On April 26 2012, results of a study conducted by the Dietitians Association of Australia showed that thousands of elderly Australians are suffering from or at a risk of developing malnutrition. This study comes soon after the Government announced so-called major reforms of Australia's aged care system that ignored this problem. This article explains more.
Date Published: 08 May 2012
Author: Joe Lederman, FoodLegal Australian Lawyers and Consultants
© Lawmedia Pty Ltd, May 2012
The recent announcements by the Australian government of aged care policies reforms are said to favour the elderly remaining in their homes while they receive aged care. It is not within the scope of this article to question the many assumptions that seem to have been made by the government, nor to question the financial imperative for government saving money in nursing home care. Nonetheless, this article examines some of the many inadequacies in government regulations regarding provision of meals and other services to the elderly in residential aged care facilities and in home delivery services.
The prevalence of malnutrition in the elderly population
Recurring evidence shows that elderly people are more susceptible to being malnourished due to physical and mental factors that come with ageing. Factors include difficulty in chewing food due to poor dentition, inability to feed oneself due to physical or cognitive incapacities, and a decrease in appetite caused by illness or depression.
In 2008, a study was conducted by the Queensland University of Technology on malnutrition prevalence and nutrition issues in eight residential aged care facilities (RACFs) in Australia. The results revealed that 43.1% of residents were moderately malnourished and 6.4% were severely malnourished.
These figures led to a public critique of the Australian aged-care system. In response to a recent submission by the Productivity Commission regarding funding of aged-care facilities, the Federal Government announced its so-called "Living Longer Living Better" plan in mid April 2012, which encourages more people to remain in their own homes rather than to live in a care facility.
Easily said, but the government is ignoring the realities of life for so many people.
The recent study published by the Dietitians Association of Australia concluded that elderly people who choose to live at home are no better off in terms of getting sufficient nourishment. The study found a third of Victorians aged between 65 and 100 who lived alone at home were at risk of malnutrition and 8 per cent were already suffering from it. Moreover, the study indicates most elderly people living in the community and receiving care were living on a fixed income of less than $30,000 a year. As a result, they were forced to cut back on grocery expenses or buy cheaper and less-nutritious foods to keep within budget.
Dehydration as a major contributor to malnutrition in aged care facilities
Malnutrition in residential aged care facilities (RACFs) is caused by a variety of factors including inadequate attention from staff for residents who need assistance eating, lack of individualised care, not providing oral health equipment prior to meals, and a lack of variety of meals or food that is unappetizing or served cold.
A major contributor to malnutrition in RACFs that is often overlooked is the issue of dehydration. Liquid intake is usually insufficiently monitored and residents may not have ready access to fresh water or juice throughout the day. Dehydration causes sleepiness and exhaustion due to a natural response by the body to preserve energy when liquid intake is low.
As a result, residents also often sleep through designated feeding times and due to a lack of supervision by staff of whether meals served are actually eaten, many residents miss meals on a regular basis and become undernourished. Anecdotally, where there is a lack of close monitoring of dehydration and food intake, many elderly quickly succumb to poor health and are at risk of premature death.
Symptoms of unattended elderly in care facilities
Apart from malnourished and underweight residents, there are various other tell-tale signs that a care facility is lacking in funding or is inadequately monitored by authorities. Examples include residents shouting or screaming to be attended to or residents experiencing falls and being left unattended on the floor.
Moreover, due to a lack of staff dedicated to feeding residents at meal times, many residents who lack the strength or agility to feed themselves, are encouraged by aged care facility management to accept peg-feeding as a substitute for ingesting food normally. Similarly, residents are easily coerced to accept the wearing of incontinence pads and nappies due to non-availability of staff for toilet functions.
Inadequacies in the current Australian regulatory framework of food and water provision in residential aged care facilities
It should be noted that all residential aged care facilities (RACFs) must have "approved provider status" and comply with the legislative obligations set out in the Aged Care Act 1997 ('the Act') in order to be eligible for government funding. Compliance with the legislation is monitored by the *Aged Care Standards and Accreditation Agency (ACSAA). *As from 1 January 2014, the Agency has been renamed to the Australian Aged Care Quality Agency (AACQA).
The ACSAA undertakes occasional visits to facilities to assess their performance against the Accreditation Standards, which are legislated under the Act (Quality of Care Principles). The Accreditation Standards contain a checklist of 44 'expected outcomes' relating to the quality of care RACFs provide and the rights of the people to whom they provide care.
The Accreditation Standards cover four main areas:
(1) management systems, staffing and organisational development;
(2) health and personal care;
(3) residential lifestyle; and
(4) physical environment and safe systems.
When it comes to the Accreditation Standard relevant to the provision of nourishment and hydration (Standard 2.10) for the residents, it is clear that the Standard is very vague and non-prescriptive, requiring only that:
(a) Meals of adequate variety, quality and quantity for each resident, served each day at times generally acceptable to both residents and management, and generally consisting of 3 meals per day plus morning tea, afternoon tea and supper;
(b) Special dietary requirements, having regard to either medical need or religious or cultural observance; and
(c) Food, including fruit of adequate variety, quality and quantity, and non-alcoholic beverages, including fruit juice.
