Anne Pamela Frances Wand

Purpose With training, non-professionals and carers working with older adults may opportunistically identify people at risk of suicide and refer for assessment and care. The study aims were to develop and test a bespoke e-learning suicide prevention tool utilising vignettes of typical gatekeeper interactions with older adults. Methods A previously published Australian e-learning tool regarding suicide prevention in older adults was adapted for New Zealand gatekeepers in consultation with cultural advisors and older people with lived experience of suicide. The tool comprised 14 questions including eight culturally-diverse scenarios of gatekeeper interactions with older adults at risk of suicidal behaviours. Learning was facilitated and assessed through pre/post-test and a middle lesson, with feedback sought. The tool was tested in New Zealand gatekeepers. Individual question and summed pre/post-test scores were assessed for change using Wilcoxon signed-rank test. Qualitative feedback regarding tool use was analysed. Results Of 77 participants starting the tool, 66 completed it. Majority of learners were tertiary educated women, in paid employment, with health professional backgrounds. Significant improvement in knowledge post-test was demonstrated in performance on all scenarios and total scores (pre:20.5/28- post:24.3/28; p < 0.001). Themes from qualitative analysis included perspectives on benefits, usability and acceptability of the tool, issues with content and reflection on gatekeeper roles. Conclusion A bespoke, collaboratively-developed and culturally-specific e-learning tool for New Zealand gatekeepers on identification and action regarding suicide risk in older people was developed. Knowledge translation and acceptability were demonstrated. Learning and culturally adaptative features may be readily applied to other international contexts.

Voluntarily stopping eating and drinking at the end of life can potentially hasten death as an expression of a person’s self-determination. With voluntary assisted dying now legally available in Aotearoa New Zealand, and all but one jurisdiction in Australia, some people who do not meet the eligibility criteria for voluntary assisted dying may consider voluntarily stopping eating and drinking. This viewpoint paper aims to examine two questions: How should voluntarily stopping eating and drinking be understood in relation to suicide or other practices which hasten death? How is voluntarily stopping eating and drinking addressed within existing legal frameworks in Australia and New Zealand? Given that voluntarily stopping eating and drinking is a complex, multifaceted phenomenon shaped by individual ethical and moral interpretations and practices, debates about whether it constitutes suicide, a hastened death or a natural death are likely to persist. A reductionist approach to categorising voluntarily stopping eating and drinking is unlikely to adequately capture this complexity. We contend that voluntarily stopping eating and drinking should be considered as a distinct clinical issue that requires its own clinical interventions and support when initiated by patients. The legal positions in Australia and New Zealand are similar, with case law supporting the proposition that a competent adult may legally choose to refuse to eat and drink, even if it results in their death. Voluntarily stopping eating and drinking may be considered as a legally acceptable end-of-life care option, prompting consideration of providing palliation to individuals who have initiated it. There is an urgent need for research to better understand the motivations, experiences and support needs of those involved, along with informing the development of culturally appropriate guidelines with patients, families, clinicians and communities.

Introduction: This study aimed to examine the patterns and predictors of health service use for people with dementia who self‐harmed. Methods: Using a retrospective linked cohort of people who accessed health services in New South Wales, Australia between 2001 and 2015, we identified 154,811 people with dementia or mild cognitive disorder (the dementia cohort), 28,972 people who self‐harmed (the self‐harm cohort), and 1541 who had a record of both dementia or mild cognitive disorder and self‐harm (the dementia and self‐harm subgroup). We examined the rates of health service use (inpatient hospital admissions, emergency department presentations, and mental health ambulatory days) for these cohorts. Using random effects Poisson regression and survival modelling, we investigated the change in and predictors of health service use following self‐harm (for those with dementia) or dementia diagnosis (for those who had self‐harmed). Results: People with dementia who self‐harmed had the highest rate of use of all health services. Ambulatory mental health service use increased after self‐harm for people in the dementia cohort, while emergency department and mental health related hospital presentations decreased. Hospitalisations for non‐mental health reasons increased after dementia diagnosis for those in the self‐harm cohort, but use of other services decreased. Ambulatory mental health service use predicted increased time to re‐presentation to hospital. Discussion: Health service use changed after an episode of self‐harm for people with dementia. People with dementia with poor mental health or substance use concerns may benefit from more proactive provision of mental health services.

