The Medical Link Issue 149

medical link THE OFFICIAL PUBLICATION OF THE GOLD COAST MEDICAL ASSOCIATION INC.

RUDAS Score & Falls Frequency in the Elderly in WA in an Aged Care Facility "The purpose of the proposed study is to determine whether a relationship exists between the Rowland Universal Dementia Assessment Scale (RUDAS) score of an elderly person (65 years and above) in a residential aged care facility and their number of falls over of a 1-year period."

ISSUE 149 | MARCH – APRIL 2024

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THE MEDICAL LINK •

Contents 06 A Message From the GCMA President Prof Philip Morris AM FEATURE STORY 20 RUDAS Score & Falls Frequency in the Elderly in WA

in an Aged Care Facility Jonathan Schirripa EDITORIALS 10

Expanding Cardiac Diagnostic Options Across Gold Coast South Coast Radiology

12 Workforce, Prevention & Sustainability Key to Next Three Years AMA Queensland 14

The Movement Towards Recommending Exercise as Being Beneficial to Cancer Care Dr Selena Young, GenesisCare

16

Metabolic Syndrome in Samoan Islands Shaoyu Xu & Dr Romal C. Stewart

26

Autumn Home Buying Bank of Queensland

28 New Year, New Practice?

Avant Law

Cover Credit: Designed by Stories / Freepik

medicallink.com.au • 5

• THE MEDICAL LINK

A Message from the GCMA President Prof Philip Morris AM, President GCMA MB BS BSc PhD FAChAM (RACP) FRANZCP FPOA FFP ABPN info@drphilipmorris.com | 0422 545 753 | www.drphilipmorris.com

Dear GCMA colleagues,

I

hope the start of 2024 is going well for you and your practice team and your family. The GCMA had a very successful social event on the 24th of February. We hired the SeaWorld Spirit of Elston vessel for a Sunset Dinner Cruise around the Broadwater, cruising from Southport to the Coomera River entrance at Sovereign Island. We had 70 GCMA members and guests on board for an enjoyable evening.

Musical entertainment was provided

by Maddy Zanatta Hinton and we were challenged by a medical orientated trivia competition! A great evening was experienced by all. I would like to thank our association administration officer, Georgia Wyllie, and my executive committee

colleagues for their assistance organising this function. The GCMA may organise another social event like this in the second half of 2024.

On the 21st of March we restart our monthly Thursday evening clinical meetings. This meeting will cover medical imaging advances for cardiac conditions. It is sponsored by South Coast Radiology.

The function will be held from 6.30 pm at Bumbles Cafe, Budds Beach, Surfers Paradise. The next meeting after that will be our GCMA Annual General Meeting in April or May. We encourage all GCMA members to write articles or advertorials for The Medical Link. Contact admin@the-

"

We are always looking to expand our membership. I encourage you to invite your doctor colleagues to join the GCMA.

THE GCMA PRESIDENT'S REPORT •

medicallink.com.au to make a contribution. We are always looking to expand our membership. I encourage you to invite your doctor colleagues to join the GCMA. It is very easy to do. Just go to the GCMA website (www.gcma.org.au) and click through to the ‘Become a Member’ page to join. The registration page can take credit card payments. The $150 annual membership is extremely good value. It covers regular evening meetings where salient updates on clinical and professional matters are presented as well as a two-course meal and complimentary beverage, and the opportunity to interact with colleagues from all professional disciplines.

"

On the 21st of March, 2024 the GCMA will restart our monthly Thursday evening clinical meetings.

I look forward to seeing you at our next meeting.

Yours sincerely, Prof Philip Morris AM President GCMA

At Lumus Imaging Varsity Lakes we specialise in Pain Management “It is important to me that I take my time with the patient and understand the source of their pain. We can perform a range of pain management techniques at Varsity Lakes, therefore I will engage with the referrer if I think we can offer a better option.

Getting our patients back to doing what they love most in life is my motivation”.

Dr Paul Chou - Radiologist Varsity Lakes

Lumus Imaging Varsity Lakes - 2 Lake St Varsity Lakes P: 5585 3700

lumusimaging.com.au

Advertising in The Medical Link If you would like to advertise your products or services, positions vacant, rooms for rent etc. in The Medical Link, please feel free to contact us at admin@themedicallink.com.au.

Advertising of medical services in The Medical Link should comply with the same advertising guidelines released in the Medical Board of Australia Code of Conduct: Be factual and verifiable | Not include testimonials | Only make justifiable claims regarding quality and outcomes | Not raise unrealistic expectation | Not offer inducements | Not make unfair or inaccurate comparisons between your services and those of colleagues The Medical Link is designed and published by Swan Management Services. It is the advertiser’s responsibility to ensure that advertisements comply with the Trade Practices Act 1947 as amended. All advertisements are published on the condition that the advertiser indemnifies the publisher and its servants against all claims, suits, actions, loss and/ or damages as a result of anything published on the advertiser’s behalf.

DISCLAIMER: The contents of articles and opinions published are not necessarily held by the publisher, editor or the Gold Coast Medical Association. No responsibility is accepted by the publisher, editor or Gold Coast Medical Association for the accuracy of information contained in any opinion, information, editorial or advertisement contained in this publication and readers should rely upon their own enquiries in making decisions touching own interest. Unless specifically stated, products and services advertised or otherwise appearing in The Medical Link are not endorsed by the publisher, editor or the Gold Coast Medical Association.

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MEDICAL EDITORIAL COMMITTEE

Philip Morris, Geoff Adsett, Stephen Withers, John Kearney, Maria Coliat

GCMA MEMBERS gcma.org.au

GCMA EXECUTIVE COMMITTEE

President Prof Philip Morris 5531 4838 Vice-President Dr Maria Coliat 5571 7233 Secretary Prof Philip Morris 5531 4838 Immediate Past President Dr Sonu Haikerwal 5564 6255 Treasurer Dr Geoff Adsett 5578 6866 Specialist Representative Prof John Kearney 5519 8319 GP Representative Dr Katrina McLean 5564 6501 Academic Representative Prof Gordon Wright 5595 4414

Keeping the Medical Community Informed The Medical Link enriches the Gold Coast medical community by uniting the voice of its doctors.

Here you will find insightful stories and the latest trends in field research conducted abroad, and of course, right here on the Gold Coast. Keep informed of new health services, developments in the medical profession, and general interest items.

We invite you to submit your company updates, new recruits and promotions to the following email: admin@themedicallink.com.au And if you would like to advertise your products or services, positions vacant, rooms for rent etc. in The Medical Link, please feel free to contact us admin@themedicallink.com.au.

"Many heart diseases can be prevented and even after diagnosis, many can be treated and managed effectively."

10 • Issue 149

ADVERTORIAL

Expanding Cardiac Diagnostic Options Across Gold Coast South Coast Radiology Varsity One, Level 3, 1 Lake Orr Drive, Varsity Lakes 1300 197 297 | www.scr.com.au

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he latest statistics indicate that cardiovascular disease (CVD) is one of Australia’s largest health issues, accounting for one in four Australian deaths and claiming the life of one person every 12 minutes. Further, one in six Australian’s self-report as living with CVD; equivalent to over 4 million Australian’s.

But positively, the prevalence of CVD, when adjusting for population growth and age distribution, has been decreasing over time due to research into risk factors, improved diagnostics, interventions, and treatment.

Many heart diseases can be prevented and even after diagnosis, many can be treated and managed effectively.

South Coast Radiology provides a comprehensive range of advanced cardiac imaging services using advanced state-ofthe-art technology to assist you in accurately diagnosing patients and developing effective treatment plans. This cardiac imaging services include:

Coronary Angiography (CTCA)

CTCA is a low risk, low radiation dose, non-invasive examination of the coronary arteries. It can accurately detect and grade stenoses or narrowing within the coronary arteries, as well as being able to demonstrate developmental anomalies of the coronary vessels.

