Medical Forum – November 2021 – Public Edition

Keeping watch on aged care Aged & Palliative Care | Palliative care; exercise & diet for elderly; music & dementia; falls MAJOR PARTNERS

November 2021 www.mforum.com.au

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EDITORIAL BACK TO CONTENTS

Cathy O’Leary | Editor

Watchful eye on aged care

There is an argument that no one thinks about residential aged care until it is their own mum or dad needing a place. That’s when decisions must be made about the best facility – based on its services, the cost (not everyone has big dollars in the bank), and often a gut instinct. Feelings of guilt are never far away either.

So, seeing harrowing images and videos of frail elderly people being roughly pushed about in their beds during the long overdue Royal Commission into aged care standards would have rightly rattled many families.

This month’s cover story explores how surveillance cameras could help improve residents’ safety.

What we saw, via hidden surveillance cameras installed by relatives, was a sad indictment of years of neglect in the sector.

It must be said there are many residential facilities whose care of our vulnerable senior citizens is second to none.

My grandmother Kate spent her final days in a lovely Perth aged care home filled with sweet-scented rose gardens, where staff were respectful and caring of an old lady largely lost to dementia.

This month’s cover story explores how surveillance cameras could help improve residents’ safety, with Perth research suggesting surprisingly high levels of support from staff as well as families.

We also look at another sometimes forgotten area of health care – palliative services for children – where words like ‘terminal’ are rarely used, and quality of life is the mantra.

And we finally pin down GP-turned politician Dr Jagadish Krishnan – or Dr Jags – who’s been as busy as a fly at a picnic since he was elected to office this year, after deciding politics was his new calling.

SYNDICATION AND REPRODUCTION Contributors should be aware the publisher asserts the right to syndicate material appearing in Medical Forum on the mforum.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publisher for copyright permission.

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MEDICAL FORUM | AGED & PALLIATIVE CARE

NOVEMBER 2021 | 1

CONTENTS | NOVEMBER 2021 – AGED & PALLIATIVE CARE

Inside this issue 12

10

20

16

FEATURES

NEWS & VIEWS

10 Q&A: Health system strain

1

Editorial: Watchful eye on aged care – Cathy O’Leary

4 6 8 24 30

In the news

– Dr Mark Duncan-Smith

12 Cover Story: Aged care in the picture 16 Path for better Alzheimer’s treatments 20 Close-up: Dr ‘Jags’ Krishnan

LIFESTYLE 56 Oz’s good witch 56 Kal lawyer pens a thriller 58 Wine review: Brown Hill Estate

In brief Letter: Dr George Crisp Palliative care for children AOD support for GPs – Dr Richard O’Regan

38 Growing smart to relieve hunger – Professor Kadambot Siddique

38 Trial for nut treatment

– Dr Martin Buck

Win Dr Martin Buck reviews the wines from Brown Hill Estate, read his thoughts on page 58.

For a chance to win a dozen bottles, click on the competitions tab at www.mforum.com.au or enter via our weekly newsletter delivered to your inbox.

Talking of winners, Dr David Bucens is enjoying the Happs Doctors Dozen, while Dr Jenny Smith, Dr Emmeline Lee and Dr Tricia Charmer have copies of a Zen-inspired book by Brigid Lowry.

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2 | NOVEMBER 2021

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MEDICAL FORUM | AGED & PALLIATIVE CARE

CONTENTS

PUBLISHERS

Clinicals

Fonda Grapsas – Director Tony Jones – Director tonyj@mforum.com.au

ADVERTISING Advertising Manager Andrew Bowyer 0403 282 510 andrew@mforum.com.au

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Age and wisdom Dr Joe Kosterich

Preventing falls and fractures Dr Marc Sim

Comprehensive end of life care needed Dr Derek Eng & Ms Louise Angus

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The role of exercise in mental health Carla Petty

Managing adrenal incidentaloma A/Prof Ming Khoon Yew

Varicella zoster & pneumococcal vaccine for elderly Xavier Cornwall and Dr Ramya Raman

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Critical laboratory results after dark Dr Michael Page

Music for dementia A/Prof Hamid R. Sohrabi & Dr Jon B. Prince

ERCP: The Good, Bad & Ugly Dr Puraskar Pateria

EDITORIAL TEAM Editor Cathy O'Leary 0430 322 066 editor@mforum.com.au Journalist Dr Karl Gruber (PhD) 08 9203 5222 journalist@mforum.com.au Production Editor Ms Jan Hallam 08 9203 5222 jan@mforum.com.au Clinical Editor Dr Joe Kosterich 0417 998 697 joe@mforum.com.au Clinical Services Directory Editor Karen Walsh 0401 172 626 karen@mforum.com.au

GRAPHIC DESIGN Ryan Minchin ryan@mforum.com.au

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Guest Columns

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Geriatric drinkers – a juggernaut Prof Tanya Chikritzhs

Building a safe place to grow old Rachel Seeley

Cruel result of time delay Theresa Bates

Autism – start early, change lives Prof Andrew Whitehouse

MAJOR PARTNERS

MEDICAL FORUM | AGED & PALLIATIVE CARE

NOVEMBER 2021 | 3

IN THE NEWS

BACK TO CONTENTS

MND family carers at high risk Few illnesses are as confronting and disruptive as motor neurone disease. A diagnosis of the neurodegenerative condition begins a journey of inevitable decline through progressive immobilisation to death.

As well as the difficulty and distress experienced by those with this condition, recent evidence suggests that bereaved MND family caregivers are more likely to be at moderate or high risk of complicated grief.

Traumatised, angry and feeling abandoned were some of the caregiver emotions reported in a national survey on carer bereavement experiences.

The study, led by Palliative Care Professor Samar Aoun from the Perron Institute and La Trobe University, found that the experiences of those with this fatal disease and their family caregivers could be overwhelming.

More doctors head bush The number of junior doctors choosing to become GPs and train in rural WA has increased for the third consecutive year, according to new figures released by WA General Practice Education and Training. In a sign that WA is becoming more attractive to new GPs, some applications have come from outside the State despite some Eastern States positions going unfilled.

WAGPET says it is on track to exceed last year’s rural placement of GP registrars, which at 170 was the largest rural placement in five years. So far, 152 GP registrars are locked in for rural training in 2022 with the last positions to be filled.

But there are more applicants than positions, with 17 applying for the final nine spots.

WAGPET CEO Dr Janice Bell said the Federal Department of Health could be asked to increase the number of rural positions allocated to WA to cater for the extra applicants for 2022.

This year WAGPET has provided GP registrars for practices in hard-to-fill locations including Ravensthorpe, Kalgoorlie, Port Hedland, Karratha and Kununurra.

4 | NOVEMBER 2021

Professor Samar Aoun

“The bulk of care is provided informally at home and is demanding, with MND caregivers averaging over 40 hours per week,” Professor Aoun said.

“Currently, it is not standard practice to screen MND caregivers for mediating risk factors such as family functioning, personal distress or support needs. There is a need for more integrated care between MND associations, MND clinics, palliative and end-of-life care services and GPs.”

Dr Bell said while WAGPET offered financial incentives to encourage registrars to take up regional positions, she attributed some of the increased rural interest to the destabilising effect of COVID-19 over the past two years.

“The pandemic has changed the way many people relate to their jobs,” she said. “Health professionals have been on the frontline the entire time and it’s no surprise that junior doctors, as they consider their specialty and their future careers, are opting for rural GP practices which give them good working conditions away from big cities and the chance to take a holistic approach to the treatment of patients.”

New role for Miller Former AMA WA president Andrew Miller has been elected president of the Australian Society of Anaesthetists. Dr Miller, who works in private practice in Perth, has been an outspoken national commentator on the airborne spread of COVID-19 and has lobbied for the protection of healthcare workers and patients, especially children, throughout the pandemic.

He sits on the Federal Council of the AMA where he chairs the ethics and medicolegal committee. He has also been a board member

of MDA National for the past six years and has been the president of the Medical Indemnity Insurance Association of Australia.

Dr Miller said that as ASA president he would continue to advocate for improved safety in patient care, with anaesthetists playing a critical role in risk management.

“When it comes to patient safety, when anyone says we have to accept bad outcomes, we say ‘no’,” he said. “Work smarter, work harder, make it safer for healthcare workers and patients alike.”

Weight takes a toll Edith Cowan University research shows WA nurses and other healthcare workers are increasingly at risk of injury due to having to care for obese patients.

Studies from ECU’s School of Nursing and Midwifery reveal WA nurses, orderlies and other patient care professionals are among the most at risk for musculoskeletal injuries, and reports of back, wrist, knee and shoulder injuries have increased when handling obese patients.

It is a growing problem, with 42% of the Australian population predicted to be obese by 2035.

continued on Page 6

MEDICAL FORUM | AGED & PALLIATIVE CARE

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NOVEMBER 2021 | 5

Credited for putting breast cancer surgery on the map, one of WA’s most prominent research-focused surgeons is headed for Victoria. Professor Christobel Saunders is taking on the position of James Stewart Chair of Surgery at the Royal Melbourne Hospital.

The fee for walk-in patients at St John of God Murdoch’s emergency department has increased to $295. The hospital argues this is to ensure it can see the sickest patients, following months of the ED being overcapacity and having to turn away ambulances. The fee does not apply to those arriving by ambulance.

IN THE NEWS

continued from Page 4 Lead researcher Kim McClean said staff were put at extra risk due to inadequate recording procedures, with obese patients rarely classified as such. Not recording patients as obese also meant hospitals missed out on millions of dollars in funding for equipment, extra staff and education.

CMO to bow out WA Health’s Chief Medical Officer has resigned, three years into his five-year contract. In a statement to his office staff, general and colorectal surgeon Michael Levitt said he felt that he had not been a good “fit” in his departmental role and preferred not to complete the full contract. He has taken up an appointment as an Executive Director within Medical Services at the WA Country Health

Service, but will continue working in his surgical practice, and serving as a member of the Medical Board of WA and a Director of St John of God Health Care.

Choking hazards A research project led by Perth Children’s Hospital has uncovered an unexpected finding about children who need surgery to remove inhaled foreign bodies blocking their airways.

The study by the Ear, Nose and Throat surgical team, published in the International Journal of Paediatric Otorhinolaryngology, reviewed 127 cases of children and infants who presented to the emergency department between 2007-2016 with suspected inhaled

continued on Page 8

Aboriginal and Torres Strait Islander health and wellbeing researcher Professor Christopher Lawrence is the first Dean of Indigenous Engagement at Curtin University’s Faculty of Science and Engineering, where he will help extend cultural understanding and open up career pathways for Indigenous students.

The WA Primary Health Alliance has two new board members.

Diana Forsyth is experienced in health leadership and governance, and Professor Jane den Hollander is Vice-Chancellor of Deakin University and Chair of Global Health Alliance.

Telethon Kids Institute director Professor Jonathan Carapetis has received an Honorary Doctor of Medicine from Curtin University in recognition of his contribution to medicine and healthcare.

TKI has been awarded more than $5 million in investigator grants from the National Health and Medical Research Council for childhood respiratory, anaesthesia and mental health research.

6 | NOVEMBER 2021

A sign of the times COVID-19 has given new impetus to a project which teaches simple hand signs in aged care and retirement villages.

The Qsign project is being run by Better Hearing Australia (WA), Edith Cowan University and Brightwater Care Group. It aims to help overcome the hearing, language and communication issues among older people that make interactions difficult.

In conjunction with aged care staff and residents, 20 signs considered most important for health, safety and family interactions have been identified, including those for eat, sleep, medicine, pain and stop.

ECU honorary senior research fellow Dr Barnard Clarkson said the signs chosen had a strong Auslan influence and were easy to mimic and replicate.

“Initially the signs will be taught in person, and we are also planning training videos and interactive graphic displays, and even personal card copies, that we hope will suit a wide range of communicators,” Dr Clarkson said.

As well as learning the signs, participants will be encouraged to do one simple thing to improve their communication – face each other while speaking.

Dr Clarkson said the pandemic had made communication challenges in aged care even harder, with staff wearing masks which prevented lipreading and socially distancing which reduced the prospect of clear communication.

MEDICAL FORUM | AGED & PALLIATIVE CARE

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IN BRIEF

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MAJOR PARTNER

Supporting the elderly to access 21st century care Technology is revolutionising health care delivery. But in the rush to deliver services better and faster, some patients, especially elderly patients, can get left behind.

Many health care solutions rely on the use of QR codes, apps and automated services. COVID-19 has exacerbated this potential for tech overload for aged clients with doctors seeing less patients face to face in favour of telehealth consultations, patients avoiding routine doctors’ visits for management of chronic conditions and vaccinations keeping surgeries busy.

As health care technology evolves, ever more challenges will face our elderly citizens.

We, as health care providers, have a responsibility to manage service changes to ensure that older generations can access the care they need to continue to live as well as they can.

Warfarin Dosing Program Australian Clinical Labs offers a laboratory-managed dosing service for patients who are on warfarin*. Ensuring warfarin doses are accurate is critical to effective management, yet it can be time consuming for doctors.

It is the motivation behind Clinical Labs’ innovative range of services that are easily accessible to the elderly cohort.

Telehealth Clinical Labs offers one of the most personalised telehealth pathology services in Western Australia. At the conclusion of a telehealth consultation, the referring doctor will send the request form to our Telehealth team.

Our team contacts the patient, directs them to their most convenient collection centre, and ensures the form is available on their arrival. This personal contact provides reassurance and comfort to patients and ensures relevant information, such as fasting requirements, are not missed.

Home Visits Accessing regular health services, including pathology, is essential to maintaining a healthy lifestyle. Clinical Labs offers a home visit service for patients who, for medical reasons, are unable to travel to a pathology collection centre. Doctors can request this service for their patients by emailing a copy of the request form to osblab.homevisits@clinicallabs.com.au.

Our team will contact the patient and book a time for a phlebotomist to visit them at home.

Nursing Homes Once patients transition into aged care, it is important to maintain continuity of health care. Clinical Labs works closely with our nursing home partners to provide a regular pathology collection service. Familiar faces visiting on regular days provides a sense of comfort for residents and reduces confusion and resistance to testing.

Our collaborative partnership with nursing homes provides effective patient management and ensures clinical needs are met in a timely manner with minimal disruption to staff and residents alike.

With more than 45% of these patients aged over 80, how we deliver dosing information is critical. Clinical Labs transmit results to patients or nominated carers via SMS to a mobile device. This written record reduces the chance of forgetting the dose, or misunderstanding doctors’ instructions.

WA’s elderly citizens deserve to enjoy the benefits of technology and we’re proud to offer these innovative services to play our part in creating an equitable health system for all.

For more information on any of these services, speak to your Australian Clinical Labs representative or call 1300 367 674. *Annual fees may apply

Large enough to lead, small enough to care

1300 367 674 | clinicallabs.com.au MEDICAL FORUM | AGED & PALLIATIVE CARE

NOVEMBER 2021 | 7

continued from Page 6 foreign bodies. More than 80% of cases requiring surgery were caused by either nuts or raw carrot given to the child by a parent or adult.

Head of the ENT Department at PCH Dr Hayley Herbert said these emergency cases were often lifethreatening and many involved children who needed to be airlifted to Perth from regional locations which posed additional challenges.

“Nuts or carrot or other hard foods should only be given to children under four years with adult supervision to reduce the risks of children inhaling these items,” she said.

From an inhalation point of view, nut pastes, nut meals or ground nuts in other foods were the safest way to feed nuts to young children.

Bad medicine A South Australian GP has been given Australia’s longest ever ban from practising, after he attempted to murder a pharmacist who reported him for inappropriate prescribing.

Dr Brian Geoffrey Holder, 71, will never practise again, after the SA Civil and Administrative Tribunal cancelled his registration and banned him from applying for registration or providing any health services for 25 years.

It is the longest ban ever imposed on a registered practitioner by a tribunal on referral from a National Board.

The finding relates to the attempted murder of the pharmacist, inappropriate prescribing for five patients as well as himself and his wife, and providing misleading information to AHPRA and the Medical Board.

The tribunal said of Dr Holder’s attempt to murder the pharmacist, for which he is now serving a 15-year jail term, constituted professional misconduct “of a most serious kind.”

Meanwhile, a Victorian chiropractor has been suspended for six months for professional misconduct which included linking childhood vaccination to poison and allowing the antivaccination movie Vaxxed to be shown in his clinic.

Study of end-of-life care Research by Hollywood Private Hospital’s two-year End-of-Life Care Study explored the experiences of bereaved family members, as well as the perceptions of clinical staff on the quality of end-of-life care in an acute private hospital.

Edith Cowan University School of Nursing and Midwifery researcher Dr Rosemary Saunders said the study showed how hospitals need to take the lead in ensuring end-oflife care processes are embedded across all clinical areas, including end-of-life education and support to staff.

The project involved a medical record audit of 100 records to review the end-of-life care provided across the hospital, as well as surveys and interviews with staff and bereaved family members.

