Emeritus Professor Kichu Nair

Background: Accurately identifying the unmet needs of community-dwelling people with dementia allows targeted support to be provided to assist these individuals to stay at home. Objective: We developed a self-report instrument to identify the unmet needs of community-dwelling people with dementia and used this to explore the prevalence and type of unmet needs present in this population. Methods: This was a cross-sectional survey of people with dementia living in the community in Australia. Participants were recruited from geriatric clinics, respite centers, aged care providers, and carers attending support groups. Eligible people with dementia were provided with a study information pack and survey which included the self-report Unmet Needs Instrument for Dementia (UNI-D), sociodemographic characteristics and survey acceptability. Results: The UNI-D contained 26 items across 5 domains and demonstrated acceptable internal consistency, face and construct validity, and acceptability. Ninety-five eligible participants completed the survey (response rate 35%) with 85% identifying at least one unmet need (median = 4; IQR = 1-9). The items most frequently endorsed included needing more help with remembering things (64%), finding possible treatments for dementia (44%), understanding who to contact regarding a problem or concern related to dementia (36%), and to see friends and family more often (33%). Conclusion: The UNI-D is a promising tool to identify the self-reported needs of people with dementia. The development and rigorous testing of interventions targeting unmet needs related to health and wellbeing, dementia support, and meaningful activities appears warranted.

Health assessments have potential to improve health of older people. This study compares long-term health care utilisation, physical functioning, and mortality for women aged 75 years or over who have had a health assessment and those who have not. Prospective data on health service use, physical functioning, and deaths among a large cohort of women born 1921¿26 were analysed. Propensity score matching was used to produce comparable groups of women according to whether they had a health assessment or not. The study population included 6128 (67.3%) women who had an assessment, and 2971 (32.7%) women who had no assessment. Propensity matching produced 2101 pairs. Women who had an assessment had more use of other health services, longer survival, and were more likely to survive with high physical functioning compared to women with no assessment. Among women who had good baseline physcial functioning scores, women who had an assessment had significantly lower odds of poor outcomes at 1000 days follow-up compared to women who had no assessment (OR: 0.67, 95%CI: 0.52, 0.85). This large observational study shows the real-world potential for assessments to improve health outcomes for older women. However, they also increased health service use. This increased healthcare is likely to be an important mechanism in improving the women¿s health outcomes.

Background and aims: Melatonin, a pineal gland hormone is reported to have a protective effect against delirium. This systematic review and meta-analysis explores the effect of melatonin and melatonin receptor agonist, ramelteon on delirium prevention in adult hospitalized patients. Methods: Randomized Controlled trials of melatonin/ramelteon published up to May 7, 2020 were identified from MEDLINE, PREMEDLINE, Embase, PsycINFO, the Cochrane Central Register of Controlled trials, PubMed, and Google Scholar. The primary outcome was delirium incidence. The secondary outcomes were sleep quality, sedation score, sedatives requirement, delirium duration, length of hospital stay, length of Intensive Care Unit (ICU) stay, mortality and adverse events. A meta-analysis with a random-effects models was performed. Estimates were presented as Risk Ratio (RR) or Mean Differences (MD) with 95% Confidence Interval (CI). Findings: Fourteen studies with 1712 participants were included. Melatonin/ramelteon significantly reduced delirium incidence (RR 0·61, 95% CI 0·42¿0·89, p 0·009) with risk reduction of 49% in surgical patients and 34% in ICU patients. Non-significant reduction was found in medical patients. Melatonin/ramelteon were associated with improvement in sleep quality, increased sedation score and lower sedatives consumption. However, they did not reduce delirium duration, length of hospital stay, length of ICU stay and mortality. Hallucinations, nightmares and gastrointestinal disorders were prevalent in melatonin group. Interpretation: Melatonin/ramelteon are associated with reduction in delirium incidence in hospitalized patients. However, this effect seems confined to surgical and ICU patients. The optimum dosage and formulation of melatonin, and treatment duration remain uncleared and open to further studies with larger sample sizes.

