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6.0 Introduction

The various life stages between birth and older ages are accompanied by different health challenges and therefore different pathways through the health system and differing health support needs over a person's lifetime.

Life stages are already a long-established focus of the health system, and are the target of specialists, researchers and policy planners. For instance, there are specialists for babies and children, mothers and childbirth, and for older people.

Most aspects of health will vary with age, with some health problems increasing in severity as a person ages. Problems that become more apparent at older ages can begin in childhood or young adulthood. For example, factors such as poor diet, smoking, and unresolved mental trauma early in life can, respectively, lead to heart disease or depression later in life.

This chapter looks at the major individual life stages in presenting an overall picture of health across the lifespan, while highlighting some of the unique challenges we face at each stage.

It covers a range of age groups, from babies and their mothers to children, youth, and the health of our working age population. The chapter also examines ageing and the health system, and the challenges, opportunities and adaptations that lie ahead as life expectancy improves and our population ages.

6.1 The health of mothers

Information and statistics about the health of mothers is important for monitoring and evaluating the provision and outcomes of maternity services and care in Australia. Attributes of Australia's mothers, such as maternal age, maternal mortality, risk factors during pregnancy and where they give birth, are described in this snapshot.

Place and type of birth

  • Of the 297,126 women who gave birth in Australia in 2011, 97% gave birth in a hospital, 2% in a birth centre, and 0.4% at home.
  • The rate of women giving birth by caesarean section has increased from 27% in 2002 to a peak of 32% in 2011 (see Chapter 6 'Caesarean births'). Instrumental deliveries remained stable at about 11% for this period.

Maternal age

The age at which a woman gives birth can be a risk factor for obstetric and perinatal outcomes. Adverse outcomes are more likely to occur in younger and older mothers. In 2011:

  • The average maternal age was 30.0 years. This has remained stable since 2009 but is an increase from 28.3 in 1994 (Figure 6.1).
  • Of the 297,126 mothers who gave birth, just over 66,900 were aged 35 or older (22.6% of all mothers) and 12,700 were 40 or older (4.3%). The proportion of mothers aged 40 or more has increased over time (Figure 6.2).
  • Almost 4% of all mothers were teenagers (under the age of 20). Births to teenage mothers have been decreasing over time (Figure 6.2).
  • 4% of mothers giving birth identified as being of Aboriginal or Torres Strait Islander origin. Indigenous mothers tended to be younger than non-Indigenous mothers, with average ages of 25.3 years and 30.2 years respectively.
  • A total of 6,686 women giving birth received assisted reproductive technology (ART ) treatment and their average age was 34.4. This was older than the average age of women who did not receive ART treatment (29.8). In 2011, 63.4% of mothers who received ART treatment were having their first baby and 36.4% had given birth previously.

Antenatal period and risk factors

Maintaining a healthy lifestyle during pregnancy and attending routine antenatal care contributes to better outcomes for both mother and baby.

  • In 2011, 95% of women who gave birth at 32 weeks or more in New South Wales, Queensland, South Australia, Tasmania, the Australian Capital Territory and the Northern Territory attended 5 or more antenatal visits; 99.9% had at least 1 antenatal visit.
  • In 2009, Aboriginal and Torres Strait Islander mothers were less likely to commence antenatal care in their first trimester than non-Indigenous mothers (62% compared with 80%) (AIHW 2013).
  • Obesity in pregnancy contributes to increased morbidity and mortality for both mother and baby (CMACE & RCOG 2010). In 2011, about 1 in 5 Australian women who gave birth were obese.
  • Just over 13% of women smoked during their pregnancy in 2011 compared with 17% in 2004 (AIHW 2013). Smoking rates were higher for Indigenous mothers (50%), mothers living in Very remote areas (36%) and mothers living in areas of most disadvantage (25%) than the overall rate of 15% (2009 data).
  • About half (51%) of all mothers in 2010 consumed at least some alcohol during pregnancy (2010 National Drug Strategy Household Survey; published in A picture of Australia's children 2012).

Figure 6.1: Average age of mothers, 1994-2011

Line chart showing the trending increase in the average age of mothers between 1994 and 2011. The average age increased from under 28.5 years in 1994 to approximately 30 in 2011.

Note: Provisional data were provided by Victoria for 2009 and 2010.

Source: Australia's mothers and babies reports, 2003-2011.

Maternal deaths

While maternal deaths are rare in Australia, they are an important measure of maternal services and obstetric care. However, rates should be interpreted with caution due to the small numbers of deaths and inconsistent review processes among states and territories.

  • Ninety-nine women died from pregnancy or childbirth-related causes in Australia between 2006 and 2010, which equates to 6.8 deaths per 100,000 women who gave birth. The rate is lower than in 2000-2002 (11.1 per 100,000, or 84 deaths) and 2003-05 (8.4 per 100,000, or 65 deaths).
  • Indigenous women were almost 3 times as likely to die from pregnancy or childbirth-related causes as non-Indigenous women (Johnson et al. forthcoming).

Figure 6.2: Proportions of teenage and older mothers, 2001–2011

Line chart showing the trending decrease in teenage mothers (from approximately 5 to under 4%), and the trending increase in mothers aged 40+ (from approximately 3 to over 4%), between 2001 and 2011.

Note: Provisional data were provided by Victoria for 2009 and 2010.

Source: Australia's mothers and babies reports, 2002-2011.

What is missing from the picture?

Alcohol consumption during pregnancy is associated with severe adverse perinatal outcomes, including fetal alcohol spectrum disorder. Historically, only limited data on this has been collected in the National Drug Strategy Household Survey, but additional questions were included in the 2013 survey and results are due in the second half of 2014.

The AIHW, in consultation with clinical experts and jurisdictions, is investigating how best to fulfil data requirements for a number of maternal risk factors and conditions, including hypertension, pre-eclampsia, diabetes, maternal height and weight.

Where do I go for more information?

More information on mothers and babies is available. Unless otherwise citied, data presented is from Australia's mothers and babies 2011. The latest and previous editions of this annual publication are available for free download.

References

AIHW (Australian Institute of Health and Welfare) 2013. National Core Maternity Indicator Data Portal. Canberra: AIHW. Viewed 11 March 2014.

CMACE & RCOG (Centre for Maternal and Child Enquiries & Royal College of Obstetricians and Gynaecologists) 2010.
Management of women with obesity in pregnancy. Viewed 11 March 2014.

Johnson S, Li Z, Hilder L & Sullivan EA, forthcoming. Maternal deaths in Australia 2006-2010. Canberra: AIHW.


6.2 Caesarean section

A baby is born by caesarean section when it is delivered through a cut in the mother's abdomen and uterus. This may be necessary if signs indicate that a normal birth will be risky to the health of the mother or the baby. The decision to have a caesarean section may be planned during pregnancy or made during labour if problems occur.

Rates of caesarean section in Australia have risen over the past 2 decades. At the same time, there have been changes in the population of women giving birth in Australia, including a rise in maternal age, fewer births per woman and increasing use of assisted reproductive technology.

Caesarean section rates in Australia

  • In 2011, 95,894 women gave birth by caesarean section, which is about 1 in 3 deliveries (32%).
  • Rates of caesarean section have risen from 18% in 1991 to 32% in 2011 (Figure 6.3). At the same time, vaginal births without intervention fell from 70% to 56%. Births requiring instrumental assistance, such as forceps or vacuum extraction, have remained relatively stable between 1991 (13%) and 2011 (12%).

Figure 6.3: Method of birth, all mothers, Australia, 1991-2011

Line chart showing the proportion of birth methods for all mothers in Australia between 1991 and 2011. There is a trending increase in Caesarean sections, a trending decline in those births that proceed with no invention, and also a trending decline in those that required instrumental assistance.

Source: Australia's mothers and babies reports, 1991-2011.

Characteristics of mothers who deliver by caesarean section

  • Caesarean sections are more common among older mothers, first-time mothers and women who have given birth by caesarean section before.
  • The rate of caesarean section was 41% among mothers aged 35-39 and 49% for mothers aged 40 and over (Figure 6.4).
  • In 2011, 1 in 3 first-time mothers (33%) gave birth by caesarean section compared with 1 in 10 women (10%) who had given birth before.
  • In 2011, 84% of mothers with a history of caesarean section had a repeat caesarean section, 12% gave birth without intervention and 4% gave birth with instrumental assistance.

Figure 6.4: Proportion of mothers who delivered by caesarean section, by maternal age, Australia, 2011

Column chart showing the trending increase in mothers who delivered by caesarean section, by maternal age, in Australia in 2011.

Source: Li et al. 2013.

Hospital sector

  • Caesarean section rates are higher in private hospitals than in public hospitals across all age groups (Figure 6.5).
  • In 2011, 43% of women in private hospitals gave birth by caesarean section compared with 30% in public hospitals.
  • The difference between sectors was greatest among mothers aged 40 and over (59% in private hospitals had a caesarean section compared with 44% in public hospitals).
  • Women who give birth in private hospitals tend to be older and live in less disadvantaged areas. After adjusting for age differences, 40% of women in private hospitals gave birth by caesarean section in 2011 compared with 30% in public hospitals.

Figure 6.5: Proportion of women who gave birth by caesarean section, by maternal age and hospital sector, Australia, 2011

Column chart showing the trending increase in mothers who delivered by caesarean section, by maternal age, in Australia in 2011, for both private and public hospitals.

Source: Li et al. 2013.

What is missing from the picture?

There are no data available on the urgency of caesarean section and the health condition(s) associated with the procedure. This is essential information for evaluating the outcomes of caesarean section.

National data development is being pursued with the states and territories to improve data used to generate information on caesarean section. Data being developed on maternal risk factors and the clinical indication for caesarean section will provide a more complete picture of an individual woman's risk profile. This should better inform policy and care aimed at minimising caesarean delivery.

Where do I go for more information?

More information on caesarean section is available at Mothers and babies. AIHW reports available for free download include Australia's mothers and babies 2011 and National core maternity indicators.

Reference

Li Z, Zeki R, Hilder L & Sullivan EA 2013. Australia's mothers and babies 2011. Perinatal statistics series no. 28. Cat. no. PER 59. Canberra: AIHW National Perinatal Epidemiology and Statistics Unit. 


6.3 Australia's babies

Every year around 300,000 babies are born in Australia. The health of a baby at birth is a key determinant of subsequent health and wellbeing. A key national objective is that 'Australians are born healthy and remain healthy' (COAG 2011). This snapshot focuses on key indicators of babies' health, including gestational age, low birthweight and perinatal mortality. 

How many births?

  • The number of babies born each year continues to increase. In 2011, there were 301,810 births to 297,126 mothers. Of the births, 299,588 (99%) were live births and 2,220 were stillbirths (1%) (Figure 6.6). 
  • In 2011, Australia's total fertility rate (TFR) was 1.92 babies per woman, a decrease from a 30-year high of 2.02 in 2008 but higher than the low of 1.74 recorded in 2001. Since 1976, the TFR has been below the population replacement level, currently estimated at 2.1 babies per woman (ABS 2012). 
  • In 2011 the rate of still births (or fetal death rate) was 7.4 per 1,000 births. This has increased since 2002 (when it was 6.7 per 1,000 births), to a maximum of 7.8 per 1,000 in 2009. 
  • Males accounted for 51.4% of all live births. 
  • About 4% of women who gave birth (11,895 women) identified as being of Aboriginal or Torres Strait Islander origin. 

Figure 6.6: Number of births in Australia, 2001-2011

Line chart showing the trending increase in the number of births in Australia between 2001 and 2011.

Note: Provisional data were provided by Victoria for 2009 and 2010. 

Sources: Australia's mothers and babies reports 2010 and 2011.

Gestational age

Gestational age is the duration of a pregnancy in weeks. A pre-term birth is before 37 completed weeks of gestation, and is associated with a higher risk of adverse neonatal outcomes. In 2011:

  • The mean gestational age for all babies was 38.7 weeks, and most babies (91%) were born between 37 and 41 weeks.
  • About 14% of babies born to Aboriginal and Torres Strait Islander mothers were born pre-term compared with 8% of babies of non-Indigenous mothers. These rates have remained within 1% of these values for the last decade.

Birth outcomes

Birthweight is a key indicator of infant health and a principal determinant of a baby's chance of survival and good health. Babies may be small due to being born early (pre-term) or be small for gestational age, which indicates a possible growth restriction within the uterus. Low birthweight is when the baby weighs less than 2,500 grams.

  • In 2011, 6.3% of babies were of low birthweight. This rate has remained relatively stable since 2006 (6.4%).
  • In 2010, babies born to Indigenous mothers were twice as likely as those born to non-Indigenous mothers to be of low birthweight (12% compared with 6%) (AIHW 2013).
  • Babies born in Remote and very remote areas were more likely to be of low birthweight (8.1%) than babies born in Major cities (6%).
  • Babies born in the lowest SES areas were also more likely to be of low birthweight (7.2%) than babies born in the highest SES areas (5.4%).

Perinatal mortality

A perinatal death is the death of an unborn baby (at least 400 grams or 20 weeks' gestation) or of a baby which is born alive but dies within 28 days.

  • In 2011, there were 2,992 perinatal deaths, equating to a rate of 9.9 perinatal deaths per 1,000 births). Of these, 74% were fetal deaths (stillbirths).
  • The rate of perinatal deaths increased from 8 deaths per 1,000 births in 2002 to a high of 10.3 deaths per 1,000 births in 2006 (AIHW mothers and babies, multiple years).
  • Higher rates of perinatal deaths were reported for babies of teenage mothers and of Indigenous mothers.
  • The most common causes of perinatal death were congenital anomalies (27%), spontaneous pre-term birth (21%) and unexplained fetal death before the onset of labour (16%).

What is missing from the picture?

The AIHW has been developing a set of national core maternity indicators to monitor the quality of maternity care in Australia. Ten indicators have been developed to date in the areas of antenatal care, normal and operative birth, and baby's postpartum health. A further 8 indicators are being developed for which data will progressively become available for reporting.

Where do I go for more information?

More information on mothers and babies and core maternity indicators is available. The latest edition (and previous editions) of the annual publication Australia's mothers and babies and the National core maternity indicators are available for free download.

References

ABS (Australian Bureau of Statistics) 2012. Births, Australia, 2012. ABS cat. no. 3301.0. Canberra. ABS.

AIHW (Australian Institute of Health and Welfare) 2013. Children's headline indicators data portal. Canberra: AIHW. Viewed 11 March 2014.

AIHW National Perinatal Epidemiology and Statistics Unit and AIHW 2013. National core maternity indicators. Cat. no. PER 58. Canberra: AIHW.

COAG (Council of Australian Governments) 2011. National Health Care Agreement 2011. Canberra: COAG.


6.4 How healthy are Australian children?

While most Australian children enjoy good health, some experience chronic or acute conditions that can disrupt normal growth and childhood development, and affect participation in school and other activities. This snapshot looks at some of the chronic diseases that have serious health effects on children (defined as those aged 0-14). In 2012, there were almost 4.2 million children in Australia (2.2 million boys and 2 million girls)-almost one-fifth (19%) of the total population.

Common long-term health conditions

In 2011-12, the most common long-term conditions affecting children were hay fever and allergic rhinitis, asthma and long- and short-sightedness (see Figure 6.7).

Figure 6.7: Most frequently reported long-term conditions in children, aged 0-14, 2011-12

Bar chart showing the most frequently reported long-term conditions in children aged 0-14 during 2011-12. The two most common conditions: hayfever and allergic rhinitis; and asthma, have a frequency of between 9 and 10%.

Notes

  1. More than 1 problem may have been reported for each child.
  2. Long-term condition is defined here as a current medical condition that has lasted, or is expected to last, for 6 months or more.

Source: ABS 2012.

The following selected serious conditions, which are also National Health Priority Areas, can affect the physical, social and emotional development of children.

Asthma

  • Asthma and allergic rhinitis commonly occur in people with hypersensitivity to allergens. In 2011-12, asthma affected 393,100 children (about 9%) (ABS 2012). There has been little change since 2007-08.
  • Asthma was more common among boys than girls (11% compared with 7%), even though after the age of 15 it was more common in women than men (ABS 2012). (See also Chapter 6 'Youth health: the prime of life?').

Diabetes

Type 1 diabetes is a serious condition that most often appears during childhood or adolescence and requires ongoing management to control and reduce the risk of complications. Type 2 diabetes is rare in younger age groups, with incidence stable over the last 10 years (AIHW 2014b).

  • In 2008, more than 5,700 children had type 1 diabetes and the number is projected to rise to more than 6,400 by the end of 2013 (AIHW 2011).
  • In 2011 there were 983 new cases of type 1 diabetes among children (23 per 100,000 children) with little difference between boys and girls (AIHW 2014a).
  • The rate of new cases of type 1 diabetes in children did not change significantly from 2000 to 2011, fluctuating between 21 and 26 per 100,000 children each year.

Cancer

Although cancer is rare in childhood, it is a leading cause of death, accounting for about 19% of deaths among 1-14 year olds in 2009-11.

  • During 2006-2010, an average of 599 of new cases were diagnosed annually (15 per 100,000 children), with little difference between boys and girls. The rate has remained unchanged from 2001-2005 (AIHW Australian Cancer Database 2010).
  • Since 2001, the most common cancer types in these cases have been lymphoid leukaemias, neuroblastoma and ganglioneuroblastoma, and acute myeloid leukaemias (4.1, 1.1 and 0.8 per 100,000 children respectively during 2006-2010).
  • The proportion of 0-14 year olds who survived cancer 5 years after diagnosis improved from 68% in 1983-1989 to 81% in 2004-2010.

What is missing from the picture?

Emotional and behavioural problems that are not dealt with during the early years can develop into full-scale, long-term mental health problems. Child behavioural problems have been identified as an indicator requiring further data development work in the National Outcome Measures for Early Childhood Development.

Where do I go for more information?

More detailed information on children's health, including overweight and obesity is available at Child health, development and wellbeing or the AIHW's data portal for Children's Headline Indicators.

References

ABS (Australian Bureau of Statistics) 2012. Australian Health Survey: first results, 2011-12. ABS cat. no. 4364.0.55.001. Canberra: ABS.

AIHW (Australian Institute of Health and Welfare) 2011. Prevalence of type 1 diabetes in Australian children, 2008. Diabetes series no. 15. Cat. no. CVD 54. Canberra: AIHW.

AIHW, 2014a. Incidence of insulin-treated diabetes in Australia, 2000-2011. Cat. no. CVD 66. Canberra: AIHW.

AIHW 2014b. Type 2 diabetes in Australia's children and young people: a working paper. Diabetes series no. 21. Cat. no. CVD 64. Canberra: AIHW.


6.5 Healthy child development

Healthy child development helps to prevent disease and improve learning outcomes for children. Protective factors that promote positive development include breastfeeding, vaccinations, good oral health, parental health status and the family environment all have significant impact on children health and development. (For risk factors associated with child development, including smoking and drinking in pregnancy and low birthweight, see Chapter 6 'The health of mothers' and 'Australia's babies'.)

Breastfeeding

Breastfeeding provides the best nutritional start in life. In Australia and internationally it is recommended that infants be exclusively breastfed until around 6 months of age (NHMRC 2012; WHO 2003).

  • In 2010, exclusive breastfeeding was initiated for 90% of babies at birth (that is their first feed was breastmilk) (AIHW 2011).
  • The proportion of babies exclusively breastfed fell to 61% before the end of the first month of life and continued to fall, with 39% of babies exclusively breastfed to around 4 months of age and 15% to around 6 months.

Vaccinations and vaccine preventable diseases

  • As at December 2012, the majority of children (92%) were assessed as fully vaccinated at each of the 3 childhood milestones (12, 24 and 60 months of age).
  • The proportion of children who are fully vaccinated at 12 and 24 months has been stable at about 90% since 2003. At 60 months, there was a substantial increase in coverage from around 80% in 2008 (see also Chapter 4 'Immunisation and vaccine preventable disease').

Dental health

Dental disease can cause pain, discomfort and difficulties with eating, potentially leading to poor nutrition, sleeping difficulties, school absences and poor academic performance.

According to the Child Dental Health Survey:

  • In 2009, about 42% of 5 year olds and more than half (53%) of 6 year olds had at least 1 decayed, missing or filled tooth.
  • The average number of decayed, missing or filled baby teeth was 1.8 for 5 year olds and 2.4 for 6 year olds (Chrisopoulos & Harford 2013).
  • Rates of tooth decay in children have risen slowly since the late 1990s (see Chapter 4 'Oral health').

Parental health

Good parental health can have a significant impact on children's health and lives in general. Conversely, living with and possibly caring for a chronically ill parent can be stressful for children and can negatively affect their health and wellbeing.

  • In 2010, around 12% of parents living with children rated their health as fair or poor, and 15% were affected by poor mental health (AIHW 2012).
  • Indigenous parents were almost twice as likely to report fair or poor health as non-Indigenous parents (21% compared with 12%).

Family environment

  • According to the Longitudinal Study of Australian Children, most families reported high levels of family cohesion in 2010-11, although the proportion of one-parent families with children aged 6-7 and 10-11 who reported 'good' to 'excellent' cohesion (83% and 81% for the age groups respectively) was lower than for couple families (93% and 91%) (AIHW 2013).
  • In 2011-12, 37,781 children aged 0 to 17 were subject to a substantiated case of abuse or neglect (7.4 per 1,000 children). The most commonly reported abuse type was emotional abuse (2.8 per 1,000), with neglect the next most common (2.1 per 1,000).

