Behaviours captured in aged care assessments
To access government-subsidised aged care services, a person will undertake an initial screening to establish their needs and the types of services that could help them. Only the most comprehensive type of assessment captures behaviour and psychological symptoms. For more information on aged care assessments, please visit Aged care assessments.
Box 15.3: Behaviours recorded in aged care assessments that align the Neuropsychiatric Inventory (NPI)
As discussed in the previous section, the NPI is the gold-standard assessment for identifying BPSD. However, the NPI is not undertaken for people accessing government funded aged care services. Instead, select behaviours are recorded in comprehensive aged care assessments that align with descriptions of some BPSD domains in the NPI. While the information presented below provide useful insight on the symptoms experienced by people accessing aged care services, ‘symptoms’ recorded in a comprehensive aged care assessment do not reflect the preferred clinical terms. For example, the description of NPI domain disinhibition overlaps with the recorded symptom, risky behaviours, in a comprehensive aged care assessment. While we present information on people experiencing risky behaviours below as recorded in the comprehensive aged care assessment data, disinhibition remains the preferred clinical term. Further, while wandering is not listed in the NPI, it is frequently cited as an example of BPSD in literature (RACGP 2019; Burley et al. 2021) and is listed as an example behaviour under the Sleep and Nighttime Behaviours NPI domain. As such, wandering information collected in the comprehensive assessments have been included in this section.
In 2020–21, 182,300 Australians completed a comprehensive aged care assessment. Across these assessments, 16% (29,500) of people reported dementia as a health condition. Among all people who completed a comprehensive aged care assessment, 51% reported experiencing one or more behaviours or psychological symptoms ‘regularly’ or ‘always.’
- Agitation – described as extreme emotional disturbance.
- Anxiety – described as an unpleasant state of inner turmoil, often accompanied by nervous behaviours such as pacing back and forth, somatic complaints and rumination.
- Apathy – described as the absence or suppression of passion, emotion, or excitement.
- Depression – described as depressive symptoms, including physical symptoms, long periods of feeling lonely, overwhelming feelings of being unable to keep going or regular tears.
- Hallucinations or delusions – delusions are described as false or erroneous beliefs that usually involve a misinterpretation of perceptions or experiences. Hallucinations can occur in any sensory modality, including auditory, visual, olfactory (smell), gustatory (taste) and tactile (touch).
- Insomnia – described as persistent difficulty in initiating or maintaining sleep.
- Risky behaviour – described as behaviours that put the person or others at risk of harm.
- Resistive behaviour – described as a person resisting, opposing or withstanding help or caregiving tasks such as taking medication, eating or self-feeding.
- Verbal aggression – described as a person yelling, screaming and/or threatening.
- Wandering – described as moving without definite destination or purpose.
A higher proportion of people with dementia reported experiencing one or more symptoms compared with people without dementia (61% compared with 49%, respectively). In addition, the proportion of people with dementia who reported experiencing 3 or more symptoms always or regularly was more than twice as high as the proportion of people without dementia (22% compared with 10%, respectively) (Figure 15.2).
Figure 15.2: Proportion of people who completed a comprehensive aged care assessment in 2020–21, by number of behaviours and psychological symptoms and dementia status
This horizontal bar graph shows the percentages of people who recorded 0 symptoms, 1-2 symptoms and 3 or more symptoms, by dementia status. A greater proportion of people without dementia recorded 0 symptoms, while a greater proportion of people with dementia recorded 3 or more symptoms.
Insomnia was the most frequently reported symptom among people who completed a comprehensive aged care assessment in 2020–21 and rates were similar among people with dementia and people who did not have dementia (30% and 33%, respectively). This was followed by anxiety (21% and 18%, respectively) and resistive behaviours (16% and 3.6%, respectively).
When comparing symptom frequency by dementia status, the following symptoms had the greatest percentage point difference:
- Resistive behaviours – 16% of people with dementia compared with 3.6% of people without dementia.
- Agitation – 13% of people with dementia compared with 3.1% of people without dementia.
- Risky behaviours – 13% of people with dementia compared with 3.2% of people without dementia (Figure 15.3a).
It is important to note that while frequency of symptoms is captured within the comprehensive aged care assessment data, there is no indication of symptom severity or carer distress. Data in this section are based on an individual reporting their experience of a particular symptom to be ‘always’ or ‘regularly,’ however it is difficult to estimate the full extent of symptom impact without further severity and distress information.
Figure 15.3a: Proportion of people who reported experiencing behaviours and psychological symptoms ‘always’ or ‘regularly’ in comprehensive aged care assessment in 2020–21, by symptom type
This horizontal bar graph shows percentage by symptom type and dementia status. Among people with and without dementia, insomnia was the most recorded symptom.
Symptoms decreased with age and varied by sex
Among people who completed a comprehensive aged care assessment and recorded dementia as a health condition:
- A higher proportion of men reported experiencing symptoms of agitation, apathy, insomnia, risky behaviour, verbal aggression and wandering ‘always’ or ‘regularly’ compared with women. A higher proportion of women reported experiencing symptoms of anxiety, depression, resistive behaviours and hallucinations or delusions ‘always’ or ‘regularly’ compared with men.
- Symptoms of risky behaviour, resistive behaviour, hallucinations or delusions and wandering decreased with age until ages 85–94, followed by a slight increase in the 95 and over age group. Symptoms of anxiety increased between the under 65 age group and 65–74, and then decreased with age. Across all remaining symptom types, rates decreased with age (Figure 15.3b).
Within Figure 15.3b, the proportion of the ‘not stated’ responses are presented for each symptom. Across all symptom types, there were a greater proportion of ‘not stated’ responses for people who recorded dementia as a health condition compared to people who did not. As such, it is likely that these estimates disproportionately undercount the frequency of symptoms experienced among people with dementia who completed a comprehensive aged care assessment.
Figure 15.3b: Reported symptoms among people with dementia who completed a comprehensive aged care assessment in 2020–21, by symptom type, age and sex
This horizontal bar graph presents percentage by symptom type, age, sex and dementia status.
Triggers for assessment
Within an aged care assessment, data are collected on triggers that indicate the need for an individual’s assessment to take place. These triggers may be closely related to an individual’s health and care needs, or related to other circumstances such as a change in care arrangements. An individual may also have more than one trigger for assessment recorded.
Comprehensive aged care assessments for people with dementia who reported behaviours or psychological symptoms were most commonly triggered by change in cognitive status (84%) and change in care needs (75%). These triggers were similarly common among people who did not report symptoms (79% and 72%, respectively). Across every trigger, except for hospital discharge, there was a higher proportion of people with symptoms recorded compared with people without symptoms.
Burley C, Casey AN, Chenoweth L and Brodaty H (2021) ‘Reconceptualising Behavioural and Psychological Symptoms of Dementia: Views of People Living With Dementia and Families/Care Partners’ Frontiers in Psychiatry, doi: doi.org/10.3389/fpsyt.2021.710703
Royal Australian College of General Practitioner (RACGP) (2019) RACGP aged care clinical guide (Silver Book), RACGP, accessed 11 November 2022.