CT Calcium Score

Provides the ability to visualise, measure and create a report of coronary calcification and calculate the calcium score using a non-contrast cardiac CT exam. The CT Calcium Score enables clinical reporting for coronary risk assessment.

Echocardiogram

A Transthoracic Echocardiogram, also called an echo, is a complex, non-invasive examination that uses ultrasound to image the heart. This examination provides detailed live images of the heart’s muscle pump and valves, giving a highly accurate assessment of the overall health of the patient’s heart.

Myocardial Perfusion

MRI images, and the patient will be required to hold their breath multiple times during the scan.

Using sophisticated ECG gating and smooth suppression techniques, this MRI technique will assess the function and structure of the cardiovascular system, producing high-quality imaging.

At South Coast Radiology, MRI cardiac studies will be tailored to individual patients using:

Myocardial scans give information useful in diagnosing and managing conditions such as coronary artery disease, dead tissue resulting from a lack of blood supply (infarcts) and diseases of the heart muscle (cardiomyopathy).

•

•

Cardiac MRI

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Cardiac MRI is a non-invasive technique used to assess the function and structure of the cardiovascular system. Utilising Magnetic Resonance Imaging (MRI) technology, South Coast Radiology can assess myocardial viability, assess cardiomyopathy, measure ventricular volumes, investigate suspected myocarditis, characterise myocardial masses, and quantify blood flow across heart valves.

• •

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Cardiac MRI scan will take 45-60 minutes to complete, with no special preparation required. During the procedure, ECG dots and leads will be placed onto the patient’s chest to monitor the heart during the scan, and a cannula will be inserted into the patient’s arm so a contrast agent can be given during the MRI. A lightweight blanket camera will be placed on the patient’s chest to acquire

•

Specialised sequences that can overcome patient specific limitations such as the presence of respiratory disease or scar tissue following cardiac surgery.

Still images that delineate cardiac structures and great vessels.

High quality cine images that measure cardiac volumes, myocardial masses and visualise regional wall motion abnormalities which may indicate underlying ischemic heart disease.

Velocity flow imaging sequences to measure blood flow in assessment of valvular abnormalities.

Gadolinium contrast agents are used to aid the diagnosis of specific cardiac pathologies.

Delayed or late myocardial enhancement imaging sequences to assess specific patterns of uptake.

S

outh Coast Radiology is proud to provide the Gold Coast region with pioneering, non-invasive Cardiac MRI services at their Pimpama practice, complementing it’s comprehensive array of cardiac imaging services offered across the Coast.

medicallink.com.au • 11

• THE MEDICAL LINK

Workforce, Prevention & Sustainability Key to Next Three Years AMA Queensland Advocacy Priorities 2024-26 Media Release, 7 February 2024 media@amaq.com.au

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oosting the regional workforce, more support for general practice, and making hospitals more environmentally sustainable are among the top priorities for AMA Queensland over the next three years.

The state’s peak medical representative body, which celebrates its 130th anniversary in 2024, has released its Advocacy Priorities 2024-26, setting out its urgent healthcare priorities.

It calls for broader incentives to attract and retain healthcare workers in regional and remote areas, greater investment in preventative health and general practice, and a reduction in carbon emissions from hospitals and health services.

“AMA Queensland has a proud history of uniting the medical workforce and advocating for patients and the community since 1894,” AMA Queensland President Dr Maria Boulton said.

“Our 2024-26 priorities reflect our status and core values and we will pursue them with all levels of government and sides of politics, particularly in this state election year.

“The past few years have been dominated by COVID-19, but the stresses on our system were there long before the pandemic. It is only due to the altruism and dedication of our hard-working doctors, nurses and healthcare staff that Queenslanders continue to enjoy quality care.

12 • Issue 149

"

Workforce is our No.1 priority. We cannot open new hospital beds without staff to operate them. We cannot solve our regional workforce crisis without recruiting, training and supporting the GPs and other specialists, nurses and allied healthcare workers our regions so desperately need.

“Workforce is our No.1 priority. We cannot open new hospital beds without staff to operate them. We cannot solve our regional workforce crisis without recruiting, training and supporting the GPs and other specialists, nurses and allied healthcare workers our regions so desperately need.

“We must make Queensland the most attractive destination in the nation for health professionals. This requires urgent investment in broader incentives to attract and retain the medical workforce in our regions, including high-quality, affordable and safe staff accommodation.

“We are also calling for investment in the physical infrastructure in hospital upgrades or builds. Doctors tell us they often do not have access to basic facilities such as offices, workstations and IT systems, directly reducing their ability to treat patients effectively.

“Patients are at the centre of everything we do, and governments must focus on preventative health to keep people living longer and healthier lives and reduce the pressure on the public health system.

“AMA Queensland will continue to advocate for greater investment in what we know works in preventing disease – high quality primary care, particularly general practice, and access to timely specialist treatment close to home. Care delivered to the community must be collaborative in nature with the right people

in these roles.

“Expanding on our previous 130 years of advocacy, our 2024-26 priorities will inform our submissions to government and other consultations with a heightened focus on addressing our healthcare issues from the ground up.”

AMA Queensland Advocacy Priorities 2024-26 is available at www. ama.com.au/qld/positionstatement/ AMA-Queensland-Advocacy-Priorities-2024-26.

Key priorities Advocacy for doctors •

•

•

Workforce – broader incentives to attract and retain the regional workforce, including pathways for further training, basic office facilities, and safe and affordable staff accommodation Training – productive training pathways for recent graduates and overseas-trained doctors, and culturally appropriate support and mentorship for First Nations doctors Leadership – embed doctors in decision-making processes and leadership at senior levels in Queensland Health and Hospital and Health Services (HHSs) Wellbeing – Reform of regulatory

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processes that lead to distress for doctors under investigation, more support for junior, First Nations and overseas-trained doctors Primary-tertiary integration – better coordination between GPs and hospitals to reduce repeat emergency department presentations, funding to establish mechanisms and support for patients to see their GP within seven days of discharge from hospital

Advocacy for patients •

•

•

Prevention – more investment in high-quality primary care, particularly general practice, and action to address the underlying causes of poor health outcomes including poverty, housing stress, and cost of living pressures Collaborative evidence-based practice – funding for a PhD research project analysing doctors’s scope of practice and identifying administrative tasks that could be safely performed by other health professionals Digital integration – investment to integrate primary care and hospital systems to promote information sharing, and rectify issues with systems including ieMR and QScript

•

•

First Nations health – First Nations people and organisations to be supported to lead policy development and decision-making at the local and regional level Women’s health – increased investment in maternity care, especially for regional, rural and remote communities, improved access to safe termination of pregnancy services, and to alcohol and other drug treatment services

Advocacy for our community •

•

•

•

Climate and sustainability – pilot programs in environmental sustainability in six hospitals and 10 GP clinics LGBTQIA+SB community – considered and sensitive government and media responses to reports and policy proposals concerning the community Aged and end-of-life care – all unallocated palliative care funding to be reinvested in end-of-life care with a focus on First Nations communities Substance-related harm – dedicated and additional funding for the anticipated 17,000 people who will access early intervention and diversion schemes

medicallink.com.au • 13

"Facilitating implementation of these recommendations for exercise during cancer treatment will require addressing barriers to this care that exist at the patient, clinician, health system, and policy levels.1"

14 • Issue 149

The Movement Towards Recommending Exercise as Being Beneficial to Cancer Care Dr Selena Young MBBS, MPallC, FRANZCR Radiation Oncologist www.genesiscare.com/au

