GP Link Lunches – Dr Carmelo Aquilina

For more information on the Live Well project visit: www.swsphn.com.au/live-well-project

To contact Carmelo and his team email: SWSLHD-FOH@health.nsw.gov.au

Dr Kenneth McCroary, Chair of Sydney South West GP Link, hosts a series of meetings with clinical/political/regional individuals or organisations to discuss issues and solutions for GPs working in South Western Sydney.

Ken McCroary – Welcome to the latest instalment of GP Link Lunches. With the ongoing rampant spread of COVID-19 throughout our community and Omicron unfortunately now finding its way to the majority of the local residential aged care facilities and with the expected significant increases in morbidity and mortality, one group or cohort of individuals has been highlighted as being affected more than most and perhaps suffering a relative greater burden than the majority, and that is individuals in the aged care sector and the elderly. This includes both people living in aged care facilities and in their own homes.

Lockdowns and curfews had significantly contributed to an increased mental health burden in this group, particularly being kept away from family and friends for prolonged periods. The loneliness has contributed to their stress and pressures of dealing with both the physical and mental impacts of the pandemic, and the ongoing vaccination rollout.

I thought today I would speak about older people’s mental health and have been lucky enough to be joined by Dr Carmelo Aquilina, who is the Director of Older People’s Mental Health Service in the South Western Sydney Local Health District. He is also involved with the Live Well Project.

Dr Carmelo Aquilina graduated in Medicine in Malta in 1989 and then trained in psychiatry in Liverpool in the United Kingdom, and specialised in old-age psychiatry in north-east London. After consultant jobs in Sheffield , Eastbourne and South London he spent two years as clinical director in Auckland, New Zealand, and then moved in 2008 to take up a similar position in Western Sydney. He is the founder and past editor of the Royal College of Psychiatrists’ Faculty of Old Age Psychiatry Newsletter ‘Old Age Psychiatry’. 

In 2019 he was the Don Kendall Leadership award winner at Murrumbidgee Local Health District. He is the main author of ‘A Guide to Psychiatric Examination’ published by Elsevier, which is in its second edition. He is clinical director and senior staff specialist in the Older People’s Mental Health Service in South Western Sydney Local Health District and has a special interest in dementia, health economics, history of psychiatry, self-neglect and hoarding in old age, and ethical issues around the end of life.

Hello Carmelo, and thank you so much for joining me today. I’m really looking forward to hearing your views regarding older peoples’ mental health. Can you just tell me your take on COVID and its impact on the aged population please?

Carmelo Aqulina – COVID is a major event not just physically in terms of the direct effect of the virus, but socially, psychologically, and in terms of the formal support networks that provide for older people, whether they’re in residential care or still living independently. It has certainly in our experience had an impact on people’s pre-existing mental health problems and it’s particularly difficult for people with cognitive impairment because it is harder for them to understand and retain the information given about the reasons why they should self-isolate or maintain social distancing.

The effect on older people who are already marginalised in terms of physical health, in terms of being already fully or partially isolated, and ones that depend a lot on formal support, that’s just disrupted all the systems we have in place to support and maintain older people and its been exacerbated now by the effect on the workforce, so we’ve had to reduce our face-to-face contact in the community.

Older people struggle more than the general population to use alternative medicine like video conferencing, and the effect of even a minor reduction in social and practical support can have a major impact on the ability of older people to survive independently if they’re already struggling, so overall it’s a major public health emergency. It’s not just the effect on hospitals but it’s the effect on people who are trying to cope and survive out in the community.

Ken McCroary – We’re seeing that here in general practice quite a lot, not just as you mentioned the mental health issues, but the impact it is having on their physical care and their psychosocial interaction and care as well.  I note you are the Director of Older People’s Mental Health Service for South Western Sydney Local Health District as well. Can you tell me a little bit about that organisation and what you guys do in South Western Sydney please?

Carmelo Aquilina – Our service is a specialised mental health service for older people. We pride ourselves on doing most of our work in the community. We do have access to 16 beds run by Hammond Care, but our service at the moment is still in the community. We have committee teams in Bowral, Camden, Campbelltown, Bankstown, Liverpool and Fairfield. They try to visit people locally, they provide psychiatric assessment, social support, psychological treatment, and try to advocate and encourage older people to access appropriate care even if its not psychiatric.

We have a major interest in working well with primary care and NGOs to provide social support and advocacy, especially when it comes to legal vulnerability and incapacity, and also to make sure that older people have fair access to medical services, cleaning and timely testing. This aligns us very well with primary care.

Ken McCroary – So with our local GPs, what would be the best way for them to refer an elderly patient to your service?

Carmelo Aquilina – The system the LHD has adopted, along with every other LHD in the state, is that there is a single point of access, through the mental health telephone access line, where generally access is quite easy, GPs can call and they will take details and refer on to the older people’s mental health services.

This allows urgent requests to be passed on to our emergency team, called CoMHET, and the nonurgent ones will get to the older person’s mental health team, either directly if its not urgent, or after an initial assessment by the emergency team. 

