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 Caring for older people
in Australia
Principles for nursing practice | 2nd edition
Edited by AMANDA JOHNSON and ESTHER CHANG
Copyright © 2014. Wiley. All rights reserved.
Copyright © 2014. Wiley. All rights reserved.
 Caring for older
people in Australia:
principles for
nursing practice
SECOND EDITION
Edited by

Amanda Johnson
Esther Chang
Copyright © 2014. Wiley. All rights reserved.
 Second edition published 2017
by John Wiley & Sons Australia, Ltd
42 McDougall Street, Milton Qld 4064

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National Library of Australia

Cataloguing-in-Publication entry

Title: Caring for older people in Australia: principles for nursing practice /
edited by Amanda Johnson and Esther Chang.
Edition: Second edition
ISBN: 9780730328346 (ebook)
Subjects: Geriatric nursing — Australia.
Older people — Care — Australia.
Older people — Health and hygiene — Australia.
Nursing — Practice — Australia.
Other Authors/
Contributors: Johnson, Amanda, 1960- editor.
Chang, Esther May La, editor.
Dewey Number: 362.1989700994

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10 9 8 7 6 5 4 3 2 1
 CONTENTS
About the editors ix Cardiovascular system 28
Preface x Digestive system 29
Endocrine system 29
CHAPTER 1 Immune system 29
Healthy ageing and the older Integumentary system 29
Musculoskeletal system 29
person 1 Nervous system 30
Introduction 2 Respiratory system 30
1.1 Knowledge and attitudes about ageing 2 Sensory changes 31
Classifying older people 2 Genito-urinary system 31
Characteristics of the ageing population 3 Mental health 32
Perspectives on ageing 3 2.4 Psychosocial theories of
Healthy, positive and successful ageing 4 ageing 33
1.2 Healthy ageing through primary healthcare Disengagement theory 34
(PHC) 5
Activity theory 34
History of PHC 5
Continuity theory 35
PHC as a philosophy 6
Erikson’s psychosocial theory 36
PHC as a strategy 7
Theory of gerotranscendence 37
1.3 Factors influencing healthy ageing 8
Selective optimisation with compensation
Definition of health 8 theory 37
Determinants of health 8 Socioemotional selectivity theory 38
1.4 Maintaining health for older people through
Psychosocial theories of ageing: implications for
policy and service provision 11
nursing 38
Health, disability and chronic illness 12
2.5 Psychosocial factors and
Community settings 12 ageing 40
Acute care setting 14 Personality, self-esteem and
Residential care setting 14 self-concept 40
Summary 15 Retirement 41
Key terms 15
Spirituality 42
Exercises 16
End of life 43
Project activity 16
Additional resources 17 Summary 45
References 17 Key terms 46
Acknowledgements 19 Exercises 47
Project activity 48
CHAPTER 2 Additional resources 49
Copyright © 2014. Wiley. All rights reserved.

References 50
Understanding the ageing Acknowledgements 52
process 20
Introduction 21 CHAPTER 3
2.1 What is ageing? 21 Person-centred care: culture,
Defining, conceptualising and categorising
ageing 22 diversity and spirituality 53
Ageing in Australia 23 Introduction 54
2.2 Theories of ageing 25 3.1 The meaning of culture, diversity
Biological theories of ageing 26 and spirituality 54
2.3 Changes to body functions and Culture 54
processes with ageing 27 Diversity 55
 Spirituality 55 How language influences effective
Recognising differences for care provision 55 communication 98
3.2 The relevance of culture, diversity Role of the family 98
and spirituality 56 Summary 101
Delivery of care to the older person 57 Key terms 102
Care for Indigenous Australians 62 Exercises 102
Care for older refugees 64 Project activity 103
Additional resources 104
3.3 Accessing and applying knowledge of culture,
References 104
diversity and spirituality 67
Acknowledgements 108
Access of information 67
Models of cultural competence 67 CHAPTER 5
The individual developing cultural competence 70
Dementia care and cultural competence 71 Nutrition, hydration and
Organisational considerations 71 feeding: impact on the older
3.4 Challenges 72
Summary 74
person 109
Key terms 74 Introduction 110
Exercises 75 5.1 Impact of the ageing process and age-related
Project activity 76 changes 110
Additional resources 76 Physiological changes 111
References 76 Physical changes 111
Acknowledgements 78 Psychosocial changes 111
Socioeconomic status 112
CHAPTER 4 Defining nutrition, dehydration and related
terms 113
Attitudes and communication: 5.2 The role of nutrition and hydration in the
the older person, carers and prevention and management of age-related
families 79 health conditions 114
Nutritional requirements 115
Introduction 80
5.3 Risk factors for malnutrition and dehydration
4.1 The importance of respectful interpersonal
in the older person in different settings 117
communication with older persons 80
Common risk factors for malnutrition
Highlighting human worth 81 and dehydration 117
Perceptions and the older person 82 The care settings 119
Perceptions and responses towards older 5.4 Assessment of malnutrition and dehydration in
persons 83 the older person 125
4.2 Promoting effective interpersonal Nutritional screening 125
communication with older persons 85
Assessment methods 126
Key parameters of interpersonal
5.5 Decision processes that promote and facilitate
communication 86 nutritional intake and hydration of the older
Copyright © 2014. Wiley. All rights reserved.

Improving self-identity and minimising person 128

vulnerability 86 Person-centred care 128
Improving sense of self in group interactions 87 Protected mealtimes 129
Interpersonal skills 88 Focus on Feeding! decision model 130
4.3 Communication difficulties among older Choice and ethical issues 132
Indigenous Australians and older persons from
Summary 133
CALD backgrounds 91 Key terms 133
Overview of culture and communication 91 Exercises 134
4.4 Older persons and care negotiations 96 Project activity 134
Role of the caregiver 96 Additional resources 135
How cultural misunderstandings influence References 136
communication 97 Acknowledgements 140

iv CONTENTS
 CHAPTER 6 Effective falls prevention interventions
in community settings 189
Pharmacology and 7.4 Falls prevention in residential aged-care
complementary therapies 141 settings 194
Risk factors for falls in residential aged-care
Introduction 142
settings 195
6.1 Physiological changes of ageing 142
Assessment of falls risk factors specific to
Pharmacokinetic changes 142 residential aged-care settings 200
Pharmacodynamic changes 145 Effective falls prevention interventions in residential­
6.2 Medications and quality of life 147 aged-care settings 200
Drug interactions 147 7.5 Falls prevention in hospital settings 204
6.3 Complementary therapies and the older Risk factors for falls in hospital settings 204
person 151 Assessment of risk factors for falls
Classifying complementary therapies 151 in hospital settings 206
Complementary therapy use among Interventions to reduce the risk of falls
older Australians 152 in hospital settings 206
6.4 Nurse-initiated complementary therapies 156 7.6 Clinical reasoning, thinking like a nurse to
Aromatherapy 156 accommodate risk assessment in nursing
Exercise 157 practice 208
Massage 157 Clinical reasoning cycle 209
Therapeutic touch 158 7.7 Involving older people in falls prevention 216
Music therapy 158 Summary 218
Nurse-initiated complementary therapy Key terms 219
programs 159 Exercises 219
Summary 160 Project activity 220
Key terms 161 Additional resources 221
Exercises 161 References 222
Project activity 163 Acknowledgements 228
Additional resources 164
References 165 CHAPTER 8
Acknowledgements 167
Care of the older person in the
CHAPTER 7 emergency department 229
Introduction 230
Risk assessment of the older 8.1 Overview of the emergency department (ED) 230
person 168 Geographical factors 231
Introduction 169 8.2 Presenting to the ED 231
7.1 What is risk? 169 8.3 Triage in the ED 233
What is risk assessment and why is it 8.4 Older people as a diverse group 234
important? 169 Frailty in older people 235
Copyright © 2014. Wiley. All rights reserved.

