Technical notes
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This analysis uses available data from aged care assessments and other data sources to describe the mental health of people using aged care services in Australia.
Included in this report were all people aged 65 years and over, and Aboriginal and Torres Strait Islander (First Nations) people aged 50 years and over, who accessed home care packages and/or permanent residential aged care from 1 July 2017 to 30 June 2022.
People who did not receive any of these services but did receive other types of aged care (for example, home support services funded by the Commonwealth Home Support Programme, transition care packages, respite care) are outside the current scope of this analysis and were excluded. Future updates of this report will include these groups.
About the data sources
The Pathways in Aged Care (PIAC) 2022 link map was used for this analysis. The Pathways in Aged Care link map brings together information from different aged care data sources about the same person. This is achieved using privacy-preserving linkage techniques that assign a unique identifier for each person in each data source. The Pathways in Aged Care link map is a set of links to all records for each person. This allows us to construct a chronological sequence of aged care events and present a more complete picture of aged care use, all the way from assessment and admission through to discharge and death.
The Pathways in Aged Care 2022 link map was used to create the following analysis data sets:
- A recipient table with demographic data for each person.
- An events table, including data collected during aged care assessments, data about service use (including entry and exit dates where available), and deaths.
- A services table describing organisations providing aged care.
These tables are populated with data from:
- the National Aged Care Data Clearinghouse (NACDC), including aged care assessment data and aged care service use
- the National Death Index (NDI), describing date and causes of death.
For more information about the Pathways in Aged Care link map, see the Pathways in Aged Care 2020: Technical Guide.
Aged care assessment data
Assessment data used for this project were collected using the National Screening and Assessment Form (NSAF) – part of the National Aged Care Data Clearinghouse. The National Screening and Assessment Form is a comprehensive assessment form that captures demographic factors and care needs at the time of assessment for aged care services. The data also include approval outcomes, indicating which services the person is approved for.
Two data tables containing information about health conditions are linked from the National Screening and Assessment Form. The first contains all health conditions listed by the assessor on the given assessment. The second contains all health conditions that have been nominated as the ‘primary health condition’ on an assessment. As individuals can complete more than one assessment over time, more than one primary health condition can be recorded in this data table.
Box 1.1: About aged care eligibility assessments
The National Screening and Assessment Form (NSAF) is used to screen and assess a person’s aged care needs. The National Screening Assessment Form was introduced for aged care assessments on 1 July 2015, and full coverage was achieved in June 2016. The National Screening and Assessment Form has 3 components:
- screening
- home support assessments
- comprehensive assessments.
Screening is conducted over-the-phone by My Aged Care contact centre staff after a person requests aged care services using My Aged Care. Contact centre staff may refer people for a home support assessment or comprehensive assessment.
Home support assessments are generally conducted face-to-face by Regional Assessment Service (RAS) assessors who provide assessment, information and advice to people requiring low level support. They assess eligibility for the Commonwealth Home Support Programme. Regional Assessment Services may also refer the person for a comprehensive assessment if they recognise that the person requires a higher level of support.
Comprehensive assessments are conducted face-to-face by Aged Care Assessment Teams (ACATs), comprising medical, nursing and allied health professionals managed by state and territory governments. Aged Care Assessment Teams assess eligibility for home care packages, permanent and respite residential aged care, transition care, and short-term restorative care. Approval can be given for more than one program and re-assessment can occur as needs change.
Data were also taken from the Aged Care Funding Instrument. The Aged Care Funding Instrument (ACFI) was used to assess the care needs of permanent residential aged care recipients from 20 March 2008 until 30 September 2022. The ACFI consisted of 12 questions about assessed care needs across 3 domains – activities of daily living, cognition and behaviour, and complex health care – and 2 diagnostic sections for health conditions that most affect the person’s care needs. While the ACFI captures details of up to 3 mental and behavioural disorders and up to 3 other health conditions for permanent residential aged care recipients, these are only recorded where the condition affects their current care needs. People can be re-assessed as their care needs change.