It found that patients and family members often need additional support, including around their spiritual and religious needs, and many staff would benefit from more end-of-life care training.

Hunt for missing genetics Families from around the world with members who have debilitating inherited diseases could benefit from a $1.2 million grant by the Federal Government to leading Perth geneticist Dr Gina Ravenscroft.

She will use her NHMRC Investigator Grant to further her Perkins Institute team’s search for missing genetics of rare diseases, ranging from recurrent miscarriage to adult-onset neurodegenerative diseases.

“We will use a range of complementary genomic approaches and sequencing to identify novel genetic causes of disease, said Dr Ravenscroft.

LETTER TO THE EDITOR Dear Editor, I’d like to point out what I regard as an error in the October magazine, when Dr Kosterich’s column states this winter has been “the coldest and wettest in decades.”

This WA winter has been neither atypically cold nor wet – even if this year has seen relatively more precipitation in the SW than the very dry six preceding winter seasons.

There is an ongoing SW drying trend (winter) and warming as BOM observations show.

8 | NOVEMBER 2021

Whilst there is clearly significant variation from year to year, statements like this (even if they appear incidental) give the false impression climate change is not occurring or insignificant when in fact the changes are proceeding more rapidly than were projected by models.

This is important when there is such limited coverage of climate change health effects in your and other medical magazines and when we know that health is being unequivocally affected in numerous ways around the world now and further change poses the greatest

challenge to health in the coming decades.

Dr George Crisp GP, Shenton Park

ED: Clinical editor Dr Joe Kosterich responds: “Thank you, Dr Crisp, for reading my column. July, for example, was the wettest since 1995 and 5mm shy of the wettest ever. As I said, this winter was “one of the coldest and wettest in decades.”

MEDICAL FORUM | AGED & PALLIATIVE CARE

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IN THE NEWS

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MAJOR PARTNER

Culture creates a winning team at Mount It says much about the inclusive culture of Mount Hospital that one of its most senior and revered members of staff, specialist cardiac anaesthetist Dr Stephen Same, is entrusted to speak on behalf of his colleagues and the organisation.

It is this strong sense of collegiality and camaraderie that has attracted some of the best doctors, nurses and technicians to undertake highly complex and skilled work at ‘Mount’.

The past 30 years have seen the hospital develop into a centre for excellence in cardiac services, the success of which Dr Same says can be attributed to its culture.

“From the early days, a special culture – a work ethic – was developed and nurtured by intensivists Drs Geoff Clarke and John Weekes, who were doyens of intensive care in Western Australia,” he said.

“They were both from Royal Perth Hospital and when this hospital opened in 1986, they were asked to consult here as well. I think the success of the cardiac unit and, indeed the entire hospital, has hinged on this one excellent decision.

“It’s truly amazing to watch this culture of care and excellence be transferred through generations.

These men were pioneers of intensive care in Australia. They were incredibly knowledgeable and, clinically, so very astute. Patients and patient care were uppermost.

They demonstrated, by thought and action, that caring for people and their families was paramount.

“Clinical success naturally follows, especially when the solid foundation created by the intensive

“I feel the success of Mount lies in the fact we never set out to try and be as good as the public system, we needed to strive to be better.”

Dr Stephen Same, Cardiac Anaesthetist

care is built upon by a dedicated team of 10 cardiac surgeons and 10 cardiac anaesthetists all striving for the best possible patient outcomes.”

“I feel the success of Mount lies in the fact we never set out to try and be as good as the public system,” Dr Same said. “We needed to strive to be better.”

Mount Hospital began its colourful history in 1908 on St Georges Terrace and moved to its current site, nestled into the side of Mt Eliza, in 1986. It was not a new build but a radical transformation of Riverside Lodge and hotel into a 224-bed private hospital with an adjoining medical centre.

While Mount has had multiple owners over the years, Steven Rubic’s chairmanship of the Healthscope board has seen a dedicated executive team appointed whose primary focus is on outstanding patient care.

It set out to build a reputation of fixing hearts by showing tremendous heart and skill – its cardiac team performed its first coronary artery bypass graft procedure in 1987 – the second private cardiac unit in the country – and it has continued to push boundaries in comprehensive private coronary care.

Dr Same was on that team and it began a career-long association with the hospital that has seen him collaborate on establishing a state-of-the art anaesthesia and perfusion service which has allowed Mount’s cardiac services to flourish.

Find out why Mount Hospital is excelling in quality patient care.

Ph: 08 9327 1100 | mounthospital.com.au | Mount Hospital

MEDICAL FORUM | AGED & PALLIATIVE CARE

“The hospital now has 12 intensive care beds, three catheter labs and a hybrid catheter lab. We started with six coronary care beds, and now we have 40,” Dr Same said.

And it’s not just hearts that Mount excels in. Over the past three decades it has also been building its capacity and reputation especially in orthopaedics, neurosurgery, breast, vascular and bariatric services, attracting the state’s finest practitioners.

It all comes down to Mount’s commitment and culture of care.

Mount Hospital

by Healthscope

NOVEMBER 2021 | 9

Q&A with...

Dr Mark Duncan-Smith, AMA (WA) president.

It’s been a rugged year for WA’s public health system, grappling with not only the demands of a looming pandemic, but also hospitals struggling to cope, despite few COVID patients. Medical Forum asked Dr Duncan-Smith why the wheels seem to have fallen off.

MF: If you had to pick the biggest contributor to what’s gone wrong with the WA health system this year, what would it be?

MDS: A continued orientation to cost cutting, and not a system that is patient outcome-centric with a focus on quality and safety.

MF: Why have big cracks appeared this year when WA has barely had any COVID-related health care/ hospital admissions and there has been no other significant spike in demand?

MDS: The system has been chronically underfunded over the past four years, the effects of which have been cumulate, and now manifest. The operational budget for WA Health has only increased approximately with CPI over the past four years. In comparison, demand has been growing steadily at 3-4% per year. This growth is compound and therefore represents a 16-25% increase in actual demand over the four years.

A flat operational budget and increasing demand has manifested as ramping, cancellation of elective surgery despite no COVID, ICUs typically full and record waitlists to see a specialist and elective surgery.

MF: Who bears responsibility – the State Government and its Health Minister Roger Cook, or health bureaucrats and the DirectorGeneral of Health David RussellWeisz?

MDS: Ultimately, this is the fault of the McGowan Government. They are in charge. The DG and Health Minister can put up the required budget to meet demand, only to see it knocked back by Treasury and 10 | NOVEMBER 2021

Cabinet. It could be contended they should have lobbied and argued harder for Health but it is Treasury, the Treasurer, Cabinet and the Premier who finally decide.

governance, I analysed WA Health and identified gross, fundamental shortcomings from a corporate/ organisational governance perspective.

MF: Should the State Government have seen the current crisis coming?

Can the situation be blamed on inaction by previous governments?

I commenced lobbying for a corporate governance review of WA Health in June this year at my first meeting with government after taking over as president of AMA (WA). The council endorsed this position and a formal letter was sent to the Health Minister.

MDS: The McGowan Government has been in control for over four years now, since 2017. They are responsible for where Health is now.

When the McGowan Government took over in 2017, ramping was approximately 1000 hours per month. Ramping since then has increased steadily to 5000 to 6000 hours per month, and a peak level of 6500 hours in August this year.

There has been no massive increase in activity as the government suggests, just slow and steady 3-4% per year. There has been no massive increase in psychiatry emergency department presentations as the government has suggested, as they have increased by 3% on average for the past four years.

There has recently been an increase in the acuity/complexity of patients presenting, but that is what happens when a health system can’t deliver care and should be seen as yet another indictment of the McGowan Government’s poor health policy, rather than yet another excuse for the failings.

MF: Some critics are suggesting the hierarchy of the WA public system needs to be pulled apart and replaced with a leaner, more responsive model. Do you agree?

MDS: Absolutely, yes. As part of my postgraduate degree in corporate

MF: How much of the current record ambulance ramping levels are linked to ED capacity and how much to the broader hospital/ health system? Are EDs the canary in the coalmine?

MDS: Ramping is not due to EDs, it is due to lack of capacity in the system.

WA has the lowest number of beds per capita of any State or territory in Australia. This has been identified to WA Health and government for some time. Our 15-point action plan released in August identified the need for 612 new beds to bring us up to the national average. The government has responded finally to this and, in the September budget, did allow for over 600 new beds, but over several years.

This is also reflected in the occupancy of our hospitals. They regularly run at over 95% occupancy, and some regularly at over 100% (with patients in non-census beds and in EDs). Maximum efficiency of a hospital runs at around 85%.

With the hospital full and no beds, when the ED is full, it can’t get patients onto the wards, and patients can’t get into ED as it is full – ergo ramping.

MEDICAL FORUM | AGED & PALLIATIVE CARE

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Q&A

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Q&A MF: Is the defence that too many GP-type conditions present at hospital EDs and too many aged care-type patients occupy hospital beds a cop-out?

MDS: Yes, it is a cop-out. The vast majority of ED presentations are not GP-type conditions. Streamlining could be undertaken to reduce GP-type presentations and better systems for patient decanting from tertiary hospital care but these are peripheral actions, and not the core problems.

MF: The AMA was a strong proponent for an extra floor at Perth Children’s Hospital while it was being built.

How has the decision (by the then-Liberal Government) not to go ahead with the extra floor impacted on the capacity of PCH to meet demand?

MDS: PCH was too small for demand from the day it opened. Both the AMA (WA) and Roger Cook in Opposition were lobbying for the extra floors to be built. We have called for this to be done now, or at least have a feasibility study. That would be part of the way to increase capacity, as would more paediatric services ‘closer to home’. Expansion of paediatric services at more peripheral sites would also be part of the solution – Fiona Stanley, Joondalup and Midland hospitals, for example.

MF: Will the death of Aishwarya Aswath tarnish PCH’s previously strong reputation in the longer-term? What can be done to help restore confidence in care at the hospital?

MDS: We saw then PMH culture almost destroyed in 2016-17, which culminated in the Geelhoed report and the chief executive of CAHS resigning the day before its release. PMH bounced back. Morale and engagement at PCH are currently low, but it is bouncing back similarly to 2016-17 due to the strength and commitment of the clinicians to their patients.

MF: What does the WA health system in 2022 look like if there are no significant changes?

MDS: Unfortunately, it is only going to get worse in the short to medium term.

The recent budget had big numbers for health, but many of them were double if not triple counted capital expenditure. For example, the new Women and Babies Hospital has been announced and funded three times (December 2020, August 2021 and Sept 2021).

Hidden in the budget and of great concern is the operational budget cuts over the next two years. We all know the current operational budget is inadequate and has resulted in an inability to do business as usual (such as elective surgery) despite there being no COVID. The year 2021/2022 will see an increase of 1.4% ($140 million), against CPI of 1.8%, so effectively a 0.4% budget cut. Astonishingly, 2022/2023 is budgeted to have a $210 million actual dollar budget cut. That will take us to less than the 2020/2021 budget that was patently inadequate to match demand, and we will have had another two years of growth in demand at 3-4%.

And what happens if we get a significant COVID outbreak? Our ICUs are already full of ‘business as usual’ heart attacks, sepsis, pneumonia and trauma, for example.

These don’t go away just because COVID has arrived.

ED: Medical Forum contacted the office of the Director-General of Health and it declined to comment.

MEDICAL FORUM | AGED & PALLIATIVE CARE

NOVEMBER 2021 | 11

Putting aged care in the picture In the wash-up of a landmark inquiry into the aged care sector, Cathy O’Leary looks at what is being done to protect some of society’s most vulnerable.

Surveillance cameras are ubiquitous – we have them at our front doors, inside public buildings and as dashcams in cars. And while there may be valid legal and ethical concerns when it comes to the use of covert surveillance, it is these hidden devices that recently confirmed some worst fears about elder abuse in several Australian aged care facilities.

the latest study, due out by the end of the year, will guide the potential use of cameras in residential aged care.

“At the moment CCTV monitoring is not widely used by the aged care sector for patient safety, however, there are growing community calls for cameras to provide stronger protections for vulnerable residents,” she said.

Images released during hearings of the Royal Commission into Aged Care Quality and Safety made for distressing viewing, showing elderly residents – some clearly frail or disorientated by dementia – being manhandled and roughly shoved around in their beds.

“Evidence provided to the Royal Commission identified that some families have installed hidden security cameras in their loved one’s room because they are concerned regarding their care and safety.

If not for the worried families who hid cameras in their relatives’ rooms, it might have been difficult to prove that neglect and abuse had even occurred in some facilities.

“We want to identify people’s concerns and opinions of surveillance in the residential aged care sector, how it may be used, for what purposes and if the use of cameras may be beneficial for private or common areas or both.”

With the commission’s final report in March this year calling for fundamental and systemic aged care reform, Perth researchers are looking at how security cameras could be part of the process to improve safety in aged care homes.

Weighing up CCTV Edith Cowan University researchers have been surveying residential aged care facility staff and family members to understand their views and attitudes about closed circuit television monitoring and how it is used.

The survey follows a previous pilot study at one Perth aged care facility, which found that 57% of family members and 38% of residents would like CCTV used in public spaces. The study also found 48% of family members and 25% of residents would like it used in bedrooms.

The study is part of ECU’s Centre for Research in Aged Care, which was established last year.

Lead researcher Dr Caroline Vafeas hopes the findings from 12 | NOVEMBER 2021

In a position paper, Aged and Community Services Australia endorses the ethical and lawful use of surveillance in aged care “where it is reasonably necessary to protect the safety of residents, and where it does not unreasonably impinge, or render unbalanced, their rights under the Charter of Aged Care Rights, or undermine the rights of staff.”

Dr Vafeas said the Royal Commission had highlighted the need for more input from residents, family and staff into safety and privacy issues.

“CCTV is one tool that is being explored in some States, but importantly we need to engage with the residents, families and staff who will be most affected by any new actions or measures.”

Dr Vafeas said that while the pilot survey asked if people were generally happy with CCTV in public areas and private rooms in aged care, the bigger project went into more depth with more than 200 family members and staff.

continued on Page 14

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NOVEMBER 2021 | 13

Putting aged care in the picture continued from Page 13

Staff supportive While the data is still being analysed, some trends are emerging, including higher than expected support from staff.

“We’re getting a lot of different responses from family members and health care staff, with some families agreeing cameras would be good and others thinking it would invasive,” she told Medical Forum.

“Likewise, there’s a big divide in health care workers, with some thinking it’s suitable and others saying it’s not, but we were surprised with more of them agreeing to its suitability.”

Dr Vafeas says acceptance of cameras also seems to depend on what surveillance is being used and who is accessing it.

“It all depends on the facility and the organisation, but I think there’s value to have them, and if everyone was offered them, they could either decline or accept,” she says.

“It’s not a cheap option if you’re going to do it properly, but it could be a very valuable resource for staff. It’s going to be a learning opportunity to see what really good care looks like, and to share it.

No Big Brother “It’s not always about Big Brother finding bad care, because people do fantastic work, but it’s hidden, and we don’t know about it.

“In the pilot interviews, staff mentioned it was really useful because if someone had a fall, they could see the trajectory, and be better able to decide whether that person needed to go to hospital or not because they obviously didn’t hurt themselves and they didn’t appear to be in pain.”

She says that while informed consent has been raised as an issue, the reality is that people in aged care usually have guardians making decisions on their behalf, and many guardians felt it should be their decision to say yes or no to cameras being used.

“Some absolutely do not want them, and that’s usually when 14 | NOVEMBER 2021

they’re happy with the standard of care, but we don’t know that everyone has got that standard,” Dr Vafeas says.

“And for some people they mightn’t want to know any more in case they start to monitor the care and get more information which they have to act on.”

While no one in the survey shared that they’d hidden a camera, some families did use cameras with the facility’s knowledge.

“One of the family members I spoke to in an interview did have a camera in the room and said it was very difficult at the start because there was this lack of trust between her and the facility, but after a while it settled down and wasn’t an issue,” Dr Vafeas says.

“No one had issues with having cameras in public areas, which is strange because things can still go on there, like falls or one resident abusing another.

“But surveillance isn’t always bad.

It’s really about seeing how we can use modern technology within the aged care industry to make the care better.”

She says it was difficult when the research started because there were no qualitative or quantitative studies that considered what to do with the information gathered from cameras.

“We go about our daily lives and

we don’t know where cameras are, and we just carry on and don’t really think about it,” she says.

“I think a camera would be useful even in an individual dwelling, so someone could keep an eye on the elderly and make sure they’re still pottering around. No one is going to be watching every single thing they do.”

The bigger picture The Brightwater Care Group, which has more than 750 permanent aged care residents, also wants to see changes after the Royal Commission, an inquiry which its CEO Jennifer Lawrence says “was a huge thing.”

“With all the media coverage and the awful stories that came out, it shocked all the people I work with – the clinical and nursing staff and our families – to the point where I had families ringing up fearful that their loved ones were being mistreated,” she says.

