This topic examines active ageing, ageing theories, the social work role in aged care facilities, and questions to include in a bio-psychosocial assessment
This page has three sections:
Background Material that provides the context for the topic
A suggested Practice Approach
A list of Supporting Material / References
Feedback welcome!
Background Material
Active ageing is the process of optimizing opportunities for health, participation and security in order to enhance quality of life as people age. Health includes lifestyle factors, such as a healthy diet and regular physical activity as well as access to and use of health information and services. Participation involves meaningful participation in work, family and community life and opportunities for lifelong learning. Security includes personal and financial security and maintenance of human rights. All of these factors require environments that support them, including policy and physical environments.
Ageing In Place
One of the themes of recent years that can support active ageing is the concept of “Ageing in Place” (AIP), i.e. the ability of older adults to live in their homes or communities for as long as possible. The benefits of AIP potentially emerge from the strong feelings of place attachment older adults develop if they have lived in their home or community for many years. Place attachment in turn may contribute to health and well-being in later life because it fosters
physical inside-ness (that is, the ability to easily navigate familiar environments),
social inside-ness (that is, feelings of belonging and confidence in accessing informal assistance), and
autobiographical inside-ness (that is, deriving meaning and self-concept (Lehning, 2017).
Wiles et al. (2011) agree with the above, suggesting AIP is linked to
A Sense of Attachment and Social Connection (Friendliness, feeling safe, good access to public transport and other services, connection to neighbours, familiarity of place, social connections)
A Sense of Security and Familiarity: Home as a Refuge, Community as a Resource (The security and safety of home, familiarity, someone to look out for you)
A Sense of Identity, Linked to Independence and Autonomy (Making one’s own choices, maintaining own budget, maintaining good relations with neighbours, local health services)
Studies exploring older adults’ perspectives on AIP suggest the need for empowerment-oriented interventions that take into account elders’ preferences around AIP and relocation (Lehning et al., 2017). This can involve developing age-friendly communities. Smith et al. (2013) suggest these communities focus attention on both the individual and the community in four ways:
Staying Active, Connected and Engaged (e.g., social interaction, access to social support, and civic engagement opportunities),
Neighbourhoods and Housing (e.g., appropriate housing conditions, neighbourhood access to services and shopping, neighbourhood safety),
Transportation and Mobility (e.g., freedom to move around using one’s own preferred mode of transport, accessible and convenient public transit), and
Access to Healthy Activities (e.g., access to food and recreational activities).
There is, however, another aspect to AIP. Some studies note that segments of the older adult population may be at a higher risk for detrimental outcomes if they age in place, including loneliness, social isolation, restricted mobility, and limited access to supports and services. A significant minority of older people may be stuck in place because they lack the resources to change their living situation (Lehning et al., 2017).
Older people should give thought to establishing enduring guardianship, power of attorney and an advanced care directive:
An enduring guardian (EG)is someone you legally appoint to make personal or lifestyle decisions when you can no longer make your own decisions, e.g. where you live, which doctor you go to, and what medical or dental treatment and other services you receive. You can give your guardian directions about how to exercise the decision-making functions that you give them.
An enduring power of attorney (PoA only authorises the person you appoint (your attorney) to make decisions about your money and property. An attorney can’t make health or lifestyle decisions for you, only financial ones. A general power of attorney is given for a certain period of time and stops operating if you lose your ability to make your own decisions. An enduring power of attorney will continue even after you have lost capacity. This is the one you should use if you want to give someone power to make decisions once you can no longer do so.
