time, but people who ate more than 10g of nuts per day decreased the likelihood of this decline. Consequently, the results suggest that consuming two teaspoons of nuts per day may preserve cognitive performance and may lead to better cognitive ageing over a lifetime. The results do not show that eating nuts improves cognitive function, as the Mirror headline claimed.
Participants in the study inevitably varied on a number of factors, including education, general health, nutritional intake and lifestyle factors, such as exercise. Although the way the data was analysed took those factors into account and still found an association, cognitive decline and dementia are strongly influenced by many environmental and genetic factors, and it is unlikely that consumption of one particular food is sufficient to ward off dementia.
Another weakness of this study is the fact that participants reported their nut consumption via a questionnaire. Evidence shows that self-reported food consumption should always be interpreted with caution.
Although randomised controlled trials indicate that eating nuts has an effect on blood flow (including to the brain), there isn’t enough evidence to draw conclusions about their impact on cognitive function.
What we can say at this point is that the evidence on nuts and cognitive decline is promising, but it isn’t strong enough to make nutritional recommendations. Simply consuming two teaspoons of nuts per day is unlikely to reduce your risk of dementia.
April 2019 | University of Pennsylvania – Empathy and cooperation go hand in hand
Taking a game theory approach to study cooperation, School of Arts and Sciences evolutionary biologists find that empathy can help cooperative behavior ‘win out’ over selfishness.
It’s a big part of what makes us human: we cooperate. But humans aren’t saints. Most of us are more likely to help someone we consider good than someone we consider a jerk.
How we form these moral assessments of others has a lot to do with cultural and social norms, as well as our capacity for empathy, the extent to which we can take on the perspective of another person.
In a new analysis, researchers from the University of Pennsylvania investigate cooperation with an evolutionary approach. Using game-theory-driven models, they show that a capacity for empathy fosters cooperation, according to senior author Joshua Plotkin, an evolutionary biologist. The models also show that the extent to which empathy promotes cooperation depends on a given society’s system for moral evaluation.
“Having not just the capacity but the willingness to take into account someone else’s perspective when forming moral judgments tends to promote cooperation,” says Plotkin.
What’s more, the group’s analysis points to a heartening conclusion. All else being equal, empathy tends to spread throughout a population under most scenarios.
“We asked, ‘can empathy evolve?’” explains Arunas Radzvilavicius, the study’s lead author and a postdoctoral researcher who works with Plotkin. “What if individuals start copying the empathetic way of observing each other’s interactions? And we saw that empathy soared through the population.”
Plenty of scientists have probed the question of why individuals cooperate through indirect reciprocity, a scenario in which one person helps another not because of a direct quid pro quo but because they know that person to be “good.” But the Penn group gave the study a nuance that others had not explored. Whereas other studies have assumed that reputations are universally known, Plotkin, Radzvilavicius, and Stewart realized this did not realistically describe human society, where individuals may differ in their opinion of others’ reputations.
“In large, modern societies, people disagree a lot about each other’s moral reputations,” Plotkin says.
The researchers incorporated this variation in opinions into their models, which imagine someone choosing either to donate or not to donate to a second person based on that individual’s reputation. The researchers found that cooperation was less likely to be sustained when people disagree about each other’s reputations.
That’s when they decided to incorporate empathy, or theory of mind, which, in the context of the study, entails the ability to understand the perspective of another person.
Doing so allowed cooperation to win out over more selfish strategies.
“It makes a lot of sense,” Plotkin says. “If I don’t account for your point of view, there will be many occasions when I judge you harshly when I really shouldn’t because, from your perspective, you were doing the right thing.”
To further explore the impact of empathy on cooperation, the researchers looked at a variety of frameworks, or social norms, that people might use to assign a reputation to another person based on their behavior. For example, most frameworks label someone “good” if they reward a fellow “good” individual, but social norms differ in how they judge interactions with a person deemed bad. While the “stern judging” norm labels “good” anyone who punishes a bad actor, the “simple standing” norm does not require this punitive approach: A “good” person can reward a bad one.