“That was a real shock and we welcomed the investigation into the current system in Australia, and I was lucky to give evidence and a submission.

“But I’d have to say the Government’s response was quite lacklustre in that they picked and chose what they were going to put into the reforms.

“And then, of course, the pandemic

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COVER STORY hit, and we’re dealing with residential aged care and disability care with very vulnerable people.”

Ms Lawrence says there has been some movement, with Government investment in the Aged Care Quality and Safety Commission, and compliance efforts have been ramped up considerably.

All about resources “But while that might be a good thing, any system that takes staff away from hands-on care – well, you’ve got to be able to get the workforce to do that,” she says.

“The final report really nailed it – it’s about resourcing, and what we haven’t seen from the Government is strong commitment to resource the industry to the level that the community and compliance expects.”

The sector has received one tranche of funding, for nutrition, which means an extra $10 a day for residents to ramp up the amount spent on food.

There is also a requirement for a minimum number of care staff which comes in during 2023, and means a client in residential aged

care will have a minimum of 200 minutes a day of care, and 40 of those minutes must be made up by a registered nurse.

“We’re yet to see what the funding for that looks like, and while we absolutely welcome this move, it would require, just for us at Brightwater, an additional $4.4 million of funding, and in the context of us finding ourselves with a quite critical workforce shortage, I’m not sure how that’s going to work,” Ms Lawrence explains.

“I think there’s a couple of years of really toughing out the workforce issues before we see a turnaround, so how it’s all going to fit together, I’m not really sure, nor how the Government is going to fund it and how we’re going to get the staff.”

Vaccinating the workforce has been a recent big task, as has been providing protective equipment, infection control training and crisis management plans.

“That takes huge energy and commitment, and while we have virtually no COVID restrictions in WA it’s easy to be complacent,” Ms Lawrence said.

She says many people now want to stay in their own homes, so Brightwater is also trying to grow services that could be delivered to them.

“We’re certainly going to have a tsunami of older people who are going to need support, with all the baby boomers getting to that point, so we’ve done a lot of modelling on what will be needed,” she says.

“But there will always be a place for residential care, and there’s been a huge increase in the acuity of the clients that come to us. They’ve got very complex medical needs, and they’re very frail, and they’re coming to us at the very end of their lives.

“That’s why high investment in residential aged care is important because the level of acuity has gone up so significantly.”

Read this story on mforum.com.au

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FEATURE

Paving the path to better Alzheimer’s treatments Hopes have been raised by a Curtin University discovery of a probable ‘blood-to-brain pathway’ that causes Alzheimer’s disease, but Kathy Skantzos explains why progress has been slow to find treatments.

The first drug to target the underlying cause of Alzheimer’s disease rather than merely addressing its symptoms could be available in Australia as early as next year if approved by the Therapeutic Goods Administration.

Seen as a “game changer”, it’s been a slow process of almost two decades since an Alzheimer’s drug has hit the market.

Developed by US biotech company Biogen, with trials involving 100 Australian participants, the anti-amyloid antibody drug, aducanumab, which goes by the commercial name Aduhelm, received Food and Drug Administration (FDA) approval after a bumpy 18 years of trials.

Professor Ralph Martins, Chair in Ageing and Alzheimer’s Disease at Edith Cowan University and Professor of Neurobiology at Macquarie University, told Medical Forum the new disease-modifying drug was a step in the right direction but not an all-round solution.

“It’s the first drug that targets the underlying cause of the disease and has huge potential. I see it as a starting point,” he said.

16 | NOVEMBER 2021

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FEATURE Even though the treatment is now available in the US, Biogen is required to undertake further trials to determine its efficacy on memory and cognition.

“While the FDA approved this drug in the US, it was a conditional approval based on its brain amyloid lowering ability for which they have to do another major clinical trial,” Professor Martins said.

Unsolved puzzle The search for a solution to Alzheimer’s is a long road. It is predicted the disease will affect over a million people in Australia by 2050. Since Dr Alois Alzheimer first discovered amyloid deposits in the brain in 1907, recent discoveries show the main contributing factor to Alzheimer’s lies in a small protein in the amyloid plaques known as beta amyloid.

The pivotal discovery of beta amyloids was made in 1985 by a Perth-based research team led by neuropathologist Professor Colin Masters, involving Professor Martins, which paved the way for further trials highlighting the importance of the proteins.

A high level of beta amyloid is a “killer of brain cells” and affects function, thinking and memory.

“Beta amyloid is like cholesterol to heart disease. We all make it in moderate amounts, and it obviously has a biological function, we think it may even be protective in low concentrations. However, when it builds up in large concentrations, it starts killing brain cells and that’s what leads to Alzheimer’s,” Professor Martins explained.

In the late 1990s and early 2000s, “active vaccination” animal trials of beta amyloid injections in mice proved to clear the proteins in the brain and improve memory, but a setback was seen in human studies showing severe side effects. Over the years, further trials of altered versions of the drug using “passive vaccination” resulted in less side effects but did not show significant reduction of beta amyloid in the brain.

That’s until Biogen developed aducanumab, which effectively modifies the brain’s beta amyloid.

“It has a very dramatic effect on removing the amyloid from the brain, that’s what has made this so exciting, but it has been a slow

process to get to that stage,” Professor Martins said.

truly disease-modifying drugs may well begin,” he said.

Paving the way

“The original trials were terminated when it looked like the drug wasn’t working – at that stage there weren’t many people on the highest dose of the drug. When researchers examined more data, which included more people who had been, for longer periods, on the highest dose, they demonstrated a significant effect.

The approval of aducanumab opens the door for drug companies to create better treatments and more powerful drugs in the near future.

Dementia Australia honorary medical advisor Associate Professor Michael Woodward said in a statement that the development was, while not a cure, a “very promising result for an anti-amyloid therapy, after many years of disappointment.”

“Soon, a new era of administering

MEDICAL FORUM | AGED & PALLIATIVE CARE

“It is possible that, if used early in Alzheimer's disease, this drug will prevent the emergence of the symptoms of Alzheimer's, but there is still research to be done in this area.”

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NOVEMBER 2021 | 17

Paving the path to better Alzheimer’s treatments continued from Page 17

Controversial results Professor Martins admits aducanumab also has its “issues”, with clinical trials showing mixed results. Even though the drug is successful at reducing beta amyloid, there are still questions surrounding its efficacy to improve memory, learning and behaviour.

One trial showed no improvement in memory, while another indicated improved symptoms at a high dose, which led to the FDA application.

“There is no question that the amyloid has been effectively removed from the brain, almost to normal, but the improvement in memory is still under debate and that’s what makes this topic still quite controversial,” Professor Martins said.

“What we know is the amyloid will definitely come down. What we need to find out is whether memory stabilises, and maybe even gets better, but we don’t know that,” he explained. “I am confident to say that it is quite likely to have a significant benefit, but we need to see from the results of the next clinical trial whether it helps memory and cognition.”

Trials are being conducted to determine if the drug has a preventative effect in people who have shown symptoms of the disease.

“There is no evidence yet of it this.

I personally think that’s going to be the most likely benefit to that group of people, but we have to wait for that result – nor has there been any trials with people who have more severe stages of Alzheimer’s,” Professor Martins added.

Restricted usage People with susceptibility to bleeding in the brain, which includes those who have the APOE4 gene – a genetic risk factor which accounts for around half the people with Alzheimer’s – are at higher risk of side effects.

“Patients need to be carefully advised of the limitations and risks associated,” Professor Martins said. “An MRI scan at the start 18 | NOVEMBER 2021

will determine if someone will be eligible. If they are already having some of these issues it will put them at higher risk. They should have MRI scans during treatment just to make sure there’s no bleeding in the brain.”

“The drug isn’t for everyone, so it should be restricted for their usage at this stage,” Professor Martins said. “We don’t want to give the message that this is the magic Alzheimer’s drug that’s going to cure all people with Alzheimer’s.”

Dosages will also require titration.

While it can be “very expensive” to test, a PET amyloid scan can detect presence of amyloid in the brain, or a lumber puncture can be performed which measures amyloid levels in the cerebral spinal fluid.

“It’s very important for doctors who are prescribing it to patients to have recommendations for how this drug is used,” he said. “As long as they follow the guidelines and take the appropriate precautions like MRI scans, then the risks can be managed. Every drug has side effects, but you need to follow appropriate guidelines for monitoring, that’s where doctors will make the call.”

At this stage, the drug should only be prescribed to “a smaller, specified group of people” who have early stages of the disease with mild cognitive impairment – and only if amyloid is present in the brain.

“In the future, I envisage a blood test will be important for screening for brain amyloid,” Professor Martins said.

“Diagnosis needs to include imaging to show amyloid in the brain. The major reason the drug was released is because it lowers amyloid. Some people have Alzheimer’s dementia where there is no amyloid in the brain,” he said.

Costing about AU$72,000 for a year’s treatment, the price of

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FEATURE aducanumab is “exorbitant”, according to Professor Martins, and government subsidies would be necessary for most Australians to access the drug.

“Hopefully there will be subsidies here in Australia,” he added. “We need significant federal funding in Australia and that’s not happening yet for dementia research.”

Even though Health Minister Greg Hunt said that if the TGA approval goes ahead, he would make the drug available on the PBS, the cost goes beyond the drug itself.

Accessing Home Care can be confusing

“These patients who are approved for treatment will need to go to hospital once a month for an infusion of the drug with some antibody, plus the MRI scans, so that is expensive,” Professor Martins said.

To help we’ve created this simple guide

Critical intervention Alzheimer’s is not age limited, but the disease usually affects people from age 50 or 60. While the number of early-onset Alzheimer’s is increasing, it’s “relatively rare” in people in their 30s and 40s.

“In those cases, it is clear they have a genetic mutation that results in massive amounts of amyloid in their brain,” he explained. “There’s genetic evidence proving that amyloid is a key factor that starts the whole process.”

About 470,000 Australians are living with the disease, according to Dementia Australia. Professor Martins describes Alzheimer’s as “a tsunami that’s really hitting and building up a momentum … and we don’t have effective treatments in place,” he said.

Step 1. The patient visits their GP to ask for an ACAT referral.

You, the GP, refer them for an ACAT assessment via www.myagedcare.gov.au/health-professionals OR

Step 2. The ACAT assesses your patient in their home

Major trials into lifestyle factors affecting dementia show a healthy diet, regular exercise, brain training and reducing vascular risk factors such as cholesterol play an important role in the prevention of Alzheimer’s disease.

Led by the worldwide Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGERS), an international partnership with the Australian ARROW study and the US POINTER study, research shows that what’s considered to be good for the heart is also beneficial for the brain.

Your patient will be contacted by the ACAT to

arrange to visit them and work out the services they may need.

Step 3. The patient completes an Income Assessment with Services Australia

Early diagnosis is critical for the treatment of Alzheimer’s, preferably before the onset of symptoms such as memory loss, confusion, concentration difficulties and language problems.

“Lifestyle accounts for at least 50% of the people with Alzheimer’s so it’s preventable,” Professor Martins said.

Ask your patient to call us and we will guide them through the process.

The patient can call us on 1300 26 26 26 (option 2) and we can mail the form to them (if applicable).

Step 4. Your patient will receive three letters 1. ACAT letter approving their care level.

2. Services Australia letter with their income assessment (if applicable).

3. Home Care Package Assignment letter - this may take 3 to 6 months.

Step 5. The patient receives the assignment letter

They have 56 days before the offer expires to call us, organise an appointment and activate the funds.

Step 6. Compare service providers

Importance of sleep

Professor Martins added that sleep was another “major pillar that affects brain function”.

Step 7. Select a service provider and sign up

“Sleep is very important because when we get a good sleep that’s when our garbage disposal system comes into play and helps clear the amyloid out of the brain.

When that sleep is disrupted or is of poor quality, it starts building up,” he said.

“Earlier intervention and trying to prevent the progression and delaying of symptoms by another 20 years or perhaps stopping them altogether, that’s what I’d like see. Within the next decade we’ll have a number of new drugs that may even be looked at in combination.”

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With their letters in hand – they call their preferred providers to compare services and costs, and hopefully we’re one of them.

Their services can start immediately.

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Call us during office hours and select option 2.

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NOVEMBER 2021 | 19

Making a new difference Earlier this year, Dr Jagadish Krishnan made the jump into State politics. As the longtime GP and businessman explains to Ara Jansen, it is another way to serve his community.

When Dr Jagadish Krishnan won the seat of Riverton in the State election earlier this year, something his father said echoed in his head: “The people of Riverton have now accepted you as their son. Do to them as you would do to me.”

Known affectionately to his community simply as Dr Jags, the GP and practice owner contested the seat, which Liberal Mike Nahan had held for 13 years before he announced his retirement. Jags won with 59% of the vote in a 13.3% swing.

Born in Tamil Nadu in India, Jags lived in the UK before moving to Perth. While in London he worked for the NHS and was on duty on July 7, 2005, the day of the London bombings. He was part of the management team, working as a senior health officer in charge of St George’s Hospital and Mayday Hospital in the aftermath of the four attacks.

Jags says for some reason he woke unusually early that day and headed to work before his shift, escaping the bombing by a matter of minutes.

The next year, Jags, his wife Dr Yaamini Jagadish and their two young children, moved to Perth.

20 | NOVEMBER 2021

The pair worked as GPs in Byford, Jags did his fellowship and GP exams and the family looked for a practice to buy.

In 2010, Jags formed his company, Perth GP, and bought a practice in South Lake. Dubbed the biggest non-corporate medical business in WA, Perth GP now has 10 practices which the family own outright. He’s also a founder and co-owner of Spectrum Health with several other GPs, which has 40 practices under their umbrella.

“Owning my own practice was an opportunity that came along and I grabbed it with both hands. Then I thought I would be able to manage more than one practice,” he said.

“I started building a management team who could look after things.

My aim was always to empower people.”

started early in leadership positions, in and out of medicine. Highly involved in his local community, Jags is a former president of both the Australian Indian Medical Association and the Hindu Association of Western Australia and still maintains a strong link with the association.

He’s also an adjunct associate professor at Curtin and a medical educator at Notre Dame and the Royal Australian College of General Practitioners.

“This is a chance to contribute in a bigger way,” he enthuses. “As a GP, my work involves dealing with people’s problems. It is my duty to discover people’s issues and help them find solutions to their problems. In this role, I will

Jags still works as a GP and was the first GP in the State to do COVID swabs in a private practice. Yaamini is a doctor working fulltime at the Willagee Medical Centre, with a special interest in women’s health and children.

Politics calls So why go into politics? Jags says it’s in his blood, with a grandfather and uncle in politics, but he also

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CLOSE-UP be providing a holistic approach to finding solutions to problems in my electorate.”

“The trade-off going into politics is a pay cut and losing some of my freedom. As a politician, you are closely scrutinised. Most importantly to me, though, is a chance to use this platform to make a difference to the community.”

Jags’s first year as an MP has been watching and paying attention to how everything works. He doesn’t rule out an interest in a ministerial portfolio but knows there’s time to serve before that happens.

On the ground “I’m proud that in Riverton we’ve delivered 22 of the 29 election commitments to date. That’s my focus. Being successful in business is one thing but being successful in politics is something else. It’s about being present and sincere and working hard, and that will be recognised.”

members, especially those more experienced.

move to the area) and the family home in Mosman Park.

“People have been kind to explain things to me and it’s helping give me a real understanding of the important role government has in driving change.

Weekends that he can spend with Yaamini and catch up with their children, daughter Dheekshana and son Sridhar, are now a little rarer, as is the time to just quietly recharge.

“Working together is something I have always liked to do and promoted. I encourage people to support each other and learn from each other.”

His children seem to be following in the family footsteps with Sridhar in second year medicine and Dheekshana stepping up to manage her father’s businesses.

With added political duties Jags’ days are full and busy and somehow even more so than when he was concentrating full time on medicine. Jags splits his time between living in Shelley (an election commitment he made to

Nimble feet

So far, he says, the workings of government are interesting and has felt welcomed by the other

MEDICAL FORUM | AGED & PALLIATIVE CARE

While he hopes to get back to playing next year, one thing which has been temporarily sacrificed to the god of politics is playing soccer. Jags has a keen interest in soccer and used to coach the under-10 team at the Western Knights Soccer Club and pulled on the boots in the master’s team, but politics has taken over that space.

“It’s important to have balance.

I did a personality assessment and ticked all my boxes but I have continued on Page 23

NOVEMBER 2021 | 21

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Making a new difference continued from Page 21 utterly failed when it came to time spent on hobbies – so I need to incorporate some things for a bit of balance.

“Change needs to happen on a constant basis to make things happen. I believe my single mission – whether it’s in management, clinical practice or politics – is to improve something every day, no matter how small. Even if you just clean your room, you have improved something. Every day you are alive is an opportunity to improve.

“I hope I’ve given that to my whole team and not just my kids – improve something for someone else and make things better for someone every day. I realise I can’t solve everyone’s problems, but I believe doing something for others is a good thing. But I also believe in giving freedom to people and empower them to take responsibility.”

