Growing old gracefully in rural and remote Australia?

This special issue is being published at a time where our nation is waiting for the interim report of the Royal Commission into Aged Care Quality and Safety. In addition, the COTA (formerly known as Council on the Ageing) Australia recently held a Public Policy Forum on the need to challenge ageism, which is defined as prejudice or discrimination on the grounds of a person's age. And often the assumption is that age discrimination increases with advancing age.1 Thus, this focus on older persons’ health is timely, particularly given that this special issue is focused on the needs of rural, regional and remote seniors.

Ageing undeniably comes with frail health, increased care needs and approaching death. And it is reassuring to know that good quality and safe aged care facilities are considered to be important enough to warrant a Royal Commission. But as this special issue demonstrates, ageing is not just about institutionalised care, illness and death. There is more to ageing, and there is more to seniors. And this is especially true in rural and remote areas, where there is limited availability of aged care facilities to begin with.2

We have a rapidly ageing population, that is also wealthier, better educated, better housed and contributes more to both paid and volunteer work.3 With this growing ageing population, it is the challenge for our rural health care system to relate to this population and to align our system of health care with their needs, which might be more diverse and not fitted to a “one size fits all seniors” approach.

Predominantly, the online imagery of seniors seems to be reduced to one of two images: either seniors are no more than a pair of frail and heavily pigmented hands folded in a lap, or they are a group of healthy, happy, smiling and very active grey-haired people, who could easily be mistaken for teenagers, but for the hair. It is our challenge to add more dimensions to these extremes, to still see the individual in the group.4

This might be facilitated by the fact that researchers are increasingly encouraged to engage with end-users (eg, people with mental health issues, Indigenous people, women, cancer patients, adolescents, migrants, refugees), in their research and to translate outcomes to tailored care. We would like to extend that encouragement to involving seniors in our research and in the shaping of their health care.

After all, whether we are male, female, adolescent, Indigenous or migrant, we are all likely to grow old and we all hope to be fit, healthy and resourceful enough to avoid the aged care facilities, relying on a health care system that will help us do so. So, we need to think about how to make that happen. The papers in this special issue give us enough food for thought.

The 13 articles together advocate for rural health issues, address health research and policy, and examine Indigenous and multicultural issues in rural communities, palliative care and more. The research articles cover five jurisdictions: NSW, ACT, Tasmania, Victoria and Queensland. In addition to research papers, there are two review papers and two papers looking at policies.

One policy-focussed paper5 focused on the excruciating topic of elder abuse and found that consideration of rural and remote communities is generally not meaningful, despite the fact that certain features might impact on elder abuse. Features mentioned include the following: geographic isolation, lack of access to services and transportation, confidentiality and privacy and culturally sensitive approaches for Indigenous elders, taking into account historical disenfranchisement. In the second policy-focussed paper, Jackson et al6 looked at service delivery around mental health programs for older people. They conclude that a sustained focus on policy and implementation has significantly improved access to specialist mental health care for older people in rural areas.

The two review papers look at very different topics. One paper7 reviewed research around the ageing farming workforce, finding that it remains a challenge to integrate the focuses of nature, economics and sociology, to address related health issues and sustainability of agricultural communities. The other paper, by Meuldijk and Wuthrich,8 reviewed stepped care models as a possible solution to address gap in provision of therapy for anxiety and depression, with a focus on older adults in rural and remote areas. They conclude that stepped care approaches are likely to increase access to high-quality interventions for older adults living in rural communities.

Of the research papers, two focus on end-of-life care. Marsh et al9 explored experiences of end-of-life care in a rural community and found that despite challenges, such as transportation and access to basic and specialised care, carers also described positive aspects of personalised and innovative expression of care. The authors concluded that rural end-of-life palliation is a complex intersection of supererogation, innovation and place-driven care.

The second paper on palliative care (Spelten et al)10 reported on a very succesful trial with supporting dying at home. Currently 70% of terminally ill patients would like to die at home, but only 14% do. The trial showed that rural care support for dying at home could be realised, but also noted that health care workers and communities alike need to be educated and have conversations on end-of-life care.

What is needed to age well in a rural environment in the face of declining health is the subject of a number of studies who looked at very different aspects of this issue. One paper (Nott et al)11 piloted the impact of a community-based program for improving cognitive skills and mobility of rural older people. The results of the pilot show a strong interest in the dual-tasking program and support the feasibility and effectiveness of the program.

In a secondary data analysis study (Holdsworth et al)12 factors associated with successful treatment plans for managing chronic conditions were investigated. Authors found that inequities in treatment plan provision seemed linked with rurality and income. They found a higher frequency of treatment plans in Indigenous respondents, which might be related to Indigenous health checks; however, the perceived lack of efficacy suggests a gap in cultural acceptability, according to the authors.

The next paper addressed the declining use of rural hospitals that are close to larger centres, as a result of increased specialisation, Padayachee et al13 trialled an allied health-led model of care supported by telehealth geriatric services. The authors found that this is a viable strategy to combat declining rural hospital usage.

Difficulties with swallowing, dysphagia was studied by Beric and colleagues.14 Dysphagia is prevalent in the older population and can lead to serious health complications. In a group of patients who underwent hip fracture surgery, they found a higher prevalence of dysphagia, with female gender, post-operative confusion and living in a residential aged care facility prior to surgery as potential aggravating factors. Their study highlights the necessity of timely assessment of dysphagia.

And finally, in three studies, seniors were actually involved in the study, leading to some interesting and positive results. Hughes and colleagues15 realised that education on ageing is predominantly textbook-based and that many rural people face social isolation. They designed university education sessions involving older people. The first results hint at a positive impact on self-esteem, community connectedness and quality of life for those involved with the project.

Hancock et al16 went old school and distributed open-ended response postcards in a rural town to investigate what is important for rural community-dwelling older adults to maintain their health and well-being. Their findings support the use of the World Health Organization's age-friendly framework, irrespective of location. They found the community and health-service domain to be the most salient, but emphasised the importance of individual activities, attitudes and capacities.

This is remarkably similar to the results of the panel survey on quality of life, conducted by Hancock and Wells.17 They also found little difference between geographic locations in trajectories for older adults’ quality of life over time and concluded that, instead, individuals’ resilience appeared to be the stronger predictor of quality of life. This is not the first time that resilience has been proven to be an important factor in general quality of life, and not just of seniors.18

If resilience is indeed an overriding factor in growing old gracefully, it does make one wonder how seniors became and stayed resilient in the first place. As we said earlier: enough food for thought.

Two guest editors were appointed, Dr Evelien Spelten (La Trobe University) and Professor Oliver Burmeister (Charles Sturt University). One of the papers in this issue was written by Dr Spelten and another co-authored by the Editor-in-Chief. It should be noted that in both cases they were not involved in any of the reviewing and editorial decision making for their papers. For instance, in the case of the paper to which Dr Spelten was a co-author, Professor Burmeister and Assistant Professor Roberts, the Editor-in-Chief of AJRH, carried out all tasks to do with reviews and acceptance/rejection decisions. The AJRH editorial system was set up such that Dr Spelten could not see that submission, nor any processing of it.

About the guest editors, Dr Spelten specialises in access to service and quality of care. Her work involves health care during the human lifespan, ranging from perinatal to palliative care.19-23 Professor Burmeister specialises in health informatics. This has involved broad topics in health24-28 including one paper in AJRH.29