Plotkin, Radzvilavicius, and Stewart discovered again that capacity for empathy mattered. When populations were empathetic, stern judging was the best at promoting cooperation. But when a group was less willing to take on the perspective of another, other norms maximized rates of cooperation.
This result prompted the team to ask another evolutionary question—whether empathy itself can evolve and become stable in a population. And under most scenarios, the answer was yes.
“Starting with a population where no one is empathetic, with people judging each other based on their own perspective, we saw that eventually individuals will copy the behavior of those who judge empathetically,” says Plotkin. “Empathy will spread, and cooperation can emerge.”
This was the case even when the researchers accounted for a degree of errors, noise, and misperception in their models.
The findings open up a new area of research for both evolutionary theory and empirical studies into how societies behave.
“Empathy is completely foreign to game theory,” Radzvilavicius say. “In a way this is finding a new niche for research to progress to in the future, accounting for theory of mind.”
Looking ahead, the Penn team hopes to pursue such questions, perhaps by pitting different social norms against one another and eventually by testing their ideas against observations from real people, either through experiments they design or through data collected from social media.
“It’s obvious that in social media people are acutely aware of their public persona and reputation and curate it carefully,” Plotkin says. “It would be fascinating to analyze these evolutionary dynamics as they play out in online interactions.”
April 2019 | the Society of Nuclear Medicine and Molecular Imaging – New PET Imaging Biomarker Could Better Predict Progression of Alzheimer’s Disease
Reston, VA—Researchers have discovered a way to better predict progression of Alzheimer’s disease. By imaging microglial activation levels with positron emission tomography (PET), researchers were able to better predict progression of the disease than with beta-amyloid PET imaging, according to a study published in the April issue of The Journal of Nuclear Medicine.
According to the Alzheimer’s Association, an estimated 5.3 million Americans are currently living with Alzheimer’s disease. By 2025, that number is expected to increase to more than seven million. The hallmark brain changes for those with Alzheimer’s disease include the accumulation of beta-amyloid plaques. When microglial cells from the central nervous system recognize the presence of beta-amyloid plaques, they produce an inflammatory reaction in the brain.
“The 18-kD translocator protein (TSPO) is highly expressed in activated microglia, which makes it a valuable biomarker to assess inflammation in the brain,” said Matthias Brendel, MD, MHBA, at Ludwig-Maximilians-University of Munich in Germany. “In our study, we utilized TSPO-PET imaging to determine whether microglial activation had any influence on cognitive outcomes in an amyloid mouse model.”
Figure 2. Longitudinal TSPO and Aβ PET and performance in behavioral testing. (A) Cortical TSPO PET and Aβ PET signal intensities of PS2APP mice at different ages are expressed as z scores relative to ﬁndings in age-matched C57BL/6 mice. Coronal and axial slices are projected on T1-weighted MRI template. (B) Progression of individual TSPO PET z scores and Aβ PET z scores in forebrain of PS2APP mice (n = 10) with age. (C) Differences between PS2APP and C57BL/6 (WT) mice for escape latency (sec) and traveled distance in pixels (pix) as WM readouts. Error bars represent SEM. *P < 0.01. **P < 0.001.
In the study, researchers compiled a series of PET images for 10 transgenic mice with beta-amyloid proteins and seven wild-type mice. TSPO PET imaging of activated microglia was conducted at eight, 9.5, 11.5 and 13 months, and beta-amyloid PET imaging was performed at eight and 13 months. Upon completion of the imaging, researchers then subjected the mice to a water maze in which the mice were to distinguish between a floating platform that would hold their weight and one that would sink. The tasks were performed several times a day during a 1.5-week period. Memory performance in the water maze was assessed by measuring the average travel time from the start point to a platform each day of training and by calculating the traveled distance at the last day of training. After completing the water maze task, immunohistochemistry analyses were performed for microglia, amyloid and synaptic density.