Measuring early childhood development

The Australian Early Development Index (AEDI) measures early childhood development across 5 domains: physical health and wellbeing, social competence, emotional maturity, language and cognitive skills, and communication skills and general knowledge. In 2012:

  • More than 1 in 5 children (22%) were developmentally vulnerable-that is, their score ranked in the lowest 10% on 1 or more domains (see Figure 6.8). This compares with almost one-quarter of children in 2009 (Australian Government 2013).
  • About 11% were vulnerable on 2 or more domains, and are considered to be at high risk developmentally. The proportion in 2009 was 12%.
  • Boys were more likely to be developmentally vulnerable than girls across all domains (see Figure 6.8).

What is missing from the picture?

The data on breastfeeding in this snapshot is from the 2010 Australian National Infant Feeding Survey. The Australian Health Survey (AHS) 2011-12 also collected data on breastfeeding, with similar results. For ABS data, see Australian Bureau of Statistics.

Figure 6.8: Proportion of developmentally vulnerable children by AEDI domain, Australia, 2012

Bar chart showing that over 15% of girls and approximately 28% of boys were vulnerable in one or more domains when considering the proportion of developmentally vulnerable children by AEDI domain in Australia in 2012. Data are shown for the five domains of: physical health and wellbeing; social competence; emotional maturity; language and cognitive skills; and communication skills and general knowledge, together with those children vulnerable under one or more domains and those vulnerable under two or more.

Source: Australian Government 2013.

Where do I go for more information?

More detailed information on children's health is available at Child health, development and wellbeing or the AIHW's data portal for Children's Headline Indicators.

References

AIHW (Australian Institute of Health and Welfare) 2011. 2010 Australian National Infant Feeding Survey: indicator results. Cat. no. PHE 156. Canberra: AIHW.

AIHW 2012. A picture of Australia's children 2012. Cat. no. PHE 167. Canberra: AIHW.

AIHW 2013. Australia's welfare 2013. Australia's welfare series no. 11. Cat. no. AUS 174. Canberra: AIHW.

Australian Government 2013. Snapshot of early childhood development in Australia 2012-AEDI national report. Canberra: Australian Government.

Chrisopoulos S & Harford JE 2013. Oral health and dental care in Australia: key facts and figures 2012. Cat. no. DEN 224. Canberra: AIHW.

NHMRC (National Health and Medical Research Council) 2012. Infant feeding guidelines. Canberra: NHMRC.

WHO (World Health Organization) 2003. Global strategy for infant and young child feeding. Geneva: WHO.


6.6 Childhood overweight and obesity

Overweight and obesity is an important public health issue in Australia and around the world. It reflects abnormal or excessive fat accumulation in the body that can present significant risks to health. It generally occurs when more energy is consumed through eating and drinking than is expended through physical activity (energy imbalance).

Childhood overweight and obesity is a major concern that puts children at an increased risk of poor physical health in the short term and of developing many chronic diseases later in life (Daniels 2006). In 2008, the total annual cost of obesity to Australia, including health system costs, loss of productivity costs and carers' costs, was estimated at around $58 billion (Access Economics 2008). The future implications of obesity in terms of the population's health and wellbeing, and the resources necessary for the health system to respond are likely to be considerable.

This article looks at the prevalence of overweight and obesity in children, and key contributing factors: physical activity and nutrition. In this article, children are defined as aged 5-14. Overweight and obesity is measured using body mass index (BMI) (See Box 6.1). Unless otherwise stated, data are drawn from customised reports from the ABS 2011-12 Australian Health Survey and the 2011-12 National Nutrition and Physical Activity Survey.

Box 6.1: Defining and measuring overweight and obesity

Body mass index (BMI) is used to indirectly measure overweight and obesity in the child population. It is calculated as the ratio of weight in kilograms divided by height in metres squared (kg/m2).

At the population level, international cut-off points are used to determine the number of children either overweight or obese based on their age and sex (Cole et al. 2000). In children, BMI changes substantially with age and can differ between boys and girls, rising steeply in infancy, falling during the preschool years and increasing through to adolescence and into adulthood (DoHA 2009).

The ABS 2011-12 Australian Health Survey collected physical measurements of the height and weight of around 85% of the children aged 5-14 sampled for the survey. Therefore, the estimate of the number of overweight and obese children presented below assumes that the pattern of overweight/obesity amongst those children who were not measured is the same as for those who were.

What do we know?

In 2011-12, of children aged 5-14 who had their measurements taken for the ABS Australian Health Survey, an estimated 26% were either overweight (19%) or obese (7%). This is equivalent to around 716,000 Australian children aged 5-14 (see Box 6.1). Over two-thirds (69%) of children had a healthy weight, with the remaining 5% being underweight. There was no significant difference between boys and girls, or between age groups 5-9 years and 10-14 years.

Implications of overweight and obesity

In the short term, overweight and obesity increases a child's risk of developing conditions that can affect physical health, such as sleep apnoea, breathlessness on exertion and/or reduced exercise tolerance, some orthopaedic and gastrointestinal problems, and non-alcoholic fatty liver disease (NHMRC 2013).

Overweight and obese children also frequently experience discrimination, bullying and teasing by their peers. This may contribute to poor peer relationships, school experiences and psychological wellbeing, particularly among older overweight or obese children (Griffiths et al. 2006; Hayden-Wade et al. 2005; NHMRC 2013; Sawyer et al. 2006).

In the long term, obese children are at greater risk of persistent obesity, cardiovascular risk factors, diabetes, certain cancers, depression, arthritis, and premature mortality (Guo et al. 2002; Reilly & Wilson 2006).

While research from the Longitudinal Study of Australian Children (LSAC) found that some children who were overweight at a young age (4-5 years) did return to a healthy body weight at 8-9 years, obesity generally becomes increasingly entrenched throughout early childhood and possibly less reversible by the middle school years (Wake & Maguire 2012). Overweight and obese children are subsequently at risk of being overweight and obese in adulthood.

Overweight and obese adults have increased likelihood of illness and early death (Daniels 2006; Guo et al. 2002). Conditions such as cardiovascular disease, diabetes and some cancers (such as colon, kidney, endometrial and breast cancer) have been associated with obesity. In addition, carrying extra weight can lead to musculoskeletal problems such as osteoarthritis and back pain (Crowle & Turner 2010). As a consequence, more bariatric surgeries are being performed, as are knee replacements and hip replacements (Bourne et al. 2007; Gilbert & Wolfe 2012). Obesity can also adversely affect fertility (Pasquali et al. 2007), and is associated with an increased rate of caesarean birth (Callaway et al. 2006; Chu et al. 2007; HAPO 2010). Obesity can also have an intergenerational health effect for the mother and baby (Li et al. 2009).

Costs

Little is known about the costs of childhood obesity. However, research based on data from the Longitudinal Study of Australian Children found that being overweight at age 4-5 was associated with significantly higher medical and pharmaceutical costs for children in their first 5 years at school (Au 2012).

In addition, the ill health that arises from overweight and obesity in adults is an added burden for the health system. The costs of overweight and obesity in 2008-09 were estimated to be $37.7 billion. This comprises direct health-care costs (associated with 4 main medical conditions: cardiovascular disease, type 2 diabetes, osteoarthritis, and some specific forms of cancer), indirect costs (productivity loss from both missing work or working when unwell and premature mortality) and burden of disease costs (financial and social costs) (Medibank 2010).

Causes of overweight and obesity

While genetic factors strongly influence an individual's predisposition to excess weight gain, the increase in overweight and obesity prevalence around the world in recent decades suggests that there are other important contributors to the energy imbalance that leads to these conditions (WHO 2000). These socio-environmental factors include the increased availability, decreased relative costs and the increased marketing of food and drinks that tend to be more energy dense and relatively nutrient-poor (NHMRC 2013). Less physical activity from an increased reliance on car travel due to urban design, an increase in sedentary pursuits, and reduced perceptions of safety leading to fewer opportunities for physical activity are also involved. Economic and consumer changes, such as a greater number of women in the paid workforce, decreased food literacy and cooking skills, and greater reliance on convenience and takeaway foods are also probable contributors (NHMRC 2013).

The key components of successful weight management in children include an increase in physical activity, dietary modification, reducing sedentary behaviours and the involvement of parents (Hughes & Reilly 2008). Early childhood is an ideal period for prevention and early intervention, particularly as food preferences and dietary habits are firmly established in the early years of life (Benton 2004; Daniels et al. 2009).

Children are central to the National Partnership Agreement on Preventive Health (NPAPH) which focuses on the rising prevalence of behaviour-related chronic diseases, including those caused by overweight and obesity, and aims to lay the foundations for healthy behaviours in the daily lives of Australians. The NPAPH came into effect in 2009.

Does overweight and obesity vary across population groups?

Children living in couple families were less likely to be overweight or obese than those living in one-parent families (24% compared with 35%) (see Figure 6.9). Overseas-born children were less likely to be overweight or obese (20%) than their Australian-born counterparts (27%). Children living in areas with the lowest socioeconomic status (33%) were more likely to be overweight or obese compared with those living in the highest socioeconomic status areas (19%). These differences are consistent with findings on overweight and obesity for the total population (see Chapter 5, 'Behavioural risk factors'; Wake & Maguire 2012). In 2012-13, 33% of Indigenous children aged 5-14 years were overweight or obese (ABS 2013a).

There were no significant differences in levels of childhood overweight and obesity between those who lived in Major cities, and those who lived elsewhere (26% compared with 27%). (Data were not collected for children living in Very remote areas.)

Figure 6.9: Overweight and obese children aged 5-14, by population groups, 2011-12

Bar chart showing the percentage of children aged 5-14 who are overweight and obese, by population group, between 2011-12. The groups depicted are: gender, age, family type, country of birth, remoteness and SES.
  1. Includes families with children aged less than 15 years only, and families with children aged less than 15 years and older.
  2. Based on 2011 Australian Statistical Geographic Standard.
  3. Other areas include Inner regional, Outer regional, and Remote areas.
  4. Based on 2011 Index of Relative Socio-economic Disadvantage.

Source: ABS 2013c.

Has there been a change over time?

Obtaining a picture of trends of overweight and obesity over time for 5-14 year olds is difficult because of a lack of directly comparable data. Between 1985 and 1995, levels of excess body weight in children showed an apparent dramatic increase for both boys (from 10.7% to 20.5%) and girls (from 11.8% to 21.1%). However, these surveys (the 1985 Australian Health and Fitness survey and the 1995 National Nutrition Survey) looked at different age groups, 7-15 years and 5-17 years respectively, which can affect comparability (AIHW 2010).

Between 1995 and 2007-08, estimates from large-scale national surveys for children aged 5-12 showed only a slight increase in measured overweight and obesity, from 21% in 1995 to 22% in 2007-08 (ABS 2009).

The 2011-12 Australian Health Survey showed that in the 4 years since the 2007-08 National Health Survey there was no statistically significant difference in the proportion of overweight or obese 5-14 year olds (23% in 2007-08 and 26% in 2011-12). Other research also suggests that childhood obesity rates plateaued between 1996 and 2008 (Olds et al. 2011).

The overall conclusion that can be drawn from this variety of data sources is that the prevalence of overweight and obesity among children and adolescents has shown little change in Australia over the last 17 years-but the rates remain high, and are therefore a cause for concern.

International comparisons

International comparisons are limited due to differences in data collection methods between countries, and the years of data collection. Data from the International Association for the Study of Obesity reported by the OECD in 2013 showed that Australia ranked 18th out of 40 countries in the proportion of overweight and obese boys. The United Kingdom reported the same proportion as Australia (22%). However, the news was not as good for Australian girls, where Australia ranked 10th in the proportion of girls who were overweight or obese, with Spain and Canada reporting the same proportion as Australia (24%). Greece had the highest values for both boys and girls (44% and 38% respectively) while Indonesia had the lowest values for both boys and girls (11% and 8% respectively) (OECD 2013).

Physical activity and screen time

How many children met the physical activity recommendations?

Based on the 2011-12 National Nutrition and Physical Activity Survey, only about one-quarter (23%) of Australian children aged 5-14 met the national physical activity recommendations every day (see Box 6.2). About half collectively met the recommendations on either 5-6 days (32%) or 3-4 days (22%) a week, while the remaining one-quarter (23%) met the guidelines even less frequently (see Figure 6.10).

Box 6.2: Physical activity and screen time recommendations for children

The National Physical Activity Recommendations provide guidance on the number of hours to spend on particular types of activities to help become healthier.

The recommendations cover 3 separate age groups for children: 0-5 years, 5-12 years and 12-18 years.

The current recommendations for children aged 5-12 and 12-18 are the same, and are:

  • at least 60 minutes of moderate to vigorous physical activity every day
  • a maximum of 2 hours screen-based activity for entertainment/non-educational purposes a day.

The ABS 2011-12 National Nutrition and Physical Activity Survey collected information on whether children met these physical activity and screen-based activity recommendations.

Figure 6.10: Number of days per week children aged 5-14 met physical and screen-based activity recommendations, 2011-12

Column chart showing the number of days per week children aged 5-14 met physical and screen-based activity recommendations in 2011-12.
  1. See Box 6.2 for physical activity and screen activity recommendations.
  2. In 7 days prior to interview.

Source: ABS 2013d.

There was no significant difference between boys and girls in meeting the recommendations (24% and 22% respectively); however, younger children (aged 5-9) were twice as likely as older children (aged 10-14) to meet the physical activity recommendations on all 7 days (32% and 15% respectively). Children living in Inner regional, Outer regional and Remote areas combined were more likely than children living in Major cities to meet the recommendations (30% to 20%).

There was little difference between children living in areas of most and least disadvantage (23.5% and 24.7% respectively). While the proportion of children of healthy weight who met the physical activity recommendations was higher than for children who were overweight/obese (23% compared with 19%), the difference was not statistically significant.

Trends in levels of physical activity among children are difficult to determine. The physical activity questions used in 2011-12 National Nutrition and Physical Activity Survey have not been used previously in ABS surveys. And while some other one-off surveys have collected relevant data, differences in collection methods make comparisons, and therefore determination of trends, problematic.

How many children met the screen-based activity recommendations?

About one-third (32%) of children met the national screen-based activity recommendations (Box 6.2) on all 7 days in a week, according to the 2011-12 National Nutrition and Physical Activity Survey. An additional one-third (32%) met the recommendation on 5-6 days. Girls were more likely to meet the guidelines than boys (38% compared with 27%). Younger children (aged 5-9) were also more likely to meet the guidelines than 10-14 year olds (39% compared with 26%).

There was no significant difference between children living in Major cities compared with other areas, nor was there a significant difference between children living in the most disadvantaged areas compared with those living in the least disadvantaged areas. There was also no significant difference between children with healthy weight and those who were overweight or obese.

It is not possible to determine national trends in children's screen-based activities because the questions on these activities in the 2011-12 National Nutrition and Physical Activity Survey have not been used before in ABS surveys. Some other surveys have collected data relevant to the topic, but due to differences in collection methods direct comparisons are not recommended.

How many children met physical activity and screen-based recommendations?

Only around 10% of children met both physical and screen-based activity recommendations on all 7 days in a week. Around 23% of children met the guidelines on 5-6 days, a further 25% on 3-4 days, and 24% on 1-2 days. Sixteen per cent of children never met the guidelines on any day (See Figure 6.10).

There was little difference between boys and girls; however, younger children (aged 5-9) were over 3 times as likely to meet both guidelines (16%) as older children (5%) (see Figure 6.11). Children in the highest socioeconomic status areas were twice as likely to meet both guidelines as children in the lowest socioeconomic areas (13% compared with 6%).

Despite an apparent difference between children in Major cities meeting both sets of recommendations (around 9%) compared with Inner regional/Outer regional/Remote areas (around 13%), the difference was not statistically significant. Nor was there a statistically significant difference in meeting both sets of guidelines between children of a healthy weight and those who were overweight or obese (11% compared with around 8%) (Figure 6.11). These conclusions nevertheless need to be treated with caution due to high variability (or 'relative standard error' in statistical terms) in the results for overweight or obese children.

Figure 6.11: Children aged 5-14 who met both physical and screen-based activity recommendations, by population groups, 2011-12

Bar chart showing children aged 5-14 who met both physical and screen-based activity recommendations by population group in 2011-12.
  1. Based on 2011 Australian Statistical Geographic Standard.
  2. Other areas include Inner regional, Outer regional, and Remote areas.
  3. Based on 2011 Index of Relative Socio-economic Disadvantage.
  4. Only includes children for whom height and weight were measured.
  5. Has a relative standard error between 25% and 50% and should be used with caution.

Note: Met recommendations in the 7 days prior to interview.

Source: ABS 2013d.

How many children eat enough fruit and vegetables?

Good nutrition is part of maintaining the 'energy balance'. The National Health and Medical Research Council (NHMRC) reports that there is a suggestive association between the consumption of fruit and vegetables and a reduced risk of obesity and weight gain (NHMRC 2013).

In 2011-12, fewer than 1 in 3 (30%) of children aged 5-14 met fruit and vegetable consumption recommendations specified in the 2003 Dietary guidelines for children and adolescents (see Box 6.3). As these guidelines recommended a lower intake of fruit and vegetables than the revised 2013 Australian dietary guidelines, the proportion of children meeting the revised guidelines would be even lower.

Box 6.3: Fruit and vegetable intake for children

The following 2003 NHMRC guidelines for the daily consumption of fruit and vegetables (from the 2003 Dietary guidelines for children and adolescents in Australia) were used in the 2011-12

Australian Health Survey:

  • 4-7 years: 1 serve of fruit and 2 serves of vegetables
  • 8-11 years: 1 serve of fruit and 3 serves of vegetables
  • 12-17 years: 3 serves of fruit and 4 serves of vegetables.

Usual daily intake of fruit and vegetables was based on self-reported data.

Figure showing what one serve of vegetables and one serve of fruit can be. One serve of vegetables can be: one half a cup of cooked vegetables or cooked legumes, one medium potato or one cup of salad vegetables. One serve of fruit can be: one medium piece (e.g. apple), two small pieces (e.g. apricots) or one cup of chopped or canned fruit.

In 2013, the NHMRC released revised dietary guidelines (Australian dietary guidelines 2013), with the following recommendations:

  • 4-8 years: 1½ serve of fruit and 4½ serves of vegetables
  • 9-11 years: 2 serve of fruit and 5 serves of vegetables
  • 12-13 years: 2 serves of fruit and 5½ (boys) and 5 (girls) serves of vegetables
  • 14-18 years: 2 serves of fruit and 5½ (boys) and 5 (girls) serves of vegetables.

There were no significant differences in fruit and vegetable consumption between boys and girls; however, younger children (aged 5-9 years) were more likely to meet the guidelines compared with those aged 10-14 (44% compared with 15%). Children living in Major cities (26%) were less likely to meet the guidelines than children living in Inner regional/Outer regional/Remote areas combined (38%).

There was no significant difference in fruit and vegetable consumption between children living in areas of the greatest disadvantage compared to those living in areas of the least disadvantage; nor was there any significant difference between children of a healthy weight, and those who were overweight or obese.

In 2012-13, only around 7% of Indigenous children aged 5-17 met the 2013 recommended guidelines for fruit and vegetable consumption (ABS 2013a).

Direct comparisons of fruit and vegetable intake in children between the 2007-08 National Health Survey and the 2011-12 Australian Health Survey are difficult because the definition of a serve of vegetables changed between the 2 surveys.

'Treat' foods consumption

A substantial proportion of children's overall energy intake comes from 'extra' or treat foods, which are generally high in energy and low in nutrients, such as potato crisps, soft drinks, cakes and biscuits.

Results from the 2007 Australian National Children's Nutrition and Physical Activity Survey found that 'extra' foods contributed 35% of the energy intake for children aged 2-16 (Rangan et al. 2011). This was less than the 40% figure from the 1995 National Nutrition Survey. Nevertheless, consumption remains well above the recommended limit of 5-20% of energy intake as set out in the Australian guide to healthy eating (Rangan et al. 2011). The 'extra' foods that contributed most to average energy intakes in the 2007 Survey were 'fried potatoes', 'cakes, muffins and slices' and 'potato crisps and similar snacks'.

Some Australian parents may face barriers to providing healthier foods such as fruit, vegetables and wholegrain foods, to their children. This may be due to the unavailability of fresh foods in some regions, or because healthier food is not as affordable as other food for some families. A recent study published in the British Medical Journal found that healthy food cost more, and that cost was a barrier to a better diet (Rao et al. 2013). The authors argued that the difference in cost between healthy and unhealthy food was minor compared with the financial burden on individuals and society caused by diet-related chronic diseases.

What is missing from the picture?

With 26% of Australian children being overweight or obese, there is a need for close ongoing national monitoring of this aspect of health through the collection of comparable data so that an accurate time series can be established. As happened in 2011-12, measured body mass index will again be included in the 2014-15 ABS Australian Health Survey. More detailed monitoring is needed, however, of the composition of young people's diets and their physical activity, particularly for overweight and obese children, to determine whether patterns are changing and whether changes accord with physical and dietary guideline recommendations.

Determining how factors such as physical inactivity, nutrition, technology use and urbanisation interact to increase rates of childhood overweight and obesity can be difficult when information about these factors comes from different data sources (Crowle & Turner 2010). While there is evidence to show that patterns in overweight and obesity in children are similar to trends in behavioural and environmental risk factors (Swinburn et al. 2011), direct relationships cannot be verified if the information is collected from different sources. Improved coverage and coordination of data collection is required so that we can have a more comprehensive and cogent view of how these factors may interact to better inform policy and affect a positive change. More research is also needed to know exactly how to extrapolate from childhood obesity to adult health and associated costs.

Where do I go for more information?

More information on children's health status is available at Child health, development and wellbeing and in the AIHW's data portal for Children's Headline Indicators. The report A picture of Australia's children 2012 and other recent publications are available for free download.