Aged care service use data
The National Aged Care Data Clearinghouse (NACDC) records episodes of aged care service use including for home support, home care packages, permanent and respite (that is, temporary) residential aged care, transition care, and short-term restorative care. For this report, data sourced from the National Aged Care Data Clearinghouse included the start (entry) date of the service (where available) and the service type (including home care package level). For more information about the National Aged Care Data Clearinghouse, see National Aged Care Data Clearinghouse: user guide.
Deaths data
The National Death Index (NDI) is a database developed and maintained by the Australian Institute of Health and Welfare. The database is a listing of all deaths that have occurred in Australia since 1980. The National Death Index contains person-level records of the date of all deaths occurring in Australia since 1980 obtained from the Registrars of Births, Deaths and Marriage in each state and territory. The National Death Index records are supplemented with cause of death information using data linkage with the National Mortality Database.
Cause of Death Unit Record File data are provided to the Australian Institute of Health and Welfare (AIHW) by the Registrars of Births, Deaths and Marriages and the National Coronial Information System (managed by the Victorian Department of Justice) and include cause of death coded by the Australian Bureau of Statistics (ABS). The data are maintained by the AIHW in the National Mortality Database.
More information about the National Death Index can be found on National Death Index.
Methods for this analysis
Defining the cohort
Included in this report were all people aged 65 years and over who started accessing home care packages and/or permanent residential aged care (for mental health conditions) or who were using these services at the time of their death (for suicide and other deaths data) from 1 July 2017 to 30 June 2022. People who did not receive any of these services but did receive other types of aged care (for example, home support, transition care packages, respite care) are outside the scope of this project and were excluded from these analyses.
People who received one of these care types prior to 1 July 2017 are also excluded from this analysis. People aged under 65 years were excluded from this analysis due to their small numbers. However, report sections specifically reporting on First Nations people include those aged 50 years and older.
The Sankey diagram below (Figure 19) demonstrates the data available for each user of aged care services during the study period.
- All people using a home care package or entering permanent residential care completes an aged care eligibility assessment using the National Screening and Assessment Form. As such, every person in our cohort completed an aged care eligibility assessment and was recorded with a list of health conditions that may or may not include mental health conditions.
- In addition, all people entering permanent residential aged care complete a funding assessment using the Aged Care Funding Instrument, which includes a list of health conditions. People entering permanent residential aged care are considered to have a recorded mental health condition if one of the included conditions is recorded in either their aged care eligibility assessment or their aged care funding assessment.
- A Cornell Scale for Depression in Dementia is included in aged care funding assessments for people entering permanent residential aged care. The Cornell Scale for Depression in Dementia is therefore not available for people receiving home care packages.
Figure 19: Defining the mental health analysis cohort of people aged 65 years and over who started accessing aged care services, 2017–18 to 2021–22
The Sankey diagram shows the process of defining the mental health analysis cohorts of people aged 65 years and over who started accessing home care (HC) and permanent residential aged care (PRAC) from 2017-18 to 2021-22. The diagram can be flipped to show data for either home care or permanent residential aged care using the flipping option located at the lower right corner.
The diagram flows from left to right, showing the transition of data through various stages:
- Analysis cohort: The starting point is identifying the first aged care service (HC or PRAC) entry that had health condition data records. 163 people (0.01%) in the home care cohort and 6,775 people (2.3%) in the permanent residential aged care cohort had no record of health conditions available in the linked dataset and were excluded from the analysis, which are not shown in the Sankey diagram.
- Health condition records (NSAF): Identifying if care recipients had health condition records in the National Screening and Assessment Form (NSAF). This stage is divided into two branches – 'No mental health conditions' (upper branch) and 'Had a mental health condition' (lower branch).
- Cornell score (ACFI): Identifying if care recipients had been assessed and had a Cornell score recorded in the Aged Care Funding Instrument (ACFI). This only applies to the cohort of people who entered permanent residential aged care. For the permanent residential aged care cohort, this stage is further divided into 'No Cornell scores' and 'Had a Cornell score'.
- Cornell category (ACFI): Identifying if care recipients had been assigned a Cornell category in ACFI (only applied to the cohort of people who entered permanent residential aged care). For the permanent residential aged care cohort, this stage is further divided into 'No Cornell category' and 'Assigned a Cornell category'.