While there has been necessary focus on careful assessments of requests for voluntary assisted dying (VAD), there has been less attention paid to the poten

Purpose: To evaluate a novel educational intervention for mental health clinicians and peer workers on Advance Care Planning (ACP). The aims of the intervention were to improve staff knowledge, attitudes, and confidence in facilitating ACP with older people with mental illness and increase staff engagement in ACP. Methods: A pre–post-intervention study was conducted across two public mental health services in Australia. Multidisciplinary clinicians and peer workers ( n = 110) participated in a one-hour, evidence-informed educational session combining theory, video demonstrations, and discussion of case vignettes. Uniquely, this study utilized purpose-developed audio–visual resources designed for local legal frameworks and engagement of peer workers as both educators and participants. Paired pre- and post-intervention questionnaires assessed staff knowledge, attitudes, and confidence. A pre–post-audit of mental health consumer (patient) electronic medical records (eMR) quantified changes in ACP documentation rates. Thematic analysis of free-text feedback was conducted. Results: The intervention significantly improved staff attitudes ( p < 0.001, r = 0.48), knowledge ( p < 0.001, r = 0.51), and confidence ( p < 0.001, r = 0.87). However, eMR audits (pre: n = 1104; post: n = 1118) with a 2–3-month follow-up period revealed no significant change in ACP documentation rates (7.6% vs. 8.0%). Participants’ feedback highlighted a desire for further practical training incorporating experiential learning (e.g., role-play) and systemic support. Conclusions: While a brief, standalone educational intervention significantly improved staff readiness for ACP, this did not translate into documented changes in clinical practice (eMR documentation). Bridging this knowledge-to-practice gap requires multifaceted strategies beyond standalone education, such as organizational governance, audit-feedback cycles, skills practice, and champions to embed ACP into routine practice.

Objectives: To examine identified needs of ‘very old’ people accessing Australian and New Zealand specialist mental health services and consider service delivery implications. Method: Examination of Australian and New Zealand routine outcome measure data from admissions to specialist mental health services. Comparison of data for over 16,500 admissions of people aged 85 years or over with people aged 65–84 years. Results: Those aged over 85 have higher total HoNOS65+ scores, driven by raised impairment and social problem subscales, without reduction in symptom subscales. Increased problems were identified in aggression/agitation, cognitive impairment, physical health and activities of daily living items but reduced prevalence of substance related problems. Whilst magnitudes vary, trends are consistent across countries, and across ambulatory and inpatient settings. On admission to Australian inpatient settings, very old age is associated with >30% of people requiring nursing assistance (measured by RUG-ADL), although <10% required two-person assistance on any domain. Conclusions: Very old age at admission to mental healthcare is associated with increasing complexity and nursing support needs, without reduced psychiatric symptoms. This requires consideration in models of care and staff capabilities. The very old with greatest aged-related support needs may be excluded from specialist inpatient care.

Objectives: To triangulate the perspectives of mental health clinicians, older people with mental illness and their carers on Advance Care Planning (ACP) to develop evidence-informed educational resources. Methods: The study setting was public mental health services. Results of previously reported reflexive thematic analyses of interviews discussing ACP with three stakeholder groups (12 older people with mental illness, 5 carers, and 15 mental health clinicians) were triangulated. The emergent overarching themes were considered within an interpretive description framework to develop educational resources to support each of the three stakeholder groups to engage in ACP. Results: Four overarching themes emerged: (i) importance of ACP recognized but ACP often not initiated; (ii) knowledge gaps; (iii) skill gaps – how to do it; and (iv) practical and process issues. Taking into account the research team’s knowledge of the local health contexts, two formats of educational resources were developed; written information sheets bespoke to identified knowledge gaps and needs for each group, and brief training films for clinicians addressing need for practical skills in ACP. The consumer and carer sheets were translated into three languages. Two brief clinician training films demonstrated introducing ACP within mental health reviews and how to address aspects of complexity in ACP with older adults with a mental illness and carers. Significance of results: The current absence of specific educational resources for ACP with older people with mental illness contrasts with the recognized importance of ACP. Written resources were created to address empirically identified knowledge gaps and misconceptions and provide practical information and training films developed to demonstrate key skills for clinicians. The resources were made freely available, with dissemination planned to promote and evaluate use as part of a more comprehensive educational intervention. Resources supporting clinician, consumer and carer education are an important first step towards empowerment and participation in ACP.