References

ABS (Australian Bureau of Statistics) 2013a. Australian Aboriginal and Torres Strait Islander Health Survey: first results, Australia, 2012-13. ABS cat. no. 4727.0.55.001. Canberra: ABS.

ABS 2013b. Australian Health Survey: users' guide, 2011-13. ABS cat. no. 4363.0.55.001. Canberra:

ABS. ABS 2013c. Australian Health Survey: 2011-12, customised report. Canberra: ABS.

ABS 2013d. National Nutrition and Physical Activity Survey, customised report. 2011-12. Canberra: ABS.

Access Economics 2008. The growing cost of obesity in 2008: three years on. Canberra: Diabetes Australia.

AIHW (Australian Institute of Health and Welfare) 2010. Australia's health 2010. Cat. no. AUS 122. Canberra: AIHW.

Au N 2012. The health care cost implications of overweight and obesity during childhood. Health Services Research 47:2.

Benton D 2004. Role of parents in the determination of the food preferences of children and the development of obesity. International Journal of Obesity 28(7):858-69.

Bourne R, Mukhi S, Zhu N, Keresteci M & Marin M 2007. Role of obesity on the risk for total hip or knee arthroplasty. Clinical Orthopaedics and Related Research 465:185-88.

Callaway LK, Prins JB, Chang AM, McIntyre HD 2006. The prevalence and impact of overweight and obesity in an Australian obstetric population. Medical Journal of Australia 184(2):56-59.

Chu SY, Kim SY, Schmid CH et al. 2007. Maternal obesity and risk of cesarean delivery: a meta-analysis. Obesity Review 8(5):385-94.

Crowle J & Turner E 2010. Childhood obesity: an economic perspective. Melbourne: Productivity Commission.

Daniels S 2006. The consequences of childhood overweight and obesity. The Future of Children 16:47-68.

Daniels LA, Magarey A, Battistutta D, Nicholson JM, Farrell A, Davidson G et al. 2009. The NOURISH randomised control trial: positive feeding practices and food preferences in early childhood-a primary prevention program for childhood obesity. BMC Public Health 9(1):387-96.

Franks P, Hanson R, Knowler W, Sievers M, Bennett P & Looker H 2010. Childhood obesity, other cardiovascular risk factors, and premature death. New England Journal of Medicine 362:485-93.

Gilbert E & Wolfe B 2012. Bariatric surgery for the management of obesity: state of the field. Plastic & Reconstructive Surgery 130:513e-23e.

Griffiths LJ, Wolke D, Page AS, Horwood JP & ALSPAC Study Team 2006. Obesity and bullying: different effects for boys and girls. Archives of Disease in Childhood 91(2):121-5.

Guo SS, Wu W, Chumlea WC & Roche AF 2002. Predicting overweight and obesity in adulthood from body mass index values in childhood and adolescence. American Journal of Clinical Nutrition 76:653-8.

HAPO Study Cooperative Research Group 2010. Hyperglycaemia and Adverse Pregnancy Outcome (HAPO) study: associations with maternal body mass index. British Journal of Obstetrics & Gynaecology 117(5):575-84.

Hayden-Wade HA, Stein RI, Ghaderi A, Saelens BE, Zabinski MF & Wilfey DE 2005. Prevalence, characteristics, and correlates of teasing experiences among overweight children vs. non-overweight peers. Obesity Research 13(8):1381-92.

Hughes A & Reilly J 2008. Disease management programs targeting obesity in children. Disease Management and Health Outcomes 16(4):11.

Li L, Law C, Lo Conte R, Power, C 2009. Intergenerational influences on childhood body mass index: the effect of parental body mass index trajectories. The American Journal of Clinical Nutrition 89: 551-7.

Medibank 2010. Obesity in Australia: financial impacts and cost benefits of intervention. Canberra: Medibank.

NHMRC (National Health and Medical Research Council) 2013. Australian dietary guidelines. Canberra: NHMRC.

OECD (Organisation for Economic Co-operation and Development) 2013. Health at a glance 2013: OECD indicators. Paris: OECD.

Olds T, Maher C, Zumin S, Péneau S, Lioret S, Castetbon K et al. 2011. Evidence that the prevalence of childhood overweight is plateauing: data from nine countries. International Journal of Pediatric Obesity 6:342-60.

Pasquali R, Patton L, Gambineri A 2007. Obesity and infertility. Current Opinion in Endocrinology, Diabetes, and Obesity. 4(6):482-7.

Rangan A, Kwan J, Flood VM, Louie JCY, Gill TP 2011. Changes in 'extra' food intake among Australian children between 1995 and 2007. Obesity Research and Clinical Practice 5:e55-e63.

Rao M, Afshin A, Singh G, Mozaffarian D 2013. Do healthier foods and diet patterns cost more than less healthy options? A systematic review and meta-analysis. British Medical Journal Open 3:e004277.

Reilly J, Wilson D 2006. ABC of obesity: childhood obesity. BMJ 33: 1207-10.

Sawyer MG, Miller-Lewis L, Guy S & Wake M 2006. Is there a relationship between overweight and obesity and mental health problems in 4-5 year-old Australian children? Ambulatory Pediatrics 6(6):306.

Swinburn BA, Sacks G, Hall KD, McPherson K, Finegood DT, Moodie ML & Gartmaker SL 2011. The global obesity pandemic: shaped by global drivers and local environments. Lancet 378:804-14.

Wake M & Maguire B 2012. Children's body mass index: cohort, age and socio-economic influences. In: Australian Institute of Family Studies (ed.). The Longitudinal Study of Australian Children annual statistical report 2011. Melbourne: Australian Institute of Family Studies.

Wake M, Nicholson J, Hardy P & Smith K 2007. Preschooler obesity and parenting styles of mothers and fathers: Australian National Population Study. Pediatrics 120(6):7.


6.7 Youth health: the prime of life?

Adolescence and young adulthood is a significant transition period in a person's lifetime. Its beginning is marked by the onset of puberty, and it is generally considered to end when social milestones are met such as completing schooling, entering employment or tertiary education, beginning a serious intimate relationship, and having children. With many young people taking on these social roles at older ages, the duration of adolescence and young adulthood is increasing.

Many of the physical, emotional and neural changes and development that occur during adolescence and young adulthood can impact on health and wellbeing. The brain continues to develop until the early 20s and improved self-control, judgement and decision-making appear late in adolescence (NIMH 2001). Many important modifiable risk factors for later life either emerge or accelerate during this period. These include smoking, drinking excessively, using illicit drugs, physical inactivity, poor nutrition and obesity. These risk factors can determine whether a person becomes a healthy adult or develops chronic illnesses or experiences the consequences of injury. Preconception health for young women also becomes an important issue during these years, as risky health behaviours can have intergenerational effects in terms of maternal and newborn child health (see also Chapter 6 'The health of mothers').

For these reasons, adolescence and young adulthood offer opportunities for health gains both through prevention and early intervention. This article examines what is known about issues that can have an impact on the health and wellbeing of Australia's youth, defined here as aged 15-24. An overview of the health of Australia's young adults is presented first, before exploring the risky health behaviours that young people may engage in. The article concludes by investigating the leading cause of death among youth-injury and poisoning. Relevant data are disaggregated for the age groups 15-19 and 20-24 where possible; in some cases, however, different age ranges are used due to the limitations of various data sets.

What do we know?

In 2012, there were more than 3 million young people aged 15-24 in Australia-1.6 million males and 1.5 million females, or about 14% of the population. Young people are commonly thought to be in the best of health with the majority (91%) of young adults assessing their own health as 'excellent', 'very good' or 'good' in the ABS 2011-12 Australian Health Survey (ABS 2013c). This has not changed significantly since the 2007-08 survey (93%) (ABS 2008).

A long-term Australian study also found that the majority of young people were 'very satisfied' with their lives in 2011 (79% of 15-19 year olds and 69% of 20-24 year olds), an improvement from 2001 (73% and 64% respectively) (FYA 2013).

However, this is not the same for everyone. During this stage of life, health inequalities are likely to become embedded and to continue throughout life. Indigenous young people, refugees and young people living in areas of lowest socioeconomic status often have poorer outcomes, a higher prevalence of risk factors and worse health than the general youth population (AIHW 2011b). Youth is also a time when mental disorders may arise, particularly anxiety and depression, and concerns about body image. Attention Deficit/Hyperactivity Disorder often persists into adolescence as well (Sawyer & Patton 2011).

In adolescence and early adulthood, young people, and males in particular, are most vulnerable to the influences of peer pressure and popular culture, and may be inclined to experiment, push boundaries and take risks that could result in accidents or injury (NPHP 2004). Rates of self-harm, suicide, injuries and sexually transmitted infections such as chlamydia are also high. Adolescence and young adulthood is also a critical period for establishing personal health behaviours that can protect against chronic diseases such as maintaining a healthy body weight, getting sufficient physical exercise and good nutrition.

How healthy are Australia's young adults?

Long-term health conditions

In 2011-12, the 2 most common chronic conditions reported among young people were hay fever and allergic rhinitis (18.8%) and short-sightedness (18.7%). The small increase in short-sightedness from about 17% in 2007-08 was not significant. Asthma was the third most commonly reported long-term condition, affecting about 11% (323,400) of young people. Mood problems and anxiety-related problems were reported by about 8% of the youths surveyed (ABS 2012a).

In 2011, there were an estimated 469 new cases of type 1 diabetes-a rate of about 15 per 100,000 young people. The rate decreases with age (around 18 per 100,000 those aged 15-19 compared with about 13 per 100,000 for those aged 20-24 respectively) (AIHW 2014a).

In 2011-12, there were an estimated 389 new cases of type 2 diabetes-a rate of around 13 per 100,000. The rate rose with age, from about 10 per 100,000 population for 15-19 year olds to around 15 per 100,000 for 20-24 year olds (AIHW 2014b).

Although cancer is uncommon in young people, it is a leading cause of death. The most common cancer types were melanoma of the skin and Hodgkin lymphoma (around 6 and 4 per 100,000 young people respectively) and cancer of the testis (about 4 per 100,000 males).

Mental health

Young people can experience difficulties coping with stress (see also Chapter 4 'Mental health in Australia'). In the ABS 2011-12 Australian Health Survey, an estimated 258,100 (12%) of young adults aged 18-24 reported 'high' or 'very high' levels of psychological distress (ABS 2012a). There was no statistically significant difference between young women and young men. There has been no change between 2007-08 (12%) and 2011-12 in the proportion of young adults reporting 'high' or 'very high' levels of psychological distress.

The 2007 National Survey of Mental Health and Wellbeing found that an estimated 671,100 or 26% of young people aged 16-24 were suffering from a mental disorder. More young women (30%) than young men (23%) reported a mental disorder. Of the 3 categories of disorders investigated in this survey, 15% of young people had anxiety disorders, 13% had substance use disorders and 6% had affective disorders (such as mania or depression) (ABS 2008) (Figure 6.12). Some survey respondents had more than 1 type of disorder.

A 1998 survey found that Attention Deficit/Hyperactivity Disorder (ADHD) continued to be prevalent in adolescents aged 13-17, and was more common among young males (10%) than females (4%) (Sawyer 2000). A 2013 study (Slade et al.) found that the average age of onset of first anxiety disorder was 20 for males and 19 for females.

Young people with a mental disorder are more likely to have lower educational attainment, experience joblessness, and to have poor physical health. It is not possible to decide whether these things cause mental problems or vice versa, but the experience of adverse situations during youth can contribute to the worsening of a mental disorder (AIHW 2008).

Figure 6.12: Mental disorder among young people aged 16-24, by sex, 2007

Column chart showing the percentage of young people aged 16-24 who met criteria for diagnosis of a lifetime mental disorder (with hierarchy), and had symptoms in the 12 months before interview, for anxiety disorders, affective disorders and substance use disorders.
  1. People who met the criteria for diagnosis of a lifetime mental disorder (with hierarchy) and had symptoms in the 12 months before interview.

Source: ABS 2008.

Eating disorders

Eating disorders are a group of mental illnesses that include anorexia nervosa, bulimia nervosa and binge eating disorder. Anorexia nervosa develops frequently in young women between the ages of 13 and 18, while bulimia nervosa usually occurs between 16 and 18 (Deloitte Access Economics 2012).

Prevalence data on eating disorders is not routinely collected in Australia. A recent study based on epidemiological studies, estimated that 75,150 young girls aged 15-19 and 105,622 aged 20-24, suffered from eating disorders in 2012. Young men also suffered: 29,543 aged 15-19 and 41,386 aged 20-24 (Deloitte Access Economics 2012).

Body weight, physical activity and nutrition

Maintaining a healthy body weight through adequate exercise and good nutrition is an important determinant of good adult health. Being overweight or obese is a significant risk for many chronic health conditions such as diabetes, heart disease and some cancers. It also influences the psychological wellbeing of young people. In 2011-12, 33% of young Australians aged 15-24 were overweight (20%) or obese (13%). Rates of overweight and obesity were similar to 2007-08 when 23% of 15-24 year olds were overweight and 13% were obese (AIHW analysis of ABS National Health Survey 2007-08).

In 2011-12, young people (15-24 years) had higher rates of overweight and obesity (33% total) than children aged 5-14 (26%), indicating that excess body weight increases with age (see also Chapter 6 'Childhood overweight and obesity'). Young people aged 20-24 were also more likely to be overweight or obese (38%) than those aged 15-19 (28%) (ABS 2013).

While 30% of children aged 5-14 consumed the recommended daily intake of fruit and vegetables, this drops dramatically to 4% of 15-24 year olds (ABS 2013).

Almost half (46%) of 15-24 year olds were either sedentary (9%) or reported low levels of exercise (37%) (ABS 2013). Young adults aged 18-24 spent an average of 4.6 hours on physical activity in the week prior to the survey, and an average of 38.5 hours per week on sedentary behaviour. An average of 9 hours was spent watching television, and an average of 9 hours was spent using the computer or internet (ABS 2013b).

Risky health behaviours

Young people who engage in risky health behaviours, such as smoking, excessive alcohol consumption and unsafe sex, place themselves at an increased risk of injury, acquiring a sexually transmissible infection, or developing a long-term illness such as coronary heart disease, liver disease or mental illness. As we will see in the following sections, the relationships among all of these risks and consequences are complex.

Substance use

Tobacco smoking

Tobacco smoking is a leading cause of preventable death and disease around the world. It is a major cause of coronary heart disease, chronic obstructive pulmonary disease, stroke, peripheral vascular disease and cancer (AIHW 2008, see also Chapter 5 'Tobacco smoking'). The nicotine in tobacco is highly addictive and, as a result, people who begin smoking tobacco at a young age have a high chance of becoming an adult smoker. In 2010, an estimated 398,463 Australians aged 15-24 (13%) were daily smokers (NDSHS 2010, unpublished data). An additional 4% smoked either weekly or less than weekly, 6% were ex-smokers and 77% had never smoked. In 2012-13, 42% of Indigenous Australians aged 18-24 were daily smokers compared with 16% of non-Indigenous Australians (ABS 2013a).

The number of young people who begin to smoke tobacco is gradually declining every year, with the proportion of young smokers in Australia halving between 1998 and 2010, from 24% to 13%. Rates for males dropped from around 25% in 1998 to around 13% in 2010, and for females from around 25% to 12% (Figure 6.13). Between 2007 and 2010, there was no change in the average age at which young people (aged 15-24) first started smoking tobacco (15 years).

According to results from National Health Surveys conducted in 2001 and 2007-08, and the Australian Health survey conducted in 2011-12, the proportion of young people who had never smoked rose slightly between all 3 surveys. In 2001, less than 60% of people aged 18-24 had never smoked, compared with 64% in 2007-08 and 67% in 2011-12 (ABS 2002, 2010, 2012a).

Figure 6.13: Proportion of daily smokers aged 15-24, 1998 to 2010

Line chart showing the trending decline in the proportion of daily smokers aged 15-24 between 1998 and 2010 for both sexes. The proportion for both sexes fell from approximately 25% in 1998 to below 15% in 2010.

Source: 2010 National Drug Strategy Household Survey, unpublished data.

Alcohol consumption

The risks of long-term damage to brain and body from drinking are higher for young people than for adults, as youths' brains are still developing. Already more vulnerable to risk-taking behaviour, intoxication with alcohol in young people further lowers inhibitions, impairs decision-making, increases the risk of accidental injury, and increases vulnerability to predators or unsafe situations. In addition, a lack of experience with alcohol, and a propensity to binge drink, makes young people more vulnerable to alcohol poisoning.

In 2010, 24% of young people reported that they were involved in drinking sessions that risked alcohol-related injury (more than 4 drinks on a single occasion) at least once a week. The proportion of people who drink at this level has not changed significantly since 2001 (27%). About 45% of young people reported drinking at levels that risked alcohol-related injury at least once a month (see Figure 6.14) (NDSHS, unpublished data).

Figure 6.14: Proportion of young people aged 15-24, drinking more than 4 drinks per occasion, males and females, weekly and monthly, 2001 to 2010

Line chart showing the proportion of young people aged 15-24 drinking more than 4 drinks per occasion for males and females, weekly and monthly, between 2001 to 2010.

Source: 2010 National Drug Strategy Household Survey, unpublished data.

The risk of lifetime harm from alcohol-related disease or injury increases when people consume more than 2 standard drinks per day (NHMRC 2009). Young men were almost twice as likely as young women (30% compared with 17%) to have more than 2 drinks a day, on average.

There was little difference between the proportion of Indigenous youths aged 18-24 (in 2012-13) and non-Indigenous youths (2011-12) reporting drinking at risky levels on a single occasion (more than 4 standard drinks) in the week before being surveyed (68.4% compared with 66.6%).

Similarly, there was no significant difference between the proportion of Indigenous youths aged 18-24 (in 2012-13) and non-Indigenous youths (2011-12) reporting drinking at lifetime risky levels in the week before being surveyed (18% compared with 19%) (ABS 2013a).

Illicit drugs

Young people are more likely than adults to experiment with psychotropic drugs. Depending on the type of drug used, users expose themselves to increased risks of HIV infections and hepatitis C virus (if needles are used and shared), malnutrition, infective endocarditis (leading to damage to the heart valves), mental illness, suicide, self-inflicted injury and accidental overdoses (AIHW 2011b). Because illicit drugs are usually illegal (see also Chapter 5 'Illicit drug use-current and future issues'), users also expose themselves to the risks of police charges and a criminal record, which can influence employment opportunities and international travel as an adult.

Figure 6.15: Selected illicit drug use (ever used) by young people aged 15-24, 2007 and 2010

Bar chart showing that marijuana/cannabis was by far the most common illicit drug (ever used) by young people aged 15-24 between 2007 and 2010. The rate of use increased from approximately 18% in 2007 to over 20% in 2010. Data are also shown for ecstasy, hallucinogens, cocaine, meth/amphetamine (speed) and inhalants.
  1. Included 'designer drugs' prior to 2004.
  2. For non-medical purposes.

Source: 2010 National Drug Strategy Household Survey, unpublished data.

In 2010, more than 1 in 5 young people (23%) aged 15-24 reported they had used a non-pharmaceutical illicit drug at some time in their lives (ever used) (see Figure 6.15). Cannabis use (ever used) increased slightly among younger Australians (15-19 years), from 15% in 2007 to 18% in 2010, though this was still markedly less than in 2001 (27%). Ecstasy use among this younger age group halved between 2007 and 2010 (from 6% to 3%) (NDSHS, unpublished data).

In 2012-13, around 28% of Indigenous 15-24 year olds had used substance(s) in the past 12 months, and a further 15% at some other time in their lives (ABS 2013a). Comparable data for non-Indigenous youth are currently not readily available.

The consequences of alcohol and drug use for youth

In 2010, 23% of youths who had used an illicit drug in the last 12 months and 19% of those who had more than 4 standard alcoholic drinks on 1 occasion at least once a week, reported experiencing 'high' or 'very high' psychological distress in the previous month. This compares with 15% of 15-24 year olds who did not report alcohol or drug use (Figure 6.16).

Figure 6.16: Proportion of young people aged 15-24 using illicit drugs and alcohol in the last 12 months, by health condition, 2010

Column chart showing the proportion of young people aged 15-24 in 2010 who used an illicit drug in the last 12 months, and those who drank more than 4 drinks at least weekly, in terms of those afflicted by: (a) (Very) high psychological distress, (b) a mental health condition, and (c) an STI. (Very) high psychological distress was the most common condition amongst these groups.

Source: 2010 National Drug Strategy Household Survey, unpublished data.

Youths who had used an illicit drug in the last 12 months (17%) or who drank more than 4 standard alcoholic drinks on 1 occasion at least once a week (12%), were more likely to have been diagnosed or treated for a mental illness in the previous 12 months than the 15-24 year old population as a whole (9%).

The association between mental health issues and the use of drugs and alcohol is complex. In some cases, alcohol and drug use can cause feelings of anxiety and depression, and in other cases people with mental illness may use alcohol and drugs to improve their mood or to deal with stress (Slade et al. 2013).

Alcohol consumption and drug use may also increase risky behaviours such as unsafe sex and needle sharing. Sexually transmissible infections (STIs) were twice as prevalent among those who had used an illicit drug in the last 12 months or who reported having consumed more than 4 standard drinks on 1 occasion at least once a week (4% respectively compared with 2% of all 15-24 year olds) (Figure 6.16).

Alcohol consumption and drug use may also affect young people's work and education activities. In 2010, over 1 in 10 15-24 year olds (11%) who consumed more than 4 drinks on 1 occasion at least once a month had missed attendance at work, university or school in the previous 3 months because of their alcohol use. Five per cent of those who used an illicit drug in last 12 months had similarly missed attendance at work, university or school because of their drug use in the previous 3 months.