An advance care directive (ACD) (also called an advance care plan or a living will) is a written record of your wishes or instructions for doctors and health care workers about the treatment you want or don’t want in particular circumstances in the future. An advance care directive is only used in situations when you are unable to communicate or have lost the ability to make medical treatment decisions for yourself. The culture of independence that drives the desire to age in place can impact on an older person’s need or wish to move into aged care; he or she may perceive a stigma associated with such a move. This is problematic when older people can no longer care for themselves. The decision to relocate to aged care can involve justifying life as usual, while finding excuses to relocate to an aged care home. This can make the relocation to aged care a stressful and threatening event. It is important that older people are supported through the process as the older person may push limits to stay in place as far as possible, lay claims for assistance for as long as possible but feel bad when not fully corresponding with the expectations of others. A solely needs-based assessment may deprive the older person of their independence (Soderberg, et al., 2013).
Two Theories of Ageing
It is important to be aware of two theories of ageing:
The sociocultural theory maintains that people, as they age, adopt living patterns that suit their earlier personalities—for some social withdrawal will suit, for others a fast-paced social life, for others an intermediate course with a strategic reduction in some areas and an increase in others. This model challenges ageism—expectations that older people act in a certain way. Older people should be able to participate in work (paid or unpaid), engage in cultural and spiritual activities with and without friends, maintain independence, contribute to society in a manner that is both familiar and satisfying, feel secure in their place of living and lifestyle and be treated with dignity.
The psychological theory recognises that, as people age and experience biological losses (e.g. hearing, short-term memory), they draw on life experience to compensate for losses through selecting alternative paths that enable them to optimise their skills /strengths (S-O-C). How do they do this? By reducing the range of tasks, limiting social contacts to most valuable while devoting more time to these, and allowing more time for tasks. This model supports empowerment and self-management for older people, encouraging and assisting them to maintain a lifestyle that is healthy, participatory, and secure.
Transitioning to and Aged Care Facility
The transition to an aged care facility can be either a positive or negative experience. For older people who choose to make this transition it will often be positive. However, if the transition is forced on older people, or occurs suddenly through illness or a change in life circumstances, it can be quite traumatic and lead to loneliness. In the worst-case situation, it can result in depression, anxiety and suicide. In fact the highest age specific suicide rate is for men in their 80’s, and they are usually lethal attempts (Polacsek, 2023 webinar).
To put this in context with the material above, the culture of independence that drives the desire to age in place can impact on an older person’s need or wish to move into aged care; he or she may perceive a stigma associated with such a move. The transition leads to a redefinition of self, and people need support to manage this. This support can be managed by ensuring staff have relevant background information about the person and can treat the person as an individual. Some of the challenges can be overcome by ensuring older people (and their family, friends and carers) are very clear on the ‘nuts and bolts’ of how the facility works in real work language, e.g. the daily timetable, type of meals, choice of activities, privacy arrangements, ability to come and go. Teaming the person with a ‘buddy’ can help, as well as demystifying the role of those who offer help to residents as part of their role in the facility (Polacsek, 2023 webinar).
Transitioning to an aged care facility is especially problematic when older people can no longer care for themselves. Unless people have been prepared for the possible transition, the relocation to aged care will be a stressful and threatening event. It is important that older people are supported through the process as the older person may push limits to stay in place as far as possible, lay claims for assistance for as long as possible but feel bad when not fully corresponding with the expectations of others (Soderberg, et al., 2013).
Responding to residents in an aged care facility is about implementing positive ageing:
Get to know the person
Co-develop strategies to optimise autonomy: showing and encouraging residents to continue what they can still do, e.g. standing up and walking a short distance
Facilitate help seeking—ask people what they want.
Recognise and support diversity, e.g. attend to cultural issues
Acknowledging and responding to residents’ and families’ experiences: be with people where they are at, when they feel able to, to encourage them, and when they are not feeling positive not force them to be.
Identify residents’ strengths: though a person might not be physically able to cook anymore, this does not mean that they do not remember the recipes they used. Just because residents cannot walk, does not mean they cannot garden, cook, knit or even clothe parts of themselves.
Learn to know the person, their likes and dislikes. Find creative ways to enable residents to do things within the scope of their abilities.