Transgenic mice with the highest TSPO PET signal in the forebrain or other areas associated with spatial learning tended to have better cognitive performance in the water maze, while beta-amyloid signals in the same areas of the brain showed no correlation to cognitive outcomes in the maze. Researchers found that an earlier microglial response to amyloid pathology in transgenic mice also protected synaptic density at follow-up. Specifically, transgenic mice with higher TSPO expression at eight months had much better cognitive outcomes in the water maze and higher synaptic density as confirmed by immunochemistry analyses.
“This study provides the first evidence that the level of microglial activation could be a far better predictor of current and future cognitive performance than beta-amyloid levels,” noted Brendel. “Keeping the limitations of mouse models in mind, it could be crucial to modify an individual’s microglial activation state to ameliorate future cognitive decline. We believe that a balanced microglia activation is crucial for prevention of cognitive impairment.”
The authors of “Early and Longitudinal Microglial Activation but Not Amyloid Accumulation Predicts Cognitive Outcome in PS2APP Mice” include Carola Focke, Maximilian Deussing, Claudio Schmidt, Simon Lindner, Franz-Josef Gildehaus, Leonie Beyer and Barbara von Ungern-Sternberg, Department of Nuclear Medicine, University Hospital of Munich, LMU Munich, Munich, Germany; Tanja Blume, Department of Nuclear Medicine, University Hospital of Munich, LMU Munich, Munich, Germany, and Center for Neuropathology and Prion Research, Ludwig-Maximilians-University of Munich, Munich, Germany; Benedikt Zott and Helmuth Adelsberger, Institute of Neuroscience, Technical University of Munich, Munich, Germany; Yuan Shi and Mario M. Dorostkar, Center for Neuropathology and Prion Research, Ludwig-Miximilians-University of Munich, Munich, Germany, and DZNE-German Center for Neurodegenerative Diseases, Munich, Germany; Finn Peters, DZNE-German Center for Neurodegenerative Diseases, Munich, Germany; Gernot Kleinberger, Munich Cluster for Systems Neurology, University of Munich, Munich, Germany, and Biomedical Center, Biochemistry, Ludwig-Maximilians-University of Munich, Munich, Germany; Peter Bartenstein and Matthias Brendel, Department of Nuclear Medicine, University Hospital of Munich, LMU Munich, Munich, Germany, and Munich Cluster for Systems Neurology, University of Munich, Munich, Germany; Laurence Ozmen and Karlheinz Baumann, Roche Pharma Research and Early Development, F. Hoffman-La Roche Ltd., Basel, Switzerland; Christian Haass, DZNE-German Center for Neurodegenerative Diseases, Munich, Germany, Munich Cluster for Systems Neurology, University of Munich, Munich, Germany, and Biomedical Center, Biochemistry, Ludwig-Maximilians-University of Munich, Munich, Germany; Jochen Herms, Center for Neuropathology and Prion Research, Ludwig-Maximilians-University of Munich, Munich, Germany, DZNE-German Center for Neurodegenerative Diseases, Munich, Germany, and Munich Cluster for Systems Neurology, University of Munich, Munich, Germany; Axel Rominger, Department of Nuclear Medicine, University Hospital of Munich, LMU Munich, Munich, Germany, Munich Cluster for Systems Neurology, University of Munich, Munich, Germany, and Department of Nuclear Medicine, Inselspital, University Hospital Bern, Bern, Switzerland.
For more information or to schedule an interview with the researchers, please contact Rebecca Maxey at (703) 652-6772 or firstname.lastname@example.org. Current and past issues of The Journal of Nuclear Medicine can be found online at http://jnm.snmjournals.org.
About the Society of Nuclear Medicine and Molecular Imaging
The Society of Nuclear Medicine and Molecular Imaging (SNMMI) is an international scientific and medical organization dedicated to advancing nuclear medicine and molecular imaging, vital elements of precision medicine that allow diagnosis and treatment to be tailored to individual patients in order to achieve the best possible outcomes.
SNMMI’s more than 17,000 members set the standard for molecular imaging and nuclear medicine practice by creating guidelines, sharing information through journals and meetings, and leading advocacy on key issues that affect molecular imaging and therapy research and practice. For more information, visit www.snmmi.org.