Drinking exposes youths to increased risks of injury or death in a motor vehicle accident, or a drink-driving charge, with 18% of 20-24 year olds and 6% of 15-19 year olds reporting driving a motor vehicle while under the influence of alcohol in 2010. For the same age groups, 8% of 20-24 and 4% of 15-19 year olds had driven while under the influence of an illicit drug. Around 47% of 18-19 year olds were put in fear or were the victims of alcohol-related verbal and physical abuse (AIHW 2011a).

Unsafe sex and sexually transmissible infections

Sexual development is a normal part of young adulthood; however, not all young Australians practise safe sex (Smith et al. 2009). Sexually transmissible infections can cause significant long-term health problems and are a major public health concern (DoHA 2010).

In 2012, there were 57,119 notifications of chlamydia, gonorrhoea, syphilis and donovanosis among 15-24 year olds-a rate of 1,853 notifications per 100,000 young people (Department of Health 2013). More than half (around 57%) of all sexually transmissible infections notified in Australia were among 15-24 year olds. Chlamydia was the most commonly notified infection in this age group, accounting for about 90% of these notifications.

From 1991 to 2012, chlamydia notification rates increased over tenfold from 104 to 1,663 notifications per 100,000 young people. Increased testing may account for some of the increase (AIHW 2011b). Gonorrhoea notification rates also rose (from 38 to 178 per 100,000). In contrast, syphilis notification rates fell between 1991 and 2005 (from 25 to 11 per 100,000), and have remained relatively stable since (12 per 100,000 in 2012) (Figure 6.17).

In 2012, there were 154 HIV notifications for 15-24 year olds, a rate of 5 per 100,000 young people, higher than the 3 per 100,000 in 2001 (AIHW analysis of Australian HIV Public Access Dataset).

One way of avoiding sexually transmitted infections is the use of condoms, which is also effective in preventing unwanted pregnancies. But in 2008, a survey reporting on sexually active students found only an estimated two-thirds of students reported using condoms at their last sexual encounter. Half of students reported using the contraceptive pill, 10% used the withdrawal method to avoid pregnancies, and 8% the morning after pill (some students reporting using more than 1 form of contraceptive). In the same survey, only half (51%) of sexually active young people said they had always used a condom in the previous 12 months, and 43% said they sometimes used one (Smith et al. 2009).

Figure 6.17: Notification rates of selected sexually transmissible infections in people aged 15-24, Australia, 1991-2012

Line chart showing the notification rates of chlamydia, gonorrhoea, syphilis and HIV in people aged 15-24 in Australia between 1991 and 2012. There was a trending increase in notification rates for chlamydia and gonorrhoea, and a trending decline in rates for syphilis and HIV over this period.

Note: Data are presented using a log scale.

Sources: Department of Health 2013; AIHW analysis of Australian HIV Public Access Dataset 2013.

Over the last 10 years rates of births to teenage girls have remained stable. In 2012, the rate of women aged 15-19 giving birth was 16 births per 1,000 women compared with 17 in 2002 (ABS 2013d). However, little is known nationally about the total number of pregnancies to teenage mothers as the number of pregnancy terminations is not known.

Injuries in youth

In adolescence and early adulthood, young people tend to engage in more risky behaviours, many of which can result in injury. These include risky driving and intentional injuries such as self-harm, suicide and assault (AIHW 2011b). Injuries are often preventable, and can have a major impact on the health of young people. Depending upon their severity, injuries can result in time off school or work, hospitalisation, a long-term condition, disability, or death. Information on the prevalence of injury that does not result in hospitalisation is not collected in Australia, so hospitalisations data must be used to present a picture of injury to Australia's youth.

Hospitalisation usually means an injury is serious; but because some injuries result in more than 1 stay in hospital, hospitalisations probably exceed the number of injuries.

In 2011-12, there were almost 604,000 hospitalisations due to injury within Australia, with 15-24 year olds accounting for 14% of these hospitalisations-equivalent to their proportion of the population (14% at 30 June 2011). Males in this age group were more than twice as likely to be hospitalised as females. Injury hospitalisations related to poisonings by pharmaceuticals and by alcohol, were also high among young people (AIHW: Pointer 2013).

Accidental injury and death

Road traffic accidents

In 2010-11, hospitalised injuries from land transport accidents were more common for males, especially for teenagers and young adults (see Figure 6.18). Injuries for young males aged 15-19 (609 per 100,000) were more than double those for young females (276 per 100,000) and almost double those for 45-49 year old males (329 per 100,000) (AIHW: Pointer 2013). Transport injury rates for Aboriginal and Torres Strait Islander young males (15-19 years) were higher than for non-Indigenous young males (809 and 614 per 100,000 population respectively).

Young men are significantly more likely than the rest of the population, including young women, to be killed or injured in a motor vehicle accident. In 2012, young males accounted for three-quarters of road transport accident deaths involving young people, with death rates over twice as high among males as females (13 and 5 per 100,000 respectively) (Figure 6.19). In 2012, almost half (47%) of 15-24 year olds killed in a vehicle accident were the driver; around 28% were passengers. The rest were motorcycle riders (13%), pedestrians (9%) or cyclists (0.7%) (Department of Infrastructure and Regional Development 2013).

Young people differ from the general population in that their fatal vehicle accidents occur more often at weekends or at night. Age and inexperience separately or combined are associated with the higher death rate as well as risky driving behaviour, including speeding, driving when fatigued, and driving under the influence of alcohol or drugs (AIHW 2011b; BITRE 2013).

Figure 6.18: Rates of transport injury-related hospitalisations, by age and sex, 2010-11

Line chart showing the rate of transport injury-related hospitalisations by age and sex in 2010-11. Males had a higher rate than females across this whole period. Both sexes saw a spike in incidence the 15-19 age bracket.

Source: AIHW: Pointer 2013.

Overall (all ages) injury and death rates from road accidents are slowly falling and fewer deaths of young people are part of this decline. In 2012, there were 272 road deaths for the 15-24 age group, a rate of 9 per 100,000, which is a substantial fall from 34 per 100,000 rate of 1989 (when there were 928 deaths) (Australian Road Deaths Database). The decline is the collective result of a range of factors, including better roads, safer vehicles, a legal requirement to wear seat belts and random alcohol and drug testing of drivers.

For the period 2005-06 to 2009-10, fatal land transport injury rates for Indigenous young people tended to be higher than for other young people. The greatest disparity between Indigenous and non-Indigenous young people was among 15-19 year old males (35.2 compared with 16.6 per 100,000 population) (AIHW: Henley & Harrison 2013).This may be explained, in part, by the fact that more Indigenous people live in Remote and Very remote areas where local factors can include greater distances travelled, higher speed limits, lack of public transport, and poor roads (Thomson et al. 2009).

Figure 6.19: Fatal accident death rates for young people aged 15-24, 1989-2012

Line chart showing the trending decline in fatal accidental death rates for young people aged 15-24, for both sexes, between 1989 and 2012. The male death rate was more than double that of females over this whole period.

Source: AIHW analysis of Australian Road Deaths Database (Department of Infrastructure and Regional Development 2013).

Intentional injuries and death

Self-harm

Intentional injury, including attempted suicide, is a substantial cause of hospitalisations in young people. In 2010-11, 26,000 people in Australia were hospitalised for intentional self-harm and, of these, 29% were aged 15-24. Young women aged 15-19 had hospitalisation rates for self-injury almost 3 times those for young men (421 and 141 cases per 100,000 respectively) (AIHW: Pointer 2013) (Figure 6.20).

Suicides

In 2011, suicide was the most common cause of death among young people aged 15-24-there were 321 deaths in that year (26% of deaths in this age group), at a rate of 11 per 100,000 population. Young men committed suicide 2.5 times as often as young women. Suicide rates rose from 1991 to 1997 (from 16.7 to 19.4 per 100,000), then fell to 2004 (9.6 per 100,000) and have remained relatively stable since (Figure 6.21).

Figure 6.20: Intentional self-harm hospitalisation rates, by age group and sex, Australia, 2010-11

Line chart showing the number of hospitalisations as a result of intentional self-harm (per 100,000 population), by age group and sex, in Australia in 2010-11. Females had a higher rate of self-harm for all ages up to age 70-74.

Note: Excludes data for 0-9 year olds due to small case numbers.

Source: AIHW: Pointer 2013.

Between 2001 and 2010, suicide rates for Indigenous young people were higher than for non-Indigenous young people, particularly in the 15-19 age group. Rates for Indigenous females in this age group were 5.9 times those of non-Indigenous females, while for males the corresponding rate ratio was 4.4 (ABS 2012b).

Helpline services available to assist young people at risk of suicide include: Lifeline Australia: 13 11 14; Kids Helpline: 1800 55 1800; Suicide Call Back Service: 1300 659 467.

Figure 6.21: Suicides of young people, aged 15-24, by sex, 1991 to 2011

Line chart showing the rate of suicide of males and females aged 15-24 between 1991 and 2011. The rate for males was more than double the rate of females over this period, though there is a notable decline in the male suicide rate beginning in the late 1990s.

Notes

  1. Deaths registered in 2009 and earlier are based on the final version of cause of death data; deaths registered in 2010 and 2011 are based on revised and preliminary versions respectively, and are subject to further revision by ABS.
  2. Data for 2010 have not been adjusted for the additional deaths arising from outstanding registrations of deaths in Queensland in 2010.

Source: AIHW National Mortality Database, unpublished.

Box 6.4: Intentional self-harm and suicide deaths-data issues

Determining intentional self-harm

According to inclusion notes in the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification (ICD-10-AM), cases should be assigned codes in the range X60-X84 if they were purposely self-inflicted poisoning or injury, suicide, or attempted suicide (NCCH 2010). Determining whether an injury is due to intentional self-harm is not always straightforward. Cases may appear to be intentional self-harm, but inconclusiveness of available information may preclude them being coded as such. In this situation, the case can be coded to an 'undetermined intent' category (for example, 'Y30 Falling, jumping or pushed from a high place, undetermined intent' or 'Y32 Crashing of motor vehicle, undetermined intent').

Some patients may choose not to disclose that their injuries resulted from intentional self-harm, or may be unable to do so due to the nature of the injuries, or because their motives were ambiguous. In very young children, ascertaining whether an injury was due to intentional self-harm can be difficult and may involve a parent or caregiver's perception of the intent. Ability to form an intention to inflict self-harm and to understand the implications of doing so requires a degree of maturation that is absent in infancy and early childhood. The age at which self-inflicted acts can be interpreted as intentional self-harm is not well-defined and is the subject of debate. Such sources of uncertainty about the assignment of intent limit the certainty of any estimates of intentional self-harm based on routine hospital data.

Mortality data and suicide deaths

Since 2006, cause of death mortality data are revised for coroner-certified deaths 12 and 24 months after the initial release of data to include more complete cause of death information. This process results in 3 versions of data for each reference year: a preliminary version (the first release of data), a revised version (with open or recently closed coroner-certified cases revised 12 months after the preliminary release) and a final version (with the remaining open or recently closed coroner-certified cases revised 24 months after the preliminary data release). The revisions process mainly affects deaths due to external causes, and deaths from suicide in particular. The data reported here includes revised data for 2010 and preliminary data for 2011.

Another factor to consider with suicide statistics is how they can be affected by aspects of the coroner system (AIHW 2009). In some instances, it may take a long time for a coroner to decide that a case was suicide, and in the meantime the case is not recorded as such. The revisions process described above was implemented by the ABS to enable cases which took a long time to finalise to be coded using the coroner's final decision. Also, the way that coroners decide a case is suicide, and the way they record it, may also mean that some suicides are not recorded as such in official statistics. For example, if no suicide note was found, one coroner might find that a self-inflicted hanging was of undetermined intent, whereas another coroner might find it to be suicide regardless of the presence of a note. Coroners may also be reluctant to determine that a child or young person intended to commit suicide due to the difficulty in establishing the intent of the action in young people (ABS 2011).

What is missing from the picture?

Adolescence is the stage in life when risk behaviours begin and may continue into adulthood and later life. This period offers opportunities for health gains through prevention and early intervention. However, little is known, for example, about young women's preconception health behaviours. Also, the changing shape of adolescence and early adulthood as a result of influences such as social networking and the digital media is not known.

More comprehensive data on suicides and attempted suicides would enable better planning of support, prevention and early intervention services. The number of suicide-related contacts by ambulance services, mental health crisis teams and the police is not known, nor what services they provided.

The limited data available on eating disorders also highlights the need for regular data monitoring at a national level for these conditions. A recent report sponsored by the Butterfly Foundation recommended that this could be done by including eating disorder questions in the Australian Health Survey, including binge eating disorder as a category in non-hospital treatment data, and including eating disorders as a possible cause for seeking financial support in welfare data (Deloitte Access Economics 2012).

Where do I go for more information?

More information on youth health is available. The reports Young Australians: their health and wellbeing, 2010 National Drug Strategy Household Survey report and other recent publications are available for free download.

References

ABS (Australian Bureau of Statistics) 2002. National Health Survey: persons aged 18 years and over: selected risk status by ASGC remoteness area 2001. ABS cat. no. 4364.0. Canberra: ABS.

ABS 2008. National Survey of Mental Health and Wellbeing: summary of results, 2007. ABS cat. no. 4326.0. Canberra: ABS.

ABS 2010. National Health Survey: summary of results, 2007-08 (Reissue). ABS cat. no. 4364.0. Canberra: ABS.

ABS 2011. Causes of death, Australia, 2011. ABS cat. no. 3303.0. Canberra: ABS.

ABS 2012a. Australian Health Survey: first results, 2011-12. ABS cat. no. 4364.0.55.001. Canberra: ABS.

ABS 2012b. Suicides, Australia 2010. ABS cat. no. 3309.0. Canberra: ABS.

ABS 2013. Australian Health Survey: 2011-12. Canberra: ABS.

ABS 2013a. Australian Aboriginal and Torres Strait Islander Health Survey: first results, Australia, 2012-13. ABS cat. no. 4727.0.55.001. Canberra: ABS.

ABS 2013b. Australian Health Survey: physical activity, 2011-12, Australia. ABS cat. no. 4364.0.55.004. Canberra: ABS.

ABS 2013c. Australian Health Survey: updated results, 2011-12. ABS cat. no. 4364.0.55.003. Canberra: ABS.

ABS 2013d. Births, Australia, 2012. ABS cat. no. 3301.0. Canberra: ABS.

AIHW (Australian Institute of Health and Welfare) 2008. Making progress: the health, development and wellbeing of Australia's children and young people. Cat. no. PHE 104. Canberra: AIHW.

AIHW 2011a. 2010 National Drug Strategy Household Survey report. Drug statistics series no. 25. Cat. no. PHE 145. Canberra: AIHW.

AIHW 2011b. Young Australians: their health and wellbeing 2011. Cat. no. PHE 140. Canberra: AIHW.

AIHW 2012a. Australia's food & nutrition 2012. Cat. no. PHE 163. Canberra: AIHW.

AIHW 2012b. Trends in serious injury due to land transport accidents, Australia 2000-01 to 2008-09. Injury research and statistics series no. 66. Cat. no. INJCAT 142. Canberra: AIHW.

AIHW 2013a. Australian hospital statistics 2011-12. Health services series no. 50. Cat. no. HSE 134. Canberra: AIHW.

AIHW 2013b. The health of Australia's males: from birth to young adulthood (0-24 years). Cat. no. PHE 168. Canberra: AIHW.

AIHW 2014a. Incidence of insulin-treated diabetes in Australia, 2000-2011. Cat. no. CVD 66. Canberra: AIHW.

AIHW 2014b. Type 2 diabetes in Australia's children and young people: a working paper. Diabetes series no. 21. Cat. no. CVD 64. Canberra: AIHW.

AIHW: Henley G & Harrison JE 2013. Injury of Aboriginal and Torres Strait Islander people due to transport, 2005-06 to 2009-10. Injury research and statistics series no. 85. Cat. no. INJCAT 161. Canberra: AIHW.

AIHW: Pointer S 2013. Trends in hospitalised injury, Australia: 1999-00 to 2010-11. Injury research and statistics series no. 86. Cat. no. INJCAT 162. Canberra: AIHW.

BITRE (Bureau of Infrastructure, Transport and Regional Economics) 2013. Young adult road safety: a statistical picture. Information sheet 51. Canberra: BITRE.

Deloitte Access Economics 2012. Paying the price: the economic and social impact of eating disorders in Australia. Sydney: The Butterfly Foundation.

Department of Health (2013). National Notifiable Diseases Surveillance System, customised report. Canberra: Department of Health.

Department of Infrastructure and Regional Development 2013. Australian Road Deaths Database . Viewed 10 November 2013.

FYA (Foundation for Young Australians) 2013. How young people are faring 2013: the national report on the learning and earning of young Australians. Melbourne: FYA.

Kirby Institute 2014. 2013 Australian HIV public access dataset. Darlinghurst: Kirby Institute, Viewed 25 November 2013.

NCCH (National Centre for Classification in Health) 2010. The international statistical classification of diseases and related health problems, 10th revision, Australian modification (ICD-10-AM), Australian Classification of Health Interventions (ACHI) and Australian Coding Standards (ACS), 7th edn. Sydney: University of Sydney.

NHMRC (National Health and Medical Research Council) 2009. Australian guidelines to reduce health risks from drinking alcohol. Canberra: NHMRC. Viewed 11 March 2014.

NIMH (National Institute of Mental Health) 2001. Teenage brain: a work in progress. NIH publication no. 01-4929. NIMH.

NPHP (National Public Health Partnership) 2004. The National Injury Prevention and Safety Promotion Plan: 2004-2014. Canberra: NPHP.

Sawyer MG, Arney FM, Baghurst PA, Clark JJ, Graetz BW, Kosky RJ et al. 2000. Mental health of young people in Australia. Canberra: Commonwealth Department of Health and Aged Care.

Sawyer S, Patton G 2011. Why adolescent health matters. Health 2011. Albert Park: Future Leaders. Viewed 12 March 2014.

Slade T, McEvoy PM, Chapman C, Grove R & Teesson M 2013. Onset and temporal sequencing of lifetime anxiety, mood and substance use disorders in the general population. Epidemiology and Psychiatric Sciences. Available on CJO 2013 doi:10.1017/S2045796013000577.

Smith A, Agius P, Mitchell A, Barrett C, Pitts M 2009. Secondary students and sexual health 2008. Melbourne: Australian Research Centre in Sex, Health & Society.

Thomson N, Krom I, Ride K 2009. Summary of road safety among Indigenous peoples. Mount Lawley, WA: Australian Indigenous HealthInfoNet 2013. Viewed 20 February 2013.


6.8 The health of our working-age population

Around 53% of Australia's population (12.1 million people) are aged 25-64, and are classified as being of working age. During this life stage, many people experience major life events and transitions such as establishing themselves in the workforce, purchasing a home, raising a family, changing careers and retirement planning. Restrictions to their health can reduce their earning capacity and affect how these life events are experienced. Life events can also impact on health through, for example, stress or workplace injuries. It is also during working age that many long-term health conditions emerge and behaviours and patterns that can influence longevity or health in later years are established.

The aim of this article is to present an overview of the health of Australia's working-age population (aged 25-64) and the factors that influence it. Because health issues faced by the working-age population change between the ages of 25 and 64, this article explores patterns in the health and lifestyles of people aged 25-44 and 45-64 separately. Measures of health, such as long-term health conditions, causes of death and self-assessed health are investigated, along with behavioural risk factors and social and economic factors related to employment, housing and family. The relationship between work and physical and emotional wellbeing is also explored.

The health of people of working age is important because it affects not only them, but their families, workplaces and society in general. Gaining a better understanding of this group's health and lifestyles can lead to improvements in their wellbeing and to overall improvements in productivity and planning for future health needs.

Policy development for, and research into, the health and wellbeing of working-age Australians are sometimes approached from the viewpoints of men's health and women's health, or people studying or in the workforce. Such approaches, however, may miss the long-term conditions, behavioural risk factors and life stressors common to all people at this age. A more holistic approach to this age group integrates the effects of life events and transitions experienced during these ages on physical and emotional wellbeing. It also recognises the diversity of experiences within this age group, and how different life paths can have different effects on health.

Australians aged 25-44

During the ages of 25-44, many Australians are likely to be establishing themselves in the workforce, forming long-term relationships and buying their first home. It is also the age when they may start a family and may adjust their working arrangements to care for their children. Others might be studying while working to extend their skills and improve their employment prospects. At the same time, there are Australians in this age group who face barriers and are unable to find work or afford a home of their own, or they may be under housing stress. This can create a cycle whereby these challenges affect their physical and emotional wellbeing, which in turn can affect their work engagement.

Milestones and transitions

Employment rates are at their highest in this age group. Around 8 in 10 Australians (79%) aged 25-44 were employed according to the 2011 Census, and men in this age group were almost twice as likely as women to work full time (71% compared with 38%). Unemployment for both men and women in this age group was 4%; however, women were less likely to be in the labour force than men (76% compared with 91%) since many women have children at this age and, as outlined later, are more likely to be caring for children than men. As earning capacity increases, another important milestone for people in this age group is the purchase of a home. Six out of 10 people (61%) aged 25-44 in 2011 owned or were purchasing their home. Having a secure home has been found to be beneficial for both physical and mental health (Foster et al. 2011).

Long-term relationships and child rearing are also important aspects of life during this period. In 2011, marriage rates were highest among men and women aged 25-29, but Australians are tending to marry later, as indicated by more men and women marrying in their thirties and early forties in 2011 compared with 1991 (ABS 2012b).