Jags’ inspiration During his maiden speech to the Legislative Assembly in May, Jags paid homage to four generations of women who have influenced, inspired and supported him. He named his wife as unashamedly being his better half, supporting him when he quit his job to do his medical exams and for standing by him in the difficult times. He thanked his daughter for stepping in and stepping up.

He speaks lovingly of his grandmother for “teaching me the values of hard work, being humble and taking every opportunity to help people whenever I can” and his mother, who while spending much of her life illiterate, supported her son to have the best education possible.

Much of his speech talked about the positive skills and attitudes he has learnt as a doctor and businessman or were instilled in him by family – the college where he graduated which “taught me the basic values of medicine, which were more valuable than the clinical skills that they taught me” – which he hopes to reflect in the way he

serves his electorate and uses daily when dealing with his patients.

Indeed, testament to his drive to succeed, Jags and his team doorknocked at more than 14,000 homes – twice – ahead of the polls.

One evening after a tiring day of doorknocking, Jag’s son asked which door was the best one he had knocked on that day. While Jags paused to think of an answer, his son jumped in and proclaimed: “The door that is yet to be knocked, Dad, where Mum is going to be inviting us inside with a big smile and a hot plate of food on the table.”

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Focus on palliative care for kids With WA’s first children’s hospice due to turn the sod next year, efforts are underway to promote holistic palliative care for children, as Dr Karl Gruber (PhD) discovers.

While palliative care is invariably associated with adults, particularly the elderly, people often overlook that children sometimes need these services too.

A significant number of children are referred each year to palliative care in Western Australia, and that triggers access to a wide range of services for both patients and their families or carers.

Among those services, patients receive assessment and management of symptoms such as pain, seizures, or irritability, while patients and carers receive education and information about medications and equipment. There is also psychosocial support for the child, siblings and family members, as well as social support, which includes providing information about finances, respite care options and relevant details about the National Disability Insurance Scheme.

In addition, carers are supported with clear information about care planning and goals of care, and services that can be provided for children as inpatients or outpatients. Patients also receive care and support during their end of life stage, and parents or other carers can access bereavement support.

The basic goal of paediatric palliative care is to improve the quality of life of children and support their families or carers.

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NEWS In some cases, palliative care services are provided before a child is born. Perinatal palliative care is available in WA with the goal of providing the best possible care during pregnancy and childbirth, when the fetus is diagnosed with a serious abnormality, or a lifelimiting condition. In these cases, palliative care can be extended to the mother, providing care by the obstetric management team, particularly if there is high risk of early pregnancy loss.

The Child and Adolescent Health Service is WA’s only provider of specialist palliative care for children, through the WA Paediatric Palliative Care Service (WAPPCS).

Currently, about 110 children under care from WAPPCS, based at PCH. The palliative care team comprises a doctor, nurses, social worker, and a secretary, who work closely with the clinical team of each child.

Children referred to this service suffer from severe conditions that need regular supervision and support from a health professional.

It is commonly thought that children under palliative care are at a terminal stage, however, Dr Lisa Cuddeford, who leads the WAPPCS at PCH, says the reality is that only a small percentage of children currently under palliative care are at a terminal stage at any one time.

“The word terminal is something that we wouldn't often use,” she told Medical Forum. “For me it would signify a child that's in a more active dying phase. Many of the children that we support are not in the final weeks or even months of life, but their families live with the threat of their death constantly.”

So rather than being limited to terminally ill children, palliative care is a service broadly aimed at any

children with a long-term, lifelimiting condition, who may still live for a significant period of time. These children and their family or carers are in need of specialised service that only WAPPCS can provide.

Another common misconception is that most of these children are cancer patients. In reality, children currently supported by WAPPCS come from many different clinical backgrounds.

“The majority of children have metabolic conditions, neurodegenerative conditions and static conditions, like very severe cerebral palsy,” Dr Cuddeford said.

These conditions in themselves are not progressive, but some of the associated complications are, Dr Cuddeford explains. “They develop increasing lung disease or increasing seizures, and that probably constitutes the majority of the diagnoses.”

The WAPPCS team works with these children to meet their needs.

But the team’s goal is not just to provide comfort and pain relief, but to provide a broader approach to improve their wellbeing.

Quality of life The work led by PCH’s palliative care team is not just about providing support for children at the end of their lives. Rather, the team seeks to add value to whatever time children have.

“We really see ourselves as a team that is trying to help families and children live as well as possible for however long they have. There's a beautiful quote from Ann Goldman, who was a paediatric palliative care specialist at Great Ormond Street Children’s Hospital (in the UK): ‘It's really about adding life to years, not years to life’,” Dr Cuddeford said.

NEW SS RE ADD AME & N iously

Prevylands “Ma unding” po C om

With these goals in mind, the PCH’s palliative care team is now set to offer their services at a new location. Recently, it was announced that WA’s first children’s hospice will be built in Perth at the former site of the Swanbourne Bowling Club in Odern Crescent, Swanbourne. The project is funded by the WA Government, the Child and Adolescent Health Service and Perth Children's Hospital Foundation.

Health Minister Roger Cook said while there were already good services available in WA, the hospice would give families the choice of accessing care away from a hospital environment.

Construction of the hospice is expected to begin in late 2022, with a planned inauguration in 2024.

Ian Campbell, chairman of Perth Children’s Hospital Foundation, said in a statement that the project team had refined the requirements for the hospice to serve the needs of palliative care patients and families for decades to come.

“The next step is to turn these concepts into formal designs which we hope to have finalised this calendar year,” he said. We look forward to sharing these with the wider community.”

Once completed, WA’s new hospice is set to benefit children with longterm conditions and their families, providing a much-needed service, at an accessible location.

Read this story on mforum.com.au

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NOVEMBER 2021 | 25

SPONSORED CONTENT

The ageing population a medico-legal perspective

By Nerissa Ferrie, Medico-legal Adviser, MDA National

Nerissa Ferrie explores some of the common medico-legal issues which arise for doctors treating elderly patients.

Capacity Loss of capacity can affect patients of any age, but if you treat elderly patients it is often the case of not if, but when, capacity becomes an issue. Adult patients are presumed to have capacity once they reach the age of 18 and this will generally remain so until such time as an adult's decision-making ability comes into question.

Cognition can be decision-specific and variable in elderly patients, so it is vital to understand how to best advise the patient, and their family, about the options available to them. If the patient still has decision making capacity\ but is in poor health or of advancing age, this is the perfect time for the patient to consider an enduring power of guardianship for health decisions and/or an enduring power of attorney for financial decisions.

If the patient has strong views on end of life care, they should consider an advance care directive2.

If a patient is unable to make their own decisions, you should obtain consent for non-urgent treatment from their substitute decision-maker.

If there is disagreement between people on the hierarchy of decision making3 (for example, two adult children) you can suggest the family make an application to the Guardianship Tribunal4 • The tribunal will often request a report from the treating doctor/s to assist in their decision and might appoint a family member or an independent body (such as the Public Trustee) to act in the best interests of the patient.

Testamentary capacity Declining cognition can create disputes over the legitimacy of legal instruments such as powers of attorney/guardianship and wills. Patients and their families often only think about these important legal documents after cognition starts to decline. This can result in a request for notes5 and the retrospective assessment of testamentary capacity6 once the patient has passed away.

You may also be asked to provide a prospective assessment of a patient's testamentary capacity.

Unless you have experience in applying the legal test necessary to assess testamentary capacity7, you should restrict your opinion to the patient's cognition from a clinical perspective, and suggest a referral to a geriatrician for formal assessment if necessary.

Fitness to drive As noted in the Austroads Guidelines8 :

"... advanced age, in itself, is not a barrier to driving, and functional ability rather than chronological age should be the criterion used in assessing the fitness to drive of older people."

Doctors are understandably reluctant to recommend that an elderly patient cease driving, particularly if it will have a significant impact on their independence. Cognitive decline is often gradual, and there are some simple strategies which assist elderly drivers to remain safe on the roads - such as no night driving, avoiding peak hour and busy roads, and limiting driving to local areas well known to the patient. When the time comes for a more difficult discussion, try and handle the process sensitively and include a family member if appropriate.

If cognition becomes so poor that the patient continues driving regardless of their undertaking to stop, and they become a danger to themselves and the public, you should contact the driving authority and recommend a family member remove the car and/or keys from the patient.

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Voluntary Assisted Dying Voluntary assisted dying became an option for eligible people in Western Australia after the Voluntary Assisted Dying Act 2019 9 (the Act) came into effect on 1 July 2021.

If you receive a 'First Request' for access to voluntary assisted dying during a medical consultation you must take a number of steps10 , even if you don't want to be involved or have a conscientious objection. Whatever your response is to this First Request, it is important that it is well documented in the patient records, including the reason for your objection. Conscientious objectors must immediately advise the patient.

Medical practitioners who meet the eligibility criteria and who have completed the approved practitioner training1 1 , may undertake roles in the voluntary assisted dying process under the Act.

References 1. https://www.mdanational.corn.au/advice-and-support/library/ articles-and-case-studies/2015/10/assessment-of-capacity 2. https://ww2.health.wa.gov.au/~/media/Files/Corporate/ general%20documents/advance%20care%20planning/PDF/ preparing_an_advance_health_directive.pdf

3. https://ww2.health.wa.gov.au/~/media/Files/Corporate/ general%20documents/Advance%20care%20planning/ PDF/1153 4-you r-choices-to-make-an-ahd.pdf

4. https://www.sat.justice.wa.gov.au/G/guardianship_and_ administration.aspx

5. https://www.mdanational.corn.au/advice-and-support/library/ articles-and-case-studi es/2016/11/access-deceased-patientrecords

6. https://www.mdanational.corn.au/advice-and-support/library/ articles-and-case-studi es/2016/03/testam enta ry-capacity

7. https://lplc.com.au/uploads/main/Resources/Checkli sts/ Testamentary-Capacity-Checklist.pdf

8. https://austroads.com.au/__data/assets/pdf_file/0 022/1 O 4197/ AP-G56-17_Assessing_fitness_to_drive_2016_amend ed_ Aug2017.pdf

9. https://www.legislation.wa.gov.au/legislation/prod/ filestore.nsf/FileU RL/mrdoc_42491.pdf/$FI LE/Voluntary%20 Assisted%20Dying%20Act%202019%20-%20%5B00-00-00%5D. pdf?OpenElement

10. https://ww2.health.wa.gov.au/-/media/Corp/Documents/ Health-for/Voluntary-a ssisted-dy in g/What-Every-HealthPractition er-and-Healthcare-Worker-Needs-to-Know.pdf

11. https://ww2.health.wa.gov.au/~/media/Corp/Documents/ Health-for/Voluntary-a ssisted-dy in g/ Approved-training.pd f

This article is provided by MDA National. They recommend that you contact your indemnity provider if you need specific advice in relation to your insurance policy or medico-legal matters. Members can contact MDA National for specific advice on freecall 1800 011 255 or use the "contact us" form at mdanational.com.au.

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NOVEMBER 2021 | 27

Facing a geriatric juggernaut Curtin University’s Professor Tanya Chikritzhs warns that people living longer and using prescription drugs and alcohol will challenge Australia’s health sector.

Earth has never sheltered so many senior citizens. Forecasts estimate that for many Western nations, people aged 65 and over will account for more than 30% of total population by 2030.

That might be a good or bad thing, depending on your point of view, but indications are that if labour forces are allowed to diminish while health and social needs grow, ageing populations will create serious challenges for social and economic stability.

The pandemic has illustrated that simply increasing existing health system capacity is not an option.

The geriatric juggernaut is on target to crack publicly funded healthcare systems wide open, and rich countries with high expectations of their public health sectors – like Australia – will be hit hard.

One popular solution (from the likes of the OECD and WHO) is to help workers remain productive for longer through effective policies that promote good health in older age. Swift repositioning of government and employer attitudes towards older workers, particularly women, are also necessary.

Women’s paid labour is a powerful weapon against poverty and more likely to elevate the health status of those around them, yet female workforce participation rates are about 26% lower. Women live longer on average but tend to have more illness, doctor visits and hospitalisations. Moreover, women live more of their life with disability while dominating the ageing health care and social assistance sectors across Europe and Australia.

Addressing these impacts of 28 | NOVEMBER 2021

ageing populations is going to be a challenge, so where do prescription drugs and alcohol fit in?

Alcohol is one of Australia’s favourite psychoactive substances, with 79% of males and 74% of females considered current drinkers.

Although people tend to drink less overall as they age, older people are more likely to drink daily than any other age group and those in their 70s lead the way (about 13%).

Secondly, more than one third of older Australians continuously consume five or more prescription drugs (PDs). Risk of polypharmacy increases with age, is higher for women and, in terms of total number and cost per script, PDs are one of the fastest growing areas of health expenditure in Australia.

Thirdly, increasing PD use among older people is occurring alongside significant increases in proportions of older drinkers (male and female) who drink above national guidelines for minimising alcohol-related harms.

Contrasted against large declines in risky drinking among the under 40s, this is a striking trend. For example, from 2001 to 2019, consumption of >4 standard drinks on a single occasion fell from 40% to 20% among teenagers but rose from about 13% to 17.5% among the 60+ age group.

Alcohol is well-established as a cause of many of the acute (falls, physical abuse) and chronic (hypertension, cancer) health problems common in older age and deserves the full attention of continued on Page 30

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NOVEMBER 2021 | 29

AOD help just a call away Dr Richard O’Regan explains how a drug and alcohol support service for WA doctors is helping patients and reducing doctor-shopping.

The Drug and Alcohol Clinical Advisory Service has been operating in WA for 18 months, providing WA clinicians across the state with support and advice in the management of alcohol and other drug (AOD) use.

The DACAS addictions specialist can assist GPs, hospital clinicians, psychiatrists, AOD counsellors and psychologists in a wide range of clinical situations, including: • A 63-year-old single patient who lives alone wants to stop drinking three-quarters of a bottle of spirits a day. She has had withdrawal seizures previously.

Where can she go for help?

• A 21-year-old male recovering from alcohol intoxication-related road trauma wants to enter residential rehabilitation. How much does it cost and how does he get in?

• A 38-year-old mother of three has completed a home-based alcohol withdrawal and wants help staying off alcohol. Is there any medication that can help?

Where can she access supportive AOD counselling?

• A 47-year-old roof plumber with chronic pain has presented

early for script renewal on four occasions, and the local pharmacist called to say three GPs are now prescribing oxycodone, tramadol and diazepam. The Department of Health has requested that a specialist support the opioid prescribing. How do I proceed?

Is there anything I can do to help keep him safe?

• A 25-year-old woman, who was recently released from prison after serving 22 months for stealing, says she has begun using heroin again and wants to stop. She also says she is pregnant. How can I help her?

What services are available to support her through the pregnancy?

In addition to expedient access to specialist AOD advice, callers will be offered summaries on a range of addiction medicine issues.

Regional support Epidemiological data indicates that the prevalence of many substance use disorders is higher in the rural and remote areas than it is in metropolitan Perth. It can be a challenging task for GPs to manage

complex problems associated with AOD use in their communities without support from specialist addiction services.

DACAS now offers telehealth support to WA clinicians including videoconferencing to discuss a specific patient or addiction medicine topics.

Real-time prescription monitoring RTPM will create a demand for AOD clinical advice on chronic pain management and associated substance use issues, as a number of patients are likely to be identified as oversupplied or drug dependent.

The capacity of WA GPs to manage these patients will be increased through access to expert AOD advice.

How it might help doctors A 65-year-old man has been under your care on the ward since admission eight days ago following a deliberate medication overdose in response to a strained relationship with his wife. On presentation his history included use of prescribed oxycodone modified-release at a dose of 40mg TDS, oxycodone

Facing a geriatric juggernaut continued from Page 28 health policy and practice decisionmakers. Concurrent use of alcohol and PDs, however, brings unique risks of which many senior patients – and their healthcare professionals – may be unaware.

International evidence suggests between 21% and 35% of older people have a propensity for adverse alcohol and PD interaction effects.

Prevalence of concurrent alcohol and PD use among older Australians appears to be on par, with a 2005 30 | NOVEMBER 2021

national survey finding more than one third had consumed both alcohol and PDs in a 24-hour period.

However, the magnitude and distribution of adverse outcomes (AOs) arising from concurrent alcohol and PD use are unknown.

Older people who combine alcohol and PDs are at risk of a wide range of harms including higher blood alcohol levels, increased/decreased drug metabolism and unexpected increased (i.e., overdose) or reduced (i.e., therapeutic failure) PD effects.

Concurrent use also increases risk of AOs such as liver damage, gastrointestinal bleeding, sedation, dizziness, hypotension, hypertension, insomnia, cognitive and psychomotor impairment (i.e., visuo-motor control, reaction time, working memory) and a range of injuries (i.e., falls, traffic accidents).