In the home care cohort, both branches from stage 2 lead to 'Not applicable - ACFI only conducted at the entry to PRAC'.
Hover over the nodes in each stage to display the number of people using the care service in that node and the proportion of people in that node over the total number of the analysis cohort. Hover over a connecting line to the right of the node to display the number of people identified from that node to the next and the proportion of people coming from that node.
Mental health conditions
In reporting on the number of people using aged care living with mental health conditions (based on available information in assessment forms), the cohort was divided based on the first entry to each care type during the study period – home care packages and permanent residential aged care.
Defining the cohort in this way means that a person may have used more than one care type over the study period, and if so is included in more than one group of reported proportions. This ensures that the reported proportions are reflective of all people entering each service type during the study period.
Data from aged care eligibility assessments were taken from the aged care assessment that occurred closest to the date of entry to that care type (before or after entry date). For people entering permanent residential aged care, data were also taken from the first ACFI available in the study period.
The data therefore provide information on the proportion of people with mental health conditions at the time of assessment only, as a proxy measure of mental health at the time of entry to care. People can experience an extended elapsed time between an aged care eligibility assessment and entry to care. As such, mental health captured at the time of assessment may have changed at the time of care entry.
The presence of mental health conditions was calculated as the proportion (in percentage) of individuals accessing the included aged care services who had a recorded mental health disorder in their assessment data. The denominator was all eligible cohort members during the study period.
People living in permanent residential aged care were considered to have a mental health condition if one of the eligible conditions was recorded in their aged care eligibility assessment or in their ACFI.
Depression in people entering permanent residential aged care
The proportion of people entering permanent residential aged care recorded with symptoms of depression on the Cornell Scale for Depression in Dementia was calculated. Categories were defined according to the pre-determined categories used in the ACFI:
- ‘minimal or no symptoms of depression’ (less than 9)
- ‘mild symptoms of depression’ (9–13)
- ‘moderate symptoms of depression’ (14–18)
- ‘major symptoms of depression’ (19–38).
Death by suicide
Deaths by suicide were categorised by the type of aged care service that was being accessed at the time of death. Categories were mutually exclusive, such that each person that died by suicide was categorised only into the service they were using at the time of death (that is, the last service they used).
Age-specific crude suicide rates were calculated using the total number of people using each service type in the financial year as the denominator. To allow for comparison with other populations, age-standardised suicide rates were also calculated using direct standardisation against the Estimated Resident Population (ERP) of Australia at 30 June 2001 from the 2001 Census.
Because of their very small numbers, causing instability of rates and potential risk of identification, people aged under 65 years using aged care services were excluded from this analysis. Age groups are combined to protect confidentiality in the case of small numbers (defined here as n<3).
Variables used in the analysis
Data about mental health conditions, mental wellbeing, and death by suicide were used for this analysis, together with demographic information and data about aged care service use. Table 3 describes the variables used for this analysis.
No. | Variable | Variable type | Original or generated (source) | Description |
|---|---|---|---|---|
1 | AIHW PPN | Character | Original from AIHW’s linked aged care program IDs (PIAC) | An AIHW-derived project-specific person number, or person identifier. The AIHW PPNs were output alongside all linked aged care program-specific client identifiers (program IDs) to create the Pathways in Aged Care 2022 link map. |