Figures from 2011 indicate that, on average, Australian women were 28 when they had their first baby. However, the proportion of women having children later in life is increasing. The proportion of women aged 35 and over giving birth to their first child increased from 11% in 2001 to 14% in 2011 (Li et al. 2013). In 2011, Australia's fertility rate was 1.92 children per woman (ABS 2013c).

Women aged 25-44 are more likely to be caring for children than men. In the 2 weeks before the 2011 Census, 58% of women spent time caring for a child or children aged under 15 without pay, compared with 43% of men. Of these women, 86% were caring for their own child or children, as were 91% of these men. Women of this age group were also more likely than men to provide care or assistance to family members who have a disability, long-term illness or problems due to old age (12% compared with 8%).

Caring responsibilities can weigh heavily on people's emotional and physical health and wellbeing. Carers often need to reduce their working hours or leave the workforce completely due to their responsibilities and this reduction in income can affect their savings and superannuation, while also limiting their career prospects (Austen 2013; Nepal et al. 2008). In addition to the change in their financial circumstances, about one-third (32%) of informal carers in 2009 reported that their wellbeing had changed due to their caring role, specifying weariness, depression, stress and sleep interruption as some of the adverse effects they experienced (AIHW 2013a).

While this period is characterised by first-time marriages and starting a family, it is also the time when most divorces occur. People aged 40- 44 had the highest percentage of divorces granted in 2011, with about 17% of men and women in this age group being granted a divorce. Almost half of all divorces (48%) in 2011 involved couples with children (ABS 2012b). A long-term Australian study found that the end of marriage, either through separation or widowhood, significantly worsened the mental health of both men and women (Hewitt et al. 2012).

The proportion of lone-person households is also increasing in Australia, which can mean that these people have fewer financial and emotional supports, which could have a negative impact on their health (Kharicha et al. 2007). The ABS has also projected that more men and women between the ages of 25 and 49 will be living alone in 2031 than in 2006 (ABS 2010).

Around 10% of people aged 25-44 reported that they had a disability in the ABS 2012 Survey of Disability, Ageing and Carers, and of these people, around two-thirds (67%) had a disability that restricted their employment participation (ABS 2013d). People with employment restrictions may be restricted in the type of work that they can do or the number of hours they can work. They may also require ongoing assistance at work or modifications to their work environment.

How healthy are Australians aged 25-44?

Around 6 in 10 Australians (61%) aged 25-44 rated their health as excellent or very good in the 2011-12 Australian Health Survey (AHS), and only 10% considered their health to be fair or poor. The remaining 29% rated their health as good. The same proportion of young adults (aged 15-24) rated their health as excellent or very good (61%). Men and women in the 25-44 age group were similar to each other in the way they assessed their health (Figure 6.22). There was a difference, however, between men and women in levels of psychological distress experienced in the 4 weeks before the 2011-12 AHS. About 9% of men aged 25-44 were assessed as having high or very high levels of psychological distress, compared with 13% of women of the same age (ABS 2013a). These levels were similar to those found in the 2007-08 National Health Survey (ABS 2009b).

Figure 6.22: Self-assessed health status of Australians aged 25-44, by sex, 2011-12

Column chart showing the self-assessed health status of Australians aged 25-44, by sex, in 2011-12. 'Very good' was the most popular choice with over 35% of men and 40% of women choosing this option.

Source: AIHW analysis of ABS 2013b.

The most common chronic health conditions reported by this age group in the 2011-12 AHS were vision problems, hay fever and allergic rhinitis, and back pain-the same as in the ABS 2007-08 National Health Survey (ABS 2009b). About 1 in 4 Australians aged 25-44 (25%) were short-sighted and almost 1 in 8 (12%) were long-sighted. Hay fever and allergic rhinitis affected 22% of this age group, and around 15% had back pain, back problems or disc disorders. Mood problems such as depression also affected 12% of this age group and anxiety affected 5% (see Chapter 4 'Chronic disease-Australia's biggest health challenge').

Although people aged 25-44 experience fewer long-term health conditions than older age groups, they can put themselves at a greater risk of developing these conditions later in life if their lifestyles and behaviours are unhealthy (see Chapter 5 'Behavioural risk factors'). For example, smoking and not exercising can increase their risk of developing high blood pressure, heart disease and some types of cancer. Figure 6.23 shows that key behavioural risk factors are common in men and women aged 25-44 according to the 2011-12 AHS.

Figure 6.23: Prevalence of selected health risk factors in people aged 25-44, by sex, 2011-12

Bar chart showing the prevalence of selected health risk factors in people aged 25-44, by sex, in 2011-12. Inadequate fruit and vegetable consumption, insufficient physical activity and 'overweight and obesity' were the most prevalent health factors, followed by daily smoking, risky alcohol use (long-term) and high blood pressure.
  1. Includes all people reporting sedentary or low activity.
  2. Defined as blood pressure of 140/90 mmHg or higher.

Sources: AIHW analysis of ABS 2013a, 2013b.

Inadequate fruit and vegetable consumption was very common among this age group. The NHMRC recommends that adults consume 2 serves of fruit and 5 serves of vegetables each day. According to the 2011-12 AHS, 96% of men and women aged 25-44 did not meet those requirements. Compared with other age groups, adequate fruit and vegetable consumption improved with age from 4% in people aged 18-24 to 8% in people aged 65-74.

Low levels of exercise were also common in this age group, as 60% of men and 70% of women reported that they were sedentary or undertook low levels of exercise in the week before the survey. Compared with other age groups, men aged 25-44 were less physically active than those aged 24 and under, but more physically active than older age groups. For men, sedentary or low levels of exercise increased with age from 45% in those aged 15-24 to 69% in those aged 65-74. There was a more gradual change for women from 69% in those aged 15-24 to 74% in those aged 65-74.

Poor nutrition and low levels of exercise may have an impact on the high levels of overweight and obesity in this age group, which were 70% for men and 49% for women. Findings from the 2011-12 AHS suggest that most of the increase in men's body mass index (BMI) occurred around the ages of 25-34; however, for women the increase in BMI was more gradual across the decades. Rates of overweight and obesity have increased for men in this age group from 66% in 2007-08 to 70% in 2011-12; however, for women the rates were similar (50% in 2007-08 compared with 49% in 2011-12). On a positive note, rates of smoking have fallen from 2007-08 when 24% of people aged 25-44 were daily smokers, compared with 20% in 2011-12 (ABS 2009b, 2013a).

Risky alcohol use in this age group was more common among men than women. Around 3 in 5 men (61%) reported that they had consumed alcohol at short-term risky levels (more than 6 standard drinks in a single episode) in the 12 months before the 2011-12 AHS, compared with 2 in 5 women (43%). Long-term risky alcohol consumption (regularly drinking more than 4 standard drinks per day) was also more common among men than women aged 25-44 (14% compared with 10%).

Despite the prevalence of risk factors in this age group, the majority of people aged 25-44 are yet to develop the chronic conditions that these risk factors can bring about. This is evident in the leading causes of death seen in this age group. Deaths among people aged 25-44 are predominantly due to injuries resulting from suicide, transport accidents or drug overdoses.

People aged 25-44 made up only 3.5% of all deaths in Australia in 2012 despite making up 29% of the total population (ABS 2013c). Men in this age group were almost twice as likely to die as women (104 deaths per 100,000 in 2012 compared with 54 deaths per 100,000). In 2011, suicide was the most common cause of death for both men and women, and accidental poisoning-from, for example, an overdose or unintentional contact with chemicals-was in the top 3 causes for both sexes (Table 6.1). The leading causes of death for women in this age group have remained similar since 2006; however, for men there has been a significant increase in the proportion of deaths caused by accidental poisoning in the same period (up 69%), and significant falls in the proportion of deaths caused by car accidents (down 30%) and coronary heart disease (down 16%) (AIHW analysis of National Mortality Database).

Table 6.1: Leading causes of death(a)(b) in people aged 25-44, by sex, 2011(c)
Rank Men No. % Women No. %
1 Suicide (X60-X84) 672 19.9 Suicide (X60-X84) 199 11.0
2 Accidental poisoning (X40-X49) 406 12.0 Breast cancer (C50) 173 9.6
3 Coronary heart disease (I20-I25) 243 7.2 Accidental poisoning (X40-X49) 103 5.7
4 Car accident (V40-V49) 138 4.1 Diseases of the liver (K70-K77) 63 3.5
5 Other forms of heart disease(d) (I30-I52) 118 3.5 Car accident (V40-V49) 54 3.0
  1. Based on ICD-10 groupings.
  2. Excludes the category 'Event of undetermined intent' as these deaths are subject to a revision process by the ABS upon further information from the coroner.
  3. Deaths registered in 2011 are based on the preliminary version of cause of death data and are subject to further revision by the ABS.
  4. Includes diseases of the myocardium (heart muscle), endocardium (lining of the heart), heart valves and pericardium (membrane covering the heart).

Source: AIHW National Mortality Database.

Australians aged 45-64

In the second half of their working lives, Australians are likely to be more settled in their family lives and established in their careers. By this age, most women have had their children and may have adjusted their work hours in response. However, both men and women in this age group may be contemplating or embarking on a career change, changing their working hours or planning for retirement. Others may retire from work before the age of 64, while some will elect to continue working beyond 65.

Australians aged 45-64 who have difficulty finding work or are experiencing changes to their family lives due to divorce or remarriage may face challenges such as financial stress or psychological distress that could have a negative effect on their health.

Milestones and transitions

For some people, the range of major life transitions in the second half of working age can be less disruptive than in the first half; however, changes such as children leaving the family home and caring for elderly parents can affect their physical and mental wellbeing.

According to the 2011 Census, the proportion of employed people aged 45-64 was lower than for those aged 25-44 (71% compared with 79%). This is due to more people in this age group leaving the labour force, because of disability or retirement. At the same time, fewer Australians aged 45 and over got married, and fewer divorced as they got older. Around 16 out of 1,000 married men and women, respectively, aged 45-49 were granted a divorce in 2011, compared with 7 out of 1,000 married men and 4 out of 1,000 married women aged 60-64. Older men have higher rates of divorce than older women because they are more likely than older women to remarry and remarriages tend to be less stable than first marriages (Weston & Qu 2013). It should also be noted that divorce rates do not present the complete picture of relationship breakdowns as they do not capture the number of de facto relationships that dissolve.

Caring responsibilities at 45-64 also differ to those during the ages of 25-44. Around 1 in 4 people aged 45-64 (27%) spent time caring for a child or children without pay in the 2 weeks before the 2011 Census, compared with 1 in 2 people aged 25-44 (51%). However, people in the older age group were more likely to be caring for other children, such as grandchildren, than people aged 25-44 (41% compared with 8%). Research shows that more Australian grandparents are caring for their grandchildren since parents feel more comfortable leaving their children with a trusted relative and find them more flexible and less expensive than formal child care (Jenkins 2010). In some cases, grandparents may look after their grandchildren due to circumstances in their children's lives, such as relationship breakdowns, mental health problems, substance abuse, death or incarceration.

While people aged 45-64 were less likely to be caring for children than those aged 25-44, they were more likely to be providing care or assistance to a partner or family members who had a disability, long-term illness or problems due to old age (17% of people aged 45-64 compared with 10% of people aged 25-44). About 1 in 5 women aged 45-64 (21%) provided this type of assistance compared with about 1 in 8 men (13%). As mentioned earlier, caring responsibilities can have a negative impact on the physical and mental wellbeing of carers.

Around 23% of people aged 45-64 reported that they had a disability in the ABS 2012 Survey of Disability, Ageing and Carers, and of these people, 69% had a disability that restricted their employment participation (ABS 2013d).

Another major transition faced by females in this age group is menopause, which is the end of the reproductive years marked by the ending of menstruation. This generally occurs between the ages of 45 and 55. Symptoms may include flushes, aches and pains, headaches, irritability, loss of sex drive and difficulty sleeping.

How healthy are Australians aged 45-64?

Australians aged 45-64 were 1.7 times as likely to rate their health as fair or poor compared with those aged 25-44 in the 2011-12 AHS, suggesting that there is some deterioration of health as people of working age get older. The proportion of this age group assessing their health as fair or poor in 2011-12 was similar to the proportion in 2007-08 (17% compared with 18%). Figure 6.24 shows that there were similarities in the way that men and women aged 45-64 tended to rate their health. Levels of psychological distress were the same for both age groups, with 9% of men and 13% of women having high or very high levels in the 4 weeks before the survey (ABS 2013a). In comparison, 11% of men and 15% of women aged 45-64 had high or very high levels of psychological distress in 2007-08 (ABS 2009).

Figure 6.24: Self-assessed health status of Australians aged 45-64, by sex, 2011-12

Column chart showing the self-assessed health status of Australians aged 45-64, by sex, in 2011-12. 'Very good' was the most popular choice with approximately 35% of respondents choosing this option. Women were slightly more likely to assess their health as 'very good' than men.

Source: AIHW analysis of ABS 2013b.

Although self-assessed physical health tends to decrease with age, self-assessed mental health does not follow this pattern (AIHW 2010)-and both are influenced by socioeconomic status (SES). Data from the Australian Longitudinal Survey of Women's Health (ALSWH) show that among ALSWH participants aged 45-50, physical health was poorer among those of low SES at the start of the study and declined more quickly over the following 15 years than among those of higher SES. Mental health in this cohort was poorer at the start for women of low SES and improved more slowly in ensuing years among those of low SES compared with women of high SES (Williams et al. 2013).

Chronic diseases are more common in the second half of working life than in the first, and this can have an impact not only on people's health, but also on their working and earning capacity, and ability to care for other family members. As with the younger group, vision problems (90%) and back pain (20%) were in the top 3 most common long-term health conditions experienced by people aged 45-64, according to results from the 2011-12 AHS. The proportion of people who reported long-sightedness was much higher in people aged 45-64 than those aged 25-44 (57% compared with 12%).

Hay fever and respiratory conditions (such as asthma and sinusitis) were less prominent in this older age group, with high blood pressure (17%) and osteoarthritis (15%) being more prominent.

Vision problems, back pain, high blood pressure and osteoarthritis were also the most commonly reported chronic conditions among people aged 45-64 in the earlier 2007-08 National Health Survey.

About 14% of the 45-64 age group reported mood problems such as depression in 2011-12, and 5% reported experiencing anxiety-related problems.

According to the 2011-12 AHS, the health of people aged 45-64 was at risk due to poor nutrition and lack of exercise. Figure 6.25 shows the proportion of men and women with selected health risk factors.

Figure 6.25: Prevalence of selected health risk factors in people aged 45-64, by sex, 2011–12

Bar chart showing the prevalence of selected health risk factors in people aged 45-64, by sex, in 2011-12. Inadequate fruit and vegetable consumption, 'overweight and obesity' and insufficient physical activity were the most prevalent health factors, followed by high blood pressure, daily smoking and risky alcohol use (long-term).
  1. Includes all people reporting sedentary or low activity.
  2. Defined as blood pressure of 140/90 mmHg or higher.

Sources: AIHW analysis of ABS 2013a, 2013b.

While more people in this age group met the NHMRC guidelines for fruit and vegetable consumption than in the 25-44 age group, the majority still fell short. In addition, overweight and obesity rates were higher among people aged 45-64, as were rates of physical inactivity. However, the greatest change was seen in the proportion of people with high blood pressure. Men aged 45-64 were twice as likely to have high blood pressure as men aged 25-44, and women were nearly 3 times as likely. In contrast, the proportion of men aged 45-64 who smoked daily was lower than for men aged 25-44 (19% compared with 22%), and the proportion for women was also slightly lower (15% compared with 17%).

Alcohol consumption at short-term risky levels was also lower in this age group than in those aged 25-44. In 2011-12, 40% of men aged 45-64 reported drinking at short-term risky levels in the 12 months before the survey compared with 61% of men aged 25-44. The corresponding proportions for women were 24% compared with 43%. However, there was a different pattern in long-term risky alcohol consumption. The same proportions of men aged 25-44 and 45-64 reported drinking at long- term risky levels (14%), whereas for women, the proportion was higher among those aged 45-64 (12% compared with 9%).

Compared with rates in 2007-08, levels of overweight and obesity among people aged 45-64 have risen from 70% to 73% in 2011-12 (ABS 2009b, 2013a). However, in a similar pattern to those aged 25-44, the proportion of those aged 45-64 who were current daily smokers decreased from 19% in 2007-08 to 17% in 2011-12.

The influence of risk factors on the health of Australians aged 45-64, and their likelihood of developing chronic diseases, begins to show in the leading causes of death among this age group. Compared with the younger age group, people aged 45-64 were more likely to die due to a chronic disease. In 2011, cancer and coronary heart disease (diseases that reduce blood supply to the heart, such as a heart attack) were the predominant conditions causing death in both men and women (Table 6.2).

Table 6.2: Leading causes of death(a) in people aged 45-64, by sex, 2011(b)
Rank Men No. % Women No. %
1 Coronary heart disease (I20-I25) 1,968 15.5 Breast cancer (C50) 999 13.0
2 Lung cancer (C33-C34) 1,174 9.3 Lung cancer (C33-C34) 818 10.6
3 Suicide (X60-X84) 549 4.3 Coronary heart disease (I20-I25) 457 5.9
4 Diseases of the liver (K70-K77) 541 4.3 Bowel cancer (C18-C20) 348 4.5
5 Bowel cancer (C18-C20) 463 3.7 Chronic lower respiratory diseases (J40-J47) 306 4.0
  1. Based on ICD-10 groupings.
  2. Deaths registered in 2011 are based on the preliminary version of cause of death data and are subject to further revision by the ABS.

Source: AIHW National Mortality Database.

The leading causes of death in this age group were largely unchanged between 2006 and 2011 for women. For men, however, there was a 19% fall in the proportion of deaths caused by bowel cancer, a 10% fall in deaths caused by coronary heart disease and a 6% rise in deaths caused by diseases of the liver (AIHW analysis of National Mortality Database).

The relationship between work and health

The importance of the health of working-age people was recognised in a review presented to the British Secretaries of State for Health and for Work and Pensions in 2008 (Black 2008). This was the first review that measured the economic costs of ill health and its impact on work in Britain, while acknowledging the human and social costs. The review identified risk factors and causes of ill health in the working-age population and recommended interventions to minimise their effects.

Sweden's National public health report in 2012 also explored the main causes of death and hospitalisations and the impact of workforce participation and lifestyle factors on the working-age group's wellbeing (Danielsson & Berlin 2012). A Japanese study, which looked at the impact of income on self-assessed health, found that health was better in employed people (Kachi et al. 2013), while a study of the United States working-age population showed that people with higher education levels were more likely to report their health as excellent (Zajacova et al. 2012).

In Australia, this topic has been approached mainly from an economic perspective where data from surveys that track working-age people over time have been used to explore the relationships between health and labour force participation (Cai & Cong 2009; Cai & Kalb 2006, 2005, 2004; Carter et al. 2013) and between health and income (Brown & Nepal 2010; Gunasekara et al. 2013).

Australians who are in good health and have fewer health conditions are more likely to participate in the labour force (Cai & Cong 2009; Cai & Kalb 2006, 2005, 2004; Pit et al. 2012; Schofield et al. 2008). People who are not employed may experience poorer health. A British review of research into the health benefits of work found that, in general, work improves physical and mental health and wellbeing (Waddell & Burton 2006). The research showed that unemployed people had poorer physical and mental health, higher rates of hospitalisation and were more likely to die than those who were employed. However, people in poor health were also unlikely to be employed.

Despite its overall beneficial effects, at times work can also be harmful to health. Workers may be injured or killed while doing their jobs, and some may develop health conditions from their work practices-for example, people who are exposed to asbestos at work may develop mesothelioma. Serious work-related injuries and illnesses, which involved death, permanent incapacity or temporary incapacity requiring absence from work of 1 week or more, were 25% more common in men than in women in 2010-11 (Safe Work Australia 2014). Preliminary compensation claims data indicate that there were 128,050 serious claims in 2011-12 in Australia, or 12.2 serious claims per 1,000 workers. In the same year, 228 workers died from a work injury, which equated to a rate of 2.0 deaths per 100,000 workers. The incidence rates of serious claims and fatalities have fallen since 2003-04, when there were 16.5 serious claims per 1,000 workers and 3.3 deaths per 100,000 workers (SafeWork Australia 2013a).

While Australians work fewer hours a year than the OECD average (1,693 hours a year compared with 1,776 hours), their labour productivity, measured by gross domestic product per hours worked, is above the OECD average, suggesting that Australians are more productive when they are at work (Conway & Meehan 2013). However, the proportion of Australian employees who work very long hours is higher than the OECD average. More than 14% of Australian employees work more than 50 hours a week, compared with the OECD average of 9% (OECD 2013).

Long hours, heavy workload and job insecurity can lead to work-related stress, which may result in long-term absences from work, and has been estimated to cost the Australian economy $14.81 billion a year (Safe Work Australia 2013b). Work stress through high job demands and low job control has also been shown to increase the risk of developing mood and anxiety disorders, coronary heart disease and metabolic syndrome, which can be a precursor to type 2 diabetes, stroke and heart disease (Chandola et al. 2006; Marmot et al. 1997; Rosengren et al. 2004; Szeto & Dobson 2013). Body-stressing, caused by lifting, repetitive movements or awkward postures at work, was responsible for 40% of serious compensation claims and was the most common mechanism of workplace injury or disease in 2010-11.