Introduction: Australia depends on international medical graduates (IMGs) to meet workforce shortages. The current standard assessment for IMGs is by clinical examination in observed structured clinical encounter (OSCE) format lasting 200 minutes. There are con-cerns about adequateness of this assessment as it does not test the qualities required to practice in a new country. We introduced a programmatic performance-based assessment for IMGs to prepare them to meet these challenges. The workplace-based assessment (WBA) program involves six-month longitudinal programmatic assessments comprising of 12 mini-clinical evaluation exercises (Mini-CEX), five case-based discussions (CBD), two in-training assessments (ITAs) and two sets of multisource feedback (MSF) assessments. We assessed 254 IMGs since 2010. We conducted a survey to evaluate the satisfaction with the program and the outcomes of these doctors. Methods: We surveyed 254 candidates from 2010 to 2020. The survey used ¿SelectSurvey¿ tool with 12 questions and free-text comments. All candidates were sent the survey link to their last registered mobile phone using ¿Telstra Instant Messaging Service¿. We analysed the data using Microsoft ¿Excel¿. Results: We received 153 (60%) responses. Amongst them, 141 (92%) candidates did not require further supervised practice for general registration and 129 (84%) candidates hold general/specialist registration. The candidates found the program useful and felt well sup-ported. They appreciated real patient encounters. The feedback with positive critiquing was helpful in improving their clinical practice. The negative themes were program costs and frustration with the length of the program. Conclusion: Upon completion of the WBA program and obtaining the AMC certificate, most of the doctors were able to gain general registration. Seventy-eight (50%) candidates chose to continue their careers within the local area with 124 (80%) of them within the state. Our survey shows a comprehensive assessment program with immediate constructive feedback produces competent doctors to fill the medical workforce shortages.

Objective: To examine general practitioners¿ views about how health assessments for older people should be conducted. Methods: General practitioners were randomly sampled from a national database of medical practitioners and invited to complete a survey. Survey items explored general practitioners¿ views about essential components of a 75+ Health Assessment and who should assess each component, consultation time, use of standardised templates and tools, and home visits. Results: Overall, 185 (19.2%) general practitioners participated. Of 61 items presented, 24 were rated ¿essential¿ by =70% of practitioners, with an average estimated consultation time of 65 minutes. Of the 24 essential items, it was perceived that 21 could be assessed by either a general practitioner or clinic nurse. Most practitioners indicated a standardised template (86%) and standardised tools for complex issues (79%) should be used, and home visits conducted (75%). Conclusions: General practitioners agreed on 24 items as essential for every health assessment, with assessments estimated to take more than one hour. Implications for public health: Increases to remuneration for prolonged assessments or mechanisms for improving efficiency and quality of assessments are needed. Acceptable mechanisms may include standardised patient-reported tools, standardised templates and the use of non-medical staff to assist with assessments.

Context: Older and seriously ill Australians are often admitted to hospital in the last year of their life. The extent to which these individuals have considered important aspects of end-of-life (EOL) care, including location in which care is provided, goals of care, and involvement of others in decision making, is unclear. Objectives: To determine, in a sample of older and seriously ill Australian inpatients, preferences regarding location in which they receive EOL care and reasons for their choice; who is involved in EOL decisions; disclosure of life expectancy; goals of care; and voluntary-assisted dying. Methods: Cross-sectional face-to-face survey interviews conducted with 186 (80% consent) inpatients in a tertiary referral center aged 80 years and older; or aged 55 years and older with progressive chronic disease(s); or with physician-estimated life expectancy of less than 12 months. Results: Home care was preferred (69%), given the perceived availability of family/friends, familiarity of environment, and likelihood of having wishes respected. If unable to make decisions themselves, inpatients wanted family to decide care alone (31%) or with a doctor (49%). Of those who had not discussed life expectancy, 23% wished to. Most (76%) preferred care that maintained quality of life and relieved symptoms. There was some agreement for being sedated at the EOL (63%) and able to access medication to end life (43%). Conclusion: Most inpatients would prefer EOL care that maintains quality and relieves suffering compared with life extension and to receive this care at home. Family involvement in resolution and documentation of EOL decisions should be prioritized.