2 | Assessment ID | Character | Original (NSAF, ACFI) | Unique ID of an assessment in National Screening and Assessment Form or of an assessment in the Aged Care Funding Instrument. |
3 | Exit date of the closest comprehensive assessment | Date | Original (NSAF) | The completed date of the comprehensive assessment that occurred closest to the date of the first entry to the care type in the cohort of interest (before or after entry date). |
4 | Exit date of the closest assessment in the Aged Care Funding Instrument | Date | Original (ACFI) | The entry date of the assessment in the Aged Care Funding Instrument that occurred closest to the date of the first entry to permanent residential aged care. |
5 | Date of primary health condition record in National Screening and Assessment Form | Date | Original (NSAF) | Effective start date of the user record in National Screening and Assessment Form that was closest to the date of the first entry to the care type in the cohort of interest (before or after entry date). |
6 | Days from assessment to service entry | Num | Generated (NSAF, ACFI) | Days from the assessment that occurred closest to the date of the first entry to the care type in the cohort of interest: (i) Home care service: assessments in National Screening and Assessment Form (ii) Permanent residential aged care: assessments in either National Screening and Assessment Form or the Aged Care Funding Instrument. |
7 | Financial year of service entry | Categorical | Original from entry financial year variable in events table (PIAC) | Financial year of the first entry to the service in each cohort. |
8 | Sex | Binary (Male/Female) | Generated (PIAC) | Whether the person is male or female. 18 individuals (17 in Mental health condition section and one in Suicide section) recorded as ‘Intersex or indeterminate’ or ‘unknown’ were excluded in sex related demographic description. |
9 | Age group | Categorical | Generated (PIAC) | Age groups (at the service entry) were: 50-54; 55-59; 60-64; 65-69; 70-74; 75-79; 80–84; 85-89; 90-94; 95 or over. In some cases, to reduce the risk of disclosure it was aggregated at 80 or 85 or 90 or 95 years whichever ensured it was at least 3 people in each cell. |
10 | First Nations People | Binary (Yes/No) | Generated from the Indigenous description field (PIAC) | Whether the person is First Nations (that is, Aboriginal and/or Torres Strait Islander). |
11 | Culturally and linguistically diverse background | Binary (Yes/No) | Original (NSAF) | Whether the person was from a culturally and linguistically diverse background, as recorded by the assessor in the National Screening and Assessment Form. |
12 | MMM (not presented) | Categorical | Original (NSAF) | Remoteness of primary address, as defined by Modified Monash Model (2019) classifications: MM 1: Metropolitan MM 2: Regional centres MM 3: Large rural towns MM 4: Medium rural towns MM 5: Small rural towns MM 6: Remote communities MM 7: Very remote communities. |
13 | MMM group categories | Num | Generated from ‘MMM’ field (NSAF) | Remoteness categories grouped into 2 groups: Metropolitan (MM 1) Regional, rural and remote (MM 2–7) |
14 | State/territory | Categorical | Original (NSAF, SPARC) |
|
15 | Lives alone | Binary (Yes/No) | Generated from ‘lives with’ categorical field (NSAF) | Whether the person lives alone or not, as recorded by the assessor in the National Screening and Assessment Form. |
16 | Partnered | Binary (Yes/No) | Generated from ‘marital status’ categorical field (NSAF) | Whether the person married (registered/de facto) or not, as recorded in the closest user record in the National Screening and Assessment Form to the service entry date in each cohort. |
17 | Dementia | Binary (Yes/No) | Generated (NSAF, ACFI) |
|
18 | Mental health condition | Binary (Yes/No) | Generated (NSAF, ACFI) |
|
19 | Mood disorders | Binary (Yes/No) | Generated (NSAF, ACFI) |
Permanent residential aged care cohort: whether the person has a mood disorder as indicated by the assessor in either (i) the ‘assessed health condition’ or ‘primary health condition’ fields of National Screening and Assessment Form (code 552) or (ii) question 13 of the Aged Care Funding Instrument (550A). |
20 | Anxiety/stress disorders | Binary (Yes/No) | Generated (NSAF, ACFI) |
Permanent residential aged care cohort: whether the person has an anxiety/stress disorder as indicated by the assessor in either (i) the ‘assessed health condition’ or ‘primary health condition’ fields of National Screening and Assessment Form (code 560, 561, 562) or (ii) question 13 of the Aged Care Funding Instrument (560). |