I personally would like to see more easy access and earlier access to the service but that’s obviously constrained by our ability and staffing to respond quickly to problems before they become crises. But we hope to develop forums where we can have formal or even informal discussions with GPs about cases practitioners are more concerned about – but that’s for the future. At the moment access to the service is through our single number called the mental health access line.

Ken McCroary – Now GP Link is a local organisation and we are wondering if your are aware of any particular issues or challenges that are facing GPs working in South Western Sydney?

Carmelo Aquilina – Well, where do I start?  I’m only going to comment on the issues affecting older people, and my expertise in mental health so I may be missing other issues that a geriatrician would be able to advise on better, but we have the second highest increasing elderly population by 2031, only one other area has a higher increase and that is only by 1 or 2 percentage points. 

So the number of older people is increasing. With that, inevitably there will be two main impacts and challenges to all healthcare providers. One is the increased number of people with dementia, and the increased number of what I call the ‘older old’, which is the over 85s. They are more likely to have chronic health problems and frailty, and the implication of that is that it has a direct influence on the risk of depression. 

We often have cases where it’s unclear whether or not reported problems are due to dementia, depression or a combination of both emerging at the same time. So the number of older old people will increase and therefore the incidence of physical issues interacting with mental health issues will increase, and that makes it diagnostically messier, although its more realistic because these diseases do not fit easily in with one service or the other. 

The other issue that is variable across the local health districts is the number of people coming from non-English speaking backgrounds. This means social support and family support can sometimes be quite fragile and socially the usual support services like churches or social groups may be harder to access.

When you have got cognitive impairment and you need residential care, ideally you need a home where the staff and the other residents speak the same language as well, because as you know, in dementia people lose more recently acquired skills and languages. So a large number of older people with different language backgrounds lose their command of English and revert back to their original language. 

The issue of frailty also makes people quite vulnerable to psychological and financial abuse and this is compounded when people are isolated – although the majority of elder abuse cases occurs within the family.

So there’s a lot more older people and the number of psychiatric problems and dementia which comes with that increased number is going to be more complicated. We are really challenged to respond to this by working differently and flexibly and more collaboratively, so that’s as much a challenge for us as a specialist service as it is for primary care, in trying to overcome institutional barriers to working closely as colleagues.

Ken McCroary – That’s going to be really important as we go forward, with our silver medal for the amount of older people in the region – but my understanding is that we are moving towards the gold medal for the highest concentration for dementia patients per capita in the region and I’m wondering if that’s going to have an impact with the geriatrician and geriatric psychiatrist workforce. I’ve spent more than a decade prescribing and initiating cholinesterase inhibitors but with Medicare changes I’m not allowed to do that anymore. Will we have the workforce within our psychogeriatricians and geriatricians moving forward as South Western Sydney does become the number one region for dementia in the next two decades?

Carmelo Aquilina – I hope so. I’m worried that dementia does not easily fit into either psychiatry or geriatrics. It has elements of both but in my ideal world there would be a service for dementia along the same lines as say cardiology or renal medicine, which will allow staff to be trained.

I think we also have a problem in duplicating and overlapping efforts because the two different services run to different KPIs and have different ways of accessing services. Given that over the lifetime of someone with dementia, behavioural problems will emerge in more than 90% of cases, there are public health arguments as to whether a behaviour is primarily psychiatric or cognitive-related which is a really, not just tedious argument, but also fruitless because it is always both, and we need to develop with primary care a clear pathway. We need a service where the responsibilities for people with dementia at every stage of the illness from diagnosis to death is clearly laid out and we co-operate, identify gaps in the service and make things simple from the point of view of the patient and their families. 

I trained in the UK where the pathway was really clear, old age psychiatry managed the great majority of services. Over here I struggle to identify which service is supposed to be more appropriate. And this is without even mentioning the federal funding of a separate panel of services with Dementia Support Australia, which duplicates, overlaps and really confuses GPs and aged care facilities as to which is the right service at the right time for that person. 

So there is a major re-design exercise we should be undertaking. And your mention of us being the gold medal in the number of people with dementia per capita makes me more certain we need to come together and think strategically but also outside the box. We simply cannot meet the needs of people with dementia by continuing to do what we are already doing, because it is inefficient, patchy, confusing and difficult to access.

Ken McCroary – Confusing and difficult to access for the people that are the most vulnerable to confusion and difficulties of access to begin with.

Carmelo Aquilina – Absolutely.  I am a professional and even I get confused.

Ken McCroary – So being a GP in the region, what do you think that your service can do to help us or support us with looking after old aged and particularly mental health in old age in South Western Sydney?

Carmelo Aquilina – What we can do now is we are very open to any requests for education, whether to GPs or to practice nurses, because clearly this cannot rest on the shoulders of GPs, let alone specialists. So we have to train more people to recognise, diagnose, assess the severity and stage and be aware of the needs of that person at that stage of the illness, not to mention the needs of their carers and family who provide the majority of care for people with dementia. Education and training, we are always open to help with. 

The second thing is, within the limitations of the referral pathway, our mental health access line tends to channel requests for diagnosis to geriatrics, but requests for any other associated behavioural symptom to old age, and that works to some extent, but it works with some agreement between primary care and our local health district specialist services as the right pathway, I think all of us can help GPs better.