The Federal Department of Health and Ageing has published a Standards and Guidelines for Residential Aged Care Services Manual to assist service providers to comply with their obligations under the Act. This includes information on the quality management and services expected of a RACF.
However, neither the Standard itself nor the Standards and Guidelines for Residential Aged Care Services Manual provide specific guidance to auditors about the adequacy of dietary supervision or food choices that should be available to residents in order to satisfy basic nutritional requirements.
Staff in many of Australia's aged care facilities may have limited information or trained understanding of the guidelines and responsibilities for the hydration and nutritional needs of individual residents. Some of the larger residential facilities contract-out the whole meal preparation function to third party caterers or service-providers at a contracted price.
However, these outside meal suppliers are typically not directly responsible for attending to the dietary intake of individual residents and thus are not in a position to monitor the nutritional needs or intake of each individual resident.
At the State level, there are nutrition and menu planning standards for use in the hospital sector which also incorporate recommendations for aged care facilities. For instance, the Nutritional Standards for Menu Items in Victorian Hospitals and Residential Aged Care Facilities creates a standard for food suppliers catering to public hospitals and RACFs in Victoria. The Standard contains sample menu options and guidelines in relation to the nutritional content and minimum portion sizes for each type of food to be included with a meal.
However, while few (if any) aged care facilities will adopt a 'medical' model of care, the 'hospitality' model does not ensure that there are professional personnel who are able to ensure adequate fluid and food intakes or the meeting of medical dietary standards or to monitor the fluid and nutritional intakes of residents on an individualised level.
"What day of the week?"
The "Living Longer Living Better" plan recently announced by the Government focuses on providing tailored Home Care Packages designed for people who wish to remain in their own homes rather than live in a care facility.
However, as mentioned earlier in this article, malnutrition is not a condition exclusive to residents living in aged-care facilities. Home care is often provided in a low-budget and erratic manner whereby an elderly resident will receive a phone call by the Municipal Council asking them 'what day of the week' they would like their food delivered or their laundry done. It is unrealistic to make the presumption that residents receiving home care in all parts of Australia will be automatically in a better position than those in a residential care facility when it comes to food or fluid intakes.
The Productivity Commission, in its recent enquiry report regarding government funding of RACFs titled 'Caring for Older Australians', seems to confirm concerns that the current accreditation process focuses on monitoring compliance rather than operating as a quality improvement process.
The Productivity Commission stated in its report that the status of being either compliant or non-compliant 'largely ignores quality of life outcomes for residents' and that 'standards alone do not provide incentives for providers to improve quality above the minimum'. When it comes to nutrition and lack of proper fluid or food intakes, anecdotally, it appears that this would be a plausible view.
A solution to the malnutrition problem in RACFs is a needs to be focused on the end-objective of providing elderly residents with optimum care outcomes, rather than merely meeting bare minimums of delivery.
a) Development of better standards, guidelines and training
Although there are minimum standards in the current Australian framework that require RACFs that say there needs to be adequate nourishment and hydration of residents, there are no specific national guidelines on how RACFs should do this or plan their menus to best meet the nutritional requirements of residents. Additionally, monitoring of allergens and food sensitivities should also be addressed in a uniform standard. There also needs to be better understanding and training to create a culture of improving the end-results for aged care, rather than acceptance of low level care.
b) Standard on staffing ratios and better monitoring
Currently, the Accreditation Standards do not have specific requirements as to how many staff should be allocated to a particular number of residents. As a consequence, many RACFs are understaffed and the consistency, continuity, and cohesiveness in the delivery of care are compromised. A standard should be developed stipulating a set staff-to-resident ratio in order to ensure adequate attention is given to individual residents. Currently, a typical RACF will have 1 to 3 staff members per 30 residents. It is therefore impossible to ensure people who are disabled are eating their food properly or sitting up regularly to have a drink of water, when one carer is responsible for 30 residents. In addition, that carer may be required to spend considerable time filling out paperwork such as reports for the government. Lack of priority given to disabled residents needs to be addressed.
Apart from additional staffing, care standards ought to require scheduling methods that allocate specific duties to staff members, especially supervising drink and dietary intake at all times.
One of the biggest issues plaguing the government funding scheme for RACFs is that funding is allocated very selectively. Funding is only provided to accredited facilities that meet size and performance requirements under the Accreditation Standards. These facilities use funding as a leverage to meet performance standards. Smaller more intimate facilities that fall short of funding eligibility requirements are not even considered for funding. Some continue to operate despite being under-resourced.
FoodLegal is of the opinion that people are entitled to a competent level of aged care as a basic human right. Disability in old age is a common experience and ageing itself is not a selective process. The current Government funding scheme has a selective money-oriented focus whereas the real focus should be on the end-objective of making aged care available at a competent level to all Australians. Lacks of water intake or an unsupervised nutritional food intake are matters that definitely require further attention.
- Accreditation Standards in the Quality of Care Principles 1997 (Current Version)
- DAA Scoping Project on the Development of Nutrition and Menu Planning Standards for Residential Aged Care Facilities in Australia and New Zealand (Final Project Plan) - 25 November 2011 (pdf)
- Aged Care Crisis: Factors contributing to malnutrition and dehydration in elderly people - 28 February 2012