I

n May 2022, the American Society of Clinical Oncology (ASCO) added to the growing chorus of voices recognising exercise as an important part of cancer care.1-4 While the ASCO guidelines mirrored previous recommendations, theirs took a different approach to reviewing the extensive literature describing the benefits of exercise.1 They aimed to provide guidance on exercise, diet and weight management during active treatment.1 This approach helps to clarify the value of exercise during this critical phase of the cancer continuum and offers insight into the value of clinicians incorporating exercise guidance into care.1 The recommendations were based on evidence from 42 systematic reviews and 13 randomised controlled trials (RCTs) that were specific to exercise.1 Breast cancer was one of the most commonly studied cancer types across the literature reviewed.1 The evidence showed exercise offers several benefits for patients undergoing treatment, which may include:1,5 • • •

T

Decreased fatigue Preservation of cardiorespiratory fitness, physical function, and muscular strength For some cancers, including breast cancer, increased quality of life and decreased anxiety/depression

here is also emerging evidence from animal models that exercise may enhance treatment effectiveness.6,7 Based on these outcomes, ASCO concluded that oncology providers should provide guidance on exercise during cancer treatment.1 Specifically, to recommend regu-

lar aerobic and resistance exercise during active treatment with curative intent.1

Moving the guidelines into practice

A

s noted by the ASCO guideline authors, it is important to consider how these guidelines will be implemented into care as exercise is not yet routinely offered in oncology care.1,8 “Facilitating implementation of these recommendations for exercise during cancer treatment will require addressing barriers to this care that exist at the patient, clinician, health system, and policy levels.”1

P

revious research has identified a long list of barriers to implementation of exercise recommendations in cancer care.8 These have included organisational issues, such as lack of referral systems and lack of time to provide referrals, a lack of awareness about which patients would benefit from exercise, what to recommend and how to safely prescribe during treatment.8 Clinician assumptions of patient willingness to receive exercise instructions and current fitness were also key barriers to implementation in practice.8

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he health benefits of regular exercise and physical activity are compelling. Many people are able to benefit from exercise, regardless of age, sex or physical ability. Every person’s circumstances are unique, and these should be taken into account. Tailored exercise programs designed by an exercise profes-

sional that include both aerobic and resistance training activities have shown to provide benefits.1,5,9

A

t GenesisCare in Southport, the team has partnered with Atkins Health, a provider of exercise and rehabilitation services. One of the allied health care services that patients are offered access to is an Exercise Physiologist (with onsite gym at the Southport centre), who is able to design bespoke exercise programs, tailored to support an individual patient's needs during their treatment journey. An achievable exercise plan is designed together with the patient, taking into consideration their baseline cardiovascular fitness and strength, their goals and their limitations. The Exercise Physiologist also follows up on the patient, increasing accountability and lifestyle change.

Learn more about GenesisCare: genesiscare.com References 1.

2.

3.

4.

5.

6.

7.

8.

Ligibel JA, et al. J Clin Oncol 2022;40:2491-2507.Hayes SC, et al. J Sci Med Sport 2019;22:1175–1199.

Clinical Oncology Society of Australia.

Position statement on exercise in cancer care. Version 3, December 2020.

Campbell KL, et al. Med Sci Sports Exerc 2019;51(11):2375-2390.

Juvet LK, et al. Breast 2017;33:166-177.

Betof AS, et al. J Natl Cancer Inst 2015;107(5).

Pedersen L, et al. Cell Metab 2016;23(3):554–562.

Kennedy MA, et al. J Cancer Surviv 2022;16:865-881.

Buffart LM, et al. Cancer Treat Rev 2017;52:91–104.

medicallink.com.au • 15

Metabolic Syndrome in Samoan Islands The following article is the work of a student of the Oceania University of Medicine, our partner organisation for our previous medical conference held in Samoa last year, 28-30 September, 2023.

Shaoyu Xu, MPhil & Dr Romal C. Stewart, PhD shaoyu.xu@oum.edu.ws |

16 • Issue 149

Abstract

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he Samoan Islands have experienced a dramatic increase in the prevalence of metabolic syndrome, with recent data suggesting that it has reached epidemic proportions. This review examines the epidemiology of metabolic syndrome in Samoa, exploring the underlying causes from genetics to rapid modernisation and subsequent lifestyle changes. A stark contrast in health outcomes is evident between Samoa and American Samoa, with the latter exhibiting significantly higher rates of the syndrome. Lifestyle modifications, shifting dietary patterns influenced by globalisation, and deeply ingrained cultural values have been identified as key contributors. Public health professionals advocate for community-driven interventions and early screenings to address this alarming trend.

Introduction

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he prevalence of metabolic syndrome has increased in recent decades, and studies have shown that it has reached epidemic levels in the Samoan Islands. (Wang et al., 2017; DiBello et al., 2009) When four Asia-Pacific countries, namely Samoa, Australia, Japan, and Korea, were assessed using various diagnostic criteria for metabolic syndrome, Samoans consistently ranked the highest, with a prevalence of 17%-60% (Lee et al., 2008).

Due to the high prevalence of metabolic syndrome in Samoa, this article aims to review the epidemiology and raise awareness of the causes of metabolic syndrome across the Samoan Islands.

The Samoan Islands

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he Samoan Islands are divided into two jurisdictions:

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Samoa comprises four inhabited

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islands and several small islands and outcrops. It is located in the northeast of Fiji and is the first Pacific Island nation to gain independence. It currently has a population of 200,010 (Samoa, n.d.).

American Samoa comprises five islands and two atolls. It is located between New Zealand and Hawaii and is a territory of the United States with a population of 55,000 (American Samoa, n.d.).

What is metablic syndrome?

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etabolic syndrome is a cluster of metabolic disorders, including high serum triglycerides, low high-density lipoprotein (HDL) cholesterol, elevated blood pressure, raised fasting serum sugar, and abdominal obesity. It is associated with a high risk of developing atherosclerotic cardiovascular disease, type 2 diabetes, and cerebrovascular accident (Wang et al., 2017). To meet the diagnosis of metabolic syndrome, a patient must have any three of the following disturbances: • • • • •

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Abdominal obesity, with a waist circumference of over 102 cm in men and 88 cm in women Hypertriglyceridemia, with serum triglycerides 1.7 mmol/L or greater Reduced serum HDL, of under 1.0 mmol/L in men and under 1.3 mmol/L in women Raised fasting glucose, of 100 mg/ dL or greater Elevated blood pressure, with systolic blood pressure of 130 mmHg or higher and/or diastolic blood pressure of 85 mmHg or higher (Wang et al., 2017)

t is important to note that measuring waist circumference for abdominal obesity, rather than body mass index (BMI), plays an important role in the clinical diagnosis of metabolic syndrome.

This is because abdominal fat is a marker of "dysfunctional adipose tissue" and is highly linked to insulin resistance (Després & Lemieux, 2006).

Metabolic syndrome among Samoan islanders

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lthough geographically close, there are health disparities between Samoans due to the different levels of modernisation present across the islands. American Samoans have a higher prevalence of metabolic syndrome and obesity than Samoans. Approximately 71% of women and 61% of men are obese in American Samoa, whereas close to 30% of men and over 50% of women are obese in Samoa.

Correspondingly, 49.4% of American Samoans meet the diagnostic criteria for metabolic syndrome, compared with 30.6% of Samoans. Samoan women have a higher prevalence of metabolic syndrome than Samoan men (Dibello et al., 2009).