Addressing risk management issues 170 Aboriginal and Torres Strait Islander people 236
7.2 What kinds of health risks are older people 8.5 Reasons for ED presentations 236
vulnerable to? 171 Cardiovascular diseases and conditions 237
Internal and external health risk factors 172 8.6 Nursing assessment of the older person in the
A comprehensive look at assessing the risk of falls ED 243
for older people 175 Development of the comprehensive geriatric
The nature, context and importance of falls assessment 244
prevention 175 Structure of the comprehensive geriatric
7.3 Falls prevention in community settings 177 assessment 245
Risk factors for falls in community settings 178 Summary 249
Assessment of falls risk factors in Key terms 249
community settings 187 Exercises 250

CONTENTS v
 Project activity 250 CHAPTER 11
Additional resources 252
References 252 Pain and the older person 300
Acknowledgements 254 Introduction 301
11.1 Types of pain experienced
CHAPTER 9 by older people 301
Rehabilitation, co-morbidity Nociceptive pain 302
Neuropathic pain 302
and complex care 255 Psychological pain 303
Introduction 256 Pain from mixed or unknown causes 303
9.1 Human functioning, disability Pain in dementia 303
and wellbeing 256 11.2 Impacts from pain occurring in the older
Human functioning and disability 256 person 304
Wellbeing 258 Pain experiences specific to older people 304
9.2 The purpose and nature of rehabilitation 259 Cascading impacts in older people 304
Rehabilitation: what’s it all about? 259 Access to pain relief 305
Clinical rehabilitation as a service or program 11.3 Pain assessment for older people 306
type 260 Direct enquiry 306
Rehabilitation interventions and activities 261 Observation 308
9.3 Maximising nursing’s rehabilitative potential Measurement 308
across the continuum of care 262 11.4 Pain management for the older
Function-promoting nursing practice 263 person 310
Summary 272 General principles of pharmacological
Key terms 272 management 310
Exercises 273 Commonly used medications 311
Project activity 273
Non-pharmacological treatments 313
Additional resources 274
Summary 317
References 275
Key terms 318
Acknowledgements 277
Exercises 318
Project activity 319
CHAPTER 10
Additional resources 320
Transition of settings: loss and References 321
Acknowledgements 324
grief 278
Introduction 279 CHAPTER 12
10.1 The meaning of place 279
The meaning of home 280
A palliative approach 325
Community 282 Introduction 326
10.2 Transition 283 12.1 Why is there a need for a palliative
Transition and loss 284 approach? 327
Copyright © 2014. Wiley. All rights reserved.

10.3 Facilitating adjustment 286 Who can provide a palliative approach? 327
Communicating effectively 287 Where can a palliative approach be
provided? 328
Ensuring dignity and respect 289
When should a palliative approach
Empowering older people in residential aged-care
be implemented? 329
settings 290
12.2 How to provide a palliative approach 335
Summary 293
Key terms 293 Communication 331
Exercises 294 Dignity 333
Project activity 295 Quality of life 334
Additional resources 296 Advance care planning 336
References 297 12.3 A palliative approach to advanced
Acknowledgements 299 dementia 337

vi CONTENTS
 12.4 Physical, psychological and spiritual Severity and subtypes of depression 391
issues 339 Epidemiology of depression in older people 391
Physical symptoms 339 Risk factors and causes (aetiology) 392
Psychological, social and spiritual issues 346 14.2 Assessment and screening for
Summary 353 depression 394
Key terms 354 Further assessment of mental state 396
Exercises 354 14.3 Suicide risk, detection and intervention 399
Project activity 355 Suicide risk 399
Additional resources 356
Detection of suicide risk in older people 399
References 356
Interventions when older people are suicidal 400
Acknowledgements 362
14.4 Managing depression 401
CHAPTER 13 Healthy ageing and health-promoting strategies for
preventing depression in later life 401
Promoting continence in older Treatment strategies for depression 402
people 363 Psychotherapeutic interventions for depression in
the older person 403
Introduction 364
Pharmacological treatment for depression 404
13.1 The nature and context of the problem
of incontinence 364 Summary 409
Prevalence 365 Key terms 410
Exercises 410
Types and causes of incontinence 365
Project activity 411
Risk factors 367
Additional resources 413
The impact of incontinence 367
References 413
13.2 Promoting continence 369 Acknowledgements 415
Prevention 369
Resources and referral 371 CHAPTER 15
13.3 Important aspects of health assessment 374
Subjective data (the health history) 374 Understanding and responding
Objective data (physical examination) 375 to behaviours 416
Clinical reasoning 376 Introduction 417
13.4 Treatment options for urinary and faecal 15.1 Considering the context for
incontinence 377 behaviours 417
Supportive interventions 378 Explanatory factors 418
Therapies that increase the ability to store urine 378 Societal and cultural norms 419
Bowel management programs 379
Attitudes, beliefs and values 420
Continence aids and appliances 380
Use of language 420
Summary 383
15.2 Reflecting on the nurse’s own role in
Key terms 384
responding to behaviours 420
Exercises 384
Attitudes and behaviours to foster a safe emotional
Project activity 384
Copyright © 2014. Wiley. All rights reserved.

environment 421
Additional resources 385
References 386 Judgement 423
Acknowledgements 388 Expectations 423
Clinical supervision 423
CHAPTER 14 15.3 Recognising and engaging with
behaviours 423
Depression in older Behaviour labels 423
people 389 Identifying the risks 424
Introduction 390 Starting assessment 428
14.1 Types of depression, their causes and 15.4 Addressing contributing factors for
the epidemiology of depression in older behaviours 429
people 390 15.5 Person-centred care 435

CONTENTS vii
 15.6 Understanding dementia 437 17.2 Continuous improvement systems
Dementia and ageing 437 for healthcare in the hospitals and the
Types of dementia 438 community 479
Assessment and symptoms of dementia 439 Care in hospitals 480
Dementia and medication 443 Care in the community 481
Summary 444 17.3 Continuous improvement for healthcare in
Key terms 444 residential aged-care facilities 483
Exercises 445 Framework of standards 485
Project activity 445 17.4 The role of the nurse within the continuous
Additional resources 447 improvement system 487
References 447 Advocacy 488
Acknowledgements 449 17.5 Organisations involved in continuous
improvement monitoring of aged
CHAPTER 16 healthcare 488