Helping people die well by making the lives of residents and family members as positive and meaningful as possible (Polacsek, 2023 webinar).
In 2020 Hardy, Hair and Johnstone suggested the social worker’s role in aged care facilities is to challenge narrow scopes of physical care, reveal the person behind the resident, and to assist the person in achieving the best possible life for themselves. This is achieved via:
Provision of holistic, person-centred care – a person-in-environment approach that considers the individual and their relationships with their family, carer and support networks to achieve more effective service delivery and contribute to better health and wellbeing outcomes.
Biopsychosocial assessments - social workers are often the only member in the multidisciplinary team who could identify psychosocial problems and emotional distress. Social work’s emphasis on the importance of autonomy, self-determination, strengths, and possibilities are crucial to improving quality of life and wellbeing.
Supporting the needs of residents and families - in both pre-admission as well as once older people enter care.
Supporting other staff members
Supporting decision making
Advocacy - older people with high care needs are at an increased risk of abuse, neglect and being silenced; it is a core role of social work to challenge and advocate for the person’s rights. However, this often proves difficult in a system that may not listen or act.
Diet, Gender and Frailty
Recent research around frailty in middle-aged and older people has highlighted its link to diet and gender. An Australian study (Xu, Inglis and Parker, 2021) using data from the 45 and Up Study found links between diet, gender and frailty. Using data stretching back to 2006 Xu et al. were able to track the dietary changes of both men and women over the long term. They found that men were more likely to have better diets as they aged, while women’s eating habits got worse. These changes in diet affect the odds of frailty, with results showing that females were more likely to suffer from frailty than men – particularly women over the age of 80 who were widowed, with low education levels and from low socioeconomic areas. Conversely, men and women who had diets rich in fruits, grains, or ate a variety of foods, had a low risk of frailty. Furthermore, women who added lean meat and poultry to their diet, were less frail. These results support previous research that shows eating a variety of healthy foods is one key to preventing frailty. Xu et al. suggest that developing dietary advice tailored to each gender could go some way towards preventing frailty.
Exercise
A 2022 meta-analysis by Aghjavan et al. demonstrated that aerobic exercise improves episodic memory in late adulthood. This study examined the effects of aerobic exercise randomized controlled trials on episodic memory in older adults without dementia and assessed whether the effects depend on the characteristics of the sample and intervention. Thirty-six studies were included in a meta-analysis, representing data from 2750 participants. The study found that aerobic exercise positively influences episodic memory, with larger effects observed among various sample and intervention characteristics. Subgroup analyses revealed a moderating effect of age, with a significant effect for studies with a mean age between 55–68 but not 69–85. These results highlight regular aerobic exercise (150 min/week) as an accessible, non-pharmaceutical intervention to improve episodic memory in late adulthood. The Australian Government provides examples of activities that can be included in aerobic exercise (https://www.health.gov.au/health-topics/physical-activity-and-exercise):
Low impact aerobic exercise includes dancing, swimming, cycling, walking, yard and garden work, tennis, mopping and vacuuming, and rowing.
Higher impact aerobic exercise includes running, jumping rope, climbing stairs, moderate yard work (e.g. digging), calisthenics (push-ups and sit-ups) and high impact routines or step aerobics.
It is recommended that everyone reach a minimum of 30 minutes of some form of cardiovascular exercise 5 to 7 days per week. This can be broken up into 10-minute time periods. People can progress aerobic exercise by increasing the speed, the resistance and/or the duration.
Healthy lifestyle linked to avoiding residential aged care placement
A recent study (Gibson, 2023) of 125,000 Australians aged 60 years or older, published in the Journal of Epidemiology & Community Health, found that having the healthiest type of lifestyle is linked to a lower risk of entering aged care compared to those with the unhealthiest lifestyles across all age groups. This link is strongest among 60 to 64 year olds – the unhealthiest in that age bracket were more than twice as likely to be admitted to aged care than those with the healthiest lifestyle. The earlier one starts living a healthy lifestyle, the better.