The relationship between work and health can also have an influence later in life through income security, savings and superannuation contributions, which can affect physical and mental health as well as self-esteem. In 2007, 15% of males and 23% of females aged 45-64 had no superannuation coverage (ABS 2009a). Average retirement savings are generally lower for women, who historically have lower rates of employment participation and are more likely than men to have breaks in employment due to having and caring for children. In addition, divorces can have a negative impact on both men and women's financial status in later life (Caruana 2011). On the other hand, poor health and disability in either males or females may result in decreased workforce participation, loss of earnings and decreased capacity to save for older age. People of lower SES tend to have poorer general and mental health, and fare more poorly in these measures over time compared with people of higher SES.

Research indicates that overall, work is beneficial to physical and mental wellbeing (AFOEM 2011). Working improves people's economic situation, increases their self-esteem and promotes community connectedness. These outcomes benefit not only individuals, but also their families and society as a whole.

What is missing from the picture?

Information on the effects of life events and transitions on Australians' health is limited because not all health-related data sets collect information on aspects such as marital status and employment status. Even if these data were collected for a particular point in time, they may not be useful when looking at how these factors affect the development of long-term health conditions compared with data from long-term studies that collect data at many points in time. Health is also multidimensional and it may not always be clear whether it is a cause or an effect of other aspects of life. For example, people who work may be healthier because work has beneficial effects or because people who have poor health may be less likely to be working.

Further information on the health of working-age Australians will be available when the ABS releases more results from the 2011-12 AHS. In addition, the AIHW is using 2011 data to measure the burden of disease experienced by Australians, which will provide updated information on the effect of disability, long-term conditions and premature death on the working-age population.

Where do I go for more information?

More information on the health and wellbeing of working-age Australians is available. Recent AIHW reports and other publications available for free download include: The health of Australia's males: 25 years and over and Young Australians: their health and wellbeing 2011.

See Chapter 7 for information on the health of Indigenous Australians. Information on the impact of life events and transitions on families can be found on the Australian Institute of Family Studies website.

References

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6.9 Ageing and the health system: challenges, opportunities and adaptations

Older Australians are accounting for an increasing share of the population (see Chapter 1 'Who we are'). In 2013, 14% of the population (3.3 million people) were aged 65 and over and 1.9% were aged 85 and over (439,600 people). By 2053, based on Australian Bureau of Statistics (ABS) medium-level growth assumptions, 21% of the population will be aged 65 and over (8.3 million people) and 4.2% aged 85 and over (1.6 million people) (Figure 6.26).

Figure 6.26: Number and proportion of older people, 2013-2053

Combined line and column chart indicating the increase in the aging population from 2013 through 2053. The proportion of the population aged 65 and over is expected to more than double by 2053 (to over 4% of the total population), compared with less than 2% in 2013.

Note: Data are as at 30 June. Data presented for 2023 onwards are based on population projections (series B).

Sources: AIHW analysis of ABS 2013a, 2013j.

As well, health and social trends are changing the circumstances of our older population, redefining what it means to be 'old' (see Box 6.5).

There is concern that this ageing of the population will put unsustainable pressure on public spending, with particular concerns about rising health costs and the ability of the health system to serve the increasing numbers of older people needing care. These issues are discussed at some length in this article (see also Chapter 2 'How much does Australia spend on health care?').

Undoubtedly, ageing will present challenges to the health-care system, given the larger number of older people, the fact that many health conditions and associated disability become more common with age, and that older people are higher users of health services. However, the majority of Australians consider themselves to be in good health, and manage to live independently-with or without community-based supports-until their final days. Further, good health is itself a resource, enabling older people to contribute socially, culturally and economically to the community-and evidence suggests that many are.

This article analyses the key areas of challenge for the health system as it adapts to an ageing population. It then sets out ways Australia's health system is adjusting, and can continue to adapt.

Box 6.5: How do we define 'old'?

For population measurement purposes, 'old' is conventionally defined as people aged 65 and over, based on the original qualifying age for the Age Pension. While this article also uses this convention, it is important to stress that at the individual level, a person does not necessarily become frail or 'dependent' at age 65 (or at any other particular age).

Like the broader Australian population, the group of 'older people' is far from uniform. The diversity of the older Australian population, combined with ongoing changes in the health, economic and social circumstances faced by all Australians, results in a very complex range of differing circumstances and needs as we grow older. Where possible in this article, data referring to the 65-and-over age group are split into subcategories (for example, 65-74, 75-84 and 85+) since health, and the need for health services, often varies with age.

Ageing and the health system: key challenges

The ageing of the population will have far-reaching implications for society. Direct challenges for the health system will include changing health profiles, increased demand for health service use, and rising health costs.

The challenges are twofold: first, the rapidly growing group of 'old old' (85 and over) people who have a range of typical age-related health problems (for example, arthritis, dementia and cancer); and secondly, the younger cohort entering the '65 and over' age bracket with a larger burden of lifestyle- related diseases (for example, type 2 diabetes) than previous generations.

Further, social changes among the next generation of older people-such as greater understanding and awareness of health issues and greater expectations of health services-pose additional challenges. These challenges may influence future models of health-care delivery and engagement.

Changing health profiles

A key challenge for the health system will be how to best meet the health needs of an ageing population and, in particular, how to manage the increasing impact of chronic disease.

The prevalence of many health conditions is higher in older age groups (Figure 6.27). The 2011-12 Australian Health Survey (AHS) shows that, among older Australians living in households, the most common long-term health conditions (excluding short- and long-sightedness) are arthritis (affecting 49% of those aged 65 and over), hypertensive disease (38%) and hearing loss (complete or partial) (35%) (AIHW analysis of ABS 2012a). Just over 1 in 5 older people (22%) reported having heart, stroke and vascular diseases, 15% had diabetes, and 7% had cancer. Age-related vision problems that are likely to be disabling include cataracts (affecting 10% of those aged 65 and over), glaucoma (3%), macular degeneration (5%) and blindness (2%).

Figure 6.27: Prevalence of selected self-reported health conditions among people aged 55 and over, by age group, 2011-12

Column chart showing the prevalence of selected self-reported health conditions among people aged 55 and over, by age group, in 2011-12. Arthritis and hypertensive disease were the two most commonly reported in all given age groups (55-64, 65-74 and 75 years and over). Others shown include: heart, stroke and vascular diseases; osteoporosis; diabetes; and genito-urinary system disease.

Source: AIHW analysis of ABS 2012a.

Dementia is a significant health problem among older Australians-an estimated 332,000 Australians had dementia in 2014, of whom 93% were aged 65 and over. Based on projections of population growth and ageing, the number of people with dementia is estimated to reach around 900,000 by 2050 (AIHW 2012). (See Chapter 6 'Dementia, dementia treatment and the future' for more information.)

Older people are also more likely than younger people to have multiple long-term health conditions. For example, in 2009, about 49% of people aged 65-74 had 5 or more long-term health conditions, increasing to 70% of those aged 85 and over (ABS 2010).

Falls are common among older people and often result in fractures or other serious injuries (Bradley & AIHW 2013). In 2009-10, there were an estimated 83,800 hospitalisations due to falls in people aged 65 and over (accounting for 1 in 10 days spent in hospital by older people) (Bradley & AIHW 2013). Older women sustained a greater number of hospitalised fall injuries than men (constituting 69% of cases in 2009-10), and the rate of fall injuries increased with age in both sexes.

Despite the increasing prevalence of many conditions with age, most older people consider themselves to be in good health. The 2011-12 AHS shows that, of older people living in households, 76% of those aged 65-74 and 67% of those aged 75 and over rated their health as excellent, very good, or good (ABS 2013c). In comparison, in the 2004-05 National Health Survey, 69% of people aged 65-74, and 65% of those aged 75 and over rated their health as good, very good, or excellent (ABS 2006). Research indicates that the simple measure of self-rated health has complex determinants, but is consistently associated with major health outcomes such as physical and functional health status, health service use, stroke and death (French et al. 2012).

Broader population trends in chronic disease are also important in the context of the health of the future older population. These trends are mixed. On the positive side, there has been a substantial reduction in deaths due to chronic disease in Australia (see Chapter 4 'Chronic disease-Australia's biggest health challenge'). For example, since 1980, mortality due to coronary heart disease and stroke has declined by 73% and 69% respectively. On the negative side, chronic diseases have been the leading causes of illness and death in Australia for many decades, and risk factors for these conditions have become more common. For example, in 2011-12, 63% of Australian adults (aged 18 and over) were overweight or obese, compared with 56% in 1995 (ABS 2013c). As such, the future older population may have a larger burden of lifestyle-related diseases than in the past.

Disability and disability-free life expectancy

Population ageing is expected to result in an increase in the absolute number of people with disability, simply because there are more people in the older age groups and disability becomes more common with age. Data from the ABS 2012 Survey of Disability, Ageing and Carers (SDAC) indicate that just over half (53%, or 1.7 million people) of Australians aged 65 and over had disability; this compares with 16% of those aged 25-64 and 7% of those aged under 25 (AIHW analysis of ABS 2013d).

In 2012, 1 in 5 older Australians (20%, or nearly 663,000 people) had severe or profound core activity limitation, meaning that they sometimes or always needed assistance with at least 1 core activity (self-care, mobility or communication), with higher rates among women than men (ABS 2013d).

However, an important question is whether, as overall life expectancy has lengthened, the number of years lived with disability has fallen or risen. In 2012, women aged 65 could expect to live an additional 22.0 years of life and men an additional 19.1 years, compared with 19.8 and 16.1 in 1998 respectively (Figure 6.28). In 2012, older women could expect to live 9.5 years free of disability, 6.7 years with disability but no severe or profound core activity limitation, and 5.8 years with a severe or profound core activity limitation (8.7, 6.7 and 3.7 years for men).

Figure 6.28: Expected years of life at age 65, by disability status and sex, 1998 and 2012

Bar chart showing expected years of life at age 65, by disability status and sex, in 1998 and 2012. Data are shown in years for those: free of disability; with disability but no severe or profound core activity limitation; and those with a severe or profound core activity limitation. Women typically had greater expected years of life than men.

Note: People with a severe or profound core activity limitation always or sometimes require help with communication, mobility and/or self-care.

Sources: AIHW analysis of ABS 1998 Survey of Disability, Ageing and Carers confidentialised unit record file; ABS unpublished data table of 2012 Survey of Disability, Ageing and Carers; ABS unpublished abridged Australian life tables 1996-1998, 2010-2012.

AIHW analysis indicates that, between 1998 and 2012, between 37% (females) and 54% (males) of the gains in life expectancy were years free of disability, and between 76% (males) and 89% (females) of the gains were years without severe or profound core activity activity limitation. This suggests that not only are people living longer, but that older people, on average, gained more years of life without severe or profound limitation than with it.

More detailed analyses of changes in life expectancy and disability in Australia will be published by the AIHW in the second half of 2014.

Increasing demand for health services

Demand for health services is affected by many factors, but older people are generally higher users of health services than younger people, and so demand is expected to increase with the ageing population.

Older people are more likely to visit health professionals than younger people. According to the 2011-12 AHS, 98% of people aged 65 and over had consulted at least 1 health professional in the previous 12 months, compared with 90% of those aged under 65 (ABS 2013b). Among people aged 65 and over, 96% had consulted a GP in the previous 12 months, including 38% who had done so in the previous 2 weeks compared with 82% and 18% of those aged under 65, respectively.

In terms of other health services, 57% of older people had consulted a specialist within the last 12 months (compared with 28% of people aged under 65), and around 20% had been admitted to hospital as an inpatient (compared with 11% of younger people) (AIHW analysis of ABS 2013b).

The AHS does not include information about people living in residential aged care. Administrative data provided to the AIHW National Aged Care Data Clearinghouse show that, at 30 June 2013, there were nearly 169,000 people living in permanent residential aged care. Between 2003 and 2013, the number of permanent residents in aged care rose by just over 20%. Within this total increase, the number of residents aged 85 and over rose by 37%, with this group accounting for just over 58% of the total population of permanent aged care residents (up from around 51% in 2003). These rises reflect growth in the older population, as well as associated increases in government-subsidised residential places (which are set to increase further following recent aged care reforms).

Most permanent residents in aged care facilities are highly dependent, with 82% receiving high-level care at 30 June 2013. Information about the health conditions of residents is collected as part of an assessment of their care needs. Up to 3 mental and behavioural disorders (such as dementia) can be recorded, as can up to 3 other medical conditions that impact on care needs. Circulatory disease was the most common main (first listed) condition (22%) followed by musculoskeletal conditions (19%) and endocrine disease (including diabetes) (8%). Fifty-two per cent of permanent residents had diagnosed dementia. About half of all permanent aged care residents had symptoms of depression (52% at 30 June 2012), and about 45% of people who were admitted for the first time to residential aged care from 2008 to 2012 had symptoms of depression (see AIHW 2013b).

Higher use of health services by older people also has implications for the health workforce. The health labour force in Australia is large and diverse, covering many occupations, ranging from highly qualified professionals to support staff and volunteers. An ageing population will require an adequate health workforce-in terms of numbers, distribution, and skill set-to meet changing needs and increased demand (Scott 2009). Future shortages of appropriately skilled workers are also expected to be a particular challenge in the aged care sector (see Productivity Commission 2011).

Funding rising health costs

With older people being high users of the health system, and health costs being higher in older age groups, population ageing has led some to express concerns about unsustainable pressure on expenditure within the health system. The relationship between ageing and health costs is complex, however, and there is considerable debate about the extent to which current and projected growth in health expenditure should be attributed to population ageing (see Chapter 2 'How much does Australia spend on health care?' for details about these issues). Notwithstanding this, there is little doubt that some increased health costs will be attributable to the ageing population and that health systems and policies will need to adapt to this significant demographic shift.

Funding for health goods and services comes from a range of sources, including the Australian Government; state and territory, and local governments; non-government sources such as private health insurers and injury compensation insurers; and out-of-pocket payments by individuals.

Government funding

Governments are the main funders, with about 70% of total health expenditure coming from government sources in 2011-12. As outlined in Chapter 2 ('How much does Australia spend on health care?'), over the last decade increases in government health expenditure have been largely matched by increases in government tax revenue. Whether this will continue in the future is unclear because projecting future tax revenue is complex. At the least, such projections need to take account of the ways that labour supply and productivity patterns may change over time as the economy diversifies and education levels in the population increase (Productivity Commission 2005).

Personal resources to fund health care

In 2011-12, individuals contributed about 17% of health funding. Older people tend to have lower incomes, but are also more likely to have greater wealth (although this is unevenly distributed) (ABS 2013f).

Property constitutes over half the total net worth of 'older' households (AIHW analysis of ABS 2013f ). Although these funds can in theory be accessed by means such as reverse mortgages, they are generally not readily accessible to fund health and other costs. Moreover, older people who do not own their homes spend a high proportion of available income on housing (AIHW 2013a), leaving a smaller proportion available for health and other costs.

The next generation of older people-the baby boomer cohort-has on average higher levels of income and wealth than previous generations. However, this is also not evenly distributed (Productivity Commission 2011), with 60% of the group's net worth held by the wealthiest quarter, and only 4% held by the poorest quarter (AMP & NATSEM 2007).

Labour force participation among older people is also increasing (see Chapter 1 'Who we are'), which will help to offset expenditure growth, both directly and through the contribution of a longer working life to superannuation balances.

At 30 June 2013, 51% of people aged 65 and over had private hospital insurance, compared with 40% in June 2003 (AIHW analysis of ABS 2013a; PHIAC 2013). The proportion of older people covered by ancillary or extras (officially known as general treatment) increased from 31% to 44% in the decade to June 2013. Among older people, in 2013, 55% of those aged 65-74 had hospital coverage, compared with 38% of those aged 85 and over. The proportion with ancillary coverage was 50% for those aged 65-74, and 27% for those aged 85 and over. From the age of 65 onwards, higher proportions of the population were covered by hospital insurance than by ancillary.

Superannuation coverage is increasing; in 2010-11, around 64% of people aged 45 and over who were retired from the labour force had made contributions to a superannuation scheme, compared with 56% in 2008-09 (ABS 2009b, 2011a). However, many older Australians have never contributed to a superannuation scheme, or have done so for a relatively short time. Increased superannuation is not expected to significantly reduce the proportion of people receiving a pension, but it is expected to result in a greater shift towards part (rather than full) pensions (Productivity Commission 2013).

Pockets of pressure

The challenges associated with an ageing population are likely to be greater among some groups and geographic regions of Australia, and the demand for health services is likely to differ among locations and service types.

Differences by sex

In 2012, women accounted for 54% of people aged 65 and over, 65% of people aged 85 and over and 81% of all centenarians.

Older women are more likely to need assistance with daily activities and have higher rates of severe disability than men. According to the 2012 SDAC, 37% of women aged 75 and over had a severe or profound core activity limitation, compared with 26% of men (ABS 2013d). Older women were also more likely to report needing assistance with daily activities (for example, housework, health care and property maintenance). In 2012, 49% of women aged 65 and over reported needing assistance with at least 1 activity due to age or disability, compared with 34% of older men (ABS 2013d).

Women's greater life expectancy, together with lifetime differences in earnings and workforce participation, means that many older women experience economic vulnerability. Although superannuation coverage is increasing, there remain large gaps between the retirement savings of Australian men and women. In 2009-10, the average superannuation balance for women aged 60-64 was just over half that of the average balance for men (AIHW analysis of ASFA 2011).

Older Aboriginal and Torres Strait Islander Australians

The Indigenous population still has a relatively young age structure due to their lower life expectancy and higher fertility rate compared with non-Indigenous Australians. At 30 June 2011, there were about 22,700 Indigenous Australians aged 65 and over (constituting 3.4% of the Indigenous population), and 88,200 aged 50 and over (13%) (AIHW analysis of ABS 2013e). The number of older Aboriginal and Torres Strait Islander people is increasing, however, and those aged 50 and over have poorer health and higher rates of disability than non-Indigenous Australians of the same age (AIHW 2011a, 2013a). This, together with the central role that older Indigenous people play in maintaining culture and traditions in their communities (Cotter et al. 2007), means that particular attention needs to be paid to the health care and support needs of older Indigenous Australians (AIHW 2011a). (See Chapter 7 for information about the health and health system use of Indigenous Australians.)

Differences by geography

The age profile of the population varies between different regions of Australia. In 2013, the proportion of people aged 65 and over ranged from 6% in the Northern Territory to just over 17% in Tasmania.

In general, older people are more likely to live outside capital cities-at 30 June 2012, 16% of those living outside capital cities compared with 13% of people living in greater capital cities were aged 65 and over (AIHW analysis of ABS 2013i). Consequently, regional areas-particularly those with high concentrations such as the mid-north coast of New South Wales where one-quarter of the population is aged 65 and over-are likely to require a relatively greater focus of services targeted at older people than cities.

Differences by cultural diversity

Some health characteristics also vary by cultural diversity. For example, after taking into account differences in age structures and response rates of the population groups, 2011 Census data indicate that older people born overseas in non-main English-speaking countries (25% of those aged 65 and over) were somewhat more likely to report needing help with core activities-that is, activities related to mobility, self-care and communication-than those born in Australia (17%) and those born in main-English-speaking countries (15%) (see AIHW 2013a: Table A5.7). ABS data also indicate that people (of all ages) born in non-main English-speaking countries have lower levels of health literacy (ABS 2008).

The overseas-born population has an older age structure than the Australian-born population. At 30 June 2013, more than one-third (37%) of Australians aged 65 and over were born overseas-14% in main English-speaking countries and 23% in other countries (ABS 2013g). Of all people born overseas, 19% were aged 65 and over, compared with 13% of people born in Australia.

Overseas-born older Australians are likely to be from European countries, having migrated after World War II. In 2013, 72% of older overseas-born people were born in Europe (AIHW analysis of ABS 2013g). Since the 1970s, migrants (of all ages) have increasingly come from non-European countries, particularly Asian countries (ABS 2013g). For example, in 2013, a higher proportion of overseas-born Australians aged 55-64 were born in Asia than those aged 65 and over (26% compared with 14%), while a smaller proportion were born in Europe (50% compared with 72%) (AIHW analysis of ABS 2013g).

Differences by socioeconomic status

Socioeconomic factors, including associated disadvantage, are important determinants of health. In general, overall health tends to improve with each step up the socioeconomic ladder, commonly referred to as the socioeconomic gradient of health. For example, data from the 2011-12 AHS show that people who live in areas of most disadvantage were more likely than those in areas of least disadvantage to report certain long-term health conditions (such as diabetes and heart, stroke or vascular disease) and to be obese or smoke (ABS 2013c). Poor health can itself contribute to disadvantage, through, for example, lack of employment due to ill health (Case et al. 2005).

Health inequalities impose costs on society, both in terms of health care and lost productivity. The very existence of health inequalities implies that there is scope for population health gain.

The future-responses to an ageing population

As outlined above, the ageing of the population presents a number of challenges to Australia's health system. This means that the mix of services required by society, and the ways in which they are funded and delivered, will need to change as the population ages. There are ways-examples are outlined below-in which Australia can adapt to an ageing population and respond to the challenges it presents. The mix and intensity of these strategies will vary in response to the needs of people and local communities with particular characteristics.

Promoting good health across the lifespan

Ageing is associated with increased risk of many health conditions, disability and dependency. Research indicates, however, that the association between health status and age is more variable than often assumed, as many chronic conditions are preventable (or can at least be postponed) and are not an inevitable consequence of ageing (Khaw 1997).

Postponement of disease involves 4 strategies: prevention of risk factors for disease; reduction of the prevalence of risk factors before disease develops; prevention of progression of disease after onset; and reduction of morbidity from disease/complications that have already developed (Fries et al. 2011).

The high prevalence of certain modifiable risk factors for chronic disease among Australians suggests that opportunities for health improvement exist. Compared with other OECD countries, Australia's smoking rates in the general population are low, but rates of drinking alcohol, and being obese and sedentary, are all high (ABS 2012b). Encouraging wellbeing across the lifespan is an important means of improving the health of future generations of older people.