Purpose: To determine the prevalence and incidence of atrial fibrillation (AF) among older Australian women from 2000 to 2015, determine factors associated with AF, and to calculate risk of stroke at the time of AF diagnosis. Methods: This is a retrospective analysis of 6671 women of the 1921¿1926 birth cohort of the Australian Longitudinal Study on Women's Health, linked to data from hospital admissions to identify AF and National Death Index to determine date of death. Yearly prevalence and incidence proportions of AF, and stroke risk using CHA2DS2-VA scheme, were calculated. Factors associated with AF were assessed using logistic regression. Results: From 2000 to 2015, a total of 1827 women with AF were identified. AF prevalence increased every year as women aged from 2.71% (95% CI 1.62%¿3.80%) in 2000 among women aged 74¿79 years to 24.83% (95% CI = 23.23%¿26.44%) in 2015 among women aged 89¿94 years. The incidence proportion remained constant (between 3% and 5%) throughout the study period. Sedentary lifestyle (OR = 1.24, 95% CI = 1.04¿1.49), hypertension (OR = 1.24, 95% CI = 1.09¿1.42), arthritis (OR = 1.24, 95% CI = 1.09¿1.41), heart attack (OR = 1.62, 95% CI = 1.18¿2.24), and angina (OR = 1.39, 95% CI = 1.14¿1.70) were independently associated with AF. Mean CHA2DS2-VA score for women with AF was 3.43 (SD ± 1.23). Conclusions: The prevalence of AF reported in Australian women is among the highest compared to previous estimations from other countries and regions. According to the findings, about one in four women over the age of 90 years had AF. These women were also at high risk of stroke. This has significant public health implications especially with changing demographics of increase in the aging population. Further research is required on understanding how women with AF are treated in Australia and their health outcomes.

Background: Despite the perceived ethical, personal and health service benefits of advance care planning (ACP), the extent to which older and seriously ill Australian inpatients have considered future health decisions remains uncertain. This study aimed to determine in a sample of older and seriously ill inpatients, the proportion who had: 1) engaged in four advance care planning (ACP) activities; 2) not engaged in ACP activities but wanted to; and 3) reasons why they had not engaged. Methods: Cross-sectional face-to-face standardised interview survey with inpatients in a tertiary referral centre who were either: aged 80+ years; aged 55+ years with progressive chronic disease(s); or judged by treating clinicians as having a life expectancy of less than 12 months. Patients indicated whether they had engaged in four ACP activities: (1) appointed medical substitute-decision-maker(s), (2) recorded end-of-life wishes in an advance directive or care plan; and talked about their end-of-life wishes with their: (3) support persons and/or (4) doctors. Patients who had not engaged in activities were asked whether they wished this to occur and reasons why. Results: One hundred eighty-six inpatients consented to the study (80% of approached). Of these, 9% (n = 16) had engaged in four ACP activities; 27% (n = 50) had not engaged in any. Half (n = 94, 52%) had appointed a medical substitute-decision-maker, 27% (n = 50) had recorded wishes in an advance directive or care plan, 51% (n = 90) had talked about their end-of-life wishes with support persons and 27% (n = 48) had talked with their doctor. Patients who wanted to, but had not, engaged in the four ACP activities were unaware they could record wishes or appoint decision-makers, or indicated providers had not initiated conversations. Conclusion: Relatively few inpatients had engaged in all four ACP activities. More inpatients had discussed end of life issues with family and appointed substitute decision makers, than completed written documents or talked with doctors. Community education and a more active role for community and hospital-based providers in supporting patients and families to collaboratively resolve end-of-life decisions may increase the probability wishes are known and followed.

Objective: To assess which older Australian women had Medicare subsidized health assessments between 1999 and 2013. Methods: This study used prospective, longitudinal survey data from the 1921 to 1926 birth cohort of Australian Longitudinal Study on Women¿s Health (ALSWH) linked with Medicare Australia data on health services use. Over 11,000 Australian women were included in the study. Latent class analysis was used to identify assessment patterns over time, accounting for death, and based on three categories (¿no assessment¿; ¿assessment; ¿deceased¿) for each year between 1999 and 2013. Further analysis explored the impact of health and sociodemographic characteristics on class membership. Results: Of the women included in the latent class analysis, 37% never had any assessment and the remainder had had at least one assessment. After a steady uptake from 1999 to 2003, there was decline in uptake from 2003 onwards. A six-class model with sufficient homogeneity and reliable estimation was selected to represent assessment patterns and mortality risk, labelled as: ¿high mortality¿ rate with little chance for assessment (12.4%), ¿intermediate mortality, low assessment¿ (14.1%), ¿later mortality/low assessment¿ (13.1%), ¿later mortality, high assessment¿ (7.0%), ¿low mortality, low assessment¿ (31.8%), ¿low mortality, high assessment¿ (21.6%). Older women with certain conditions (such as diabetes, depression, heart disease) were more likely to be in the low assessment groups, and women with difficulty managing on income were more likely to be in low assessment groups. Conclusion: Distinct assessment and mortality patterns were seen, with many women not having assessment, in particular those who had certain health conditions, were taking 3+ medications, had difficulty in managing on income, needed help or were in respite care, and had caring responsibilities. The findings point to a need to promote these assessments among older women, and to reduce financial barriers, even within the context of a heavily subsidized health care system.