21 | Psychotic disorders | Binary (Yes/No) | Generated (NSAF, ACFI) |
Permanent residential aged care cohort: whether the person has a psychotic disorder as indicated by the assessor in either (i) the ‘assessed health condition’ or ‘primary health condition’ fields of National Screening and Assessment Form (code 550, 551, 553) or (ii) question 13 of the Aged Care Funding Instrument (550B). |
22 | Other mental health disorders | Binary (Yes/No) | Generated (NSAF, ACFI) |
Permanent residential aged care cohort: whether the person has another mental health condition as indicated by the assessor in either (i) the ‘assessed health condition’ or ‘primary health condition’ fields of National Screening and Assessment Form (code 580, 581, 582, 599) or (ii) question 13 of the Aged Care Funding Instrument (580). |
23 | Date of death | Date | Generated from day of death, month of death, year of death columns (NDI) | Date of death of care recipients as specified by the National Death Index. |
24 | Main cause of death | Categorical | Original (NDI) | Main cause of death specified in the National Death Index. Cause of death codes from the ICD-10-AM. |
25 | Suicide death flag | Binary (Yes/No) | Generated from ‘main cause of death’ column (NDI) | Whether the person has suicide recorded as the main cause of death (codes X60–X84, Y87.0). |
26 | Other deaths of interest | Binary (Yes/No) | Generated from ‘main cause of death’ column (NDI) | Whether the person has a main cause of death of (1) suicide (codes X60–X84, Y87.0), (2) alcoholic liver disease and cirrhosis (codes K70, K73–74), or (3) accidental poisoning (codes X40–X45, Y10–Y15, Y45, Y47, Y49). |
27 | Event pathway | Binary (Yes/No) | Generated from ‘date of death’ variable and aged care events table (PIAC) | Whether the person had used permanent residential care, home care (home care packages program) or home support (Commonwealth Home Support Programme) any time prior to the date of death. |
28 | Event closest to death | Categorical | Generated from ‘event pathway’ variable (PIAC) | Where an aged care service was used prior to the date of death, which aged care event happened closest to death. |
ACFI: Aged Care Funding Instrument; MMM: Modified Monash Model; NDI: National Death Index NSAF; NSAF: National Screening and Assessment Form; PIAC: Pathways in Aged Care; PRAC permanent residential aged care; PPN: project-specific person number; SPARC: System for the Payment of Aged Residential Care.
Codes used to identify and categorise mental health conditions in aged care eligibility and funding assessments are described in Table 4a and 4b.
Description | Code | Grouping |
|---|---|---|
Depression, mood and affective disorders, Bipolar disorder | 0550A | Mood disorders |
Psychoses (for example, schizophrenia, paranoid states) | 0550B | Psychotic disorders |
Neurotic, stress related, anxiety, somatoform disorders (for example, post-traumatic stress disorder, phobic and anxiety disorders, nervous tension/stress, obsessive-compulsive disorder) | 0560 | Anxiety / stress disorders |
Other mental and behavioural disorders (for example, due to alcohol or psychoactive substances (includes alcoholism, Korsakov’s psychosis), adult personality and behavioural disorders). | 0580 | Other |
Description | Code | Grouping |
|---|---|---|
Psychoses & depression/mood affective disorders | 550 | Psychotic disorders |
Schizophrenia | 551 | Psychotic disorders |
Depression/Mood affective disorders | 552 | Mood disorders |
Other psychoses (includes paranoid states, hallucinations) | 553 | Psychotic disorders |
Neurotic, stress related & somatoform disorders | 560 | Anxiety / stress disorders |
Phobic & anxiety disorders (includes agoraphobia, panic disorder) | 561 | Anxiety / stress disorders |
Nervous tension/stress | 562 | Anxiety / stress disorders |
Obsessive-compulsive disorder | 563 | Anxiety / stress disorders |
Other neurotic, stress related & somatoform disorders | 564 | Anxiety / stress disorders |
Other mental & behavioural disorders | 580 | Other |
Mental and behavioural disorders due to alcohol & other psychoactive substance use (includes alcoholism, Korsakov’s psychosis (alcoholic)) | 581 | Other |
Adult personality & behavioural disorders | 582 | Other |
Post-traumatic stress disorder | 586 | Anxiety / stress disorders |
Other mental & behavioural disorders not otherwise specified or not elsewhere classified (includes harmful use of non-dependent substances for example, laxatives analgesics, antidepressants, eating disorders for example, anorexia nervosa, bulimia nervosa, mental disorders not otherwise specified) | 599 | Other |