The lessons for dementia are absolutely clear – diagnose early, support people in terms of arranging for care, arranging for advanced care directives, power of attorney and guardianship, try and slow down the illness with cholinesterase inhibitors, minimise the numbers of other medications and polypharmacy that may make things worse, and make sure services try to support people at home for the longest possible time. All specialist services are supporting families and primary care in trying to achieve this.

Our service can also provide assistance with the really interesting cases, where the diagnosis is unclear or the management of someone is difficult – there are some services providing diagnosis through a memory clinic, but the memory clinic capacity and scope varies from clinic to clinic and its not just patchy but at the moment I would struggle to identify which clinics are still running.

Lastly, one of the major developments of the last year has been the report of the Royal Commission on Aged Care which has highlighted the issue of care in the residential aged care sector where you have a major concentration of people with depression and dementia. I believe one of the recommendations of the Commission was to try and train GPs specifically in residential aged care service provision and easier access to specialists to visit aged care.

So they need to stop trying to treat dementia in residential aged care like an acute condition, when you go in, prescribe something and move out, rather it should be re-designed like chronic disease management where you keep people there because the condition is not going to improve, and you have to work closely with several teams and you have to provide a patient-focused seamless approach to try and treat early, minimise the number of medications and maximise the ability of the person to live a good life.

Ken McCroary – With our earlier discussions, we were talking about the Canadian program ‘Fountain of Health’ and you were touching on formulating or leading your own program out here.  Are you able to tell me a little bit about the Live Well Project?

Carmelo Aqulina – The Live Well Project has arisen from seeing the Canadians in the last three years develop a really simple intervention, primarily delivered by GPs but also by practice nurses and psychiatric staff, in trying to nudge, encourage and collaborate with their older people. 

The project works with over-45s to make people aware of lifestyle’s effect on health and wellbeing, to try and look at areas that people could improve in their lifestyle. This includes physical activity, mental activity, social connections, healthy eating and mental well-being – by that I mean the ability to think clearly without getting stressed, and stress management, and encouraging optimism, positivity and creativity – all of which have been shown to improve health, wellbeing and resilience in older people. 

The Canadian project and ourselves decided last year that we wanted to adapt the Canadian project to an Australian audience with multi-cultural identities, with different approaches to how we can encourage and train staff to bring up the topic, and the Canadians said that it would be good if we could develop our own resource under our own name.

The inspiration has been Canadian but we are really excited by this brief intervention which involves roughly a 10-minute initial discussion, looking at health and lifestyle as it is, and then encouraging people to choose one of the six domains mentioned, to try and do something differently and then to link up with local resources, give them enough information to think about what they want to do and to continue supporting them to make small sustainable changes that can be built on which may not have a major or significant impact for one person although we have accounts from our staff from people who have made major positive changes in their life. 

The approach assumes that small changes in a lot of people amounts to a major public health improvement. We talked about dementia earlier. It is known that all these lifestyle domains I mentioned do have an impact not just on delaying the onset of dementia but also improving cognitive flexibility even with people with mild dementia or mild cognitive impairment. It’s trying to get people to accept that you can change things one very small step at a time. We are excited to start rolling out the training and the resources later this year, hopefully by March/April.

Ken McCroary – That sounds very interesting and exciting.  There is a lot of overlap too with the foundational domains of general practice in terms of that lifestyle intervention which we probably need to spend more time doing.

Carmelo Aquilina – Absolutely.  I admit we have a so-called ‘green book’ for general practice from the Royal College of General Practice which sets out some of the principles. What we hope to do differently is that this is short, this is very practical for any staff, not just GPs, to incorporate in their routine clinical encounters with people.

Ken McCroary- Absolutely. I think with the Canadian idea too – we don’t get funding for our practice nurses to do anything really, it’s all face-to-face with the GPs, so most of the practice nursing stuff we could be using, unfortunately doesn’t get funding here so that’s another issue we need to look at. We’ve also got a ‘silver book’ at the College as well dealing with aged care, have you had any interaction with that one?

Carmelo Aquilina – Not yet. But we would really like to reach out to practice nurses as we think this would be a really exciting project for them to get involved in. We are offering training, we also would like either a GP or a practice nurse to work with us at the development and implementation stage because we might think something is a good idea but in practice we need people who work in primary care to tell us the realities of whether something is practical enough for people to use routinely.

Ken McCroary – I appreciate those comments – we don’t see enough of that understanding of people developing projects and policies that involve primary care needing to get primary care input.  I appreciate your understanding – that shows some good insight. I really appreciate what you’re doing locally to support us and patients with mental health in that age group. 

If you want some more information please feel free to log on to sswgp.link and I will have some connections for the aged care services as well.

*For more information on the Live Well project visit: www.swsphn.com.au/live-well-project

To contact Carmelo and his team email: SWSLHD-FOH@health.nsw.gov.au

Thanks so much for your time and have a great weekend. Remember if you’re not a member of GP Link already or you would like to learn more log onto our website at sswgp.link