Objective: To develop a data-informed research strategy for a public mental health service (MHS). Methods: Data collection involved consultation with MHS key stakeholders and external partners and a MHS staff survey regarding research training, experience, needs and suggested research themes for the MHS. Results were descriptively analysed, discussed in a MHS research planning workshop and used to inform the research strategy. Results: Enablers of research included time, funding, research training and resources/infrastructure and linkage with supervisors/mentors. Barriers included lack of time, funding/resources and managerial support, competing clinical demands and lacking confidence, skills or experience. Key workshop outcomes were two strategic goals: to build a collaborative research culture, and to focus on translational multidisciplinary research which improves outcomes and experiences for consumers, families and MHS staff. To achieve goals, strategic actions with matching priorities and signs of success were outlined. Conclusions: Multidisciplinary and peer worker staff perspectives directly informed development of the MHS’s Strategic Plan for Research, anchoring the plan in the local context and identifying strengths and limitations to be addressed to achieve the Plan. These study findings may assist other public MHSs wishing to establish their own research strategy and embed a research culture as part of clinical practice.

Purpose: To examine the attitudes, experiences, and perceived facilitators and barriers to Advance Care Planning (ACP), of older people with schizophrenia and other psychotic illness and their carers. Methods: Older people with a psychotic illness and carers were recruited from public mental health services in Sydney, Australia. Semi-structured interviews to explore attitudes, experiences, and perceived barriers and facilitators to ACP were conducted by an external clinician. Consumers’ medical, psychiatric and drug health diagnoses were recorded and they completed cognitive and symptom rating scales. Reflexive thematic analysis was used to analyse the transcripts of interviews, within an interpretive description framework. Results: Thematic saturation was achieved with 12 consumers and 5 carers. Emergent themes from consumer interviews were (i) ‘What is ACP?’; (ii) ‘I have not done ACP because…..’; (iii) ‘I want to do ACP’; (iv) ‘If I was to do ACP I would need..’; and (v) ‘Mental health clinicians have the skills to help me with ACP’. Carer themes included (i) ‘We do not participate in ACP’, (ii) ‘I want to participate in ACP’, and (iii) ‘Key clinician skills are needed’. There was convergence of themes from both groups. Conclusion: This study demonstrates that older people with a psychotic illness can express views regarding ACP, despite ongoing symptoms of psychosis, cognitive impairment and mild–moderate severity of illness. The emergent themes highlight opportunities to intervene to overcome barriers to ACP, including education for both participant groups and clinicians, practical considerations and the need for all to collaborate, including with primary care.

Assessment and management of older people with cognitive impairment, especially those associated with psychiatric symptoms; are recognised as core capabilities of old age psychiatrists. Bi-national collections of HoNOS65+/HoNOS reveal that over 40% of older people entering public mental health services across Australia and New Zealand have a clinically significant rating on the HoNOS65+/HoNOS cognitive problem scale, with rates increasing with age, and significant regional variability. The high rates of cognitive impairment in these data reinforce the need for all mental health clinicians working with older people to have the capability to assess people with cognitive impairment. Once cognitive impairment is identified, clinicians must be equipped to incorporate the implications into individualised management plans, appropriate referral pathways and community support services. Such skills cannot be the sole responsibility of old age psychiatrists or aged care psychiatry services given the significant number of older people seen by adult mental health services. Regional variability in rates of cognitive impairment raises significant questions regarding variation in service eligibility criteria, equity of access to appropriate mental health care and the availability of a workforce and clinical environments that can meet the needs of older people with cognitive impairment. Finally, psychiatry trainees must learn about working with older people with various degrees of cognitive impairment as part of providing high-quality psychiatric care for an ageing population.