Description | ICD-10 Code |
|---|---|
Intentional self-poisoning by and exposure to nonopioid analgesics, antipyretics and antirheumatics | X60 |
Intentional self-poisoning by and exposure to antiepileptic, sedative-hypnotic, antiparkinsonism and psychotropic drugs, not elsewhere specified | X61 |
Intentional self-poisoning by and exposure to narcotics and psychodysleptics [hallucinogens], not elsewhere classified | X62 |
Intentional self-poisoning by and exposure to other drugs acting on the autonomic nervous system | X63 |
Intentional self-poisoning by and exposure to other and unspecified drugs, medicaments and biological substances | X64 |
Intentional self-poisoning by and exposure to alcohol | X65 |
Intentional self-poisoning by and exposure to organic solvents and halogenated hydrocarbons and their vapours | X66 |
Intentional self-poisoning by and exposure to other gases and vapours | X67 |
Intentional self-poisoning by and exposure to pesticides | X68 |
Intentional self-poisoning by and exposure to other and unspecified chemicals and noxious substances | X69 |
Intentional self-harm by hanging, strangulation and suffocation | X70 |
Intentional self-harm by drowning and submersion | X71 |
Intentional self-harm by handgun discharge | X72 |
Intentional self-harm by rifle, shotgun and larger firearm discharge | X73 |
Intentional self-harm by other and unspecified firearm discharge | X74 |
Intentional self-harm by explosive material | X75 |
Intentional self-harm by smoke, fire and flames | X76 |
Intentional self-harm by steam, hot vapours and hot objects | X77 |
Intentional self-harm by sharp object | X78 |
Intentional self-harm by blunt object | X79 |
Intentional self-harm by jumping from a high place | X80 |
Intentional self-harm by jumping or lying before moving object | X81 |
Intentional self-harm by crashing of motor vehicle | X82 |
Intentional self-harm by other specified means | X83 |
Intentional self-harm by unspecified means | X84 |
Sequelae of intentional self-harm | Y87.0 |
Description | ICD-10 Code |
|---|---|
Alcoholic liver disease | K70 |
Chronic hepatitis, not elsewhere classified | K73 |
Fibrosis and cirrhosis of liver | K74 |
Description | ICD-10 Code |
|---|---|
Accidental poisoning by and exposure to nonopioid analgesics, antipyretics and antirheumatics | X40 |
Accidental poisoning by and exposure to antiepileptic, sedative-hypnotic, antiparkinsonism and psychotropic drugs, not elsewhere classified | X41 |
Accidental poisoning by and exposure to narcotics and psychodysleptics [hallucinogens], not elsewhere classified | X42 |
Accidental poisoning by and exposure to other drugs acting on the autonomic nervous system | X43 |
Accidental poisoning by and exposure to other and unspecified drugs, medicaments and biological substances | X44 |
Accidental poisoning by and exposure to alcohol | X45 |
Poisoning by and exposure to nonopioid analgesics, antipyretics and antirheumatics, undetermined intent | Y10 |
Poisoning by and exposure to antiepileptic, sedative-hypnotic, antiparkinsonism and psychotropic drugs, not elsewhere classified, undetermined intent | Y11 |
Poisoning by and exposure to narcotics and psychodysleptics [hallucinogens], not elsewhere classified, undetermined intent | Y12 |
Poisoning by and exposure to other drugs acting on the autonomic nervous system, undetermined intent | Y13 |
Poisoning by and exposure to other and unspecified drugs, medicaments and biological substances, undetermined intent | Y14 |
Poisoning by and exposure to alcohol, undetermined intent | Y15 |
Accidental poisoning by and exposure to alcohol | Y45 |
Accidental poisoning by and exposure to other gases and vapours | Y47 |
Accidental poisoning by and exposure to other and unspecified chemicals and noxious substances | Y49 |
Abbreviations
Terms | Description |
|---|---|
ACAT | Aged Care Assessment Team |
ACFI | Aged Care Funding Instrument |
AIHW | Australian Institute of Health and Welfare |
CALD | Culturally and linguistically diverse |
CHSP | Commonwealth Home Support Programme |
HCP | Home Care Packages Program |
MMM | Modified Monash Model |
NACDC | National Aged Care Data Clearinghouse |
NDI | National Death Index |
NSAF | National Screening and Assessment Form |
PIAC | Pathways in Aged Care |
PRAC | Permanent residential aged care |
PPN | Project-specific person number |
PRAC | Permanent residential aged care |
SPARC | System for the Payment of Aged Residential Care |