Sexuality 451 Summary 490

Key terms 491
Introduction 452 Exercises 491
16.1 Sexuality, sexual health and wellbeing 452 Project activity 492
16.2 Ageing and LGBTI individuals 453 Additional resources 493
16.3 Effects of ageism on sexuality 455 References 493
Ageism and sexual wellbeing 456 Acknowledgements 494
Ageism in healthcare: implications for
sexuality 457 CHAPTER 18
Changing trends of ageing and sexuality 458
Bereavement care 495
16.4 STIs, HIV/AIDS and ageing 458
Introduction 496
16.5 Culturally and linguistically diverse (CALD)
Australians 461 18.1 The concept of bereavement 496
Sexuality and culture 461 Models 497
The importance of cultural awareness in What does bereavement look like? 497
nursing 462 Who are bereaved? 497
16.6 The nurse’s role in sexual wellbeing with Goal of bereavement care 500
age 463 18.2 Loss, grief and mourning 500
Putting a ‘partners in sexual health’ framework into Loss 500
nursing practice 464 Grief 501
Summary 467 Mourning 502
Key terms 468 The ageing process and its impact on loss, grief
Exercises 469 and mourning 502
Project activity 470 18.3 Complicated grief 504
Additional resources 471 18.4 Supportive interventions and
References 471 self-care 506
Acknowledgements 474
Copyright © 2014. Wiley. All rights reserved.

Supportive interventions 507

Self-care 508
CHAPTER 17
Summary 511
Continuous improvement in Key terms 511
Exercises 512
aged care 475 Project activity 512
Introduction 476 Additional resources 513
17.1 Continuous improvement 476 References 514
Quality systems 477 Acknowledgements 515

viii CONTENTS
 ABOUT THE EDITORS
AMANDA JOHNSON
Associate Professor Amanda Johnson is State Head of School at the
School of Nursing, Midwifery & Paramedicine, Australian Catholic
University, NSW. She has worked in the tertiary sector since 1992.
­
Dr Johnson’s PhD thesis is in undergraduate palliative care education.
She has been an active leader in the development of undergraduate curric-
ulum in the areas of aged care, chronic illness and palliation. In 2011,
Dr Johnson was the winner of the Vice-Chancellor’s Excellence award in
Leadership for the IRONE project and in 2010 was Highly Commended
in these awards for her teaching of chronic illness and palliation. Dr
Johnson’s research over the last 12 years has been focused on aged care,
dementia and palliation. She is committed to making a difference in the
lives of older people through her teaching and research activities.

ESTHER CHANG
Professor Esther Chang is Director for Higher Research Degree and
Course Advisor for the Honours program in the School of Nursing
and Midwifery, University of Western Sydney. She has worked in aca-
demia since 1986, with three tertiary institutions. She has been a Head of
School, Dean of the Faculty of Health, and Acting Pro-Vice-­Chancellor
(Academic) at the University of Western Sydney, Hawkesbury. ­Professor
Chang is committed to aged, dementia and palliative care; has received
many large grants to investigate nursing and health needs in older people;
and has developed models of care for acutely ill elderly patients and clients
with end-stage dementia. Professor Chang’s international links have gen-
erated collaborative research into aged care across several countries. This
process has influenced her ideas and reflections on the approach that texts
need to embrace for effective student learning.
Copyright © 2014. Wiley. All rights reserved.

ABOUT THE EDITORS ix

 PREFACE
Caring for older Australians should be of paramount concern to all in our community. Older people are
from many walks of life, and deserve to be cared for in a manner that promotes their wellbeing and pre-
serves their dignity to the end of their life. Nurses and other health professionals are pivotal in ensuring
that their needs are met, at a time when they are most vulnerable. Importantly, nurses and other health
professionals require knowledge and skills, informed by evidence, to provide care that is appropriate
for the older person in their home, community, or acute care setting or residential aged-care facility.
This text is developed to provide undergraduate students, students in the TAFE sector, newly registered
nurses and other health professionals with contemporary knowledge and skills that enable them to prac-
tise effectively and competently across the continuum of care settings. Further, this text recognises that
never before has Australia had to face such an ageing population in its history, necessitating that nurses
and other health professionals have an increased awareness of the needs of the young-old, middle-old
and the old-old specifically.
It was our intent in conceptualising this text that the reader would gain a deeper understanding of
the importance of caring for older Australians in a way that would make a difference in their everyday
lives. Underpinning our conceptualisation was our commitment to primary healthcare, on many levels,
that would act as an overarching stimulus for us to encourage undergraduate nursing students and newly
graduated nurses to also practise differently. We also hoped that those caring for older Australians would
reflect on their practice, striving for excellence in the delivery of care, inform policy to better reflect
the needs of the older person and promote change in how we see older people in practice. We also
believe that competent practice is achieved by sound teaching, informed by international and Australian
research. This text has been written with this in mind.
Caring for older people in Australia brings together contributors who are at the forefront of critical
areas relevant to the needs of the older person and nurses who are required to provide contemporary
practice. The contributors have constructed their chapters in an engaging manner, highlighting key issues
well informed by research that supports evidence-based practice. Further, the way in which the contribu-
tors have constructed their chapters with innovative and interactive learning materials enables lecturers
to easily provide effective teaching in this area. This ensures a scholarly approach in the delivery of
learning materials, and the acquisition of core knowledge and skills by students and graduates capable of
practising consistently in Australia and across the continuum of care settings.
We would like to thank those who have contributed to this text. Without their expert knowledge and
commitment, this text would not have been possible. Contributors have come from a diverse range of
academic and clinical settings and in themselves reflect a diversity which adds strength to this text. In
particular, we would like to acknowledge the contributions of the following chapter authors:
•• Deborah Hatcher (Western Sydney University) and Kathleen Dixon (Western Sydney University) —
chapter 1
Copyright © 2014. Wiley. All rights reserved.