I

nterestingly, a similar pattern is observed in adolescents. With age-relevant cutoff criteria for cardiometabolic disorder, a cluster of three or more risk factors was present in 17.9% of male and 21% of female adolescents from American Samoa, whereas very few adolescents in Samoa exhibit three or more risk factors (1.1% in males and 2.8% in females) (Hawley et al., 2012). The difference in the prevalence of cardiometabolic risk factors among adolescents is due to the varied pace and timing of economic and social transition between the two polities and the different levels of parental socioeconomic status, education, and occupation (Hawley et al., 2012). Interestingly, this study reported that BMI correlates positively with the number of cardiometabolic risk factors and that only obese adolescents exhibit a cluster of three or more risk factors (Hawley et al., 2012).

medicallink.com.au • 17

• THE MEDICAL LINK

Risk factors for metabolic syndrome in Samoans

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tudies have shown that the following are risk factors for metabolic syndrome in Samoans: • • • • • •

Older age Female sex Higher socioeconomic status index Higher BMI Larger waist circumference Lower physical activity

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n addition, certain genetic traits make Samoans more susceptible to metabolic syndrome when they eat a modern diet.

For example, Barlin et al. (2013) reported that one common variant of the insulin-induced gene 2 was associated with higher triglyceride levels and poorer metabolic control in people who followed a modern dietary pattern.

Lifestyle & dietary patterns in the islands of Samoa

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he modernisation of Samoa has led to an increase in risk factors for metabolic syndrome, such as unhealthy diet, reduced physical activity, alcohol consumption, and smoking. In both Samoa and American Samoa, the traditional subsistence culture of farming and fishing is gradually being replaced by a sedentary way of life (Hawley et al., 2012).

Samoans overall do more farm work than American Samoans (Baylin et al., 2013).

However, physical activity has decreased overall due to improved transportation infrastructure and technological advancements in the mass production and distribution of food and tobacco products (Hawley et al., 2012).

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he rapid modernisation and urbanisation of Samoa has also led to a dietary transition over the past four de-

18 • Issue 149

cades (Wang et al., 2017; DiBello et al., 2009). Increased global trade has exposed Samoans to imported foods (Hawley et al., 2012). There has been a significant decline in the intake of traditional foods, such as green leafy vegetables, fruit, soup, and fish. With the popularity of imported and processed foods, the Samoan population has undergone a gradual nutrition transition to a mix of neotraditional and modern dietary patterns (Wang et al., 2017). Neotraditional patterns are characterised by the consumption of mostly local foods, such as coconut products, tropical fruits, taro, and a small amount of processed foods. Modern patterns are characterised by a high intake of processed foods, eggs, milk, and cheese, and a low intake of local foods. It is noteworthy that most Samoans have largely abandoned their neotraditional diet and acquired a modern dietary pattern. Adherence to the modern dietary pattern has been consistently associated with a poorer metabolic profile, including higher fasting serum glucose and triglyceride levels, worse insulin resistance, higher BMI, increased waist circumference, and lower HDL levels (Baylin et al., 2013).

Influence of Samoan culture and “fa’asamoa” (the Samoan way)

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amoan culture and "fa'asamoa" are linked to the development of obesity and metabolic syndrome. Feasts are a very important part of Samoan life and foster social well-being. The phrase "food is life, food is our culture" reflects the importance of food in Samoan culture.

The high consumption of high-calorie foods at feasts, church events, and other social gatherings has a detrimental impact on individual health, as the foods that are typically served are high in carbohydrates, fat, and salt. "Fa'asamoa" also influences food preferences, taste, and how resources are used. Abundance is a key

cultural pattern of eating. Additionally, the high rate of obesity has been linked to some cultural factors, such as fat-positive attitudes (e.g., "if you are fat, you are wealthy") and the view that stillness is an embodied mode of wellness that indicates status and therefore influences physical activity (Hardin, 2014).

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hanging these cultural behaviours may challenge socially grounded well-being. The saying "it is culture, it is the whole way of life" reflects the importance of culture in Samoan society. Samoans place obligations to family, church, or community over individual health (Hardin, 2014).

Public Health Implications and potential interventions

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he increasing prevalence of meabolic syndrome has significant implications for affected individuals, families, and the community healthcare system (Hawley et al., 2012). Public health officials are increasingly concerned about this problem and have developed strategies to address the food environment and structural inequalities (Hardin, 2014). Health practitioners are encouraged to act as health mediators, but they often feel uneasy about doing so, as creating change is perceived as imposing cultural change.

They have proposed a society-wide change in food, body, and wealth meanings and have suggested that community leaders, including church pastors, engage publicly with their own health. Leadership-driven cultural change involving health prioritisation and the choice of healthier food options can change the orientations of the community. In terms of adolescents, Hawley et al. (2012) proposed a screening test to identify individuals at risk and to initiate medical interventions using existing standard of care.

RISK FACTORS

POTENTIAL INTERVENTIONS

Old age

Raise awareness of metabolic syndrome

Female sex

Health practitioners act as health mediators

Higher socioeconomic status

Society-wide change in food, body, and wealth

Higher BMI

Community leaders engage publicly

Larger waist circumference

Health prioritisation

Lower physical activity

Choice of healthier food options

Genetic predisposition

Screening tests to identify risks in adolescents

Figure 2. Risk factors and potential interventions of metabolic syndrome in Samoa islands

Conclusion

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he escalating prevalence of metabolic syndrome in the Samoan Islands highlights the urgent need for intervention. The interplay of modernisation, cultural practices, and genetic predispositions presents unique challenges in addressing this health concern. The disparity between the two main Samoan regions further underscores the complexity of the issue. Targeted public health strategies, community engagement, and a deep understanding of Samoan culture and lifestyle are essential in crafting solutions.

Emphasising early detection and prevention, coupled with community-driven health initiatives, can offer a promising pathway towards curbing this health crisis in the Samoan Islands. The increasing prevalence of metabolic syndrome has significant implications for affected individuals, families, and the community healthcare system (Hawley et al., 2012).

Public health officials are increasingly concerned about this problem and have developed strategies to address the food environment and structural inequalities (Hardin, 2014). Health practitioners are encouraged to act as health mediators, but they often feel uneasy about doing so, as creating change is perceived as imposing cultural change. They have proposed a society-wide change in food, body, and wealth meanings and have suggested that community leaders, including church

pastors, engage publicly with their own health. Leadership-driven cultural change involving health prioritisation and the choice of healthier food options can change the orientations of the community. In terms of adolescents, Hawley et al. (2012) proposed a screening test to identify individuals at risk and to initiate medical interventions using existing standard of care.

References DiBello, J. R., McGarvey, S. T., Kraft, P., Goldberg, R., Campos, H., Quested, C., Laumoli, T. S., & Baylin, A. (2009). Dietary patterns are associated with metabolic syndrome in adult Samoans. The Journal of nutrition, 139(10), 1933–1943. https://doi.org/10.3945/jn.109.107888 Wang, D., Hawley, N. L., Thompson, A. A., Lameko, V., Reupena, M. S., McGarvey, S. T., & Baylin, A. (2017). Dietary Patterns Are Associated with Metabolic Outcomes among Adult Samoans in a Cross-Sectional Study. The Journal of nutrition, 147(4), 628–635. https://doi. org/10.3945/jn.116.243733 Baylin, A., Deka, R., Tuitele, J., Viali, S., Weeks, D. E., & McGarvey, S. T. (2013).

INSIG2 variants, dietary patterns and metabolic risk in Samoa. European journal of clinical nutrition, 67(1), 101–107. https://doi.org/10.1038/ejcn.2012.124 Hawley, N. L., Wier, L. M., Cash, H. L., Viali, S., Tuitele, J., & McGarvey, S. T. (2012). Modernization and cardiometabolic risk in Samoan adolescents. Amer-

ican journal of human biology : the official journal of the Human Biology Council, 24(4), 551–557. https://doi. org/10.1002/ajhb.22269 Saklayen, M. G. (2018). The Global Epidemic of the Metabolic Syndrome. Current Hypertension Reports, 20(2):12. http://doi.org/10.1007/s11906-0180812-z Hardin, H. (2015) Everyday Translation: Health Practitioners’ Perspectives on Obesity and Metabolic Disorders in Samoa.