Researchers used survey responses from 45 and Up Study participants on physical activity, smoking status, sitting time, sleeping time and diet to give them a ‘lifestyle score’ between 0 and 10. The researchers then linked this data with participants medical records via the Medicare Benefits Schedule (MBS) and hospital data, allowing them to monitor for aged care admissions over 10 years. Of the 125,000 participants, 18% (23,000) were admitted to a nursing home in that period. Those with a lifestyle score of less than two had half the chance of entering aged care than those with the highest score of 10. Smoking had the most impact on its own out of all lifestyle factors – the risk of admission was 55% higher for current smokers compared with those who had never smoked.
While this study can’t show a direct cause between lifestyle factors and nursing home admission, the link is significant, as the number of people aged 65 and over in Australia will more than double over the next four decades , which will put unprecedented pressure on the aged-care sector. More specifically, people demonstrated physical activity by being physically active for more than 300 minutes a week; being a non-smoker; sleeping between 7 and 9 hours a day; sitting less than 7 hours a day; and following a diet with high intake of fruit and vegetables and low intake of red and processed meat. Importantly, one can still be low risk but high risk in one area. Furthermore, a a person’s body mass index has no link to risk of nursing home admission. This supports the notion in wider literature that some excess weight can be protective in older age.
Practice Approach
It is important that social workers are aware of the guiding principles for older people (Family and Community Services, 2021). These are
Recognising the value and diversity of ageing: respond to needs in ways that recognise and preserve dignity and equality.
Enabling a whole-of-life approach to ageing: embrace ageing as a natural process involving navigating changes and resisting assumptions and stereotypes about ageing.
Keeping people connected and included: enjoying being part of an inclusive community where everyone is able to contribute.
Supporting people to have healthier, longer lives: remaining healthy and independent for as long as possible, with the ability to access flexible age-related services and choices when needed.
Enabling people to live in their home and community: possess homes and services that enable continued mobility and assist with remaining independent in a community of one’s choosing
In a similar vein Polacsek (2023) outlines protective and risk factors for older people’s mental health, factors that can guide social workers when supporting older people:
Protective Factors
Sense of purpose and meaning
Social networks
Maintain physical health
Positive connection to services
Learning new skills
Connection to land, spirituality for Aboriginal and Torres Strait Islander people
Risk Factors
Poor self-rated health or medical problems
Social isolation and loneliness
Loss of or grief for a partner, family member, friend or pet
Lack of meaningful activity or connection
Loss of independence
Caregiving responsibilities
Retirement
With these principles and factors in mind, conduct a psychosocial assessment around the pillars of active ageing with appropriate follow-up as necessary:
Health—diet, falls risk (home environment), physical activity, knowledge of health information, use of health services (e.g. GP, Meals on Wheels, Commonwealth Home Support Package, My Aged Care)
Participation—work, family, friends, community, loneliness
Security—finance, personal (e.g. home environment, transport), EG, EPoA, Advaned Care Directive, My Aged Care options, elder abuse
Recent bereavement (including retirement, change of circumstance)
Problem-solving, solution-focused and/or task centred practice models may be appropriate to use. Resources to give to people around healthy eating, available community organisations, and finance may be useful.
The topic Health (in general terms) elsewhere on this website gives some guidance around health and participation for older people.
Supporting Material
(available on request)
Carers NSW Australia. (2022). Navigating My Aged Care handbook. Retrieved from https://www.carersnsw.org.au/uploads/main/Files/3.Resources/Carer/Navigating-My-Aged-Care-Handbook-final_May2022.pdf (A comprehensive outline of the Aged Care situation in Australia including an outline of services and a fees estimator).