•• Jan Sayers (Western Sydney University) and Antoinette Cotton (University of Western Sydney) —
chapter 2
•• Tracey McDonald (Australian Catholic University), Liz Frehner (Curtin University) and Philippa
Wharton (Curtin University) — chapter 3
•• Cecilia Yeboah (Australian Catholic University) and Nel Glass (Australian Catholic University) —
chapter 4
•• Shyama G. K. Ratnayake (Western Sydney University), Sara Karacsony (Western Sydney University)
and Suzanne Brownhill (Western Sydney University) — chapter 5
•• Stephen McNally (Western Sydney University) and Karen Watson (Western Sydney University) —
chapter 6

x PREFACE
J
 •• Lynette Mackenzie (The University of Sydney), Natasha Reedy (University of Southern Queensland)
and Susan Adamczuk (Catholic Healthcare Limited) — chapter 7
•• Bronwyn Smith (Western Sydney University) and Jacqueline Cahill (University of Western Sydney)
— chapter 8
•• Julie Pryor (Royal Rehabilitation Centre Sydney) and Bridget Lingane (Royal Rehabilitation Centre
Sydney) — chapter 9
•• Moira O’Connor (Curtin University) and Frankie Durack (Counsellor, Play Therapist and Credentialed
Mental Health Nurse in Private Practice) — chapter 10
•• Christine Toye (Curtin University), Sean Maher (Department of Aged Care, Sir Charles Gairdner
Hospital WA) and Anne-Marie Hill (The University of Notre Dame) — chapter 11
•• Linda Ora (Palliative Care Clinical Nurse Consultant, Primary Care and Community Health, Nepean
Blue Mountains Local Health District) — chapter 12
•• Colin Cassells (Clinical Nurse Consultant – Continence, Peter James Centre, Eastern Health Victoria)
and Elizabeth Watt (La Trobe University) — chapter 13
•• Louise O’Brien (University of Newcastle, Greater Western Area Health Service Centre for Rural and
Remote Mental Health), Rachel Rossiter (University of Newcastle) and Bryan McMinn (Hunter New
England Local Health District, University of Newcastle) — chapter 14
•• Daniel Nicholls (University of Canberra), and May Surawski (University of Canberra) — chapter 15
•• Leah East (Deakin University), Tinashe Dune (University of New England), Virginia Mapedzahama
(University of New England) and Saifur Rahman (University of New England) — chapter 16
•• Nicole Brooke (Aged Care Consultancy Australia), Lisa Hee (Queensland University of Technology)
— chapter 17
•• Amanda Johnson (University of Western Sydney) and Esther Chang (University of Western Sydney)
— chapter 18.
We would like to thank the following nurses employed by Royal Rehabilitation Centre Sydney who
contributed clinical content to chapter 9: Gail Teal-Sinclair (Clinical Nurse Specialist), Teresa Murtagh
(Clinical Nurse Consultant), Bless Ee (Acting Clinical Care Coordinator), Linda Louie (Enrolled
Nurse), Julius Pamute (Enrolled Nurse), Liliana Hurst (Enrolled Nurse), Noreen Cronin (Clinical Oper-
ations Manager), Rong Ning (Enrolled Nurse), Sandra Lever (Clinical Nurse Consultant) and Rochelle
McKechnie (Registered Nurse).
Our appreciation goes to the John Wiley & Sons team for their contribution to this text: Lori Dyer
(Publisher), Jess Carr (Project Editor), Kylie Challenor (Managing Content Editor), Tara Seeto (Pub-
lishing Administrator), Laura Brinums (Copyright and Image Researcher), Delia Sala (Graphic Designer)
Tony Dwyer (Production Controller) and Rebecca Cam (Digital Content Editor). Thanks also to the
many organisations and people in Australia who agreed to be interviewed and who supplied information
for the various case studies in this text.
Finally we would also like to dedicate this text to all those undergraduate nursing students, students in
the TAFE sector, newly registered nurses and other health professionals who share our commitment to
providing quality care to older people. We hope you find this text helpful.
Copyright © 2014. Wiley. All rights reserved.

Amanda Johnson
Esther Chang
August 2016

PREFACE xi
Copyright © 2014. Wiley. All rights reserved.
 CHAPTER 1 DEBORAH HATCHER | KATHLEEN DIXON

Healthy ageing and

the older person
LEA RNIN G OBJE CTIVE S

After studying this chapter, you should be able to:

1.1 describe the different perspectives on ageing and discuss the diverse characteristics of older people
and how they impact on healthy ageing
1.2 explain primary healthcare in terms of how its philosophical and strategic approaches support
healthy ageing
1.3 understand the concept of health and healthy ageing and discuss how the social determinants of
health influence the health of older people
1.4 describe how support and services available for older people enhance healthy ageing.
Copyright © 2014. Wiley. All rights reserved.
 Introduction
The aim of this chapter is to develop an understanding of how older people age well and the factors
that influence healthy ageing. Whilst the focus of this chapter is on older people living in Australia, we
have also included some discussion on older people living in New Zealand. This is not a comprehensive
exploration of ageing — rather, this chapter provides an examination of contemporary issues influencing
the health of older people. Understanding healthy ageing is important because of the increasing ageing
population in Australia and New Zealand. This chapter provides an overview of healthy ageing within a
primary healthcare (PHC) context.
The chapter is divided into four sections. First, we discuss knowledge and attitudes about ageing. We
then move on to explore how PHC supports healthy ageing. Following this, we look at societal factors
that influence healthy ageing and finally we examine the importance of policy and service provision in
maintaining and supporting the health of older people. Throughout this chapter, the term ‘older person’
is used to refer to all individuals over 65 years.

1.1 Knowledge and attitudes about ageing

LEARNING OBJECTIVE 1.1 Describe the different perspectives on ageing and discuss the diverse
characteristics of older people and how they impact on healthy ageing.
Our knowledge and attitudes about ageing influence the way we think about, promote and support the
health of older people. Historically, ageing was viewed in a negative way, as a time of decline and depen-
dence, and healthcare focused on providing care in residential aged-care settings (Hatcher, 2010). More
recently, our ideas have changed to view ageing and the health of older people more positively, with the
emphasis on healthy, positive and successful ageing; identification of factors to maximise independence
and enhance quality of life (QoL); and the promotion of health of older people living in the community.
To understand how PHC can be implemented as a framework to support the health of older people,
this section describes the demographics of the ageing population in Australia, classifications of older
people, and the various perspectives on ageing.

Classifying older people

There is no single agreement over what is meant by an older person (Hatcher, 2010). For centuries,
old age has been defined chronologically. However, there are shortcomings to this approach — chrono-
logical ageing is not an accurate measure of ageing as it does not explain the differences in individual
experiences of ageing. Despite these limitations, chronology is still used to define ageing, as it is con-
sidered to be a convenient and universally objective measure (Miller & Hunter, 2016).
Internationally, the United Nations (UN) refers to an older person as aged 60 and over. This takes
account of the fact that ageing is often accelerated in developing countries in comparison to devel-
oped countries (Hatcher, 2010). However, it is common in contemporary Western societies (including
Copyright © 2014. Wiley. All rights reserved.

­Australia and New Zealand) to classify an older person as one who is aged 65 years and over (Australian
Institute of Health and Welfare [AIHW], 2012a).
Increased longevity has, however, necessitated the use of subcategories — the most common being
young-old, middle-old, old-old and oldest-old. The literature describes people aged 65–74 years as
young-old, 75–84 years as middle-old and those 85 years and older as old-old (Miller & Hunter, 2016).
The oldest-old are people over the age of 100 years.
Despite the convenience of using categories and classifications, the health and social needs of older
individuals and communities differ (Hatcher, 2010). As the current categorisation of older people could
extend across 40 years or more for some individuals, it is recognised in classifying older people as
aged from 65 years and over that there is great diversity of background, lifestyle, and cultural, religious
and social practices (AIHW, 2012a). These differences — particularly those regarding gender and eth-
nicity — impact on the health of older people.