Critical Public Health, 25:2, 125-138.

10.1080/09581596.2014.909581 Lee, C. M., Huxley, R. R., Woodward, M., Zimmet, P., Shaw, J., Cho, N. H., Kim, H. R., Viali, S., Tominaga, M., Vistisen, D., Borch-Johnsen, K., Colagiuri, S., & Detect-2 Collaboration (2008). Comparisons of metabolic syndrome definitions in four populations of the Asia-Pacific region. Metabolic syndrome and related disorders, 6(1), 37–46. https://doi. org/10.1089/met.2007.0024 American Samoa. (n.d.). Australian Government Department of Foreign Affairs and trade. Retrieved from https://www. dfat.gov.au/geo/american-samoa Samoa. (n.d.). Australian Government Department of Foreign Affairs and trade.

Retrieved from https://www.dfat.gov.au/ geo/samoa Després, J. P., & Lemieux, I. (2006). Abdominal obesity and metabolic syndrome.

Nature, 444(7121), 881–887. https://doi. org/10.1038/nature05488

medicallink.com.au • 19

RUDAS Score & Falls Frequency in the Elderly in WA in an Aged Care Facility The following article is the work of a student of the Oceania University of Medicine, our partner organisation for our previous medical conference held in Samoa last year, 28-30 September, 2023.

Jonathan Schirripa jonathan.schirripa@oum.edu.ws

20 • Issue 149

FEATURE STORY •

Abstract

B

ackground: The purpose of the proposed study is to determine whether a relationship exists between the Rowland Universal Dementia Assessment Scale (RUDAS) score of an elderly person (65 years and above) in a residential aged care facility and their number of falls over of a 1-year period Methods: A retrospective review of resident medical documentation from an aged care facility within Western Australia was performed to collect data for this study. Participants were grouped based on their RUDAS assessment as either nil impairment, normal, mild, moderate, or severe. Data on falls frequency was collected for each participant and this was analysed for correlation and statistical significance.

Results: ANOVA analysis found that falls frequency was significantly increased with a decreased RUDAS assessment score (correlation coefficient (r) -0.917 and p= 0.0281). This was best evidenced in those with moderate cognitive impairment.

Conclusion: From these findings we were able to establish that a lower score in the RUDAS assessment is negatively correlated with increasing falls frequency in the elderly.

Background

A

fall is defined as an event where a person comes to rest inadvertently on the ground or floor or other lower level.1 It is estimated that 1/3 of all people aged greater than 65 years will experience falls and of those individuals 50% will fall more than once.2 Furthermore, of those who fall 1 in 40 will expect to be hospitalised and roughly 50% of those hospitalised will live for 1 year post admission.3 In 2011-2012 in Australia, 96,385 people aged 65 and over were hospitalised for a fall related injury.5 In the same population of people falls are attributable for the leading cause of death secondary to traumatic injury.3 Additionally falls account for 2/3 of all unintentional injuries

resulting in deaths.3 Falls will frequently result in complications such as fracture of femur (2%), fractures of the humerus, pelvis or wrist (5%), head trauma, intracranial hematomas and injury of internal organs (10%).4 These resulting injuries will often have profound impacts on quality of life with many long-term adverse outcomes which will likely require readmission to hospital. This begins a cycle of decline that ultimately results in death.6 There is also a burden on the Australian healthcare system, with up to 1.5% of the health care budget utilised for costs associated with falls.18

C

ognitive impairment is defined as confusion or memory loss that is occurring more frequently or is progressively worsening over the past 12 months.7 It is well supported that cognitive impairment is a risk factor for falls in the older people population as evidenced by Inacio et al (2021) which indicated that cognitive impairment was the strongest predictor of falls requiring hospitalisation among 27 different variables.19 Approximately 60-80% of older people with cognitive impairment experience 1 or more unintentional falls which accounts for twice as many as those with intact cognition.8 Chen et al (2011) found that recurrent and single-time fallers had significantly lower Mini-Mental State Examination (MMSE) scores than non-fallers and that a large percentage of recurrent fallers had a MMSE of lower than 18.10 Allali et al (2017) found that 50-64% of older adults with impaired cognitive impairment were experiencing falls compared to 25% for those who are cognitively healthy.11 Furthermore Allan et al (2009) found that those 65 and older with dementia experienced nearly 8 times the incidence of falls than healthy controls.12 The RUDAS is a simple cognitive screening assessment that determines baseline cognitive function. It is advantageous over other cognitive assessments such as the MMSE as it is designed to be less sensitive to cultural and language diversity. This is evidenced by a 2015 meta-analysis by Naqvi et al which concluded that the RUDAS is par-

ticularly useful in patients with diverse backgrounds.22 Furthermore, Rowland et al found the RUDAS to be a reliable and valid assessment that is at least as accurate as the MMSE in diagnosing dementia and less impacted by language, education or gender.9 Storey et al (2004) found that the RUDAS is easily interpreted into other languages and is considered to be culturally fair.21

E

ven though there is strong evidence to support the association between cognitive impairment and risk of falls in the elderly, far less is known about the specific association between the RUDAS assessment and risk of falls in the elderly in an aged care setting in Western Australia.

The purpose of the study is to determine whether a relationship exists between the RUDAS score of an elderly person in a residential aged care facility and their number of falls over of a 1 year period.

It is hypothesised that there is a negative correlation between RUDAS score and falls frequency in the elderly population in an aged care facility (As RUDAS score decreases falls frequency increases).

Methodology

T

he study was approved by the Institutional Review Board of Oceania University of Medicine which included ethics approval. HREC Reference OUMHREC24_013

T

his pilot study consisted of collecting data from an internal database within a residential aged care facility in Perth, Western Australia. All residents in the age care facility consented for data collection. Data was collected within a 1-year period from April 2021 to March 2022.

The participants that were included must have had a RUDAS completed by an appropriate allied health professional as well as a documented history of all falls in the 1 year period following the RUDAS assessment. Any resident that did not fulfil the inclusion criteria was excluded from this study. A total of 15 participants did not meet the eligibility criteria as they did

medicallink.com.au • 21

• THE MEDICAL LINK

not have a RUDAS assessment completed and therefore were not included in the data for this study. The study exceeded the target sample size with a total of 98 participants with at least 10 participants in each group. Participants were split into groups based on their score from the RUDAS assessment (nil impairment, normal, mild, moderate and severe). Nil impairment indicates a perfect score or no cognitive impairment, normal indicates an expected age-related decline in cognition, mild indicates a noticeable decline in cognition, moderate indicates a significant impairment of cognition and severe indicates a profound impairment of cognitive function. With regards to scoring nil impairment achieved a score of 30, normal achieved a score of 26-19/30, mild 20-25/30, moderate 1019/30 and severe 9 or less out of 30. The RUDAS score and number of falls for each of the 98 participants was tallied and documented. Demographic data was also collected.

N

o materials were required to facilitate the study, simple convenience sampling was utilised for all participants medical documentation within the internal database of the facility unless they did not meet inclusion criteria.

S

tatistics and frequency data is provided and the ANOVA test has been calculated in order to determine correlations and p values. The number of participants, mean age, gender split, mean RUDAS and mean number of falls was documented for each for the 5 groups.

Correlation data and p values were generated for each individual group. All analysis was achieved via use of the ANOVA test.