Chronic Diseases (an outline of the common diseases that affect older people)
My Aged Care Services Summary (Home Care Packages, Commonwealth Home Support Program (CHSP), Transition Aged Care Package (TACP), Community Packages (ComPacks), and Community Nurse
FACS: Family and Community Services. (2021). Ageing well in NSW: Seniors strategy 2021-2031. Retrieved from https://www.facs.nsw.gov.au/download?file=798429
Five Steps to Entry into an aged care home (2016)
Gibson, A. (2023, August 25). Healthy lifestyle in 60s linked to avoiding aged care when older. Sax Institute. https://www.saxinstitute.org.au/news/healthy-lifestyle-in-60s-linked-to-avoiding-aged-care-when-older/
Hardy, F., Hair, S. A., & Johnstone, E. (2020). Social Work: Possibilities for Practice in Residential Aged-care Facilities, Australian Social Work, 73(4), 449-461, doi: 10.1080/0312407X.2020.1778051
Information Booklet on Fees for Home Care Packages and Residential Aged Care for People Entering Care from 1 July 2014 (2014)
Lowry, F. (2021). Depressive symptoms plus inflammatory diet add up to higher frailty risk. Medscape, March 31, 2021. Retrieved from https://www.medscape.com/viewarticle/948404?src=WNL_dne_210331_mscpedit&uac=410643FT&impID=3281866&faf=1#vp_1
Meagher, G., Cortis, N. Charlesworth, S., Taylor, W. (2019). Meeting the social and emotional support needs of older people using aged care services. Sydney: Macquarie University, UNSW Sydney and RMIT University. http://doi.org/10.26190/5da7d6ab7099a
Speaking for Myself (Legal Aid, NSW) (2013)
Advanced Care Planning
Enduring Guardian
Power of Attorney
Functions of a Guardian (NSW Trustee and Guardian) (2015)
Aged Care Royal Commission (https://agedcare.royalcommission.gov.au/publications)
This site contains a number of background and research papers, as well as the final report, all of which may be relevant to social workers supporting older people
Trewren, C. (2017). Ageing in an aged care facility. Social Work Focus, 2(2), 24-25.
Family and Community Services. (2021). Ageing well in NSW: Seniors strategy 2021-2031. Retrieved from https://www.facs.nsw.gov.au/download?file=798429
Xu, X., Inglis, S. C., & Parker, D. Sex differences in dietary consumption and its association with frailty among middle-aged and older Australians: A 10-year longitudinal survey. BMC Geriatrics, 21, 217-229. https://doi.org/10.1186/s12877-021-02165-2
Wiles, J. L., Leibing, A., Guberman, N., Reeve, J., & Allen, R. E. S. (2011). The meaning of “ageing in place” to older people. The Gerontologist, 52(3), 357-366. doi: 10.1093/gerontgnr098
Smith, R. J., Lehning, A. J., & Dunkle, R. E. (2013). Conceptualizing Age-Friendly Community Characteristics in a Sample of Urban Elders: An Exploratory Factor Analysis. Journal of Gerontological Social Work, 56(2), 90-111. doi: 10.1080/01634372.2012.739267
Lehning, A., Nicklett, E., Davitt J., & Wiseman H. (2107). Social work and aging in place: A scoping review of the literature. Social Work Research, 41(4), 235-246.
Söderberg, M., Ståhl, A., & Melin Emilsson, U. (2013). Independence as a stigmatizing value for older people considering relocation to a residential home. European Journal of Social Work, 16(3), 391-406. https://doi.org/10.1080/13691457.2012.685054
Aghjayan, S. L., Bournias, T., Kang, C., Zhou, X, Stillman, C. M., Donofry, S. D., Kararck, T. W., Marsland, A. L., Voss, M. W., Frandorf, S. H., & Erickson, K. I. (2022). Aerobic exercise improves episodic memory in late adulthood: A systematic review and meta-analysis. Communications Medicine, 2(15). https://doi.org/10.1038/s43856-022-00079-7 Retrieved from https://www.nature.com/articles/s43856-022-00079-7