Enabling healthy ageing

Another key response is to maintain and improve the health and quality of life of current cohorts of older people, through better management of chronic conditions and multi-morbidity, and through broader strategies to enable healthy and active ageing.

The terms 'healthy ageing', 'successful ageing', 'active ageing', 'positive ageing' and 'productive ageing' are often used interchangeably with no agreed term or definition (Cosco et al. 2013; Cyarto et al. 2013). Regardless of the term used, there is a growing consensus that ageing well is about more than the absence of disability or disease (Bowling & Iliffe 2011; Bryant et al. 2012; Carstensen et al. 2011; Hung et al. 2010). Healthy ageing is not only a state, but also a process, for example, engaging in health-promoting behaviours and adapting successfully to life's circumstances.

In this vein, research suggests that perceived self-efficacy and optimism are associated with quality of later life (Bowling & Iliffe 2011). The importance of encouraging active lifestyles throughout the lifecycle is indicated by research showing physical activity and sitting time are independently associated with self-rated excellent health and quality of life in men and women aged 45 and over (Rosenkranz et al. 2013).

The primary health care sector plays a vital role in promoting and supporting healthy ageing, with GPs and other allied health professionals instrumental in providing lifestyle advice, managing disease risks and avoiding or averting complications of disease before the onset of old age, as well as during old age.

Aged care programs also provide a setting for preventative health care, given evidence of the high rates of modifiable lifestyle risk factors and health conditions among recipients of such programs (Jorm et al. 2010). Other targets for preventive health care among older people might include programs to prevent falls and fractures, as these are relatively common among older people, and add considerable costs to the health system (Bradley & AIHW 2013).

Enabling healthy ageing is not limited to the health or aged care system. For example, many older Australians express the desire to remain in their own homes for as long as possible (AIHW 2013c). However, this requires that there are appropriate health and social services available in the community setting. A cross-national study found that people who live in more accessible homes, and those who think that external influences are not responsible for their housing situation, have a better sense of wellbeing and are more independent (Oswald et al. 2007).

Supporting socioeconomic participation

Supporting and better enabling the economic and social participation of older people within the community is also likely to be an important means of mitigating the challenges associated with an ageing population.

Health is positively associated with engagement in paid work (Cai 2010; Pit et al. 2010; Schofield et al. 2013). Consequently, promoting good health has the potential to bring health gains to the individuals and increase their ability to participate actively in the workforce and more generally in the community.

Older people are increasingly likely to remain in the workforce beyond the traditional retirement age. In 2013, 12% of people aged 65 and over were in the labour force; this was an increase from 6% in 2003 (AIHW analysis of ABS 2014). Among people aged 65-69, the proportion of women in the labour force was 2.3 times as high in 2013 (20%) as in 2003 (8.5%), and 1.7 times as high for men (33% and 20% respectively).

Removing barriers to labour force participation is an important aspect of enabling older people who want to remain in the workforce to do so. In September 2012, there were about 64,300 people aged 55 and over who wanted, and were available for, work, but were not actively looking for a job because they believed they would not find one (referred to as 'discouraged job seekers'). In September 2012, discouraged job seekers aged 55 and over represented 60% of all discouraged job seekers (ABS 2013h). Of older discouraged job seekers, the most commonly reported main reason for not actively looking for work was that they believed they were considered too old by employers (59%).

As well, many older Australians make indirect economic and other contributions to the community through voluntary work, as carers, and as providers of informal child care. According to the ABS 2010 General Social Survey, 31% of people aged 65 and over had participated in voluntary work in the previous 12 months (AIHW analysis of ABS 2011b). Of those older people who volunteered, 55% did so at least fortnightly, compared with 45% of those aged 18-64.

In 2012, an estimated 579,700 Australians aged 65 and over (19%) were informal carers, providing unpaid support and assistance to relatives and friends who were aged, ill or living with disability (ABS 2013d). In addition, in 2011, grandparents provided care on a regular basis for 26% of children (or 937,000 children) aged 12 or under; this was higher than in 2008 (19%) (AIHW analysis of ABS 2009a, 2012c).

Enhancing productivity in health-care delivery

One way to mitigate increased health costs associated with the ageing population is to improve productivity in health care. Along with broader efforts to improve the efficiency of the health system (see Chapter 2 'How much does Australia spend on health care?'), there is scope for specific efforts focused on the care of older people. For example, with of high rates of chronic conditions and use of multiple medications within the older population (Morgan et al. 2012; Schofield et al. 2013), a focus on efficient coordination of care, and safe and effective use of medicines, can reduce the risk of duplication of tests and medical records not being available at the time of care.

Productivity of the health system can also be enhanced by recognition of its interaction with the aged care system, together with efforts to ensure that relevant care is provided in the most appropriate setting. Interaction between residential aged care and the hospital system is common-1 in 4 residents (25%) had at least 1 admission to hospital in 2011-12. A recent study of movements between hospital and residential aged care in 2008-09 estimated that 9% of hospital admissions involved permanent aged care residents (AIHW 2013d; see also Chapter 6 'Movement between hospitals and residential aged care').

What is missing from the picture?

There are several information gaps relating to the relationship between ageing and health. Firstly, the process of healthy ageing is not well understood. While quality information exists about the health status of older Australians, much less is known about the interaction of different components, such as the interdependent relationships among physical, mental and social wellbeing.

As well, projections of the future health of the ageing population and of health expenditure are particularly sensitive to the choice of underlying assumptions. For example, models may make assumptions about the health profile of older people, use of new health technologies and labour force participation, all of which are likely to change over time. Consequently, modelling needs to be kept up to date with any changes in the factors and assumptions underlying the model.

In addition, there are only limited data available about certain groups of the older population, including Indigenous Australians and people in the oldest age groups (such as those aged 85 and over). Longitudinal studies such as the 45 and Up Study, which involves more than 250,000 people in New South Wales and is the largest ongoing study of health ageing in the Southern Hemisphere (Sax Institute 2013), may help to fill some of these gaps and will contribute to our understanding of ageing and health.

With regard to health service provision, there is a lack of data relating to client outcomes, experiences of care and transitions within and between health and aged care services. Data linkage work has the potential to provide a picture of movements through services. For example, linked data has been used to look at pathways in aged care among a cohort of 105,100 people (see AIHW 2011b).

Where do I go for more information?

More information on ageing and the health of older people in Australia is available.

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6.10 Dementia, dementia treatment and the future

Dementia is a major health problem in Australia. It has profound consequences for the health and quality of life of people with the condition, as well as for their families and friends. Dementia describes a syndrome caused by many different diseases affecting the brain (see next section, 'What is dementia?'). Dementia is generally progressive in nature, and its impact increases with the growing severity of the condition. People with dementia eventually become dependent on their care providers in most, if not all, areas of daily living (unless they die from another condition first).

Although dementia is not an inevitable part of ageing and can affect younger people, it becomes more common with increasing age and primarily affects older people. Thus, one of the expected consequences of the continued growth and ageing of Australia's population is an increase in the number of people with dementia over time.

The increasing number of people with dementia will pose numerous challenges to Australia's health and aged care systems, arising from the increased need for care services, support for carers, training for health professionals and aged care workers, and research into effective treatment and prevention strategies.

What is dementia?

Dementia is not a single specific disease, but an umbrella term describing a syndrome-or group of symptoms-associated with more than 100 different diseases. It is characterised by the impairment of brain functions, including language, memory, perception, social awareness, reasoning and cognition. Although the type and severity of symptoms and their pattern of development varies with the type of dementia, it is usually of gradual onset, progressive in nature, and irreversible.

There is no single or simple test that will definitively diagnose dementia (see Box 6.6), and dementia is often unrecognised and/or undiagnosed until it is in the later stages. There tends to be a substantial gap between when symptoms are first noticed and when assistance is first sought from a health professional, and a further gap before the condition is actually diagnosed.

The most common types of dementia are Alzheimer disease (thought to account for about 50% to 75% of cases worldwide), vascular dementia (20% to 30%), frontotemporal dementia (5% to 10%) and dementia with Lewy bodies (up to 5%) (ADI 2009).

In addition to the 4 most common types of dementia, there are many other less common types, including dementia caused by other diseases (such as Parkinson disease, Huntington disease and Creutzfeldt-Jakob disease), HIV/AIDS-related dementia, and dementia due to metabolic causes or trauma.

The literature is inconsistent in terms of how common the various types of dementia are. Reasons for this may include the lack of distinct borders between the different types of dementia, and that a definitive diagnosis cannot be made unless autopsy evidence is available (which is rarely the case). Also, some studies suggest that mixed forms of dementia (for example, the coexistence of Alzheimer disease and vascular dementia) may be more common than 'pure' forms (ADI 2009).

The course of dementia is often characterised as occurring in 3 stages: mild or early-stage dementia, moderate or middle-stage dementia, and severe or late-stage dementia (see AIHW 2012: Table 1.1). There are overlaps between the stages, and identifying the stage that a person has reached is not always straightforward (Draper 2011).

Box 6.6: Assessment and diagnosis of dementia

The assessment process for dementia may vary according to both the person conducting the assessment and the symptoms the person presents with. In general, the aim of the assessment is to gather sufficient information about changed behaviours, functional capacity, psychosocial issues and relevant medical conditions to allow for a diagnosis to be made and a management plan to be formulated.

Often, the information-gathering process includes input from third parties (for example, carers, family members and service providers) and the use of screening tools. A wide range of screening tools are available, including the Mini-Mental State Examination (MMSE), the General Practitioner assessment of Cognition (GPCOG), the Rowland Universal Dementia Assessment Scale (RUDAS), and the 7-Minute Screen.

If the results from a screening test suggest cognitive impairment, a more comprehensive assessment is required. This may require referral to a medical specialist such as a geriatrician, psychiatrist or neurologist. During this second assessment stage, a number of other tests, such as radiological and laboratory investigations, may be undertaken.

There are many conditions other than dementia that may have cognitive impairment as part of their presentation. Examples are depression, thyroid disease, vitamin deficiency, side effects from medication and age-related cognitive decline. Thus, a key component of the diagnostic process involves determining if dementia or some other condition is the cause of the symptoms.

Sources: AIHW 2012; Draper 2011; Phillips et al. 2011.

Risk and protective factors

The causes of dementia are complex and influenced by many factors acting in combination. The prevention, delay of onset and treatment of dementia depend on an understanding of these determinants. Many risk and protective factors have been identified. However, evidence for many of these is lacking, inconsistent, or only recently starting to emerge.

The main risk factor for most types of dementia is advancing age. Research on other risk factors has focused on the main types of dementia-Alzheimer disease and vascular dementia.

Apart from age, other factors known to increase the risk of dementia include a family history of the condition, Down syndrome, a common genetic polymorphism-the apolipoprotein E (APOE) e4 gene-and stroke (Seeher et al. 2011; van den Berg & Splaine 2012).

There is growing evidence that suggests that a number of lifestyle and health factors may influence the risk of developing dementia (Seeher et al. 2011; van den Berg & Splaine 2012). However, relatively few of these factors have been definitively established, with most considered either probable determinants or inconclusive (Seeher et al. 2011).

Studies also indicate that a number of other factors-many of which are modifiable-may increase the risk of dementia. These include diabetes, mid-life hypertension, excessive alcohol consumption, smoking, head injury, depression and obesity (Seeher et al. 2011; van den Berg & Splaine 2012).

In addition, many factors that probably protect against developing dementia have been identified, although none of these have been definitively established. These include better cardiovascular health, maintaining physically, socially and cognitively active lifestyles, and higher levels of education (ADI 2009; Seeher et al. 2011).There are numerous other possible protective factors for which evidence is inconclusive, including intake of omega-3 fatty acids, and use of cholesterol-lowering medications, nonsteroidal anti-inflammatory medications and aspirin.

How many people have dementia?

Prevalence refers to the total number of people who have a particular condition at a specified point in time. Common approaches to determining prevalence, such as counting the number of people diagnosed or reporting the condition, are inadequate for dementia, because it is often unrecognised or undiagnosed, especially in the earlier stages. Thus, surveys which rely on respondents reporting the condition cannot be used to accurately describe the prevalence of the condition. The primary Australian survey of this type, the Survey of Disability, Ageing and Carers (SDAC), appears to underestimate milder forms of dementia and so is not appropriate to use for estimating prevalence, although it remains the primary source of information about the characteristics of people with dementia and their carers.

The prevalence estimates presented in this article are based on data from studies that used both screening tools and clinical diagnostic assessments to identify people with dementia. As no national study has been undertaken using these methods, this article uses rates derived from a number of local and international studies. The rates used to estimate the prevalence of dementia among people aged 60 and over are based on rates published in the World Alzheimer Report 2009 (ADI 2009), while the rates for those aged under 60 were based on other sources. More detailed information can be found in Dementia in Australia (AIHW 2012: Appendix D, Notes 2.1-2.3).

Applying these rates to the Australian population suggests there are 332,000 people with dementia in Australia in 2014, of whom 62% are women. Among Australians aged 65 and over, almost 1 in 10 (9%) have dementia, and among those aged 85 and over, 3 in 10 (30%) have dementia (Table 6.3).

Table 6.3: Estimated number of people with dementia, by age and sex, 2014
Age Age-specific rates(a) (per 100 population) - Males Age-specific rates(a) (per 100 population) - Females Age-specific rates(a) (per 100 population) - Persons Number(a)(b) - Males Number(a)(b) - Females Number(a)(b) - Persons Per cent - Males Per cent - Females Per cent - Persons
Under 65 0.1 0.1 0.1 13,000 11,800 24,700 10.2 5.7 7.4
65-74 3.0 3.3 3.2 29,200 33,200 62,400 23.0 16.2 18.8
75-84 8.7 10.3 9.6 42,600 60,100 102,800 33.6 29.3 31.0
85+ 24.7 33.1 30.0 42,300 99,900 142,100 33.3 48.7 42.8
Total: 65+ 7.0 10.3 8.8 114,100 193,200 307,300 89.8 94.3 92.6
Total all ages 1.1 1.8 1.4 127,000 204,900 332,000 100.0 100.0 100.0
  1. Rates (per 100 population) and numbers were calculated using projected population data (series B) for 30 June 2014 (ABS 2012).
  2. Numbers may not sum to the total due to rounding.

Note: See AIHW 2012 for information about the method used to derive prevalence estimates.

Sources: Calculations by AIHW, using rates based on ADI 2009 and Harvey et al. 2003.

Almost half (49%) of women with dementia were aged 85 and over, compared with one-third of men. The estimated number of women with dementia was higher than the estimated number of men in all age groups 65 and over. Further, in each of the age groups from 85-89 onwards, the estimated number of women with dementia was about double or more the estimated number of men.

Based on projections of population ageing and growth, the number of people with dementia is projected to reach almost 400,000 by 2020, and around 900,000 by 2050 (Figure 6.29).

These projections assume that the underlying age and sex-specific rates of dementia will remain constant. As such, the accuracy of the estimates will be affected by changes in the underlying rates, from, for example, changes in risk factors and in the prevention, management and treatment of the condition. These estimates are also sensitive to deviations from projected changes in the age-sex structure or total size of the projected populations.

Younger onset dementia

Younger onset dementia typically refers to the onset of dementia before the age of 65. There were an estimated 24,700 Australians under the age of 65 who had dementia in 2014, with men accounting for just over half (52%). Those under 65 represented 7% of all people with dementia in Australia in 2014.

Younger onset dementia is much less common than dementias occurring at later ages. Further, research suggests that, compared with late onset dementia (that is, dementia with onset at 65 or over), younger onset dementia is more frequently misdiagnosed (Mendez 2006). One reason is said to be the greater variation in the types of dementia diagnosed among those with younger onset dementia. In particular, compared with those with late onset dementia, Alzheimer disease is believed to be less common (although still the most common dementia diagnosis), while dementias attributed to alcohol abuse, head trauma, HIV and a number of other causes are considered to be more common among those with younger onset dementia (McMurtray et al. 2006; Mendez 2006; Werner et al. 2009).

Figure 6.29: Estimated number of people with dementia, by sex, 2010 to 2050

Line chart showing the trending increase in the estimated number of people with dementia from 2010 to 2050 for both males and females.

Note: See AIHW 2012 for information about the method to derive prevalence estimates.

Sources: Calculations by AIHW using rates based on ADI 2009 and Harvey et al. 2003 and applied to population data for 2010 to 2011 (ABS 2012) and population projections for 2012 to 2050 (ABS 2008).

Dementia among Aboriginal and Torres Strait Islander Australians

Due to the lack of national data on how common dementia is among Indigenous Australians, most information is drawn from a small number of localised, largely community-based studies. One such study in a remote area of Western Australia was undertaken by Smith et al. (2008). This study, which involved screening 363 Indigenous Australians aged 45 and over, found that 12% of those screened had dementia. Preliminary results from another study, the Koori Growing Old Well Study, involving urban Indigenous communities in New South Wales, suggest a prevalence rate of 13% among 336 Indigenous Australians aged 60 and over (NeuRA 2013). In comparison, among all Australians, an estimated 3.6% of those aged 45 and over, and 7% of those aged 60 and over, had dementia in 2014 (calculations by AIHW using rates based on Harvey et al. 2003 and ADI 2009).

These results suggest that dementia is more common in Indigenous Australians than in the general population. However, further studies with larger sample sizes would be required to confirm the overall prevalence of dementia among Indigenous Australians.

Where do people with dementia live?

Estimates of the number of people with dementia are important for service planning purposes. Estimates vary according to whether or not they live in the community (such as in a private home or a retirement village) or in cared accommodation (such as residential aged care facilities-see Glossary) and the severity of the condition. (For information on the method used to estimate prevalence by residency and severity, see AIHW 2012: Chapter 2.)

In 2013, an estimated 71% of people with dementia lived in the community, while 29% lived in cared accommodation. Men were more likely to live in the community than women (78% compared with 68%).

Of people with dementia in 2013, an estimated 55% had mild dementia (176,900), 30% moderate (96,500), and 15% severe (48,200). People living in cared accommodation were more likely to have more moderate (63%) or severe dementia (31%) than those living in the community (17% and 8% respectively).

Even so, of people with severe dementia, an estimated 40% lived in the community, with men more likely to do so than women (54% compared with 32%).

Deaths due to dementia

Dementia was the third leading cause of death in 2011, recorded as the underlying cause of 9,864 deaths across Australia-on average, 27 people died from dementia every day. Twice as many women as men died from dementia.

After adjusting for differences in age structures, the death rate due to dementia was 25% higher for women than men (age-standardised rate of 37.9 versus 30.2 per 100,000 population). Overall, deaths due to dementia accounted for 7% of all deaths in 2011 (9% of female deaths and 4% of male deaths).

Overall, the number of deaths attributed to dementia increased by about half (51%) between 2006 and 2011 (from 6,550 to 9,864 deaths) (Figure 6.30). Not all of that change can be attributed to changes in population ageing and growth since the age-standardised rate rose from 28.4 per 100,000 population in 2006 to 35.2 per 100,000 population in 2011. Some of the increase may be due to changes affecting how and the extent to which dementia is recorded on death certificates (see ABS 2013: Explanatory note 84).

The impact of these changes may be spread over a number of years as awareness of the changes increases. Hence, it is unclear if the continued increase in the rate of deaths due to dementia can be explained by these changes or if they represent an actual increase in the number of deaths due to dementia.

Figure 6.30: Number and age-standardised rate of deaths with an underlying cause of dementia, 2006 to 2011

Combined line and column chart showing the trending increase in the number and age-standardised rate of deaths with an underlying cause of dementia each year between 2006 and 2011.

Note: Deaths registered in 2009 and earlier are final versions of cause of death data; deaths registered in 2010 and 2011 are based on revised and preliminary versions of cause of death data, respectively, and are subject to further revision. Data for 2010 have not been adjusted for the additional deaths arising from outstanding registrations of deaths in Queensland in 2010. For more detail, please refer to Technical note 3 in ABS 2013.

Source: AIHW National Mortality Database.

Treatment of dementia

Current treatments are targeted at the symptoms of dementia rather than the underlying causes. Interventions fall into 2 groups: non-drug and drug.

Non-drug treatments

A wide range of non-drug treatments are used for treating the cognitive symptoms of dementia; however, the evidence base for the effectiveness of many of these is limited.

Some research suggests that engaging more frequently in cognitive activity is associated with a lower risk of developing dementia (Wilson et al. 2007), and a recent review by Alzheimer's Disease International (ADI) found that there is strong evidence that cognitive stimulation is an effective intervention in mild dementia (Prince et al. 2011). Cognitive stimulation targets cognitive and social function through reality orientation, activities, games and discussions, prioritising information-processing rather than knowledge (Prince et al. 2011). However, the efficacy of cognitive training (which involves guided practice on a set of standard tasks designed to reflect particular cognitive functions such as memory, attention or problem solving) has not been demonstrated for those who already have dementia (Prince et al. 2011, Seeher et al. 2011).

The ADI review also found that there was some evidence that support groups (for quality of life and depression), behavioural treatment (for depression), and cognitive rehabilitation (for goal performance, satisfaction and subjective memory impairment) can be helpful in the early stages of the condition.

For people with mild to moderate dementia, there is strong evidence that caregiver-focused psychosocial interventions, such as care support, counselling and respite, improve the caregiver's mood and quality of life (Prince et al. 2011). These interventions can also delay entry of the person with dementia into institutional care (Prince et al. 2011).

Drug treatments

Drug interventions target cognitive functioning, and behavioural and psychological symptoms of dementia or other co-occurring diseases (Seeher et al. 2011). There are currently no known drugs that can reverse or cure the various forms of dementia, but some medications have been found to reduce some symptoms experienced by those with Alzheimer disease.