Results

T

his study had a total of 98 participants, with 42 males (43%) and 56 females (57%) who’s age ranged from 73 to 99 with an overall mean age of 87.7 years. There were 12 participants in the nil impairment group, 15 in the normal

22 • Issue 149

group, 18 in the mild impairment group, 32 in the moderate impairment group and 21 in the severe impairment group.

Data surrounding demographics is provided in Table 1. RUDAS score and corresponding falls frequency data is provided in Table 2.

the study had more females(n=56) than males(n=42) there was no correlation between gender and RUDAS score or gender and falls frequency as seen in Table 3.

This is evident as the average number of falls over a 1 year period for males and females were 3.19 and 3 respectively.

T

Discussion

he hypothesis of this study was to determine whether a relationship exists between the RUDAS score of an elderly person (65 years and above) in a residential aged care facility and their number of falls over of a 1-year period. Statistical analysis of the data revealed that a negative correlation exists between RUDAS score and risk of falls.

I

n the group with nil impairment, there was an average falls frequency of 0.75 over a 1 year period. The normal group achieved a mean RUDAS score of 27.06 and experienced on average 1.13 falls.

The pattern continued with the mildly impaired group achieving an average RUDAS of 21.63 and a falls frequency of 1.39. Moderately impaired group had an average RUDAS score of 15.88 and a falls frequency of 2.5. Lastly, the severely impaired group had an average RUDAS score of 6.48 and an associated falls frequency of 8.14. When analysing the mean RUDAS score and mean falls frequency from each group, a strong negative correlation of -0.917 was established with an associated statistically significant p value of 0.028 (figure 1). When analysing the data in each group individually the only group with a statistically significant p value of 0.014 was the moderate impairment group. This was likely the case as this was the largest group by number of participants and therefore best accounted for outliers in the data.

T

he age and gender of the participants was analysed against the RUDAS score and falls frequency to expose any additional relationships and therefore bias to the hypothesis however it was found that there was no correlation between age and number of falls and between age and RUDAS as per Table 4. Although

T

he results of this study reveal that reveal that a relationship does exist between declining cognition via the RUDAS score and an increased falls frequency, most evidently in those with a moderate cognitive impairment in the RUDAS which best reflects the greatest number of participants in this study and likely the target population (elderly in aged care facilities).

P

rior research into the topic of cognition and falls frequency is well established in the literature however most of the body of research utilises the MMSE which is the Mini-Mental State Examination. Allali et al (2017) used the MMSE and in their study participants with non-Alzheimer’s dementia and Alzheimer’s dementia were more likely to fall compared to cognitive healthy individuals which supports the findings in this paper.11 Interestingly, those with non-Alzheimer’s dementia were more likely to fall with a prevalence of 64% compared to Alzheimer’s dementia with 50% and cognitively healthy with 25%.11 Seijo-Martinez (2016) used the MMSE to categorise participants into absent, mild, moderate and severe cognitive impairment. The study found that those with no cognitive impairment had a falls frequency of 34% and this increased in each subsequent group with severe cognitive impairment having a falls frequency of 50%.20 In summary the available data shows that with declining MMSE score there is an increased risk of falls.8,10,11,12,20 Despite the frequent use of the RUDAS in the elderly population, the data surrounding its relationship with falls is extremely limited.

Nevertheless, our findings are congruent with the available data and consistent

FEATURE STORY •

with the findings that the MMSE shows.

W

hen analysing our data, we concluded various limitations. Being a preliminary study with a simple data analysis, the findings and therefore the applicability to the elderly population must be further explored and scrutinised.

More specifically, despite achieving the desired sample size, we were unable to ensure similar number of participants in each group which introduced a possibility of data bias. In contrary, it could also be concluded that the size of each group best reflects the cognition levels of the elderly population in aged care facilities and therefore the data is more applicable.

However, as the data is collected from only 1 residential aged care facility, the applicability of the findings is reduced as compared to a methodology whereby participants were selected from across different facilities in Western Australia.

Furthermore, in ideal future studies, accounting for other confounding variables such as medications, chronic disease and previous mobility levels should be analysed. An example of the impact of medication on falls is seen in Sharif et al (2018) paper where they looked into the various risk factors of falls and stated the many medications that are associated with increase of falls and they include antipsychotics, antidepressants, hypnotics, sedatives and antihistamines.13 All of which are common in the geriatric population.13 Further studies that account for such variables will expand on and build upon the findings in this study and therefore generate improved data that can be considered more actionable.

A

physiological decline in cognitive function is expected with age however when cognition deteriorates past the expected age-related decline further challenges arise for the elderly. These challenges are not limited to physical function and extend to virtually all aspects of life. With the high prevalence and morbidity of falls in elderly it is important to establish any relationship between common assessments of cognition

such as the RUDAS and the subsequent likelihood of falls. Generating data as well as highlighting findings will contribute to deepening our understanding of the relationship between cognitive impairment and falls. Subsequently, this may guide and focus therapeutic interventions such as physiotherapy, occupational therapy, pharmacological therapy and provision of equipment. As evidenced by Montero-Odasso (2018) who found mounting evidence supporting the use of cognitive therapies such as cognitive training, virtual reality and dual-task training in improving mobility and therefore reducing falls in older adults with cognitive impairment.16 Frequency and/or intensity of the therapeutic intervention may be altered and adapted for the specific person of interest based on their assessment findings.

More broadly, this may guide aged care facilities to more appropriately allocate resources as well as indicate the need for additional funding in order to achieve the best outcomes for their residents and staff.

A

dditionally, this study highlights the need for accurate cognitive assessment as the result of the cognitive assessment will dictate the level of falls prevention required. However, this conclusion will require more extensive research as echoed by Cuevan-Trisan (2017) who strongly advocates for cognitive assessment for falls prevention but believes the recommendations and evidence for falls prevention in those with cognitive impairment is not well documented.14 This is also supported by the 2019 Cochrane review by Sherington et al which concludes various falls prevention recommendations however the research cited in the review excludes participants with cognitive impairment.15 Furthermore, Montero-Odasso (2022) concluded only two recommendations for falls prevention in cognitively impaired individuals.

They recommended routine assessment of cognitive and involvement of the individual and their caregiver in the decision of falls prevention as it showed better adherence.17 This highlights the need for

further research into the assessment of individuals with cognitive impairment in order to guide future falls prevention recommendations and strengthen the body of evidence available.

References 1.

WHO Global Report On Falls Prevention In Older Age. Appia: WHO Press; 2007.

2. Tinetti M. 2. Preventing Falls in Elderly Persons. New England Journal of Medicine.

2003;348(1):42-49. doi:10.1056/nejmcp02071 3. Pasquetti P. Pathogenesis and treatment of falls in elderly. Clinical Cases in Mineral and Bone Metabolism. 2014. doi:10.11138/ccmbm/2014.11.3.222 4. Rubenstein L. Falls in older people: epidemiology, risk factors and strategies for prevention. Age Ageing. 2006;35(suppl_2):ii37-ii41. doi:10.1093/ageing/afl084 5. AIHW: Bradley C 2012. Hospitalisations due to falls by older people, Australia 2007–08. Injury research and statistics series no. 61. Cat. no. INJCAT 137. Canberra: AIHW. 6. Boyd C, Landefeld C, Counsell S et al.

Recovery of Activities of Daily Living in Older Adults After Hospitalization for Acute Medical Illness. J Am Geriatr Soc. 2008;56(12):2171-2179. doi:10.1111/ j.1532-5415.2008.02023.x 7. Cognitive Impairment. A Call For Action Now. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2011.

8. Lord SR, Sherrington C, Menz HB & Close JCT (2007) Falls in Older People.

Risk Factors and Strategies for Prevention.

Cambridge University Press, Cambridge.