Many PDs commonly prescribed for older patients are implicated in alcohol-related AOs including antihypertensives (diuretics, betablockers), digoxin, anticoagulants, NSAIDs, benzodiazepines,

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•

•

•

•

•

immediate-release 5mg TDS, oxazepam 60mg TDS, pregabalin 300mg BD, quetiapine 100mg BD and venlafaxine 300mg daily. He has a vague and distant history of pain “everywhere” with severe anxiety, and reports that he attends at least three different medical practices for scripts. Where do you take this? How can this man’s medications be rationalised, and prescribing made safer with a view to his discharge?

By calling the Drug and Alcohol Clinical Advisory Service (DACAS, phone 6553 0520), you will immediately be in contact

tricyclic antidepressants, opioids, antihistamines, antibiotics, H2 blockers and anti-diabetics.

Effects are mediated by type and dose of medication, frequency and quantity of alcohol use, drinking setting and age-related physical changes such as absorption, metabolism and tolerance.

Crucially, alcohol-related AOs are indicated for medicines used to treat conditions highly prevalent among ageing populations such as heart disease, hypertension, diabetes, GI problems and arthritis, and many arise from alcohol consumption levels considered low/moderate and within national guidelines.

with an addiction specialist for advice and receive the following recommendations: • Call the Medicines and Poisons Regulation Branch (MPRB, 9222 6883) for advice about the authorisation for long-term, high-dose Schedule 8 opioid prescribing. (You later discover that in the past three months, six practitioners from four medical practices have all prescribed oxycodone for the patient, and that a single prescriber has DoH authorisation to do so.)

• Make contact with the Prescription Shopping

Once again, however, we have little to go on in determining the realworld scope and magnitude of these harms across Australia.

Key priority areas outlined in national alcohol and preventative health strategies include supporting people to obtain help, and systems that reduce alcohol and other drug harms.

The ageing population challenge is mammoth but mitigatable. If we accept keeping older people healthy for longer is part of the solution, then united public health sector insistence on rapid investment into understanding the who, what, when, where and why of concurrent alcohol and PD-related harms is warranted.

MEDICAL FORUM | AGED & PALLIATIVE CARE

Information Service (PSIS – 1800 631 181) to determine the extent of medication access. (You later do so and are advised the patient fulfils the criteria for doctorshopping.)

Make contact with the man’s GP to discuss the information provided by the DoH and PSIS. Plan to safely manage future medications through staged supply via a single nominated pharmacy. (You agree that a second daily collection is reasonable at this point).

Refer to a sample opioid and benzodiazepine dose reduction regime You are provided with details for community support and referral via the local Community Alcohol and Drug Service.

Finally, the addiction specialist recommends you provide the man with take-home naloxone and discuss its use with the patient and his partner.

A short time later you receive several summaries via email, including Coming off opioid medication (an information sheet for patients), Management of Opioid Withdrawal in General Practice, and Naloxone advice for practitioners. You decide to keep the DACAS contact details handy for future reference!

ED: Dr Richard O’Regan is clinical services director with the Mental Health Commission’s Next Step Drug and Alcohol Services.

This would go a long way to supporting much needed evidencebased discussion of cost-effective intervention strategies that can be rapidly deployed to reduce the health burden of our ageing population.

ED: Professor Chikritzhs is based at the National Drug Research Institute and had input from Vic Rechichi at NDRI and Dr Ya Ping Lee from the Curtin Medical School

NOVEMBER 2021 | 31

Complex non-melanoma skin cancer patients?

Refer cases to the Non-Melanoma Skin Cancer Advisory Service for multidisciplinary review

The benefits of a multidisciplinary approach to patient management are well known. The Non-Melanoma Skin Cancer Advisory Service (NMSCAS) has been established to enhance the care of patients with complex non-melanoma skin cancers.

To submit cases to the NMSCAS for advice or management, visit genesiscare.com/au/refer-a-patient then click on Refer to the WA non-melanoma skin cancer advisory service to download the forms. Case information must be received no later than 1 week prior to the scheduled meeting.

 NMSCAS meets every third Thursday of the month  Clinipath Pathology 310 Selby Street North Osborne Park WA 6017

NMSCAS specialist team: Dermatology Dr Kate Borchard Dr Judy Cole Dr Glen Foxton Dr Louise O’Halloran Dr Jamie Von Nida Dr Yee Tai Pathology Dr Trevor Beer Dr Gordon Harloe Dr Joseph Kattampallil Dr Stephen Lee Dr Ben Ryan Plastic Surgery Dr Adrian Brooks Dr Sharon Chu Dr Mark Hanikeri Dr Qadir Khan Dr Daniel Luo Dr Linda Monshizadeh Dr Remo Papini Radiation Oncology Dr Sean Brennan Dr Eugene Leong Dr Susan Mincham Dr Evan Ng Dr Kasri Rahim Dr Craig Wilson Dr Yvonne Zissiadis

All enquiries: mdtskinwa@genesiscare.com 0452 277 752

32 | NOVEMBER 2021

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Building a safe place to grow old Plans are underway for a hub for Aboriginal people in which to grow old, in a culturally appropriate environment.

Health Consumers’ Council’s Rachel Seeley explains. assisted living and palliative care arrangements specifically for Aboriginal elders.

Aboriginal people in Western Australia have voiced their concerns about elder abuse and the mistreatment and neglect of older people in their communities, providing strong support for the need for a safe place in the Perth metropolitan area for them to grow old in a culturally appropriate environment.

“The Aboriginal Elder Aged Care Community Hub would empower members of the Aboriginal community to live independently, socialise with others, and experience a safe and supportive environment,” Ms Ryder said.

The project will have a staged approach that will ultimately be managed and delivered by Aboriginal people.

Since 2013, Langford Aboriginal Association (LAA) and Relationships Australia WA have been working together to establish an Aboriginal Elder Aged Care Community Hub on Wadjak Noongar Boodja (Boorloo/Perth).

The hub will be a safe place for elders, offering independent living, assisted living, palliative care and respite. Plans include a cultural centre, childcare facilities and a bush tucker café.

“We need a place where community can come together to pass down the learnings of our cultural practices to the younger generations,” said Relationships Australia (WA) Senior Manager of Aboriginal Services Angela Ryder.

needed and would provide a service that is not currently available.

Workshop participants provided feedback on the design and priorities of such facilities and services, helping to determine the architectural site, concept planning, costings and staged approaches.

To understand the broad spectrum of needs, visions and priorities for Aboriginal elder care and answer key questions concerning community priorities, LAA and NAJA Business Consulting Service worked with community and industry stakeholders.

NAJA also engaged with stakeholders from all levels of government, aged care, allied health services and others, indicating strong support for the concept and development of the Aboriginal Elder Care Community Hub.

A series of five workshops were held in key communities across the metropolitan area.

As well as the need for culturally appropriate and trauma-informed aged care specifically designed for Aboriginal elders, there are other cultural and population-based trends which point to the need for such a facility.

“They were well attended with community members from all ages actively engaging and providing important feedback,” said Langford Aboriginal Association Acting Senior Executive Officer Sophie Walker.

The feedback from these workshops indicated an Aboriginal elder care facility in the metropolitan area was urgently

Stage 1 includes the construction of a residential aged care facility with capacity for 76 residents, while Stage 2 would see the construction of a community hub, lifestyle village, medical clinic with hydrotherapy pool and associated parking, roads and landscaping.

When completed, private residential units accommodating up to 48 residents, and community amenities including a commercial café, childcare and medical services will be delivered.

Stage 3 includes the construction of a cultural centre, recreational facilities for residents and visitors and extensive landscaping with a lake feature. By this stage, the facility will support partnerships for cultural experiences, recreational use and hire.

With the business case for the proposed facility now finalised, the project is applying for funding to develop architectural designs. For more information on the project, contact Langford Aboriginal Association on admin@laalangford.org.au or 9451 1424.

In Perth there are some aged care services and support available for people from culturally and linguistically diverse backgrounds, however, there are currently no dedicated services or infrastructure that support independent living,

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Cruel consequences of time delay Dementia care specialist Theresa Bates explains the steps for a patient diagnosed with dementia once they leave their doctor’s rooms.

The most important advice we can give a family embarking on the dementia journey is to be proactive not reactive, yet this is hard when they do not know what to expect or how to go forward.

Dementia care advice is available, yet many people leave their GP, geriatrician or neurologist appointment and believe there is no one that can support them and nothing they can really do from here.

Many are told to wait six to nine months for an appointment at a memory clinic. At these appointments they undergo another memory test and someone records what new symptoms are occurring and out the door they go, again.

This is equivalent to someone being

given a diagnosis of terminal cancer with no idea what to do or where to turn to – dementia is also a terminal illness.

It is imperative to obtain knowledge about the illness, not the myths or opinions of bystanders.

Most families do not understand the difference between the terms Alzheimer’s and dementia.

These terms seem to be used interchangeably by many professional and non-professional people, without realising the confusion that causes. When people understand what they are dealing with, it makes it easier to understand the possible trajectories of the illness.

Our four main types of dementia – Alzheimer’s disease, vascular

dementia, Lewy body dementia and frontotemporal dementia – all present with different signs and symptoms and the progression also differs. If we are able to develop extensive care plans based around their specific diagnosis, it gives families the ability to be ready for possible behaviours or situations that may occur and what they can implement at this time.

Knowing what to expect helps to support decision-making early in the illness. Feeling comfortable they have all the official paperwork completed and lodged with the appropriate government agencies and understanding the support that can be received – both financial and in-home – brings relief and another checkbox that can be ticked off.

One area that causes a great deal

Hand-wash fail despite COVID Not even a global pandemic can stop poor hand hygiene, Curtin University research has found.

A study has revealed that the average Australian only occasionally washed their hands properly during the height of the COVID-19 pandemic, despite hand hygiene being one of the key recommendations for protecting against the deadly disease.

The research, published in Psychology and Health, surveyed people across the nation to understand the behaviours behind these results, as well as possible ways to encourage Australians to wash their hands more regularly.

Lead researcher Professor Barbara Mullan, from Curtin’s School of Population Health, said the study would help to encourage people to practise improved hygiene that would slow the spread of mild and severe infectious diseases, such as the flu and COVID-19.

34 | NOVEMBER 2021

“Australians were surveyed when many of the nation’s states were in the midst of lockdown restrictions, between May and November last year,” Professor Mullan said.

intention of using soap, but when they look at the mirror and see a sign that encourages them to use the soap, they are more likely to use the soap.

“While COVID-19 highlighted the importance of hand washing, this study showed that people reported only occasionally washing their hands properly, on average.”

“People may not care about the effects of poor hand hygiene on themselves, but stronger messaging around protecting the people close and vulnerable to you such as older or pregnant people, may be more beneficial in motivating a person to wash their own hands.

Professor Mullan said future research should consider designing an intervention to test the effects of environmental factors, such as stronger visual cues in the form of posters or advertisements in locations where people should be washing their hands.

“It might seem obvious but the environmental cue of soap being kept beside the sink may trigger an individual to actually use it, even when their motivation to do so is low,” Professor Mullan said.

“Given the benefits of good hand hygiene, interventions to improve adherence should be a top health priority.”

According to the Centre for Disease Control and Prevention, washing your hands can be done properly following five simple instructions – wet, get soap, scrub (for at least 20 seconds), rinse and dry.

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a certain stigma. It requires a multi-disciplinary approach from several professionals. Everyone involved with a person living with dementia and their families need to understand that this approach is for the benefit of their patient.

This needs to be from knowledgeable and experienced specialists through to the carers providing day to day care and everyone in between.

We need to do better and create a team approach that will give families a chance to succeed and not be overwhelmed with the carer role. of stress is younger onset dementia.

Anyone diagnosed aged under 65 is in this category. The majority of people who have younger onset dementia comment on how it took years to get a diagnosis. Most of the time their symptoms were put down to stress, depression or other mental health disorders.

My youngest client currently is aged 48 and has had to wait until she can no longer live her daily life without a carer to finally be diagnosed. Other families tell of

their experiences of not being able to convince doctors to request tests or refuse to give them a referral to a neurologist.

The numbers are staggering and only growing so let’s create a way to make the journey of dementia easier.

Would it not be better to rule out an illness than leave someone confused and lost? Many of these clients are unable to qualify for NDIS support due to being diagnosed too late when they were clearly under 65 at the onset of their illness.

ED: Theresa Bates has a degree in dementia care and has worked with families in this area for four years. She also has 10 years’ first-hand experience caring for her mother with dementia.

Dementia can be confusing, confronting and still carries

Scoliosis Corrective Surgery Don’t let your privately insured patients wait unnecessarily for years to have corrective elective surgery for adolescent idiopathic scoliosis.

Privately insured patients can request surgery at a convenient time for them rather than being allocated a surgical date in the public system that may be inconvenient or conflict with schooling and other commitments.

Refer your patient to be seen by experienced Spine Surgeons from NeuroSpine Institute, who trained in Europe’s biggest scoliosis clinic, The Royal National Orthopaedic Hospital, London.

Specialised Dual Service Drs Taylor and Cunningham have a specific interest in corrective scoliosis surgery with combined experience of over 20 years.

Each scoliosis surgical case is performed at Mount Hospital by both Drs Taylor and Cunningham together.

Dr Paul Taylor Spine Surgeon Spinal

Dr Greg Cunningham Spine Surgeon

Read 16 year old Ella’s story of scoliosis surgery www.nsiwa.com.au/patientstories

4 CONVENIENT METRO LOCATIONS

Plus visiting regional clinics in Mandurah, Vasse, Albany and Geraldton.

Murdoch Perth Wembley Suite 77, Level 4 Suite 7, Level 4 Suite 10, First Floor Wexford Medical Centre 140 Mounts Bay Road 178 Cambridge Street 3 Barry Marshall Parade Perth WA 6000 Wembley WA 6014 Murdoch WA 6150

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1800 NEUROSPINE Carine Unit 1, 2 Gemstone Boulevard St John of God Carine Specialist Centre Carine WA 6020

(1800 638 767)

(08) 6147 8200 info@nsiwa.com.au nsiwa.com.au

NOVEMBER 2021 | 35

From Nov 1st 2021, PET now available for Alzheimer’s disease at Perth Radiological Clinic The new item will allow patients with suspected Alzheimer’s disease to access more effective diagnostic imaging where diagnosis through clinical evaluation is equivocal.

• The item is only available following referral from a recognised specialist or consultant physician.

• The item will not be available for patients who have undergone a brain SPECT investigation in the previous 12 months.

• The item is only available 3 times per lifetime.

• Please note MRI head (or CT head if MRI is contraindicated) is still indicated for investigation of structural abnormalities such as vascular ischaemic changes. If a recent MRI/CT has not been performed this could be undertaken on the day of the PET scan.

Don’t forget PET for Alzheimer’s @ PRC

perthradclinic.com.au 36 | NOVEMBER 2021

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GUEST COLUMN

Autism – start early, change lives A landmark trial which shows how therapy can change the trajectory for infants at risk of autism could help GPs help their patients, says Professor Andrew Whitehouse.

Most GPs will see children and adults on the autism spectrum within their practice, and GPs are often the ‘medical home’ of these families as they navigate the ups and downs of their life.

parent about how their baby is communicating with them, and they can communicate back to have back-and-forth conversations.

The infants in the study were assessed on multiple occasions up to three years of age. We found that the iBASIS-VIPP therapy was effective in supporting social and communication skill development – so much so, that only 6.7% of the children met diagnostic criteria for autism at age three years, compared to 20.5% of children in the ‘therapy as usual’ group.

Like all neurodevelopmental conditions, autism is diagnosed using “deficit-focused” diagnostic criteria. In other words, individuals are assessed on what they can’t do.

The Diagnostics and Statistical Manual is the authoritative guide describing the behaviours we use to diagnose neurodevelopmental and psychiatric conditions. It specifies individuals must have “persistent deficits” in social communication and behavioural interaction to receive a diagnosis of autism.

Significantly more children are now recognised as having difficulties learning social communication skills than previously. This has led to an increase in the numbers of children being diagnosed with autism – now estimated to be 2% of the population.

Early behaviours that may indicate a possibility of developmental differences are often observed in the first year of life. These behaviours can include reduced eye contact, lack of pointing, fewer social gestures and imitation, and lack of a response to their name.

Any one of these behaviours on their own is not a clinical indication, but when all of these are observed in the same child, they may indicate developmental differences.

Typically, in the clinical pathway for autism, these early behaviours are monitored until the age of two years, after which children may receive an assessment that leads to a diagnosis of autism.

This ‘wait and see’ approach to early developmental differences is based on the premise that child development is highly variable, and that we should be cautious in providing clinical services when they may not be required.

Of course, the drawback of this approach is that, for those children who are developing differently, our therapies are not being applied in the first two years of life, when the brain and mind are developing rapidly.

At CliniKids, part of the Telethon Kids Institute, we have just released the findings of landmark clinical trial, which has turned this clinical pathway on its head.