Four dementia-specific drugs are subsidised by the Australian Government through the Pharmaceutical Benefits Scheme (PBS) and the Repatriation Pharmaceutical Benefits Scheme (RPBS) for patients who have a diagnosis of Alzheimer disease confirmed by (or in consultation with) a specialist or consultant physician, subject to specific clinical criteria being met (Department of Health 2013). The drugs (and their trade names) are: donepezil (Aricept®); galantamine (Reminyl®, Galantyl®); rivastigmine (Exelon®); memantine (Memanxa®, Ebixa®, APO-Memantine®). Memantine is approved for use in moderate to severe Alzheimer dementia, while the others are approved for use in mild to moderate Alzheimer dementia. Note that people with Alzheimer disease and other types of dementia may use medications other than these (see Prince et al. 2011). For example, there is some evidence that gingko biloba may have some beneficial effects on cognitive function in people with mild to moderate dementia (Prince et al. 2011).

The data presented in this section do not capture non-dementia specific medications received by those with dementia, nor do they capture drugs that may have been prescribed specifically to manage a person's dementia but can also be used to treat other diseases, as these data are not separately available.

In 2012-13, 48,277 people received government-subsidised dementia-specific medications. Based on estimates of the number of people who have dementia, this suggests that about 15% of those with any type of dementia were receiving dementia-specific medications. (Note that the estimate of the number of people with dementia includes those who have not received a diagnosis, and people with forms of dementia other than Alzheimer disease, who would thus not qualify to receive these medications under PBS or RPBS subsidy.) About 60% of people receiving dementia-specific medications in 2012-13 were female.

Donepezil was the most commonly dispensed prescription (received by 64% of people), and memantine the least (7%). However, prescription also varied according to age, with older patients more commonly prescribed memantine-the drug approved for moderate to severe dementia (Figure 6.31).

The number of people who received government-subsidised dementia-specific medications increased by an annual average of 2.4% between 2008-09 and 2012-13, with a greater increase for men (3.2%) than women (1.9%).

Figure 6.31: Proportion of people receiving each government-subsidised dementia-specific medication, by age, 2012-2013

Bar chart showing the proportion of people receiving each government-subsidised dementia-specific medication, by age, in 2012-2013. Of the given age brackets (0-64, 65-74, 75-84, 85-94 and 95+), 75-84 was the most populous. The medications shown are: Rivastigmine, Donepezil, Galantamine and Memantine.

Note: Some people received more than 1 type of medication over the year. People with unknown age were excluded prior to calculation of proportions.

Source: AIHW analysis of unpublished Pharmaceutical Benefits Scheme data maintained by Department of Health and sourced from Department of Human Services.

How will dementia affect us in the future?

Due to the growth and ageing of the population, the number of people with dementia is projected to reach around 900,000 by 2050 (Figure 6.29). Dementia has profound personal and social costs for individuals with the condition, their families, and the community at large. Dementia is already a leading cause of death, disability and overall burden of disease and, on a personal level, a condition feared by many Australians. People with dementia often rely heavily on health and aged care services, and there is also a significant burden on informal carers. There are also substantial challenges for society in supporting people living (and in the mild stages, even working) with the condition. In the absence of effective prevention, treatment or cure options, the impact of dementia is likely to increase with the projected increase in the number of people with the condition.

As mentioned earlier, the projections of dementia prevalence presented here assume that the underlying prevalence rates will remain constant. However, the rates could change in the future, due to, for example, changes in risk factors and in the prevention, management and treatment of the condition.

On the one hand, improved medical and social care may result in a higher prevalence of dementia by allowing more people to survive longer with the condition (Vickland et al. 2010). Increases in the prevalence of dementia risk factors may also result in dementia being more common. On the other hand, computer modelling indicates that medical breakthroughs which delay dementia onset (Vickland et al. 2010) and reduce risk factors such as obesity (Nepal et al. 2010) have the potential to substantially reduce the prevalence of dementia.

Recent international studies have reported reductions in dementia prevalence rates overseas (Matthews et al. 2013). However, due to the lack of Australian data, it is not possible to determine the extent to which there has been any change in Australia.

What is missing from the picture?

Despite the growing body of information available about people with dementia and their carers, there are a number of data gaps and issues that impact on our ability to monitor and report on the condition.

Australia lacks national data which can be used to derive reliable estimates about the prevalence of dementia. Thus, international data and modelling are required to produce estimates. There is also limited information about the prevalence of different types of dementia.

Multistage surveys in which participants are systematically assessed for dementia using both screening tools and clinical diagnostic assessments may be of most value in deriving comprehensive estimates of how common dementia is, because they are more likely to detect mild and moderate cases of dementia, and cases are clinically established. This approach was taken in Canada, for example, where a national study of the prevalence of dementia among those aged 65 and over was conducted in the early 1990s (CSHAWG 1994). In Australia, no such national study has been undertaken. In addition, there is also limited information about the number and characteristics of people with dementia from several important population groups, including people from culturally and linguistically diverse backgrounds, Aboriginal and Torres Strait Islander people, and people with younger onset dementia. Results from a study (not yet published) in Eastern Sydney will provide some more information about the number and experiences of Australians diagnosed with younger onset dementia (Withall et al., forthcoming), while the Koori Growing Old Well Study (NeuRA 2013; see also earlier section, 'How many people have dementia?') is expected to provide further information about dementia within the Indigenous population.

There are also many other gaps in our knowledge about dementia, including in relation to the underlying mechanisms of the condition (Seeher et al. 2011). For example, the boundaries between 'normal' age-related decline and mild dementia are not clearly defined at either a research or clinical level, particularly in the oldest age groups (Draper 2011). As well, it is difficult to distinguish mild cognitive impairment from early dementia, and the ability of pre-clinical symptoms to predict the development of dementia is currently unclear (Le Couteur 2013). Data from studies such as the Sydney Centenarian Study (Sachdev et al. 2013), the Sydney Memory and Ageing Study (Sachdev et al. 2010), and the CSIRO's Australian Imaging, Biomarker and Lifestyle (AIBL) study of ageing (Ellis et al. 2009; CSIRO 2013) may help fill some of these data gaps.

Further research is also required to identify factors that can reduce a person's risk of developing dementia, as well as those that might slow progression in those who already have the condition. A number of longitudinal studies currently under way may provide further information about dementia and its determinants, for example, the AIBL study of ageing, as mentioned above. This is a large-scale prospective longitudinal study of cognition involving more than 1,100 people aged 60 and over. This study aims to investigate which biomarkers, cognitive characteristics, and health and lifestyle factors determine the development of Alzheimer disease.

In terms of information about the characteristics, service use and care of people with dementia, existing data collections include a wide array of relevant information. However, many of the data sets relating to service use are maintained separately. People with dementia and their carers often access multiple services, which means that on their own these data do not provide a comprehensive picture of the nature and extent of services individuals use. Fragmentation and inconsistency are also evident across data collections in terms of the type of data collected, and there is sometimes limited comparability of definitions. For example, the way in which people with dementia are identified varies in approach and quality across collections. Data linkage projects may fill some of these gaps-for example, the Pathways in Aged Care Project (AIHW 2011) has provided valuable information about the aged care service use pathways of people with dementia.

Where do I go for more information?

For more information about people with dementia. The report Dementia in Australia provides a comprehensive overview of dementia in Australia, including information on prevalence, mortality, characteristics of people with dementia, and their use of aged care services.

Dementia care in hospitals: costs and strategies presents information about the costs of caring for people with dementia in New South Wales hospitals, and reports on strategies and practices being implemented in Australia and internationally that might improve the quality and cost efficiency of dementia care in hospitals. These and other recent publications are available for free download via the link above.

References

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ABS 2012. Australian demographic statistics, September 2011. ABS cat. no. 3101.0. Canberra: ABS.

ABS 2013. Causes of death, Australia. ABS cat. no. 3303.0. Canberra: ABS.

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Withall A, Draper B, Seeher K, Brodaty H, forthcoming. The prevalence and causes of younger onset dementia in Eastern Sydney, Australia. International Psychogeriatrics, accepted 9th December 2013.


6.11 Movement between hospitals and residential aged care

Many older Australians need to visit hospital for management of a chronic or acute health condition or to receive treatment for an injury. Many also require the support of a residential aged care facility, either permanently or on a respite basis; hence, there is considerable movement of people between hospital and residential aged care.

In the first study of its kind, the AIHW examined the movements of people aged 65 and over between hospital and residential aged care (permanent and respite), and also looked at use of the Transition Care Program (TCP-see Box 6.7). The study identified transfers among the 3 types of care for hospital episodes in 2008-09.

Box 6.7: The Transition Care Program

The TCP provides short-term care to older Australians directly after discharge from hospital. The program includes at least low-intensity therapy and either nursing support or personal care, and is provided either in people's homes or in a home-like residential setting.

It aims to help older people leaving hospital to return home rather than prematurely enter residential care, by improving their independence and functioning to an optimal level.

How many movements were there?

During 2008-09, for people aged 65 and over (Figure 6.32):

  • About 9% of hospital admissions were from residential aged care-9 out of 10 of these admissions were for people in permanent residential aged care, most of whom were on leave from the residential aged care facility for the hospital visit (that is, they were not discharged from the residential aged care facility and were expected to return).
  • About 1 in 3 admissions to residential aged care were from hospital (of which two-thirds were to permanent aged care); two-thirds of admissions to residential aged care were from people's homes or transfers from other residential facilities.

What were the differences by age and sex?

  • As age increased, the likelihood of being discharged from hospital to permanent or respite residential aged care (as a new admission) rose, from less than 1 in 100 among those aged 65-69 to 1 in 10 among those aged 90 or older (Figure 6.33).
  • For most age groups, women were more likely than men to be discharged to residential aged care, which may reflect differences in the availability of a suitable carer at home.

Figure 6.32: Main movements between hospital and residential aged care (including movements through the Transition Care Program), people aged 65 and over, 2008-09

Figure showing the main movements between hospital and residential aged care (including movements through the Transition Care Program) of people aged 65 and over in 2008-09. Over this period there were 10,600 admissions from hospitals into TCP; 2,700 admissions from TCP to hospitals and 1,900 from TCP to residential aged care facilities.
  1. Comprises people being admitted from their home in the community, and transfers from other residential aged care facilities (either in permanent or respite care).
  2. Comprises people discharged from residential aged care to hospital, and people who were not formally discharged and expected to return (termed 'hospital leave').

Source: AIHW 2013.

For what conditions were people admitted to hospital from residential care?

  • The main health conditions requiring admission to hospital from either respite or permanent residential care were respiratory and circulatory conditions, and injury due to a fall. The most common conditions for people admitted to hospital from the community were circulatory conditions and cancers.
  • People admitted to hospital from residential care (either respite or permanent) were more than twice as likely as people admitted from elsewhere to have Staphylococcus aureus (golden staph) or pressure ulcers noted in their hospital record, suggesting that this group is more frail and at higher risk of acquiring these conditions.
  • People admitted to hospital from residential care (either respite or permanent) were 6 times more likely than people admitted from the community to have dementia recorded as a diagnosis affecting their hospital care.

Figure 6.33: New admissions to residential aged care from hospital, by age, sex and type of aged care admission, people aged 65 and over, 2008-09

Column chart showing the trending increase in new admissions to residential aged care from hospital by age for people aged 65 and over in 2008-09. Data are shown by sex and type of aged care admission (respite or permanent). With the exception of the 65-69 age bracket, women saw more admissions then men.

Source: AIHW 2013.

What influenced admission to residential care from hospital?

  • People were more likely to be admitted into residential care than return to the community after hospitalisation if they: had a longer stay in hospital; were diagnosed with dementia or stroke; were older; had an unplanned admission to hospital; or were in palliative care before discharge.
  • Respite care in residential aged care appears to serve a dual role: as post-hospital care before returning to home (the outcome for 34% of respite admissions), and as a stepping-stone into permanent residential care (40% of respite admissions from hospital).

What is missing from the picture?

The study was limited to the movements between hospital and residential care (via the TCP where relevant), but did not look at movements in and out of community aged care programs. Also, little is known about the health conditions of people in residential care before they were admitted to hospital, and whether they had access to alternative care such as a general practitioner, which may have prevented the hospital admission.

The AIHW is building its capacity in analysis of aged care data both through more detailed data holdings associated with the AIHW National Aged Care Data Clearinghouse and through experience in data integration across health and aged care data sets. For example, the AIHW is currently undertaking an extended study of TCP clients that includes determining whether they are admitted to residential care within 12 months of being in the program. The study will contribute to an understanding of the effectiveness of the program in preventing premature admission to residential care.

Where do I go for more information?

A copy of the full report Movement between hospital and residential care 2008-09 is available for free download. More information on hospital care in Australia and more information on residential and community aged care is available. Also available is a detailed report on TCP clients: Older people leaving hospital: a statistical overview of the transition care program 2009-10 and 2010-11.

References

AIHW (Australian Institute of Health and Welfare) 2013. Movement between hospital and residential aged care 2008-09. Data linkage series no. 16. Cat. no. CSI 16. Canberra: AIHW.


6.12 Incontinence

Many people in Australia experience some level of incontinence-the involuntary leakage of urine or fecal matter. Some people experience severe incontinence, meaning they always or sometimes need assistance with bladder or bowel control and/or use continence aids. Severe incontinence affects people of all ages, but is more common among older people. It can have profound consequences on the wellbeing of people with the condition as well as their carers.

Who does it affect?

  • In 2009, 1.5% of the Australian population (or 316,500 people) experienced severe incontinence (AIHW 2013).
  • Severe incontinence was more common among females (2%) than males (1%).
  • People aged 65 and older were 12 times more likely to experience severe incontinence than people aged under 65 (7% versus less than 1%). About 1 in 4 people aged 85 or older (24%) experienced severe incontinence (Figure 6.34).
  • About 72,900 primary carers helped with managing someone else's incontinence-4 in 5 were female (81%) and nearly 3 in 4 (73%) spent 40 hours or more per week caring.

Figure 6.34: Prevalence of severe incontinence in the Australian population, by age and sex, 2009 (per cent)

Column chart showing increase in prevalence of severe incontinence in the Australian population by age (0-39, 40-64, 65-84 and 85+). Data are shown for both males and females.

Source: AIHW analysis of the 2009 ABS Survey of Disability, Ageing and Carers.

What risk factors are associated with incontinence?

The most important factors found to be associated with an increased risk of incontinence include being older, being female and past and current pregnancy (particularly the number of vaginal deliveries). Other factors include:

  • prostate problems (such as prostate disease, cancer and surgery)
  • neurological disorders (such as stroke, Parkinson disease, multiple sclerosis and spinal cord injuries)
  • cognitive impairment (including dementia)
  • type 2 diabetes mellitus
  • obesity.

How are people affected by incontinence?

Many people with incontinence have other health conditions and report other problems for themselves and their carers, including not being able to participate in work or social activities. However, it is hard to determine the extent to which these problems are caused by severe incontinence, or by accompanying limitations and health issues.

  • 91% of people with severe incontinence had a severe or profound core activity limitation, indicating they had high-care needs with self-care, mobility or communication.
  • People aged 15 or older with severe incontinence were twice as likely to report poor general health as people without severe incontinence (22% versus 10%).
  • Just over half (52%) of people with severe incontinence could not go out as often as they would like-two-thirds (68%) said this was because of their disability or condition.
  • Primary carers of people with severe incontinence were more likely than other primary carers to report strained relationships with those they care for, to need more respite care, and to report lower labour force participation. This is likely to be due, not just to the tasks involved in managing the effects of incontinence itself but also because most people with severe incontinence (over 90%) also have other limitations that require high levels of care.

How much is spent on incontinence?

  • In 2008-09, an estimated $1.6 billion was spent on incontinence. The largest share was spent on residential aged care ($1.3 billion), followed by hospitals ($145.5 million), the Stoma Appliance Scheme ($67.6 million) and the Continence Aids Payment Scheme ($31.6 million).

What is missing from the picture?

Estimates of prevalence and severity of incontinence across studies vary: partly because of differences in definitions and identification, partly because of variations in measurement of incontinence and partly because of the variation in the populations studied. The AIHW has suggested a set of standard questions for collecting information on incontinence in an effort to improve accuracy and comparability of data (see AIHW 2013).

Current research about incontinence in specific populations, such as Aboriginal and Torres Strait Islander peoples, culturally and linguistically diverse people or the sex and gender diverse population, is limited. While some groups have higher risk factors for incontinence, the extent to which this translates to higher occurrence is unknown.

How risk factors for incontinence lead to the development of the condition remains largely unexplained. Understanding these mechanisms may help reduce the number of people who experience incontinence and also help with the treatment of symptoms.

Where do I go for more information?

More information on incontinence in Australia is available in the AIHW reports Incontinence in Australia and Incontinence in Australia: prevalence, experience and cost.

Information about support for people with incontinence and their carers can be found on the Department of Health website or the Continence Foundation of Australia website.

Reference:

AIHW (Australian Institute of Health and Welfare) 2013. Incontinence in Australia. Cat. no. DIS 61. Canberra: AIHW.


6.13 Palliative care in Australia

The goal of palliative care is to improve the quality of life of patients with an active, progressive disease that has little or no prospect of cure (PCA 2003). With the growth and ageing of Australia's population, and an increase of chronic and generally incurable illnesses, the types of patient groups requiring palliative care has widened (AIHW 2010; Murtagh et al. 2013).

Palliative care is delivered in almost all settings where health care is provided, including neonatal units, paediatric services, acute hospitals, general practices, community settings (such as people's own homes) and residential aged care services. Specialist services operate from a variety of settings, including inpatient, hospice and community-based services (DoHA 2010).

Hospitalisations

Available evidence suggests that a substantial proportion of palliative care in Australia is provided in hospitals (PCOC 2010). Data on admitted patient care in Australia's public and private hospitals show that:

  • In 2010-11, there were 54,466 palliative care hospitalisations-about half of which (49.5%) were for people aged 75 and over. Between 2001-02 and 2010-11, the number of hospitalisations increased by 49%.
  • In 2010-11, 84% of palliative care-related hospitalisations were in public hospitals (45,713 separations), compared with 60% of all hospitalisations being in public hospitals in that year.
  • About half (51%) of palliative care hospitalisations in 2010-11 ended with the patient's death.
  • Cancer was the most frequently recorded principal diagnosis (58%). More than 70% (16,459) of people with cancer as a principal diagnosis, who died in hospital as admitted patients, had been palliative care patients during their final hospitalisation (Figure 6.35).
  • Of patients with a non-cancer diagnosis who died, 71% with a principal diagnosis of motor neurone disease received palliative care (Figure 6.35).

Other services and resources

  • More than 30,400 patients accessed specialist palliative care services in calendar year 2012. This was an increase of 12% from 2011 (PCOC 2010).
  • In 2011-12, about 9,600 patients received services from a palliative medicine specialist that were subsidised under the Medicare Benefits Schedule (MBS).
  • There were 49,600 MBS-subsidised palliative care-related services provided in 2011-12-an average of 5.2 services per patient.
  • Between 2007-08 and 2011-12, the number of MBS-subsidised services provided by palliative medicine specialists almost doubled, with a commensurate increase in MBS benefits paid over this period (from $1.7 million to $3.6 million).

Prescription medications are an important component of palliative care. During 2011-12:

  • More than 19,000 patients had a subsidised palliative care-related prescription, an increase of 34% from 2010-11 (14,393).
  • There were more than 36,000 subsidised palliative care-related prescriptions-laxatives were the most frequently dispensed prescription, followed by analgesics and anti-epileptics (37%, 22% and 15% respectively).

Figure 6.35: People who died during hospitalisation: proportion who were palliative care patients, selected diagnoses, all hospitals, 2010-11

Bar chart showing the proportion of patients who died during hospitalisation who were under palliative care in 2010-11. Data are shown for selected diagnoses an all hospitals. Cancer and motor neurone disease were the most common diagnoses, followed by: dementia and Alzheimer disease, Parkinson disease, renal failure, liver failure, heart failure and chronic obstructive pulmonary disease.

Notes

  1. Refers to patients for whom palliative care was the principal clinical intent during part or all of the hospitalisation that ended with their death.
  2. Disease data are based on principal diagnosis.

Source: National Hospital Morbidity Database, AIHW.

What is missing from the picture?

Differences among the states and territories in the organisation and delivery of palliative care services and the absence of a national palliative care data set make it difficult to provide a comprehensive overview of service provision in Australia.

Reporting on national palliative care expenditure, community-based palliative care services and palliative care beds is also limited. The AIHW is in discussions with federal and state and territory stakeholders to expand national palliative care information.

Where do I go for more information?

More information on palliative care in Australia is available. The report Palliative care services in Australia, 2013 and other recent publications are available for free download.

References

AIHW (Australian Institute of Health and Welfare) 2010. Australia's health 2010. Australia's health series no. 12. Cat. no. AUS 122. Canberra: AIHW.

DoHA (Department of Health and Ageing) 2010. Supporting Australians to live well at the end of life: National Palliative Care Strategy 2010. Canberra: DoHA.

Murtagh FEM, Bausewein C, Verne J, Groeneveld EI, Kaloki YE & Higginson IJ 2013. How many people need palliative care? A study developing and comparing methods for population-based estimates. Palliative Medicine 28(1):49-58 doi: 10.1177/0269216313489367.

PCA (Palliative Care Australia) 2003. Palliative care service provision in Australia: a planning guide. Canberra: PCA.

PCOC (Palliative Care Outcomes Collaboration) 2010. PCOC national report on palliative care in Australia: January to June 2010. Wollongong: University of Wollongong.