Mental health in aged care

The proportion of all people aged 65 years and over, and Aboriginal and Torres Strait Islander (First Nations) people aged 50 years and over, with mental health conditions as identified in aged care assessment data was examined for all people prior to receiving a home care package or permanent residential aged care for the first time from 2017–18 to 2021–22. Note that dementia was not considered a mental health condition for the purposes of this report; included conditions are described in the Technical notes.

There are also important limitations of the data sources used here, described more in the Notes on data quality section. The mental health conditions reported here may under- or over-estimate the true prevalence of mental health conditions in the population of users of Australian aged care services.

People using aged care aged 65 years and over

Figure 2 shows the proportion of people aged 65 years and over using a home care package or entering permanent residential aged care with a mental health condition in the period 2017–18 to 2021–22.

Figure 2: Proportion of people aged 65 years and over using aged care services with a mental health condition, 2017–18 to 2021–22

Of the 289,763 people aged 65 years and over that started receiving a home care package from 1 July 2017 to 30 June 2022, 66,997 (23.1%) were recorded as having at least one mental health condition.

Of the 296,217 people aged 65 years and over that entered permanent residential aged care from 1 July 2017 to 30 June 2022, 171,005 (57.7%) were recorded as having at least one mental health condition on an assessment.

For people entering permanent residential aged care, there were differences in the proportion of mental health conditions according to data source (Figure 3). The proportion of people with any condition was higher when assessed using entry to residential care assessments compared to aged care eligibility assessments using the National Screening and Assessment Form.

Figure 3: Proportion of people aged 65 years and over entering permanent residential aged care with a mental health condition, by assessment source, 2017–18 to 2021–22

This difference may be because an entry to residential care assessment occurred on average 2.3 days (median 0 days, standard deviation 18.3 days) before or after entry to permanent residential aged care, while a comprehensive assessment occurred on average 244.3 days (median 87 days, standard deviation 356.8 days) before or after entry to permanent residential aged care. However, it may also be due to differences in data collection (see What is available in aged care data about mental health).

In both men and women, the proportion of people receiving home care packages or living in permanent residential aged care who were recorded with an assessed mental health condition at the time of their eligibility assessment decreased with increasing age (Figure 4).

Figure 4: Proportion of people aged 65 years and over using aged care services with a mental health condition, by age and sex, 2017–18 to 2021–22

Figure 5 shows the age distribution of people with recorded mental health conditions by sex. In both men and women, the proportion with mood disorders and anxiety disorders decreased with increasing age.

Figure 5: Age distribution of people aged 65 years and over using aged care services with a mental health condition, by sex, 2017–18 to 2021–22

Figure 6 shows the proportion of people using home care packages or living in residential aged care with mental health conditions, by state and territory. The denominator for these proportions is the total number of people using the aged care type in that state or territory. There was little variation in the proportion of people using home care packages with mental health conditions by state and territory. For people living in residential aged care there was more variation – the proportion with mental health conditions ranged from 44.9% in the Northern Territory to 66.3% in Victoria.

Among people using home care packages aged 65 years and over, mental health conditions were slightly more commonly recorded among people with dementia than among people without dementia, among First Nations people than non-Indigenous people, and among people living alone than those not living alone.

Among people living in residential aged care aged 65 years and over, mental health conditions were slightly more commonly recorded among people living alone than those not living alone prior to entry to care, among people without dementia compared to those with dementia, and among people living in an urban area than people not living in a metropolitan area.

Figure 6: Proportion of people aged 65 years and over using aged care services with a mental health condition, by characteristic, 2017–18 to 2021–22

First Nations people aged 50 years and over using aged care services

During the 5 years from 2017–18 to 2021–22, 10,535 First Nations people aged 50 years and over started receiving a home care package. Of these, 31.1% (3,276) had at least one mental health condition recorded on their aged care eligibility assessment (Figure 7).

During the 5 years from 2017-18 to 2021–22, 6,757 First Nations people aged 50 years and over entered residential aged care. Of these, 58.6% (3,958) had at least one mental health condition recorded one or more of their assessments (Figure 7).

Figure 7: Proportion of First Nations people aged 50 and over using aged care services with a mental health condition, 2017–18 to 2021–22

Among First Nations people aged 50 years and over using home care packages, mental health conditions became less common with increasing age (Figure 8).