Some say they will make plans “when the need arises”. But what if you have a heart attack, go into a coma, have a stroke, or develop dementia before having shared your thoughts? We’re all ageing and none of us knows when our health will deteriorate to the point where we need daily domestic or medical assistance.
In the absence of clear instructions, you may instead be admitted into a hospital or aged care facility. That’s where most Australians aged 65 and over end up dying.
Think about how you will pay for home and aged care services, and whom you might rely on to be your advocate or carer.
Communicate your decisions (verbally and in writing) in as much detail as possible to those who need to know, such as future carers and health providers. This removes much of the guesswork later.
Relying on government-funded services is risky
Government-funded home care packages are intended to keep people in their homes for as long as possible. They provide supplementary support such as cleaning or shopping services, home visits by nurses and, in some cases, equipment to help with mobility or minor home modifications.
But while demand for these services is increasing, staffing and funding levels aren’t keeping up. Older Australians wait, on average, 18-24 months to access a home care package. In the meantime, many people are forced to move into residential care.
It’s also important to note that Australia’s aged care system is increasingly moving to a “user pays” model, whereby aged care clients are means-tested and expected to contribute financially to their care.
So it’s unwise to assume government funding will be sufficient to pay for your aged care services.
Attitudes to residential aged care
Aged care horror stories abound in the media, especially now the Royal Commission into Aged Care Quality and Safety is underway. Unfortunately, equal media coverage is not afforded to the many excellent aged care facilities in Australia.
The royal commission reported some Australians would rather die than live in residential aged care. But there is scarcely any research into public perceptions of residential aged care and whether they change over time.
In my own research, such attitudes resulted from exposure to negative media coverage, visiting residential aged care facilities, or working in aged care. Of particular concern were issues typical of institutional living – lack of privacy, personal choice or control. This was a particular issue for partnered residents, who represent one-third of aged care residents.
However, simply making a pronouncement that you reject residential care is not sufficient to prevent it happening. Entry into residential care usually happens in response to a crisis, either because people live alone or because family carers can no longer cope. The most common trigger is dementia.
Besides residential aged care, your other options include living independently with or without voluntary family or community support, a home care package and/or self-funded care. However, every scenario requires that you prepare in advance as follows.
Preparing for the end of your life
On an individual level, there are five important things you can do for yourself.
1. Adopt a healthy lifestyle
Learn about dementia, which is preventable in one-third of cases. Make lifestyle changes to reduce this and other diseases of old age. Maintaining social connections, getting regular exercise, lifelong learning, quitting smoking, losing weight, treating depression and even correcting for hearing loss all make a significant difference.
Early in your working life, plan your retirement income to last to 90 years of age and beyond. Aim to be debt-free and factor in costs associated with home care.
Assume you’ll be one of the 62% of people over 85 who needs residential aged care in their final years and budget accordingly. For this, you will need a bond of A$300,000 to A$500,000 minimum. Except in the lowest socioeconomic groups (who are exempted from bonds), insufficient bond money means many people, especially if they’re partnered, will not be able to afford residential aged care.
3. Talk about your wishes
First consider your preferences: where you want to die, who cares for you and what provisions you are likely to need. Then make your wishes widely known, especially to anyone you’d like to have care for you.
Choose representatives who will willingly act as advocates on your behalf, to ensure your wishes will be carried out. Advance care planning is especially important if you do not want medical intervention to keep you alive.
5. Choose carefully where you live
Consider the suitability of your home and suburb if walking becomes difficult and driving is no longer an option. Are you near a hospital? Can you reach it by public transport? Can you walk to the shops? Is your garden high-maintenance? Are friends and family nearby? Are there services available that could come to your home? Move before you need to.
Support (and be supported by) your community
Ageing is a whole-of-community issue – it affects us all. We cannot expect individuals to be solely responsible for their care.
In the past, caring for older people in their final years was routinely carried out by families and communities. This is still the best strategy. But it relies on communities forming volunteer groups to actively care for their older people.
Alison Rahn, Adjunct Research Fellow, School of Humanities, Arts & Social Sciences, University of New England; Senior Research Officer, School of Social Sciences & Psychology, Western Sydney University