9. Rowland J, Conforti D, Basic D, Vrantsidis F. A Study To Validate The Rowland Universal Dementia Assessment Scale (RUDAS) In Two Populations Outside The Sydney South West Area Health Service. The Australian Government Department of Health and Ageing through Alzheimer’s Australia; 2007.

10. Chen X, Van Nguyen H, Shen Q, Chan D. Characteristics associated with recurrent falls among the elderly within aged-care wards in a tertiary hospital: The effect of cognitive impairment. Arch Gerontol Geriatr. 2011;53(2):e183-e186. doi:10.1016/j.archger.2010.08.012 11. Allali G, Launay C, Blumen H et al. Falls, Cognitive Impairment, and Gait Performance: Results From the GOOD Initiative. J Am Med Dir Assoc.

2017;18(4):335-340. doi:10.1016/j.jam-

da.2016.10.008

12. Allan L, Ballard C, Rowan E, Kenny

medicallink.com.au • 23

• THE MEDICAL LINK R. Incidence and Prediction of Falls in Dementia: A Prospective Study in Older People. PLoS One. 2009;4(5):e5521. doi:10.1371/journal.pone.0005521 13. Sharif, S.I. et al. (2018) ‘Falls in the elderly: Assessment of prevalence and risk factors’, Pharmacy Practice, 16(3), p. 1206. doi:10.18549/pharmpract.2018.03.1206.

14. Cuevas-Trisan, R. (2017) ‘Balance problems and fall risks in the elderly’, Physical Medicine and Rehabilitation Clinics of North America, 28(4), pp. 727–737. doi:10.1016/j.pmr.2017.06.006.

15. Sherrington C, Fairhall NJ, Wallbank GK, Tiedemann A, Michale& ZA, Howard K, Clemson L, Hopewell S, Lamb SE. Exercise for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews 2019, Issue 1. Art. No.: CD012424. doi:10.1002/14651858.

CD012424.pub2 16. Montero‐Odasso, M. and Speechley, M.

(2018) ‘Falls in cognitively impaired older adults: Implications for risk assessment and prevention’, Journal of the American Geriatrics Society, 66(2), pp. 367–375. doi:10.1111/jgs.15219.

17. Montero-Odasso, M. et al. (2022) ‘World guidelines for falls prevention and management for older adults: A global initiative’, Age and Ageing, 51(9). doi:10.1093/ ageing/afac205.

18. Nunan, S. (2023) ‘Evaluating the validity, reliability, and feasibility of a falls risk assessment tool recommended for use in Australian residential aged care facilities. A mixed methods study’, The University of Queensland, School of Nursing, Midwifery and Social Work. doi:10.14264/0ea539d.

19. Inacio, M.C. et al. (2021) ‘The risk of fall-related hospitalisations at entry into permanent residential aged care’, BMC Geriatrics, 21(1). doi:10.1186/s12877-

021-02640-w.

20. Seijo-Martinez, M. et al. (2016) ‘Influence of cognitive impairment on fall risk among elderly nursing home residents’, International Psychogeriatrics, 28(12), pp. 1975– 1987. doi:10.1017/s1041610216001113.

21. Storey, J.E. et al. (2004) ‘The rowland universal dementia assessment scale (Rudas): A Multicultural Cognitive Assessment Scale’, International Psychogeriatrics, 16(1), pp. 13–31. doi:10.1017/ s1041610204000043.

22. Naqvi, R.M. et al. (2015) ‘Cognitive assessments in multicultural populations using the Rowland Universal Dementia Assessment Scale: A systematic review and meta-analysis’, Canadian Medical Association Journal, 187(5). doi:10.1503/ cmaj.140802.

Tables & Figures Table 1 Demographic data of study participants. Means ± standard deviations are reported Demographic Information

Participants ( n =98)

Sex

Female = 54, Male = 46

Nil Impairment score (Mean age) Normal Score (Mean age) Mild Impairment score (Mean age) Moderate Impairment score (Mean age) Severe Impairment score (Mean age)

Participants (n = 12) 83.33 ± 6.85 Participants (n= 15) 85.60 ± 7.44 Participants (n=18) 89.11 ± 5.26 Participants (n=32) 88.94 ± 7.78 Participants (n=21) 89.00 ± 3.96

Table 2 RUDAS score and corresponding mean number of falls in each group.

Group

Mean RUDAS

Mean Falls/1yr (SD)

Nil Impairment

30

0.75 ± 0.72

Normal

27.06

1.13 ± 0.88

Mild Impairment

21.63

1.39 ± 0.89

Moderate Impairment

15.88

2.5 ± 3.13*

Severe Impairment

6.48

8.14 ± 4.91

*p <0.05

Table 3 Correlation between RUDAS and mean number of falls in Males and Females Sex

Mean RUDAS

Mean number of falls

Correlation

Females

18.07

3

-0.625

Males

19.26

3.19

-0.703

24 • Issue 149

Table 4 Correlation between Age and Falls frequency and Age and RUDAS score Correlation:

P -value

Age and RUDAS

-0.222

0.088

Age and Falls

0.061

0.551

Figure 1 Correlation: r= -0.917

P-value 0.028

Figure 2 Correlation: r= -0.657

P-value 0.021

medicallink.com.au • 25

"With the property market growing 8% nationally over the past 12 months and over 13-15% in Brisbane and the West, pandemic passes and interest rates steady, now may be a good time to invest in residential property."

26 • Issue 149

ADVERTORIAL

Autumn Home Buying Bank of Queensland 1300 160 160 | www.boq.com.au

T

he current growth of the property market is an early sign that now may be the time to consider investing in residential property. According to Colin Li, BOQ Group Head of Home Buying, inflation levels are continuing to fall, with the latest annualised rate down to 4.1%, a two-year low, which may impact interest rates. He adds that rental values continue to improve, which, when combined with possible interest rate reductions, could lead to increased investor activity in the market. “The early indications are that things have stabilised,” says Trevor Robertson, BOQ Specialist’s Head of Residential Products. “That’s why Autumn could be a good time to consider investing in the property market. However, you need to be very selective in what you look for.”

Residential property has long been an attractive investment option for medical professionals, as such investments generally generate good returns, and if not, creates a negative gearing situation which may help with tax deductions, depending on each individual’s circumstances.

However, as Trevor points out, expectations of high migration levels over the coming year will continue to put pressure on stock levels and property values.

“People need to be careful that they’re not paying top price,” he says. “There still appears to be a disconnect between expectations of property value and the property’s real value.”

“The sheer movement of population after the pandemic, combined with increased immigration, means that there are significantly low vacancy rates everywhere,” adds Julian Muldoon from 1Group Property Advisory. “It also means rents are up anywhere from 10 to 30% over the last 12 to 18 months. That has meant investors have been able to hold their investment properties while rates are rising.”

Investors’ market

Do your homework

T

T

he market for residential property is generally made up of 30% investors and 70% owner occupiers, the latter of which can be further broken down into first home buyers and those upsizing or downsizing. First home buyers were previously disadvantaged in the market because of the difficulty in saving for a deposit, and reduced borrowing capacity due to high interest rates.

However, that could change quickly.

“Fixed rates are starting to look more attractive in the market as overall 2- and 3-year fixed rates are starting to fall 2030bps below the equivalent variable rate product,” says Colin Li. “This development could be particularly attractive for investors are looking for interest stability.

For home buyers whether if you are a first home buyer or upgrader, an improved fixed rate also opens up the option to do a split loan where you have partly fixed and partly variable.”

Upsizers and downsizers are in a better position, and as Julian points out, they are frequently looking for properties with vacant possession so they can buy and sell seamlessly.

“Investors have got a bit of an edge,” he says. “If someone is selling a property with a tenant and they’ve still got six to eight months to run on their lease, it’s not attractive to an owner-occupier. So, that could be an opportunity that sells at a lower price due to less competition.”