Among First Nations people aged 50 years and over living in permanent residential aged care, mental health conditions generally became less common with increasing age in both men and women. However, small numbers of First Nations people aged 85 years and over using permanent residential aged care may have caused the variability seen in the reported proportions (Figure 8).

Figure 8: Proportion of First Nations people aged 50 and over using aged care services with a mental health condition, by age and sex, 2017–18 to 2021–22

Among First Nations people aged 50 years and over with a mental health condition using home care packages during the study period, most were in younger age groups at the time of their eligibility assessment (Figure 9).

The age distribution of First Nations people entering permanent residential aged care with a mental health condition differed by sex (Figure 9).

Figure 9: Age distribution of First Nations people aged 50 and over using aged care services with a mental health condition, by sex, 2017–18 to 2021–22

Notes on data quality

These data should be interpreted in the context of their strengths and limitations. The primary strength of aged care assessments in reporting on mental health conditions in aged care users is their coverage. All people accessing the aged care services in Australia must complete an aged care eligibility assessment and be approved for a service before receiving that service. All aged care eligibility assessments include the recording of health conditions. As such, all people have an opportunity to be recorded as living with a mental health condition.

However, there are important limitations of these data sources. These include:

• Human bias in recording. Aged care eligibility and funding assessments are clinician or aged care provider assessments of need, and are confined to pre-determined definitions of need. Per the program guidelines, whether an assessor records a mental health condition at the time of assessment will depend on the perceived importance of that condition to the person’s care needs. Whether a condition is recorded will be affected by the other health conditions experienced by the person, and this may change with age. This may, in part, explain why mental health conditions were less commonly recorded as aged care users increased in age in this analysis.
• People with mental health conditions experience a shorter average life expectancy than people without conditions, and may not live to an age to be eligible to use aged care services (Momen et al. 2022).
• The ACFI assessment tool was used to inform funding requirements. Health conditions listed in this tool may reflect those most likely to affect funding needs, rather than those most disabling to the person. Whether mental health conditions are considered to affect funding needs is at the discretion of the assessor.
• Assessments for aged care eligibility occur before entry to care. For people who received a home care package during the study period, assessment occurred on average around 290 days prior to receiving the package. For people in residential aged care (and only until October 2022, see below), assessments for funding using the ACFI occurred at entry to care. While these data sources can therefore provide some information of the presence or absence of mental health conditions at the time of assessment, they cannot indicate whether the prevalence of these conditions changes over time or indicate the mental wellbeing of people after entry to care. Mental health conditions may change by the time of care entry or over the time of care use.
• Recording also relies on the accurate diagnosis of mental health conditions prior to the assessment, which is known to be limited in older adults (Faisal-Cury et al. 2022; Lavingia et al. 2020).
• The quality and missingness of aged care eligibility and funding data requires evaluation. In particular, inter-rater reliability may be low as there is considerable variation across assessors and jurisdictions.
• There is potential for reporting bias or inappropriate use of assessment tools where there are cultural or other factors affecting communication between individuals and assessors. Cultural differences may limit comparability between groups.

There have also been recent changes in funding instruments used when entering residential aged care, and these will affect monitoring of mental health conditions in the future. In October 2022 the ACFI was replaced as the funding assessment instrument for people entering permanent residential aged care with the Australian National Aged Care Classification (AN-ACC) tool. The AN-ACC tool does not include recording of health conditions (including mental health conditions) or any assessment tools to identify mental health needs. It is therefore no longer possible to use these assessments at entry to residential aged care to ascertain how common mental health conditions are in people entering residential aged care.

Other notable aged care data limitations are that there is no ongoing systematic collection of information about the health conditions or care needs of people using aged care beyond the data sources described here. Hence it is not possible, for example, to look at changes over time in the health and functioning of older people using these services.

Finally, because there is no unique person identifier for people using different aged care programs over time the analysis in this report is based on post-hoc data linkage. While linkage rates are generally very high, it was not possible to produce sufficiently high linkage rates for the Commonwealth Home Support Program (which supports around 800,000 older Australians per year). This program has currently been excluded from this analysis with plans to include this cohort in a future edition of this report.