In our study, we worked with the WA Child Development Service to identify 9- to 14-month-old infants who are showing some of those early developmental differences mentioned previously. Half of the infants received our therapy, called iBASIS-VIPP, and the other half of the infants received community therapy as usual (which often consisted of just monitoring). iBASIS-VIPP uses video-feedback to help parents recognise their baby’s communication cues so they can respond in a way that builds their social communication development. Parents are videoed interacting with their baby in everyday situations, such as feeding and playing. The trained therapist then provides guidance to the

MEDICAL FORUM | AGED & PALLIATIVE CARE

This finding provides strong evidence for a new model of how we provide clinical support to children with developmental differences.

Rather than waiting until a diagnosis to start therapy – typically at two years of age at the earliest – we need to identify developmental differences as early as possible. Then we need to provide developmental supports that nurture each child’s strengths.

At its most basic, this is a change of clinical support from “wait and see” to “identify and act”.

CliniKids at the Telethon Kids Institute currently offers this therapy and will be seeking to train as many health professionals as possible, both in Australia and internationally.

This is a good news story. By identifying babies developing a bit differently and seeking prompt referral to an evidence-based intervention, we can change developmental trajectories and hopefully the course of their lives.

ED: Andrew Whitehouse is Professor of Autism Research at the Telethon Kids Institute and the University of WA, and director of CliniKids.

NOVEMBER 2021 | 37

Growing smart to relieve hunger Smart foods are an important key to solving world hunger, argues UWA’s Professor Kadambot Siddique.

More than 60 years have passed since the Green Revolution sparked a significant increase in the production of major food grains (rice, wheat and maize) and helped reduce hunger worldwide.

The resulting agricultural practices, still used today, accomplished the incredible feat of generating food for billions of people worldwide.

On the spectrum of malnutrition there are two extremes: overnutrition and undernutrition.

Globally, 39% of adults aged more than 18 years are overweight.

Concurrently, 821 million people around the world – about one in nine – do not have access to enough food.

The United Nations predicts that by 2050, agricultural production must increase by 50% globally to meet food demand. How can we meet this goal when faced with the increasing challenges of unsustainable agricultural practices, climate change and now the COVID-19 pandemic?

Food prices are skyrocketing, which compromises the distribution

Going nuts Perth Children’s Hospital has launched a trial of an oral immunotherapy that could become Australia’s first treatment for peanut allergy.

As waitlists for children with food allergy continue to expand, PCH is investigating the efficacy, safety and tolerability of adding inexpensive off-the-shelf peanut flour to home meals under medical direction 38 | NOVEMBER 2021

and affordability of food in many countries. Something needs to change if we aim to end world hunger, improve global nutrition and ensure food security for future generations.

Since well before the pandemic, a few key factors have hindered progress in achieving food security for all. The combined effects of climate change, declining agricultural biodiversity, water scarcity and the degradation of natural resources are threatening future global food production.

for up to 70% of total caloric intake in countries including Bangladesh, Indonesia, Vietnam and Cambodia.

This over-reliance on a single food is a leading cause of low dietary diversity and persistent malnutrition.

More than 2 billion people in Asia suffer from ‘hidden hunger’ – an insufficient intake of vitamins and minerals such as vitamin A, iron and zinc. This leads to growth and developmental problems, cognitive impairment and ultimately an early death.

Too many people around the world have diets where a single type of food provides most of their energy.

In Asia, rice is the major staple and nearly 100kg of rice per person per year is consumed. Rice accounts

Hidden hunger is a serious problem among children under five years of age. Globally, some 21.3% of children under five are stunted (low height for the weight). This means their physical growth and brain

to desensitise pre-schoolers with peanut allergy.

anaphylaxis that occur when there is accidental exposure.

The randomised controlled trial, called Early Peanut Immunotherapy in Children (EPIC), is the first-of-its kind in Australia and will focus on using a possible early window of opportunity to safely and gradually reintroduce a small amount of peanut to desensitise and build up a degree of tolerance.

Currently recruiting, the 12-monthlong food-based trial will provide a small group of WA peanut allergy patients aged under five years with access to allergy treatment, while also allowing treatment protocols to be developed that could be readily adopted across Australia.

The aim is to prevent and limit severe allergic reactions and potentially life-threatening

For details visit redcap.link/EPICStudy or FoodAllergyResearch@health.wa.gov.au.

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Despite significant improvements in food security and nutrition, many countries face significant challenges. Malnutrition affects both developed and developing countries.

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GUEST COLUMN

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GUEST COLUMN development have been impaired and will have lasting effects.

Despite the existence of nearly 7,000 species of cultivated crops worldwide, just three staple crops — rice, maize and wheat — provide 60% of the world’s food energy intake. This is largely because governments have been promoting the growth of these staple crops as part of the Green Revolution push.

This has contributed to the decline and disappearance of traditionally grown crop species from the agricultural landscape.

The danger of having only a few key crops is that agriculture is more vulnerable to major threats like drought, insect pests, and diseases.

All of these are likely to become worse throughout the world as a result of climate change. At the current rate, it is estimated that one third of today’s already low crop diversity could disappear by 2050.

So, what is the solution? Do we need to go to the lab and prepare a genetically modified supercrop? Do we need to create a new

method of farming? That is all possible. But sometimes the best solutions are the simplest ones.

There are a rich variety of nutritious ‘neglected crops’, domesticated since ancient times but mostly forgotten or underutilised today.

In my work, I have dubbed these ‘Future Smart Foods’.

Future Smart Foods are diverse and nutritionally rich, able to withstand perilous impacts of climate change, economically viable and locally adapted. Examples are quinoa, drumstick, amaranth, rice bean, taro and millet. Unlike staple crops, these crops are adapted to their land, resilient to environmental challenges and rich in micronutrients.

If the solution were as simple as planting a wider variety of crops, why haven’t we already cured world hunger, diabetes and nutritional deficiencies? There are three key levels to this problem: governmental policy, educating and empowering farmers, and enabling consumers.

Governments have a central role in the transformation of current agriculture and food systems.

Recognising our current overreliance on staple crops as a leading cause of persistent malnutrition should inspire policymakers to introduce Future Smart Foods into mainstream agriculture and food systems systematically and smartly.

Governments around the world will need to create an enabling environment to promote sustainable production, processing and consumption of these foods to achieve zero hunger.

This fight needs to be fought on many fronts. A key battleground is the diversification of our food production, and Future Smart Foods are essential to this.

Nutritious and sufficient food, all year, for all people. That is worth fighting for.

ED: Hackett Professor of Agriculture Kadambot Siddique is chair and director of UWA’s Institute of Agriculture.

Rehab Direct: From GP to Hospital Is your patient not coping after discharge from hospital?

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• Rapid assessment • Prompt admission • Experienced geriatricians & rehabilitation & aged care physicians For more information, visit attadalerehabilitation.com.au MEDICAL FORUM | AGED & PALLIATIVE CARE

NOVEMBER 2021 | 39

40 | NOVEMBER 2021

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NOVEMBER 2021 | 41

Metropolitan Anaesthesia is one of Perth’s most respected anaesthetic groups.

Directly evolving from groups first established 60 years ago, Metropolitan draws on the experience and wisdom of generations of Western Australian anaesthetists.

Members include some of Australia’s high-profile anaesthetists contributing to academia, textbooks, and international research, providing the foundation for its reputation as an excellent and ethical provider of anaesthesia services.

Our collegiality, mentor system and philosophy of providing excellent service while also giving back to the profession, attracts new practitioners and encourages engagement with the most recent anaesthetic developments.

We continue to grow and welcome those new applicants wanting to be part of an inspiring and supportive anaesthetic practice.

Metropolitan Anaesthesia is a leading provider of anaesthetic services across all specialities.

CONSULTING LOCATION Unit 6/1 Station street Subiaco WA 6008 Phone: 08 6267 6040 Fax: 08 6267 6210 www.metroanaes.com.au 42 | NOVEMBER 2021

For Anaesthetic cover please contact: Tarnya Wilson - diary@metroanaes.com.au Anaesthetists joining enquiries please contact: Cara Suiter - manager@metroanaes.com.au MEDICAL FORUM | AGED & PALLIATIVE CARE

OPINION BACK TO CONTENTS

Dr Joe Kosterich | Clinical Editor

Age and wisdom The website statistica.com has a chart showing life expectancy in Australia steadily increasing since 1870. A person born in Australia in 2020 can expect to live for 83.2 years (females 85.4 and males 81.5). Some enjoy good health in later years.

The elephant in the room, though, is our societal attitude to age.

Whereas other cultures respect and seek counsel from their elders, ours does not.

My oldest patient passed away earlier this year at 104 and was independent to the end. Some predict that baby boomers will not accept the notion of ‘growing old’ in the same way previous generations have. Time will tell with the oldest boomers now in their mid-70s.

Aged care for those whose health and functionality has declined remains a challenge for society. Cabinet papers from 2000 revealed that the Aged Care Act was amended in that year following reports of residents being bathed in kerosene and that “the public had concerns about the quality of residential care”. Two decades on we had a Royal Commission which may end up being better at pointing the finger than providing solutions. Hopefully not.

This month, we look at aged and palliative care with topics covered including vaccination in the over 70s, how better nutrition can contribute to lower falls risk, the intriguing potential role of music in dementia care and a broad look at palliative care. There is a potpourri of other topics examined as well.

A recent paper published in Lancet Oncology analysed data from 61 countries finding one in seven cancer surgeries (for 15 common cancers) were postponed by a median of 5.3 months due to lockdowns. Delayed surgery leads to poorer outcomes. The palliative care system may come under increased pressure over the next few years. There won’t be a daily update though.

An ageing population may put increasing pressure on an aged care system which already struggles. Innovative ways to keep people in their homes will be needed, together with an increased emphasis on helping keep people healthier for longer (as far as is possible).

The elephant in the room, though, is our societal attitude to age.

Whereas other cultures respect and seek counsel from their elders, ours does not.

Australians over 90 lived through the Depression and World War II plus the post-war rebuild. These events shaped their lives and provided perspective.

Writing in The Weekend Australian, demographer Bernard Salt suggested an annual survey of those over age 80 as a “wisdom of the elders report”. The perspective and knowledge of those who lived through far worse than what we face today is an underutilised and undervalued asset, in my opinion.

MEDICAL FORUM | AGED & PALLIATIVE CARE

NOVEMBER 2021 | 43

Preventing falls and fractures in older Australians

By Dr Marc Sim, Institute for Nutrition Research, ECU This sobering quote reflects the daily reality for many older Australians, for whom injuries due to falls may lead to immobility for the rest of their lives. “I am finished, completely finished...The most important thing is to stay on my feet.”

One Australian is hospitalised approximately every five minutes due to a fall, which was estimated to have cost the national health service $3.9 billion in 2015-16. About a third of people aged over 65 experience a fall each year.

In addition to the trauma and injury associated with the fall itself, patients often have prolonged impaired mobility, remaining functionally dependent upon others.

Injuries from a fall, including hip fracture, substantially increase mortality risk; consequently, the fear of falling can trigger social isolation and depression, compromising even uninjured people’s quality of life.

Falls have many contributing factors, making prevention complicated. Besides muscle function, which comprises strength and physical function, other wellestablished falls risk factors include visual impairment, use of multiple medications, chronic disease, and the physical environment (e.g., tripping hazards).

Exercise has emerged as one key factor in lowering falls risk, likely through its ability to improve muscle function and prevent chronic disease.

But exercise is only one piece of the puzzle: nutrition is also significant.

Key messages

Resistance exercise and a healthy diet are essential for fall and fracture prevention

A daily serve of green leafy and cruciferous vegetables provides sufficient vitamin K and nitrate to promote musculoskeletal health

Consumption of five serves of vegetables daily, including a diverse range, should be promoted.

From a protein perspective, if intake is approximately ≥1.0 to 1.2 grams per kilogram of body weight per day, supplementation (especially in the absence of resistance exercise) is unlikely to increase muscle strength or mass.

Despite the wealth of research around falls prevention, the importance of other aspects of diet remains largely unknown, especially in community settings.

Unsurprisingly, national nutrition guidelines specific to preventing falls do not exist.

An emerging research area is the potential for vegetables and their components to improve musculoskeletal health, especially in the prevention of diseases such as sarcopenia (low muscle mass and strength) and osteoporosis.

From a nutrient perspective, research has typically focused on protein and vitamin D (with calcium) for musculoskeletal health. However, supplements may only be beneficial in the event of deficiency – an important consideration for clinicians.

When considering clinical outcomes, superior muscle function observed with higher consumption of vegetables (over three serves/day) possibly explains lower long-term injurious fall and hip-fracture risk.

Notably, consuming at least one serve a day of cruciferous vegetables (e.g., broccoli, cauliflower, cabbage, Brussel sprouts) is shown to provide the greatest benefits.

Nevertheless, maintaining circulating vitamin D levels at 75 nmol/L or above is associated with lower longterm risk for both injurious falls and hip fractures, the latter likely due to higher bone mineral density at the femoral neck and hip.

Cruciferous vegetables represent a rich source of organosulphur compounds known for their antiinflammatory properties, as well as vitamin K which has also been linked to better muscle function and bone strength.

44 | NOVEMBER 2021

For example, a diet consisting of 200g per day of vegetables, providing ~165 ug/d of vitamin K, for four weeks reduced bone turnover markers (e.g., total and undercarboxylated osteocalcin).

This suggests improved osteoblast function, which would promote bone integrity if continued over time.

Inversely, vitamin K insufficiency can increase injurious falls risk.

Nitrate is another nutrient found in high concentrations in green leafy vegetables and beetroot. Health benefits of vegetable-derived nitrate have typically centred around improved vascular function and reduced risk for cardiovascular events. However, recently, diets rich in vegetable-derived nitrate (~100 mg/d) have been linked to better muscle strength of the upper and lower-limbs, as well as physical function (e.g., timed-up-and-go test) in older adults.

The aforementioned benefits to muscle function were observed irrespective of the amount of physical activity performed (e.g. sedentary/ active). Randomised controlled trials supplementing high-nitrate beetroot juice report similar improvements to lower-limb muscle power. Such findings are promising as improving muscle function substantially reduces fall and fracture risk.

In summary, lifestyle intervention comprising diet and exercise are essential for fall and fracture prevention. Whilst the importance of resistance and balance exercise is well regarded, until recently the significance of diet remained less clear.

Specifically, vegetables providing a range of nutrients including vitamin K and nitrate may be key in supporting muscle and bone health. Therefore, key messages from public health campaigns around increasing fruit and vegetable intake such as ‘Go for 2 & 5’ must continue to be well promoted.

– References available on request Author competing interests - nil

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CLINICAL UPDATE

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CLINICAL UPDATE

Comprehensive end of life care needed

By Dr Derek Eng & Ms Louise Angus Now more than ever, palliative care needs our full support and to be understood. Here are some facts. We will all die and there is enormous fear about that process.

Only 1-2% will die under the new Voluntary Assisted Dying (VAD) Act, therefore, many patients will need palliative care; currently, only about 25% of dying patients will have access to specialist palliative care.

The WA Palliative Care workforce is inadequate, having less than half the Palliative Care Australia recommended number. Systemwide changes are needed to train and resource specialist palliative care services so that we can all feel confident that we can live as well as possible and die comfortably when it is our time.

For clinicians, the legalisation of Physician Assisted Suicide and Active Voluntary Euthanasia (PAS/ AVE) has caused confusion. End of life care now includes PAS/AVE and everyone is unsure about what palliative care is.

To be clear, the specialty of Palliative Care seeks to improve the lives of patients and their families by deliberate clinical interventions to relieve suffering, optimise quality of life and provide expert care of the dying. We do not engage in activities to deliberately hasten the process of dying.

In many research studies, effective and early specialist palliative care improves holistic quality of life (physical, emotional, social, spiritual) and prolongs survival.

Palliative care is certainly not PAS/AVE. At the end of life, patients who receive skilled and compassionate palliative care, die because of the disease, not because of medical intervention.

Key messages

Death is inevitable but generates fear in our society

The new voluntary assisted dying laws have caused confusion

Increase in palliative care workforce is needed to ensure best end of life care.

stories anger and sadden us because they can be prevented.

Vulnerable patients in our hospitals are dying in pain or gasping for breath because they are not receiving the specialised care they need.

Vulnerable elderly patients who are in the last few months of life repeatedly present to emergency departments for treatments that are essentially futile. Vulnerable patients dying of chronic and incurable illness suffer for months, even years. These patients need better health care to live better, rather than easy access to PAS/ AVE. For decades, clinicians and researchers have been aware of patients who have made comments like, “I can’t go on like this…”, or “Is there something you can give me to help me end this…”. This request for hastened death should be explored with concern and sensitivity.