2 Caring for older people in Australia

 The following sections examine characteristics of the ageing population and how older people have
been viewed through historical and theoretical perspectives on ageing. These views are important to con-
sider because they influence understanding of the health of older people.

Characteristics of the ageing population

Demographic studies show that Australians currently have one of the highest life expectancies compared to
other countries (AIHW, 2010). The life expectancy for Australians born between 1901 and 1910 was 55 years
for men and 59 years for women. Now, the average life expectancy for males has increased by approximately
24.5 years, and by 25 years for females. With these increases in life expectancy, those Australian men born
between 2008 and 2010 can now expect to live to 79.5 years, whereas women can reach 84 years. Males and
females currently aged 65 years can expect to live a further 18.9 and 21.9 years respectively (AIHW, 2012a).
Population growth is increasing at a much higher rate amongst the older age groups than younger age
groups in Australia. This growth pattern is striking; between 1994 and 2014 the proportion of people
aged 65 years and over increased from 11.8 per cent to 14.7 per cent, and those aged 85 years and over
almost doubled for the same period, from 1.0 per cent of the total population in 1994 to 1.9 per cent in
2014. For people aged 85 and over this represents a staggering 153 per cent increase, compared with the
total population growth of 32 per cent for the same 20-year period. In the 12 months to 30 June 2014
there was a 3.6 per cent increase in the number of people aged 65 years and over; this represented an
increase of 118  700 people in this age group. For this same period there was a 4.4 per cent increase in
the number of people aged 85 years and over, representing an increase of 19  200 people (ABS, 2014).
There is also a significant disparity in gender as the population ages, with twice as many females
(291  600) as males (164  900) in the 85 and older age group. This growth in the population of people
aged 65 years and over and 85 years and over is experienced across all states and territories, with the
largest increases occurring in the Northern Territory. Even more striking is the increase in the population
of people aged 100 years and over — over the last two decades this has increased by 263 per cent. In the
12 months to 30 June 2014 there was a 13.8 per cent increase in centenarians, representing 490 people,
with four times as many females as males (ABS, 2014).

Perspectives on ageing
There has been a major change in the way ageing has been represented and researched over time. Past
representations encompassed a biological focus and were based on illness and decline, whereas the cur-
rent emphasis is on healthy, active and positive ageing. At the turn of the twenty-first century, in res-
ponse to changing societal perspectives, the focus of research, policies and practice shifted from ageing
as a time of dependency and provision of residential care, to a PHC model of healthy ageing at home
with the provision of services, informal care and community care when required (Hatcher, 2010).
These historical perspectives provide a context for the development of theoretical perspectives of ageing.
Accompanying the shift in the way ageing has been viewed historically is the change in theoretical perspec-
tives on ageing, where less importance is placed on biological models, in favour of a more social focus.
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Theories of ageing concentrate on what happens to people as they age and why it happens. There have been
different schools of thought on ageing and each one has had some influence on current understandings of
ageing. While some of these theories are no longer generally accepted, they have influenced debate and
research about ageing (Hatcher, 2010). Drawing on theoretical knowledge assists in identifying factors con-
tributing to the experience of ageing and the needs of the older person in the context of how they stay healthy.
The major theories applied to ageing are usually grouped according to their discipline. These include
biological, psychological, sociological and gerontological theories (Hatcher, 2010). More recently,
however, there has been a shift in focus to genetic factors, exploring the influence genes have on ageing
and longevity (Miller & Hunter, 2016). Generally, biological perspectives focus on cellular processes and
examine the effect of ageing on these processes. In contrast to biological theories, psychological theo-
ries focus on changes in human development, cognition, perception and personality. Sociological t­ heories
are oriented around the influence individuals and society have on each other, including social roles and

CHAPTER 1 Healthy ageing and the older person 3

 relationships (Miller & Hunter, 2016). Gerontology — a multidisciplinary perspective — draws on the
strengths of the biological, psychological, sociological and (more recently) spiritual perspectives on
ageing. The emphasis now is on healthy, positive and successful ageing.

Healthy, positive and successful ageing

As a consequence of the increase in the ageing population, many older people are living longer but with
more complex health needs (Hatcher, 2010). To minimise the negative effects of health issues, healthy
ageing has become an important focus for ageing populations (Hunter, 2016). Ageing in a healthy way
results in benefits for individuals and their communities (O’Connor & Alde, 2011). The promotion of a
healthy lifestyle prevents disease and disability, and extends quality of life for older people. In addition,
being healthy reduces the demand for services and care from the family and community (AIHW, 2015b).
Generally, healthy ageing is referred to as the way older people actively maintain or restore their
health and wellbeing. Wellbeing is related to health but is also influenced by other factors, such as social
interaction, socioeconomic status and environment (McMurray & Clendon, 2011).
Health promotion facilitates healthy ageing as it enables older people to have control over the factors
that influence their health. Health promotion for the older person is about using health information to
make healthy decisions based upon sound health practices.
Healthy ageing can also be described as having a level of health that enables the older person to adapt
to the ageing process in a way that best suits their needs. Healthy ageing, therefore, is about maximising
independence and wellbeing, and so it encompasses what is required to enable older people to have
quality of life and be active and independent.
Another perspective on ageing is known as positive ageing where the focus is on wellbeing rather
than illness. This approach encompasses the older person’s attitudes to ageing as well as community
attitudes and interactions with older people. Furthermore, positive ageing recognises the contributions
older people make to society. In terms of positive ageing, it is important to note that the majority of older
people to whom this is applied live independently at home and provide assistance to their families and
community (O’Connor & Alde, 2011).
In addition to healthy ageing and positive ageing, there is a substantial amount of literature on suc-
cessful ageing. Much of the interest in this research can be attributed to increased longevity, the changing
expectations of older people, and a greater interest in the promotion of healthy ageing. The focus of suc-
cessful ageing is on maximising wellbeing through the promotion of activity and participation in society.
Each of these three perspectives on ageing can be seen to encompass principles of PHC, where the
focus is on health, active participation in maintaining health and encouraging older people to continue to
live and participate in their communities. These approaches to ageing highlight the shift in thinking from
illness and cure to the promotion and maintenance of healthy ageing.

