Mental health in aged care

There are several sources of information in national data sets that can be used to examine the mental health of people using aged care services, including aged care assessments, death records, medication data, healthcare data, and information from hospitalisations.

Aged care assessments

People seeking to access aged care services undergo assessments to determine their eligibility to receive Australian Government-subsidised aged care services, including permanent residential aged care and home care packages. Assessments are conducted by Aged Care Assessment Teams which operate in all states and territories. These assessments are completed using the National Screening and Assessment Form.

People accessing residential aged care also participate in an assessment to determine their care and funding needs. Until 30 September 2022, this assessment was completed using the Aged Care Funding Instrument (ACFI).

Included in both assessments are items identifying diagnosed mental health conditions and measures of psychological wellbeing.

Mental health conditions in aged care assessments

Mental health conditions can be identified in aged care assessments where they are recorded in the list of a person's health conditions. In aged care eligibility assessments, assessors record any major diseases or disorders that have an impact on the person’s need for assistance.

Assessors also record a 'primary health condition' considered to be the primary influence on the person's care needs. Assessors may record different primary health conditions on different assessments, depending on the person’s needs at the time.

Health conditions in aged care assessments are reported by the person being assessed and/or support people present during the assessment (professionals or family/friends), and/or are taken from medical notes. From 1 July 2017 to 30 June 2022, 17.5% of recorded mental health conditions were recorded as 'client reported', 39.5% 'GP confirmed', 27.6% 'hospital confirmed', and 10.2% 'other health practitioner diagnosis'. 3.7% had more than one recorded mental health condition, each with different record sources, and 1.5% had no recorded source.

All people accessing the aged care services included here (including Aboriginal and Torres Strait Islander (First Nations) people) must complete an aged care eligibility assessment and be approved for a service before receiving that service. All aged care eligibility assessments include recording of health conditions. As such, all people have an opportunity to be recorded as living with a mental health condition. More information about these records can be found in the Technical notes.

Until October 2022, in entry into residential care assessments, assessors recorded up to 3 major diseases or disorders that have an impact on the person’s need for assistance (with an emphasis on conditions that will most affect funding needs).

It is mandatory that aged care eligibility and entry into residential care assessments record at least one health condition, or record 'no health conditions present'.

Codes used to identify mental health conditions are displayed in the Technical notes.

Supplementary Assessment Tools in the National Screening and Assessment Form

Comprehensive assessment for aged care eligibility, using the National Screening and Assessment Form, includes Supplementary Assessment Tools that assessors can choose to complete during their assessment.

These tools include 2 validated scales of mental wellbeing:

• Geriatric Depression Scale: a 15-item measure of depressive symptoms in which the person records whether they have experienced specified symptoms of depression over the past week (for example, 'Do you feel that your life is empty?'). Scores are summed and a score >5 is indicative of depression (Sheikh and Yesavage 1986).
• Kessler-10: a 10-item measure of psychological distress in which a person indicates how often they experienced symptoms of distress over the past 4 weeks (for example, 'In the past 4 weeks, about how often did you feel tired out for no good reason?') on a scale from 'None of the time' (1) to 'All of the time' (5). Scores are summed, with higher scores indicating higher distress (Kessler et al. 2003).

The Geriatric Depression Scale and the Kessler-10 have both been culturally adapted and validated for many ethnically diverse populations and are therefore suitable for many culturally and linguistically diverse communities. Importantly however, neither tool is culturally validated for use with First Nations people (McNamara et al. 2014; Russell et al. 2022).

The Supplementary Assessment Tools also include 5 binary (that is, yes/no) items regarding the presence or absence of loneliness, social isolation, insomnia, nervousness/ depression, and anxiety.

However, these tools are rarely completed during assessments in practice. The My Aged Care – National Screening and Assessment Form fact sheet state that the use of these tools is recommended (but not mandatory) where there is an identified need for a greater level of assessment. Figure 1 demonstrates the very low rates of completion of these tools each year.

Figure 1: Completion rates of Geriatric Depression Scale and Kessler-10 in aged care eligibility assessments, 2015–16 to 2021–22

Given the very low completion rates for these tools, valid and reliable information about mental wellbeing in the whole aged care user (for example, home care, residential aged care) population cannot be drawn from them. As such, reporting on these tools is not included in this report.

Cornell Scale for Depression in Dementia in the Aged Care Funding Instrument

For people in permanent residential aged care, assessments until end of October 2022 included a modified version of the Cornell Scale for Depression in Dementia. This is a measure of depressive symptoms completed by both the resident (if possible) and by an informant (carer, staff member) (Alexopoulos et al. 1988).

The Cornell Scale for Depression in Dementia tool used in entry to residential care assessments consists of 19 questions covering 5 areas:

• mood-related signs
• behavioural disturbance
• physical signs
• cyclic functions
• ideation disturbance.

It is designed to be administered by a clinician. A Cornell Scale for Depression in Dementia may be completed for all people entering residential aged care, whether or not they have dementia.

The Cornell Scale for Depression in Dementia is scored on a 38-point scale with a score of 0–8 indicating minimal or no symptoms of depression. Scores are categorised:

• '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 and other causes

When data about aged care service users are linked to data about death, deaths due to suicide can be identified. Date and causes of death are provided to the National Death Index from state and territory Registrars of Births, Deaths and Marriages, the National Coronial Information System, and the Australian Bureau of Statistics.

Deaths due to suicide can be identified from the primary cause of death (as derived by the Australian Bureau of Statistics from death certificates) using the International Classification of Disease and Related Health Problems – Tenth Revision (ICD-10) codes ranging from X60-X84, Y87.0 (injury, poisoning, and certain other consequences of other external causes). These criteria have been previously defined by the AIHW Suicide and Self-Harm Monitoring Unit (AIHW 2024).

In addition, deaths caused by drug and alcohol poisoning (both accidental and undetermined intent – X40–45, Y10-15, Y45, Y47, Y49) and deaths due to chronic liver diseases and cirrhosis (K70, K73-74) can be identified as potential (but not exhaustive) proxy measures of deaths related to chronic mental distress. Data available on Suicide and Self-Harm Monitoring shows the rates of these deaths in the general population.

Other potential data sources

When data about aged care service users are linked to other administrative data sources it is possible to report on the rate of hospitalisations and emergency department presentations for self-injury. Suicide and Self-Harm Monitoring provides data about these events for the Australian population. These events can provide information about the mental wellbeing of people while they are using aged care services. Data about self-injury (that did not result in death) in aged care services users is not currently described in this report but will be added in future updates.

Medication data can also be used to indicate mental health needs, particularly psychotropic medication use. Mental health-related prescriptions include data about use of these medications in the Australian population.

Data about use of Medicare-subsidised mental health services can also be used to indicate use of services for mental health needs. The AIHW reporting on mental health service use includes date about use of these services in the Australian population.

Finally, quarterly reporting for the National Mandatory Residential Aged Care Quality Indicator program is a requirement for all Government-subsidised residential aged care facilities in Australia. Since April 2023, the program has included a ‘Quality of Life’ indicator in which providers must administer the Quality of Life – Aged Care Consumers tool (Hutchinson et al. 2021) with each resident (or their proxy) every 3 months. Results are published on GEN Aged Care.