For the majority, these are desperate pleas for help because

As clinicians working in palliative care, we are concerned for the vulnerable who can now access VAD much more easily than they can access palliative care. Palliative care clinicians see and hear the stories of “bad deaths” and these

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First Request Form

they have suffered immense loss of identity, purpose and will. Most patients want to keep living if they can live well. Therefore, for patients with progressive life-limiting illness who are suffering, a validated screening tool like The Surprise Question (would you be surprised if this patient died in the next 12 months?) can be helpful to trigger an outpatient referral to a specialist palliative care clinic at any of the metropolitan tertiary hospitals (contact the switchboard and ask for palliative care).

The Joondalup Health Campus now has a public inpatient unit which opened recently. For country patients, each region has a palliative care nurse co-ordinator.

After-hours advice is available for clinicians on ph:1300 558 655.

However, if a patient is seeking VAD with a clear and unambiguous request, provision of the StateWide Care Navigator Service number (ph: 9431 2755), a First Request Information Pack and completion of a First Request Form (scan the QR codes below) will fulfill the legal obligations of doctors who have not completed the six-hour online training to provide VAD. More information is available online.

Author competing interests – nil ED: Dr Eng is a palliative care physician and Ms Angus is a palliative care nurse practitioner

First Request Information

NOVEMBER 2021 | 45

Comprehensive Audiological Services

Hearing and Audiology, established and operated by Vivienne Sobon, was the first private practice in Western Australia.

Since 1985, we have been dedicated to providing professional and caring service to those who are ‘hearing challenged’, using the latest technology.

Today, we still provide the same excellent, unbiased, professional experience. Constantly changing with the times, we are active in the training of postgraduate university students and are updating our skills and technology to provide an outstanding service.

Adult Hearing Assessments

We specialise in the assessment, diagnosis and rehabilitation of hearing loss and tinnitus, taking into account our client’s needs and listening environment to determine whether medical intervention or hearing aids are recommended.

Wax Removal (Micro-Suction)

A hearing assessment and evaluation takes approximately one hour. At the conclusion of an assessment, you will receive a full explanation of your results along with a management plan.

Commercial Driver’s Assessments

SUBIACO Suite 36, Crossways Shopping Centre 184 Rokeby Road Subiaco WA 6008

DUNCRAIG Shop 11, Glengarry Shopping Centre 59 Arnisadale Road Duncraig WA 6023

MANNING Manning Medical Hub Suite 3, Ground Floor 10 Conochie Crescent Manning WA 6152

Paediatric Hearing Assessments Free Services for Pensioners & Veterans Tinnitus Assessments & Management Custom Made Earplugs WorkCover Assessments Speech in Noise Testing Pre-Employment Assessments Aviation & Driving Assessments GERALDTON Panaceum 233 Lester Avenue Geraldton WA 6530

KARRATHA Sonic Health Plus 66 Welcome Road Karratha WA 6714

(08) 9388 8003 | admin@hearingwa.com.au

www.hearingwa.com.au 46 | NOVEMBER 2021

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CLINICAL UPDATE

The role of exercise in mental health

By Carla Petty, Exercise Physiologist The World Health Organization defines mental health as “a state of wellbeing in which every individual realises his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.”

Mental health includes our psychological, emotional, and social wellbeing, which in turn affects how we think, feel, behave, and interact with others. It is important at every stage of life. Our mental health fluctuates on a continuum, it is not fixed. We can move back and forth along this scale at different times during our lives in reaction to experiences or stressors, so it is important to either promote or adopt helpful coping mechanisms and strategies to maintain good mental health.

One in five Australians aged 1685 experience a mental illness in any year. The WHO predicts that depression will be the number one health concern in both the developed and developing nations by 2030. Overwhelming research has indicated that exercise is both an effective form of treatment as well as a preventative tool in protecting against future incidents of depression. Studies show that anyone, despite their age, gender or location, can benefit both physically and mentally from exercise.

How exercise works The benefits of exercise include improved memory, focus, thinking, productivity, physical health and life expectancy. It reduces stress and anxiety and can distract from negative thoughts. It also provides opportunity for social engagement.

Ultimately, exercise positively influences neurogenesis, neuroplasticity and neurochemistry.

It has been shown to promote the growth of neurons and strengthen existing neural pathways in the central nervous system that are important for overall brain health and where individuals are better able to tolerate stress.

in treating or preventing poor mental health, but rather it is important to find exercise that is enjoyable and works best for the individual and their circumstances.

It is important they enjoy the form of exercise, otherwise they are unlikely to adhere to it in the long term. Exercise adherence is poorer in many people who suffer from mental illness, so methods to increase motivation must be included in programming considerations.

For mild to moderate depression, the effect of exercise is comparable to SSRI medication and psychotherapy; for severe depression, exercise is a valuable complementary therapy to traditional treatments.

Key messages

Good mental health is critical to overall wellbeing

Exercise can improve brain function

The best exercise is the one that is most enjoyable.

Physical activity also stimulates the release of neurotransmitters such as dopamine, norepinephrine and serotonin in the brain, which are critical in regulating mood and improving overall wellbeing.

Exercise also plays an important role in reducing the levels of stress hormones such as cortisol and adrenaline in the body.

Research also shows that people who suffer from chronic or prolonged stress and/or depression are at higher risk of developing negative side effects on the cardiovascular and immune system – again highlighting the importance to use exercise preventatively, as well as the interdependence between physical health and mental health.

Health professionals recommend at least 30 minutes of moderateintensity exercise on most (preferably all) days of the week in preventing or managing mental health. It is important to note these 30 minutes do not need to be continuous; for instance, it can be broken up into 3 x 10-minute segments throughout the day.

Moderate to vigorous intensity can be described as exercise that makes you “huff and puff”, however it is important to consider the individuals previous exercise history when prescribing a tailored program.

When faced with poor mental health, sometimes the hardest step can be getting started. Australians of all ages are encouraged to seek professional exercise advice from an accredited exercise physiologist in conjunction with treating health professional(s) to prescribe a bespoke exercise plan.

– References available on request Author competing interests – nil

Types of exercise Research has concluded that not one form of exercise is best

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NOVEMBER 2021 | 47

By A/Professor Ming Khoon Yew, Endocrine Surgeon, Subiaco Adrenal incidentalomas are adrenal lesions greater than or equal to 1cm identified serendipitously on imaging performed for unrelated indications. The widespread use of cross-sectional imaging has highlighted this entity.

Assessment focuses on both imaging and biochemical/functional characteristics of the lesion. In the evaluation of adrenal lesions, the two key clinical questions are: Is the adrenal lesion functional or non functional? And is the adrenal lesion benign or malignant?

Functional and biochemical assessment The clinical history and physical examination should focus on eliciting signs and symptoms of adrenal hormone excess. This is followed by biochemical testing.

Assessment should be undertaken for the following conditions, which are summarised in Table 1. If there are any abnormalities detected on biochemical screening, further confirmatory testing may be necessary, and referral to an

Specimen photograph of phaechromocytoma

Specimen Photograph of massive right adrenal carcinoma (enbloc excision with right kidney)

endocrinologist or endocrine surgeon is recommended.

• Higher Hounsfield unit (HU) – Radiodensity of the lesion o In fact, a non-contrast HU of <10 is almost diagnostic of a benign lesion • Larger size o Risk of malignancy is greater in lesions > 4cm o High HU and lesion diameter >10cm are almost always malignant • Invasion of adjacent organs/ structures • Low percentage CT scan contrast washout

Imaging assessment The key question is whether it is benign or malignant, If the adrenal lesion is malignant, this can either reflect a primary adrenal malignancy (quite rare), or more commonly a metastasis. The probability that the adrenal lesion is a metastasis is significantly raised if there is a prior history of any malignancy.

Imaging characteristics that suggest malignancy (either primary or secondary) include:

Varicella zoster and pneumococcal vaccine counselling in elderly patients

By Xavier Cornwall and Dr Ramya Raman Pneumococcal disease and herpes zoster represents considerable health burden both in Australia and globally accounting for 25% and 7% of Disability Adjusted Life Years (DALY) of vaccine preventable disease burden. Between 1997 and 2016, pneumococcal disease resulted in 622 deaths and 2434 hospitalisations.

Older Australians have a greater likelihood of developing both conditions than the general population. The risk of developing 48 | NOVEMBER 2021

complications in both conditions is significantly reduced by vaccination which the National Immunisation Program (NIP) funds for those over 70 years.

average rate of vaccine preventable hospitalisation compared to the national average.

This audit reviewed the proportion of patients aged above 70 years (between 1/01/2017 to 30/12/2020) receiving the recommended vaccination against pneumococcal disease and varicella. It was performed in an outer Perth metropolitan general practice, a region that has a higher-than-

A case was defined as any patient who attended two GP appointments at this medical practice between 1 January 2017 and 31 December 2020, without an additional risk factor for either condition, and turned 70 years in the review period.

Exclusion criteria were patients who received a varicella zoster vaccine

Methods

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Adrenal incidentaloma – practical steps in management

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CLINICAL UPDATE

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CLINICAL UPDATE assessment of potentially malignant lesions.

Key messages

All cases of adrenal incidentaloma should undergo biochemical screening to exclude adrenal hormonal excess

The role of image guided needle biopsy for adrenal lesions is limited

Small, biochemically inactive lesions with non-contrast HU <10 can be safely managed with one further interval CT adrenal protocol scan and discharged.

One should be cautious in drawing conclusions from low dose CT scan (e.g. CT KUB for renal calculi), as this has less sensitivity and specificity for characterisation of an adrenal lesion.

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Scan demonstrating interval growth pattern suspicious for malignancy

Occasionally FDG-PET or MRI can be useful to assist in triaging and

SYNDROME

SYMPTOMS

SIGNS

SCREENING TEST

Cushing’s or subclinical Cushing’s syndrome

May be asymptomatic Moon facies, acne, buffalo hump, central obesity, striae, easy bruising, thin skin, poor wound healing, emotional and cognitive changes

Hypertension Hyperglycaemia Hyperlipidaemia Osteoporosis

1mg overnight Dexamethasone suppression test

Conn’s syndrome

Usually asymptomatic Muscle cramps, headaches Polydipsia, polyuria

Refractory Hypertension Hypokalaemia

Plasma Aldosterone to Plasma Renin ratio

Phaeochromocytoma

May be asymptomatic Paroxysms of palpitations, sweating, headache, tremor, anxiety/panic

Severe hypertension Paroxysmal hypertension

Plasma Metanephrines and Normetanephrines

prior to the data collection period, who received a pneumococcal vaccine prior to the data collection period and those with a contraindication to either vaccine It was planned that the first 50 randomised patients not meeting the exclusion criteria would be used in this audit, however only 47 participants did not meet the exclusion criteria.

For Medicare eligible persons that attended this medical practice who turned 70 years in the data collection period; 80% patients received a recommendation for a pneumococcal vaccine and a live attenuated varicella zoster vaccine between 1/01/2017 to 30/12/2020.

The benchmark of 80% was chosen as a composite of research demonstrated greater than

70% uptake for both vaccines is standard globally with 10% refusal rate for vaccination. The data was collected from the practice’s patient management software using preprogrammed search parameters for date of birth and visit history.

Demographics, medical history, and vaccination data were checked manually. All other GP written patient notes were examined for vaccine recommendation or counselling.

Results A total of 78 cases were reviewed for this audit; 47 cases were then included in the audit.

Demographics are outlined in Figure 1.1, the gender ratio being consistent with regional data.

Neither of the standards were met in this audit. Figure 1.2 presents the performance of the practice as a percentage of achieving

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Role of needle biopsy Unlike the situation for most other solid tumours, the role of image guided needle biopsy of adrenal lesions is very limited.

The reasons for this are twofold.

If the lesion is a malignancy (primary or metastasis), needle biopsy and the resultant spillage of tumour destroys the potential for curative surgical excision. Also, if the lesion is an unrecognised Phaeochromocytoma, needle biopsy may precipitate hypertensive crisis and death.

An endocrine surgery opinion is prudent prior to considering needle biopsy.

If the adrenal lesion is small, biochemically inactive, and benign/ or likely benign on CT criteria, then usually one further interval CT with adrenal protocol scan is necessary prior to discharging the patient. The interval scan should be performed at a 6- to 12-month interval. Should there be no progression/growth then we are usually satisfied that no further surveillance or intervention is necessary.

Author competing interests – nil

Figure 1.1 Variable

Amount

Gender Male

24 (51%)

Gender Female

23 (49%)

Age

72 (70-74)

Identifies as Indigenous or Torres Strait Islander

0 (0%)

each standard. Numerically, only six cases had documentation to support that they had received a recommendation or counselling to receive the pneumococcal vaccine, and separately, the varicella zoster vaccination.

The result was unexpected, especially for pneumococcal vaccination rates, due to the nature of awareness around the continued on Page 51

NOVEMBER 2021 | 49

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CLINICAL UPDATE

Vaccine counselling in elderly patients continued from Page 49

Key messages

This clinical audit showed that

vaccine and the previous studies showing higher levels of uptake.

The varicella zoster vaccination outcome was neither expected nor unexpected, as there were large variations in the reported literature regarding the uptake in the community.

the pneumococcal and varicella vaccine education provided in general practice in patients over 70 years was lower compared to the standards

This audit highlights the increased need for vaccine education in the over 70s.

The audit has limitations. Firstly, some GPs stated that due to time constraints, not all preventative health recommendations were documented.

Furthermore, due to patients visiting several GPs for their care, it was likely that a patient presenting from another practice did not have an accurate immunisation history at the practice being consulted.

Therefore, the true rate of vaccine recommendation is likely higher.

Previous studies have identified barriers to preventative health activities including a medical model focused on curative medicine rather than preventative medicine,

Figure 1.2

12.8%

Pneumoccoc al Vaaccine

12.8%

Varicela Zoster Vaccine

0%

20%

40% Standard Met

MEDICAL FORUM | AGED & PALLIATIVE CARE

ambivalence toward preventative health activities and a lack of clearly defined roles for nurses in general practice in relation to preventative health.

The audit can cautiously be interpreted as a paucity of patients receiving education or counselling regarding the two vaccines in question, which may be comparable to other similar general practices in Australia. This is significant, as members of this age group are more likely than the general population to suffer adverse health effects related to these two conditions, with associated burden for the Australian healthcare system.

Some of the recommendations suggested included an action plan for staff education, dissemination of literature and consideration of reaudit in 12-24 months.

– References available on request

80% Standard Not Met

100%

ED: Xavier Cornwall is a medical student at the University of Notre Dame, and Dr Raman is a lecturer and supervisor Author competing interests – nil

NOVEMBER 2021 | 51

CLINICAL UPDATE

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Critical laboratory results after dark

By Dr Michael Page, Chemical Pathologist, Jandakot Medical laboratories routinely communicate ‘critical’ results, which may signify an immediate threat to life or health, directly to the requesting clinician as soon as analysis is complete.

Examples would include a very high potassium concentration or an increased cardiac troponin. Other results associated with significant but not immediate clinical risk might be directly communicated during office hours; an example would include a new histopathological diagnosis of cancer.

Just as the receipt, acknowledgement and follow-up of laboratory results are important considerations for any clinician’s practice, robust processes for the communication of high-risk results by the laboratory are an essential part of good clinical governance, as well as being required by regulation.

There are several high-profile examples of devastating patient outcomes occurring where a failure of clinical or laboratory processes for the management of high-risk results have been contributing factors.

There is little evidence to guide the most appropriate thresholds that define critical results. Excessive customisation of critical results thresholds for individual patients or clinicians is generally neither feasible nor safe. Therefore, the thresholds employed by the laboratory comprise a blunt tool that must, in effect, balance sensitivity (ensuring that those results entailing the highest risk are not missed) with specificity (minimising low-value interruptions to clinical practice).

As an example, telephoning every raised ALT (> 35 IU/L) would generate a huge number of telephone calls, most of which would be for patients with mild, chronic, or non-existent liver disease. A laboratory might instead choose a value of 1000 IU/L as a cut-off; a result of 990 IU/L, which may still indicate a significant acute liver injury, would not automatically trigger a call.

52 | NOVEMBER 2021

contact details, nor the details of any other 24-hour cover arrangements the practice may have in place.

Key messages

Laboratories directly communicate some high-risk pathology results to requesting doctors, supplementing the clinician’s own processes for results management

Laboratories endeavour to balance patient safety against unnecessary intrusion, but some results that are telephoned by the laboratory may not be deemed high-risk by the clinician

Documentation of the requestor’s after-hours contact details where a result requiring immediate action could be reasonably expected (e.g., cardiac troponin) ensures that the patient can receive the most appropriate care.

The laboratory’s mechanisms for communicating high-risk results can never be perfect and should not be solely relied upon by the clinician.

Hospitals usually have clearly defined delegation and escalation protocols for dealing with critical results at any hour. Therefore, it is uncommon for problems to occur with the communication of critical results to a clinician able to take responsibility for decision-making in this setting.

By contrast, communication of critical results after hours can present challenges in primary care.

Often, the laboratory does not have the clinician’s personal after-hours

In instances where the laboratory cannot reach an appropriate doctor to receive a critical result after hours, the laboratory’s on-call pathologist within the relevant testing discipline must decide on an appropriate course of action.