CASE STUDY
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Ageism in the workplace

Professor Jane Ambrose was retrenched from the
position she had held for the past twenty years as a
researcher with a large multinational company. Recently
the company was taken over by an Asian conglom-
erate, which made it known that they wanted a young
and energetic workforce. The company embarked on a
major restructure, resulting in a number of positions —
including Jane’s — being made redundant.
Jane is a healthy 73-year-old woman who keeps fit
by walking for an hour each day. She and her partner
Sue, who works in hospitality, live in a townhouse in

4 Caring for older people in Australia

 an inner-west suburb of Sydney. Jane has no family; however, she has two dogs and is an active member
of the gay community. Jane is an enthusiastic member of the local theatre group and enjoys entertaining
with friends. She was extremely upset when she was made redundant, as she had no intention of retiring
from the workforce, believing she still had a lot to offer, both in terms of her knowledge as a researcher and
particularly in regard to her strengths in supporting and mentoring younger researchers. Jane was a reliable
employee who was held in high regard by her colleagues. She hardly ever took sick leave and she was
always willing to stay back to support a colleague or ensure a job was completed on time. Jane suspects
that her redundancy was related to her age. Since being made redundant, Jane has applied for a number of
jobs for which she is highly qualified; however, to date, she has had no success in gaining employment.

QUESTIONS
1. What are the key limitations of classifying an older person according to their chronological age?
2. Drawing upon the perspectives on ageing, how is Professor Ambrose’s current situation likely to
impact upon her healthy ageing?

CRITICAL THINKING

1. What are some implications of an ageing population for health professionals and the healthcare
system?
2. Describe how our attitudes towards older people ageing have changed.

1.2 Healthy ageing through primary

healthcare (PHC)
LEARNING OBJECTIVE 1.2 Explain primary healthcare in terms of how its philosophical and strategic
approaches support healthy ageing.
Primary healthcare (PHC) is both a philosophy and strategy for healthcare provision for older people.
Underpinning PHC as a philosophy are the fundamental principles of equity, participation and inter-
sectoral collaboration. These principles provide an organising framework for approaches to health and
healthcare delivery for older people. As a strategy, PHC supports approaches to delivery of healthcare
services and promotion of healthy ageing.

History of PHC
During the 1970s there was a growing awareness that previous approaches to health and healthcare
­provision — especially in the developing world — had failed. It was acknowledged that Western medicine
was too expensive and of limited value in many communities. This led to the World Health Organization
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(WHO) adopting the goal of ‘Health for all by the Year 2000’ (WHO, 1978), with the intention that all people
attain the highest possible level of health to enable them to lead socially and economically productive lives.
Subsequently, in 1978 a conference in the former Union of Soviet Socialist Republics resulted in the Declara-
tion of Alma-Ata, the intent of which was to provide a strategy for governments to build sustainable systems
of healthcare and to redress inequities in healthcare provision (WHO, 1978). At the conference, PHC was
adopted as the strategy to achieve health for all (Keleher & MacDougall, 2016) and was defined as:
essential health care made universally accessible to families and individuals in the community by means
acceptable to them through their full participation and at a cost that the community and country can
afford (WHO, 1978, p. 2).
The declaration acknowledged health as a right for all people, and PHC was adopted as a global health
strategy to reduce inequities in health. More recently, both the Australian and New Zealand governments

CHAPTER 1 Healthy ageing and the older person 5

 adopted national PHC strategies. Building a 21st century primary health care system is Australia’s first
national PHC strategy, with a focus on community-based PHC services (Department of Health and Ageing
[DoHA], 2010). The four key priority directions for change identified in the Australian national strategy are:
•• improvement of access and reduction of inequality
•• better management of chronic conditions
•• an increased focus on prevention
•• improvement of quality, safety, performance and accountability.
Better, sooner, more convenient health care in the community is New Zealand’s strategy and has as
its focus access to health services and preventive health care (Ministry of Health, 2011). The key priority
directions identified in the New Zealand national strategy are:
•• better services through health professionals working more collaboratively
•• less waiting time for access to health care
•• more convenient health care provision for the consumer.
PHC is aimed at reducing reliance on medical intervention and enhancing health-creating environ-
ments (Keleher, 2012). There are many different meanings and interpretations of PHC; however,
­fundamentally PHC is both a philosophy and strategy for organising healthcare.

PHC as a philosophy
To view PHC as a philosophy of care is to see it as a comprehensive approach to health. As a
­philosophy, PHC changes the emphasis in healthcare from cure (as in the traditional medical model), to
addressing factors causing inequities in health. This approach acknowledges there are more than simply
physical factors influencing an older person’s health — there are also social, economic, environmental
and political factors that impact on the health of older people.
Under a comprehensive PHC model, health professionals become a resource for older people, their
families and communities because they take account of and endeavour to address these factors to facili-
tate the best health outcome for older people. This approach sees control over decisions about health
remaining with the older person and/or their carer. In other words, health professionals work in partner-
ship with older people and the community to make decisions about their health and healthcare through
services such as those supporting prevention, health promotion and self-management of chronic illness
(Keleher & MacDougall, 2016).
As a philosophy, PHC is underpinned by the following core principles aimed at improving the health
of older people:
•• participation
•• equity
•• intersectoral collaboration.

Participation
According to the WHO (1978), all people should be able to participate individually and collectively in
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the planning and implementation of their healthcare. Participation implies that older people are not
simply passive recipients of health information and healthcare; rather, they have the right to actively
participate in decisions about their health.
For older people, the goal of community participation is empowerment and the extent to which they
are able to participate enhances coping and resilience (McMurray & Clendon, 2015). Social aspects of
ageing and aged-care policies — such as housing, income, pension entitlements and access to ­services —
should reflect this, and health professionals have a role in providing support and services which enhance
the capacity of older people to participate in their healthcare.

Equity
Equity is an ethical principle where there is a commitment to fairness and social justice. It is not the
same as equality. Equity reduces disadvantage through distribution of resources based on need. As

6 Caring for older people in Australia

 people age, they are likely to experience inequities in access to healthcare due to age, gender, functional
capacity, culture and language, education, socioeconomic status and living environments across urban,
regional, rural or remote communities. PHC provides a framework to address inequities through access
to support and services.
For example, the 2012 Australian federal government’s Living longer, living better ten-year aged-care
reform package is designed to provide a more flexible system of support to reduce inequities, reduce the
fragmentation of services, increase services across a range of areas and better meet the needs of older
people (DoHA, 2012a).

Intersectoral collaboration
Intersectoral collaboration occurs when all sectors are working together to improve the health of older
people. As an older person’s health is influenced by many factors, the reliance on the health sector alone
to optimise health is insufficient (WHO, 1978).
Maintenance of health for older people requires cooperation between government and non-­government
sectors. These sectors include the health, education, transport and housing sectors, and environmental
and social services (McMurray & Clendon, 2015). Collaboration between these sectors enables efficient
use of resources, helps reduce inequities and enables participation of older people. For example, policies
designed to encourage more accessible and age-friendly transport will assist older people to have better
access to healthcare and other services.