A structured online survey was used to establish the views of 2,684 practising clinicians of all ages in multiple countries about the value of the physical examination in the contemporary practice of internal medicine. 70% felt that physical examination was ¿almost always valuable¿ in acute general medical referrals. 66% of trainees felt that they were never observed by a consultant when undertaking physical examination and 31% that consultants never demonstrated their use of the physical examination to them. Auscultation for pulmonary wheezes and crackles were the two signs most likely to be rated as frequently used and useful, with the character of the jugular venous waveform most likely to be rated as infrequently used and not useful. Physicians in contemporary hospital general medical practice continue to value the contribution of the physical examination to assessment of outpatients and inpatients, but, in the opinion of trainees, teaching and demonstration could be improved.

Background: Health professions education is characterised by work-based learning and relies on effective verbal feedback. However the literature reports problems in feedback practice, including lack of both learner engagement and explicit strategies for improving performance. It is not clear what constitutes high quality, learner-centred feedback or how educators can promote it. We hoped to enhance feedback in clinical practice by distinguishing the elements of an educator's role in feedback considered to influence learner outcomes, then develop descriptions of observable educator behaviours that exemplify them. Methods: An extensive literature review was conducted to identify i) information substantiating specific components of an educator's role in feedback asserted to have an important influence on learner outcomes and ii) verbal feedback instruments in health professions education, that may describe important educator activities in effective feedback. This information was used to construct a list of elements thought to be important in effective feedback. Based on these elements, descriptions of observable educator behaviours that represent effective feedback were developed and refined during three rounds of a Delphi process and a face-to-face meeting with experts across the health professions and education. Results: The review identified more than 170 relevant articles (involving health professions, education, psychology and business literature) and ten verbal feedback instruments in health professions education (plus modified versions). Eighteen distinct elements of an educator's role in effective feedback were delineated. Twenty five descriptions of educator behaviours that align with the elements were ratified by the expert panel. Conclusions: This research clarifies the distinct elements of an educator's role in feedback considered to enhance learner outcomes. The corresponding set of observable educator behaviours aim to describe how an educator could engage, motivate and enable a learner to improve. This creates the foundation for developing a method to systematically evaluate the impact of verbal feedback on learner performance.

Objective: To estimate the cost of resources required to deliver a program to assess international medical graduates (IMGs) in Newcastle, Australia, known as the Workplace Based Assessment (WBA) Program. Design and setting: A costing study to identify and evaluate the resources required and the overheads of delivering the program for a cohort of 15 IMGs, based on costs in 2012. Main outcome measures: Labour-related costs. Results: The total cost in 2012 for delivering the program to a typical cohort of 15 candidates was $243 384. This equated to an average of $16226 per IMG. After allowing for the fees paid by IMGs, the WBA Program had a deficit of $153384, or $10226 per candidate, which represents the contribution made by the health system. Conclusion: The cost per candidate to the health system of this intensive WBA program for IMGs is small.

In this series, we present authoritative advice on the investigation of a common clinical problem, especially commissioned for family doctors and written by members of the Royal Australasian College of Physicians.

Background: The purpose of this study was to compare apolipoprotein E e4 (Apo E e4) and apolipoprotein E e2 (Apo E e2) as predictors of cognitive and functional trajectories over 30 months. Methods: This prospective cohort study included 287 community-dwelling memory clinic patients with dementia, mild cognitive impairment, or no cognitive impairment. The Addenbrooke Cognitive Assessment, Mini-Mental State Examination, Montreal Cognitive Assessment, Delirium Index, and Nottingham Instrumental Activities of Daily Living tests were administered to each subject. Results: One hundred and nine subjects (40%) carried Apo E e4 and 48 (16.7%) carried Apo E e2. One hundred and nine e4-positive subjects differed significantly from 178 e4-negative subjects in 19/52 comparisons (36.5%), whereas 46 Apo E e2-positive subjects had 0/52 significant differences from 239 e2-negative subjects (P < 0.0001). The variables most affected by e4 were the Delirium Index and Mini-Mental State Examination. Instrumental Activities of Daily Living score and residence were unrelated to Apo E e4 or e2. Conclusion: Apo E e4 positivity predicted four cognitive scores measured every 6 months over 30 months. Apo E e2 scores predicted none of 52 comparisons. © 2013 Regal et al.

We report on an elderly lady with a large hiatus hernia presenting with presyncope and syncope associated with large meals. Though left atrial filling and mitral inflow was unimpaired, this case is interesting since the symptoms resolved with adjustment to meal size. Copyright 2013 BMJ Publishing Group. All rights reserved.