It can be challenging for the pathologist, without knowing the full clinical and social context, or being able to see the patient physically, to make a judgment as to clinical urgency. Sometimes, patients decline to present to emergency departments when advised to do so by a pathologist, even when informed of the gravity of the potential consequences. This could be in part due to the instruction coming from a doctor unknown to them telephoning them “out of the blue”. Therefore, this is not an ideal contingency and should only be regarded as a last line of defence.

Cardiac troponin results are frequently dealt with after hours.

Putting aside the arguments against measuring cardiac troponin to exclude acute myocardial infarction in outpatients, documentation of the requesting doctor’s mobile telephone number on the request form ensures that a positive result can be immediately communicated.

This principle applies to all other tests where a result that requires immediate action could be reasonably expected.

Author competing interests – nil

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CLINICAL UPDATE

Music for dementia: Current evidence, future direction

By A/Prof Hamid R. Sohrabi & Dr Jon B. Prince In the past two years, dementia has been the major cause of death in Australia (7,519 deaths: January to July 2021), passing ischemic heart disease (6,703 deaths for the same period) as the historically primary cause of death in previous decades.

A diagnosis of dementia relies on significant decline in cognitive functions (e.g., memory and executive function) as compared to previously normal performance.

Also common in dementia are neuropsychiatric symptoms (e.g., depression, anxiety, apathy, change in personality) resulting in impaired daily living activities, all of which degrade the quality of life of individuals with dementia.

In addition to cognitive impairment, behavioural and psychological symptoms of dementia are common and can be seen in different stages of dementia, (i.e., early to late).

Prescribed medications including antipsychotics are usually the frontline intervention to improve behavioural symptoms and quality of life of individuals with dementia.

However, using such medications to manage the behavioural and psychological symptoms has not been particularly effective in moderate to severe dementia (Mini-Mental State Examination average score between 5.5-13.7), which includes most of those living with dementia in nursing homes.

Notably, such treatments are also

Key messages

Dementia now exceeds ischemic heart disease as the leading cause of death in Australia

Treating dementia-related neuropsychiatric symptoms with medication has not been particularly effective

Music offers a non-invasive option which is showing promise.

costly for the patients as well as the health system.

Therefore, we need to provide alternative and more cost-effective approaches until more effective and affordable treatments become available. So far, nonpharmacological interventions seem to be an attractive alternative.

Power of music Music listening, as a nonpharmacological intervention, is an effective, low-cost, non-invasive intervention to target psychological wellbeing and to reduce drug consumption and shorten hospital stays. Increasing empirical evidence supports the benefits of music listening in reducing anxiety, agitation, depressive symptoms, and quality of life for individuals with dementia.

Specifically, personalised music (selected on the basis of the individual’s preferences) delivered via headphones can moderate

symptoms, with daily music exposure appearing to have at least temporary positive impact on the moods and behaviours of individuals with dementia.

Music is particularly important for older adults with relatively lower cognitive capacity and ability to communicate due to dementia progression. It evokes memories and emotions whilst also having the capacity to relax agitated or anxious individuals.

Currently, there is no unified protocol to indicate the appropriate dosage (how much music?), frequency (how often?), and duration (how long do benefits last?) of listening to personalised music. In addition, different individuals may respond differentially to personalised music. This information is crucial to develop cost-effective and appropriate interventions to assist patients and carers with managing their psychological symptoms.

This is even more important in the context of the SARS-CoV-2 pandemic, with resultant periods of lockdown and isolation.

Together with Prof Ralph Martins AO (Edith Cowan University) and Dr Ronniet Orlando at the Centre for Healthy Ageing at Murdoch University and with funding from The Lindsay & Heather Payne Medical Research Charitable Foundation (Perpetual Grant), and in-kind support of the Rotary Club of Freshwater Bay and Hall & Prior Aged Care, we will investigate different aspects of personalised music intervention in a randomised clinical trial to address these shortcomings and to prepare an authoritative protocol that can be utilised as part of the daily care plans for nursing homes.

– References available on request ED: A/Prof Hamid R. Sohrabi is Director of the Centre for Healthy Ageing, Health Future Institute and Dr Jon B. Prince is a senior lecturer in psychology, both located at Murdoch University.

Author competing interests – nil

MEDICAL FORUM | AGED & PALLIATIVE CARE

NOVEMBER 2021 | 53

ERCP: The Good, Bad and Ugly

By Dr Puraskar Pateria, Gastroenterologist, Hollywood Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a diagnostic tool to an almost exclusively therapeutic procedure. ERCP is performed with a side-viewing duodenoscope that allows identification of the major papilla. The bile duct is cannulated under endoscopic and fluoroscopic guidance (image 1) and a variety of catheters, balloons, baskets, guidewires, and stents are used for therapeutic interventions (image 2).

Indications Patients with any of the urgent indications should be referred to nearest Emergency Department, after contacting the ERCP fellow or on-call gastro registrar.

Acute cholangitis: characterised by fever, jaundice and abdominal pain and is a medical emergency with high mortality if not treated promptly. ERCP should be performed within 48 hours (preferably < 24 hours).

Acute pancreatitis with concomitant cholangitis: ERCP should be performed within 24 hours of presentation with gallstone pancreatitis and cholangitis.

Key messages

ERCP is primarily a therapeutic procedure

Diagnostic ERCP is rarely performed nowadays, and unnecessary procedures should be avoided.

Early recognition and prompt referral of post-ERCP complications is critical as most procedures are day cases and complications can develop up to seven days later.

meeting with Hepato-pancreatobiliary surgeons and depending on the clinical presentation, some of these patients undergo ERCP for biliary drainage.

Patients with non-urgent indications should be referred to a tertiary hospital or a private interventional gastroenterologist for an ERCP in following conditions: • Symptomatic choledocholithiasis • Retained biliary stones post cholecystectomy

• Bile leak post cholecystectomy (generally, these patients are reviewed and referred by the treating surgeon) • Benign biliary strictures • Sphincter of Oddi dysfunction (type 1) – biliary-type pain, abnormal LFTs, and dilated common bile duct.

Contraindications ERCP is primarily a therapeutic procedure and should be avoided in the following situations: • Diagnostic test for abdominal pain without evidence of biliary obstruction.

• Biliary-type pain with normal LFTs and non-dilated CBD (type III SOD).

• Biliary-type pain and either abnormal liver tests or a dilated common bile duct – some of these patients may considered for ERCP after review by a gastroenterologist.

• Patient with surgically altered anatomy (e.g., Roux-en-Y anatomy). ERCP can be performed in patient with altered

Obstructive jaundice due to CBD stone or malignancy: (pancreatic carcinoma, cholangiocarcinoma or ampullary adenocarcinoma).

Patients with malignancy are discussed in a multidisciplinary team

Image 1

54 | NOVEMBER 2021

Image 2

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CLINICAL UPDATE

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CLINICAL UPDATE anatomy with a surgically created stoma or access.

• Diagnostic test for pancreatic cysts/pancreatography.

and the risk of clinically significant bleeding requiring extended hospital admission or endoscopic management is 0.2%.

Complications

Incidence of post ERCP cholangitis is 0.5-3% (most often due to incomplete drainage of obstructed or infected biliary tree). Other less common complications are post ERCP cholecystitis, perforation, bacterial peritonitis in patients with cirrhosis and anaesthetic-related complications.

Despite the technical advances, appropriate patient selection, focus on adherence of safety protocols and advanced training programs, ERCP remains a procedure with high complication rates as compared to any other endoscopic procedures.

The incidence of post ERCP pancreatitis (PEP) ranges from 3-5%. Severe pancreatitis (pancreatitis with persistent organ failure lasting over 48 hours) is reported in 0.1-0.7%.

Administration of per rectal indomethacin or diclofenac and insertion of pancreatic duct stent (in cases of inadvertent pancreatic duct cannulation) at the time of procedure, has shown to decrease rates of PEP. Post sphincterotomy bleeding is more common during procedure or in first 24 hours, however, it can occur up to seven days post procedure. Risk of bleeding is 1-3%

Aside urgent indications, most ERCPs are done as a day case and post-ERCP complications happen after discharge with patients presenting to their GPs. Below are a few things to consider while managing post-ERCP patients in the community: • Early referral to ED in case of bleeding (haematemesis, melaena, dizziness or palpitations), cholangitis (fever, abdominal pain and jaundice) or pancreatitis.

• Removal or replacement of stents: The team performing ERCP is responsible for organising follow-up procedures for patients with pancreatic duct

or biliary stents. However, to ensure that patients are not lost to follow-up, it is important for GPs to be aware of: a. Pancreatic duct stent: An abdominal X-ray should be requested by the GP, 7-10 days post-procedure in cases where a pancreatic duct stent was placed during ERCP, and if the stent is still in-situ, inform the treating gastroenterology team to organise another ERCP or gastroscopy for its removal. b. Biliary stent: ERCP reports should mention the indication of plastic biliary stent (e.g., incomplete biliary clearance or CBD stricture) and the plan for its removal or replacement.

GPs should contact the treating gastroenterology team if the indication of stenting is not mentioned in the report and a repeat procedure is not performed in a timely manner.

Author competing interests – nil

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MUSICAL THEATRE

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The good witch of creativity Rachael Beck glides into town for The Wizard of Oz and explains to Ara Jansen why she’s passionate about everyone having a creative life.

Opening in Perth on New Year’s Eve, how can she possibly resist such fabulous lines as: “Go ahead and annoy me one more time ... the last witch that did is laying under a house.”

She’s also the character who reminds Dorothy she had the power all along, she just had to find it in herself. It’s an attitude the accomplished singer and actor tries to instil in all the young people she works with.

“Over the past couple of years, I have done a lot of workshops and

BOOKS

Writing what you know Kalgoorlie-Boulder lawyer Lisa Ellery used her professional knowledge to write her debut novel about a young prosecutor who bites off more than he can chew in Private Prosecution.

Ara Jansen explains

teaching,” Beck says about how she’s kept working away from the stage. As a longtime educator, she runs school programs which include Year 12 mentoring, working with teachers and being an artistin-residence to work with students in singing, acting, direction, casting and choreography.

It wasn’t until she decided to start writing what she knew – a crime novel about lawyers – that a Kalgoorliebased lawyer got her first novel published.

Fast paced, darkly comic and set in Perth, Private Prosecution is the story of a junior prosecutor named Andrew Deacon, who winds up on the wrong end of the law after the woman he spends the night with is murdered. While the prime suspect, he’s convinced the killer is a respected barrister.

“Writing what I know was a turning point for me,” enthuses Lisa Ellery. She owns a law firm in Kalgoorlie, originally hails from a farm near Esperance and did her law degree in Perth.

She’s one of several female crime and thriller writers making their debut with Fremantle Press this year. The others are Zoe Deleuil, Sally Scott and Karen Herbert and while Deleuil’s character is from Perth living in London, the rest of the stories are set in Western Australia.

A life-long writer working on a young adult fantasy novel her editors told her wasn’t great, one day it crossed Lisa’s mind that perhaps her experience with the law might inform a really good crime novel. While she always assumed such books were the domain of the John Grishams of the world, she started playing with genre and over a handful of years, Private Prosecution came into focus.

“I had an idea for a story and figured I could look up what I didn’t know,” she says about drawing on her professional background. “I gave it a go and then told

56 | NOVEMBER 2021

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Rachael Beck is very much looking forward to starring as Glinda the Good Witch in The Wizard of Oz.

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MUSICAL THEATRE Beck has a substantial and much-loved record of concert, stage, screen and recorded appearances – everything from Cats, Beauty and the Beast, Cabaret, Les Misérables and The Sound of Music to Hey Dad, City Homicide, Stingers and It Takes Two. She’s also been a regular visitor hosting workshops around the Ord Valley Muster and working with Indigenous communities.

The joy an artistic career has given her has made Beck passionate about all students having a creative outlet and being given the chance to lead a creative life, even if it’s not professionally.

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“I believe music and school musicals should be regarded as important as sport in our schools,” she says. Her work in this space is done with the aim of having strong performing arts departments in every school across Australia.

Beck is also passionate about mental health and how the creative arts – or lack of it – affect the human psyche.

“I can’t imagine a world without dance, song, painting, music, movies or poetry.

That’s not life. We must have it!” she says.

“I love helping kids build their confidence and communication skills in talking about their emotions. I think it’s something every child should be exposed to.”

a lot and loves to read most genres, with a particular interest in books on spirituality.

“I do love yoga but I’m a single mum with not a lot of time. Music and the arts are my work, so it’s nice to feel part of something else here.”

A love for the creative obviously runs in Beck’s family, not only with her siblings, parents and grandparents, but Beck’s two daughters, Tahlula and Roxie.

Twelve-year-old Roxie loves to dance and has scored a part in The Wizard of Oz. Mum and daughter have previously appeared together in a concert version of The Greatest Showman.

After living in Melbourne, Sydney and the Gold Coast for most of her adult life, Beck recently moved back to her teenage home of Byron Bay. Family is close, as are a couple of good friends.

“We’re both happy to be part of a story which is such a classic with music that’s amazing. The story is timeless and the themes like courage and bravery can make us examine our lives and ask whether we can do things better.”

She loves to cook and has been enjoying the fresh markets in Byron. She plays the piano, writes

ED: The Wizard of Oz is at Crown Theatre from December 31. Tickets from www.ticketmaster.com.au

my friends and husband that it was good. They were politely supportive, but as I kept writing, it just kept getting better and better. I got really fond of the characters and in the end had a lot of fun.”

BOOKS

Writing mainly on weekends Lisa also completed a large chunk while at a writing retreat. This was a different kind of thrill to writing legal briefs. She was putting together a complex plot, creating characters and having to make it all work.

“I learnt there’s a lot involved to make something flow and easy to read. Everything – every sentence or scene – must be doing something and you can’t have any rambling.

“I do enjoy writing legal documents and they have a lot in common with a novel in that everything needs to serve a purpose. In a legal document you can’t have any loopholes which can be interpreted differently nor do you want your plot to have holes in it. Like a legal document you need to be persuasive and less is always more if you want to persuade.”

Private Persecution is set in Perth and while you’ll recognise landmarks and streets, Lisa did want to create a bit of a fantasy world she could have some fun with.

“I wanted it to have funny parts and they seemed to come quite naturally for the character. I put him in larger-than-life situations but I was also able to keep it realistic.

“In the real world, criminals are often quite boring and not very bright. Criminal masterminds are rare. You have to make the crims a bit smarter in a novel, for in real life most crimes are solved on day one of the investigation.”

Private Prosecution is published by Fremantle Press (RRP $32.99).

MEDICAL FORUM | AGED & PALLIATIVE CARE

NOVEMBER 2021 | 57

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WINE REVIEW

Brown Hill strikes gold Brown Hill Estate is located on 24ha in Rosa Brook, which is situated 10 minutes south of Margaret River. The Bailey family established the vineyard in 1995 and produced their first vintage in 2001.

From a single vineyard, all grapes are hand-picked and hand-sorted to optimise fruit quality with ageing in French coopered barrels. Brown Hill Estate has been producing quality Margaret River wines on the premise that “great wine is made in the vineyard.”

There is no doubt they have produced some great wines.

The family’s strong links to Kalgoorlie result in a wine portfolio named after gold mines.

2019 Bill Bailey Shiraz Cabernet (RRP $85) The 2019 Bill Bailey Shiraz Cabernet is produced from a small single block in the vineyard. Deep burgundy in the glass with rich aromas of mulberry and plums. Berry quality is amazing with the hand-picking, and the wine is aged in French and American oak for 18 months. This is a well-balanced, rich wine with great berry flavours and soft tannins. A great choice for my T-bone steak.

2019 Golden Horseshoe Chardonnay (RRP $50) The 2019 Golden Horseshoe Chardonnay is from a strong year in Margaret River.

The wine is 100% barrel fermented for nine months, with whole-bunch pressing. Aromas of melon and peach with hints of cedar, a strong palate of fruit, vanilla and soft oak.

A lovely, balanced chardonnay with a great pedigree.

58 | NOVEMBER 2021

Review by Dr Martin Buck

2019 Ivanhoe Reserve Cabernet Sauvignon (RRP $50) The 2019 Ivanhoe Reserve Cabernet Sauvignon is an intense garnet red in the glass and delivers a punch of berry aromas.

Aged in French barriques for 18 months, the tannins are soft and silky. The palate has plenty of juicy, berry fruit with blackcurrants and cassis. This is a top example of a quality Margaret River cabernet.

Perseverance 2019 Cabernet Merlot (RRP $75)

'S EWER I V E R

PICK

Lastly, the Perseverance 2019 Cabernet Merlot is a beautifully balanced red with aromas of violets, anise and cigar box oak.

A full palate of soft, spicy plummy fruit with cherries and smooth tannins. A top example of cabernet merlot with a few more years of development ahead.

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Margaret River Here we come!

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