PHC as a strategy
PHC is also a strategy used to address the factors influencing an older person’s health. Through
improving participation, equity and intersectoral collaboration, PHC provides a supportive environ-
ment that promotes personal capacity and independence. As a strategy, guided by these principles,
PHC provides a framework for health professionals to deliver appropriate support and services for
older people.
PHC can be implemented across different health settings, including general practice, acute care, reha-
bilitation, and in community and residential aged care. For example, PHC for older people in community
settings includes support and services in the home — for example, shopping and provision of meals —
and in the community, through senior citizen and day care centres.
In healthcare, the term ‘primary healthcare’ is often used interchangeably with primary care. How-
ever, there are distinct differences between PHC and primary care. PHC is a social model of health,
and is referred to as comprehensive PHC, whereas primary care is a component of PHC, and is usually
termed selective PHC. Primary care is the first point of contact an older person has with the health
system, where they receive care relating to their everyday needs (usually this is via their general
­practitioner (GP)). Primary care focuses on early diagnosis, screening, treatment and chronic disease
management, and may include referrals to specialists and diagnostic services such as laboratory tests
or X-rays.
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Historically, the failure of policy makers and health professionals, in some instances, to understand
these differences or to distinguish between them has resulted in a failure of governments to fully adopt
PHC as the way forward for healthcare in Australia.

CRITICAL THINKING

1. Using a PHC framework, provide examples of how equity impacts upon the health of older
people.
2. Describe how older people can actively participate in planning and implementing their healthcare
within a PHC framework.
3. Describe the importance of intersectoral collaboration in optimising the health of older people.

CHAPTER 1 Healthy ageing and the older person 7

 1.3 Factors influencing healthy ageing
LEARNING OBJECTIVE 1.3 Understand the concept of health and healthy ageing and discuss how the
social determinants of health influence the health of older people.
Health is an individual and subjective concept. People understand and experience health differently —
the way an older person understands health may be different to the way you view it. For example, an
active 90-year-old person may consider themselves to be in better health than a 65-year-old person who
is overweight and has diabetes. Health, as it relates to older people, can be thought of as a state where an
older person can perform activities necessary for daily living.

Definition of health
WHO defines health as a resource for everyday life, which assists people to lead socially and economi-
cally productive lives. Health is understood as a positive concept which emphasises social and personal
resources as well as physical capacity (WHO, 1986).
Many factors have been identified as influencing health, not the least of which is access to:
•• clean water
•• good nutrition
•• adequate sanitation
•• housing
•• healthy environmental conditions
•• health-related information and education
•• income
•• participation in health-related decision making.

Determinants of health
There are many factors or determinants that influence the health of older people. These can broadly be
classified as social, economic and environmental. Here, we will concentrate more specifically on those
social determinants of health that are most relevant to older people — including culture, income,
employment and workforce participation, gender, education and social support. Individuals prevent ill-
ness and disease and promote their health through their health practices and coping skills. Older people
who develop resilience and self-reliance make choices that lead to better health. Decisions about life-
style choices are influenced by the social determinants of health.

Culture
Customs and beliefs affect the health of older people. Dominant cultural values can lead to marginalis­
ation, stigmatisation and reduced access to culturally appropriate services for some older people (Keleher
& MacDougall, 2011). This section will focus on two important groups in society: older people from
Copyright © 2014. Wiley. All rights reserved.

culturally and linguistically diverse backgrounds and Indigenous older people.

Many older people in Australia are migrants from non–English-speaking backgrounds. In 2011, 36 per
cent of people aged 65 years and over in Australia were born overseas (AIHW, 2014b). It is believed as
a result of post–World War II immigration, the number of culturally and linguistically diverse (CALD)
older people will increase (ABS, 2014). Furthermore, it is recognised that the different migrant groups
of older people will turn 65 in the same order that they migrated to Australia. As the profiles of these
groups change, they will have different health and social service needs.
The older population in New Zealand is largely comprised of New Zealand Europeans; however, there
is increasing ethnic diversity with growing Asian, Maori and Pacific populations. It is anticipated that in
the next 10 years there will be a significant increase in those aged 65 and over, with a 50 per cent growth
expected in the population of New Zealand Europeans, 115 per cent in Maori, 203 per cent in Asian
people and 110 per cent in Pacific peoples (Office for Senior Citizens, 2015).

8 Caring for older people in Australia

 Language, communication, education and the location of migrant communities affect the health and social
needs of CALD older people, particularly when accessing services. Difficulty with communication, cultural
differences and attitudes to ageing (especially in terms of support from services) can lead to social isolation
and impact on the ability of the older person to stay healthy. As the needs of older people from a CALD back-
ground may be more varied, healthcare policies and services need to be flexible in order to support them.
Issues arising from language barriers and cultural expectations also relate to care and family support, and can
impact upon the care and assistance provided to older people from a CALD background.
Despite the fact older people from CALD backgrounds have lower mortality rates and higher self-­
reported levels of disability, they are less likely to move to residential care, and are more likely to
remain living at home with a higher use of community services (AIHW, 2014b). This suggests support
and services need to be culturally sensitive to prevent isolation and enable the older person to optimise
their health. It is thought older people from a CALD background in future will be concentrated in cities
as they tend to age in place near family (ABS, 2012b). In this way, close proximity to family provides
support for older people’s health.
Whilst recognising that there is no single culture for Indigenous older people, culture is a significant
determinant of health. It is important to note that only some Aboriginal and Torres Strait Islanders live
to 65 years. Indigenous Australians have a lower life expectancy — living 9.5–10.6 years less than non–­
Indigenous Australians — and they have a younger population profile than the nation as a whole (AIHW,
2015a). Only 4 per cent of Aboriginal and Torres Strait Islanders were aged 65 or over in 2010–2012
(Wall et al., 2013), and life expectancy was 69 years for males and 73 years for females (AIHW, 2015a).
Therefore, the current marker of 65 years and over, used to classify older people in Australia, is not
appropriate for Indigenous Australians. Indigenous Australians are defined as an older person at age
50 years or over (O’Connor & Alde, 2011).
Indigenous communities are disadvantaged across a wide range of socioeconomic indicators, which
accounts for their poorer health status (AIHW, 2015b). There is a higher incidence of chronic illness and
higher rates of hospital admission compared with non-Indigenous people. Poverty and other social
and economic circumstances — such as poor housing, low levels of education and employment, inad-
equate nutrition and substance misuse — underlie the health issues of cardiovascular and respiratory
disease, cancer, diabetes and renal failure (AIHW, 2010).
There is great cultural and linguistic diversity amongst older Indigenous people. In terms of ser-
vice provision and support, there are some culturally specific services available, including housing for
older Indigenous Australians, Home Care Packages, Aboriginal health workers and traditional healers.
In ­Australia and New Zealand there is recognition of the need for increased provision of culturally
appropriate services (DoHA, 2012a; Office for Senior Citizens, 2015). For Indigenous Australians, in
acknowledgement of their poorer health and lower life expectancy, it is recommended these services be
available at age 50, as distinct to age 65 for non–Aboriginal Australians. The aim of these services is to
enable older Indigenous Australians to participate in their community (AIHW, 2015b; Wall et al., 2013).