He points out that the main reason the property market is holding up better than expected at the moment is because stock levels have gone down significantly and demand has not wavered. “The competition cooled off when stock levels were low. But stock levels have improved significantly. We expect early 2024 to be an exciting time in the property market.”

So investors need to be ready. “The best opportunity in the property market is always in retrospect,” says Julian.

he fundamental truth about the property market is, despite fluctuations, it has always been very resilient.

“Historically, residential property has been a very sound asset,” says Trevor. Julian adds, “The key thing is to get to the coalface and do your research. Be across the market and ready to buy so you’re not scrambling when everyone else piles back in when sentiment rises.”

Doing your research entails having a long-term goal, for which you can draw up an investment strategy. “It’s about working out where that set of numbers, growth target, borrowing capacity, cash flow capacity and objectives fits into the property market,” says Julian. “Every state has different price points, different yields, different major projects to tap into.

There are definitely windows of opportunity. I would suggest this year is certainly going to be an opportunity for those that are financially viable and ready.”

Trevor adds that the general principles of picking the right locations still apply. “For example, don’t buy in an area that is flood prone,” he says. “Some councils have fantastic online tools where you can check for this – particularly if you’re looking in a regional or rural area. Make sure the property is not subject to environmentally protected areas. You need to really do your research, and find out the environmental and legal impacts the property may be subject to, so you don’t get caught short.”

Looking to invest in property this autumn? Find out more about BOQ Specialist’s investor rate today by contacting one of their financial specialists on 1300 160 160 Disclaimer: This article may contain general advice.

This article has not been prepared with reference to your financial circumstances and should not be relied on as such. You should consider the appropriateness of the advice before acting on it and obtain your own independent financial, tax and legal advice as appropriate. BOQ Specialist is not offering financial, tax or legal advice.

medicallink.com.au • 27

• THE MEDICAL LINK

ADVERTORIAL

New Year, New Practice?

Ben Ryan Senior Associate | Avant Law 1800 867 113 | www.avant.org.au

I

t’s the new year, you’ve had some time off to refresh and recharge for the year ahead and you might be thinking about actioning some new goals for the year. If one of those goals is establishing or starting a medical practice, then this is the guide for you!

Ownership & corporate structure

O

ne of the first decisions to be made when establishing a practice is how the business will be owned and structured. This decision will depend on several factors including the number of owners involved and the scale of the business that will be operated. The most typical methods of ownership include: 1.

2.

3.

4.

Sole trader Partnership Company Trust (whether Unit, Discretionary or Hybrid) or 5. A company acting as trustee for the trust Where there is more than one owner in the business, the relationship between the owners should also be governed by an ownership document. The table below shows the typical document and its corresponding business structure.

These documents can record important factors, including: 1. The way the owners make decisions 2. The process that needs to be followed if the owners have a dispute 3. How the owners will be paid or how the profits of the business

28 • Issue 149

BUSINESS STRUCTURE

OWNERSHIP DOCUMENT

Partnership

Partnership Agreement

Company

Company Constitution Shareholders' Agreement

Trust (Unit, Discretionary or Hybrid)

Unitholders' Agreement Trust Deed

Trust with a Corporate Trustee

Share and Unitholders' Agreement Trust Deed Company Constitution

will be used and shared 4. How owners can enter and exit the business in the future

Location, location, location

E

ven in the age of remotely run businesses, the reality is that practices predominately require a practice location.

With various factors such as location, demographic and price – it’s easy to be overwhelmed by the options available when choosing your location. However, before you pick your fit-out company, you will need to decide whether you will own or lease your location.

No matter what you decide, securing premises and having a detailed lease outlining the security of your tenure and rent payable is a fundamental step. For leased premises, this often means Terms Sheets/Heads of Agreements and draft leases being negotiated with the landlord.

Of course there are agents out there that can assist with finding and negotiating these terms for you. If you are looking to purchase a property, you will need to

ensure the usual due diligence steps are followed and the premises are zoned for your intended purpose. Unsurprisingly, a contract that protects you properly during the purchasing process and lease will be a key aspect of your property plans.

Key employees Before you hire any employees, it’s important to understand the relevant minimum legal terms of employment that will apply to roles in your practice and to have appropriate employment documentation in place.

You will need solid template employment contracts that reflect the relevant minimum legal terms of employment in accordance with the National Employment Standards (NES) and any applicable award.

Awards are legally binding instruments made under the Fair Work Act 2009 (Cth), which supplement the NES to specify additional minimum legal terms of employment on an industry or occupational basis. The Health Profes-

sionals and Support Services Award 2020 and the Nurses Award 2020 are the two awards that commonly cover employees working in a private medical practice.

You will need different template employment contracts for permanent and casual employees.

Generally, less is more when it comes to written workplace policies and procedures. However, some policies are essential to ensure compliance with legislation, including policies dealing with workrelated discrimination, sexual harassment and bullying. All employees should be trained on these policies.

You will need to give all new employees a copy of the Fair Work Information Statement. Casual employees and employees whose contract will terminate at the end of an identifiable period will also need to be given additional information statements.

Plan for the unexpected

A

s the adage goes in business, ‘expect the unexpected’. While you work hard to ensure that the unexpected is managed properly, it’s important to ensure that this also extends to planning what will happen with the business if you, or other key owners and personnel are not available to undertake the roles you are usually able to perform.

This could involve several matters, including: 1. Ensuring your personal wills and powers of attorney are appropriately configured 2. Ownership documents are appropriately drafted to consider these circumstances

3. Investigating insurance structures which may assist the business to continue being properly managed if unfortunate circumstances unfolded (including the potential for a life insurance or TPD event to occur)

Key contracts

O

f course, there are other considerations and agreements required when establishing or joining a practice that will help mitigate risks. These include: ‍

1. Privacy policies and disclaimers – practices have particular obligations under the Privacy Act1998 (Cth) including to have a privacy policy (also sometimes known as privacy statements) which set out the way private and sensitive information will be handled and used by the practice. Subject to where your practice is located, you may also need to comply with additional obligations when dealing with patient records.

2. Facilities and Services Agreement – following recent case law and clarification provided by various state revenue offices across Australia regarding payroll tax, it’s important to ensure the practice is properly documenting the relationship with the doctors and understand what different relationship structures can exist between doctors and the practice.

For more considerations, we’ve created an extensive checklist to help you through-

out the process. Be sure to download your checklist via avantlaw.com.au. ‍

We can help you

A

vant Law is here to help with all the legals required when establishing or joining a medical practice. The Avant Law team includes lawyers who specialise in vast areas of law including Corporate & Commercial, Property, Estates & Succession and Employment law. Our team can guide you through the entire process.

Please call 1800 867 113, or to organise a confidential discussion at a time that suits you, please click here.

About the Author

B

en Ryan is a Senior Associate in the commercial and corporate law practice at Avant Law, based in Brisbane. Ben has been working with medical practices since 2013. Ben works primarily on commercial structuring and intellectual property matters to help clients achieve strategic and commercially sensible results. He pursued a career in law to provide reliable and honest support to those in need of legal assistance and enjoys working with clients to develop solutions-oriented legal strategy and advice.

Disclaimer: The information in this article does not constitute legal advice or other professional advice and should not be relied upon as such. It is intended only to provide a summary and general overview on matters of interest and it is not intended to be comprehensive. You should seek legal or other professional advice before acting or relying on any of this content. The information in this article is current to 23 January 2024. Liability limited by a scheme approved under Professional Standards Legislation.

Legal practitioners employed by Avant Law Pty Limited are members of the scheme. © Avant Mutual Group Limited 2024

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