Income
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Health is associated with economic and social conditions and these appear to be key determinants of
health (Keleher & MacDougall, 2016). Older people who have low incomes generally have poorer health
and higher levels of disability and chronic illness. Older people with low incomes often postpone
obtaining medical assistance and use less preventive and after-care services. At the same time, they have
poorer nutrition and housing, and higher rates of hospitalisation. Income, therefore, has implications for
the health of older people — in particular, the ability to afford food, healthcare, adequate housing and
other services.
Income influences the capacity of older people to purchase services and have supportive accommo-
dation. The income levels of older people vary greatly. For some people, income inequalities increase as
they age. In particular, women acquire less wealth and retirement provision through their working lives,
and therefore have less as they age (Hatcher, 2010).

CHAPTER 1 Healthy ageing and the older person 9

 The Age Pension and home ownership provide a minimum standard of wellbeing for older
people in Australia and New Zealand. Currently, in Australia the major source of income for people
over 65 years is the government pension. According to the AIHW (2012a), 78 per cent of people over
65 years received the Age Pension. However, a shift in social policy has seen a promotion of indi-
vidual responsibility and the push for superannuation (Hatcher, 2010). New Zealanders aged 65 years
and over are entitled to government pension known as New Zealand superannuation (Office for Senior
Citizens, 2013).
Employment and workforce participation
Employment and health are related. Paid work provides income, gives identity and provides a social
network. Lower life expectancy is linked to unemployment and poorer health. Unemployment
and stressful or high-risk/unsafe workplaces or conditions are linked to poorer health (Keleher &
­MacDougall, 2016).
Changes in workforce patterns affect older people. In the general population, over the past 50 years,
the workforce participation rate for males has decreased, whereas women’s participation has increased
(ABS, 2012a). Other trends include an increase in part-time work and early retirement.
Older people are encouraged to remain in the workforce longer and there has been an increase in
the number of those over 65 years staying in the workforce. In 2014, in Australia, the percentage of
employed people aged 65 years and over was 12.6. These rates have increased by more than 5 per cent
in the last decade (AIHW, 2015b). In New Zealand, 22 per cent of people aged 65 and over are in paid
work and this figure is projected to grow to 30 per cent by 2036 (Office for Senior Citizens, 2015).
Retirement has a significant impact on the ageing experience — currently there is no compulsory retire-
ment age in Australia or New Zealand, so the transition to retirement is a more gradual process (Office
for Senior Citizens, 2015).
Many older people undertake unpaid work — including volunteer and voluntary work, caring for
grandchildren and other older people, (the majority caring for a partner at home) (AIHW, 2015b). While
this unpaid work contributes to the economy, unfortunately it is only valued to a small extent.

Gender
Gender has particular significance for ageing as the majority of older people are women. This results in
an even greater number of women aged over 85 years (AIHW, 2015b; Statistics New Zealand, 2015).
The implication for women is that there are a greater number of older women living alone with less
financial security and support. Furthermore, as more women are living longer, women become the major
recipients of aged care.
It is predicted that the number of older men will increase in the future. This is largely because life
expectancy for men in Australia is increasing faster than women (AIHW, 2012a), possibly because of
increased awareness of health issues. Consequently, the impact of an increased number of older men will
need to be understood in terms of the provision of health and social services.

Education
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Low literacy levels are linked to low levels of education and poor health (Keleher & MacDougall, 2016).
Childhood education and lifelong learning contribute to the health of older people as education gives
people knowledge and skills and more opportunities for employment and income. It also enables greater
access to information on keeping healthy. Older people with low levels of literacy are more likely to
have poorer health and lower life expectancy. Therefore, current interest is focused on the health literacy
needs of older people.

Social support
Socialising is highly valued by many older people. Having a social network prevents isolation and gives
older people somewhere to go, to engage in activities and spend time in the company of others. By
giving them resources to draw on, it enhances health and assists older people to age successfully.

10 Caring for older people in Australia

 CASE STUDY

Struggling to manage alone

Lucia is an 85-year-old migrant woman who lives on
her own. She has been depressed since her husband
died three years ago. Her house is old and some-
what neglected, and it is extremely cold in winter.
There is no heating because Lucia feels she cannot
afford the cost of electricity. Each fortnight, after she
receives her Age Pension, Lucia carefully allocates
money for her expenses. Lucia is physically frail; at
times, she becomes unsteady on her feet and con-
sequently has experienced a number of falls. She
appears to have no other health issues except for
hypertension, which is controlled by medication.
Lucia’s doctor is concerned that she appears
sleepy, morose, withdrawn and lacking in emotional
expression despite the antidepressants and sleeping
pills she has been prescribed. Although she considers herself to be a ‘good cook’, Lucia cannot be
bothered to cook a meal for herself every day. She has one daughter who is married and living in
another state; she lives too far away to provide support for Lucia.
Lucia has a very strong faith and attends her place of worship regularly. However, she has no friends
in her religious community as she thinks they gossip too much. She does not feel part of her community
and considers herself to be an ‘outsider’. In short, she is socially isolated. Recently, Lucia has been
talking about moving into an independent living aged care facility, as she feels lonely and is not coping
on her own. She stated ‘my only disease is my loneliness’.

QUESTIONS
1. Using the definition of health, identify and discuss the factors impacting on Lucia’s health status.
2. Drawing upon your reading of the determinants of health, do you consider Lucia to be healthy?
Explain the rationale behind your answer.

CRITICAL THINKING

1. How do the social determinants of health as they apply to healthy ageing relate to PHC?

1.4 Maintaining health for older people through

policy and service provision
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LEARNING OBJECTIVE 1.4 Describe how support and services available for older people enhance
healthy ageing.
Increasingly, policies in Australia and New Zealand based on economic and social implications of an
ageing population are directed towards assisting older people to remain healthy and continue to live at
home. These policies turn the focus to the community setting where there is heavy reliance on informal
support by family, friends or neighbours, and the older person is seen in the context of their family and
community.
As people age, there is a need for more targeted approaches to supporting optimal health. Supporting
older people to age well requires the implementation of a PHC approach across all sectors of the com-
munity. In Australia and New Zealand services and support are delivered through a selective PHC

CHAPTER 1 Healthy ageing and the older person 11

 or primary care framework in all settings. The Living longer, living better aged-care reform package
(DoSS, 2016) in Australia and the Better, sooner, more convenient health care in the community strategy
(­Ministry of Health, 2011) in New Zealand move closer to a comprehensive PHC model. These strat-
egies attempt to address the needs of older people by including the principles of participation, equity and
intersectoral collaboration.

Health, disability and chronic illness

Increasing life expectancy has impacted on levels of health and disability in older people. Generally,
older people view their health positively and, despite many older people experiencing a chronic illness,
most report they are content with their level of health (AIHW, 2015b).
Chronic health conditions, however, can limit personal satisfaction and social participation. If older
people are healthy, there are benefits for individuals and society. Older people with good health have less
chronic illness and disability, better quality of life, remain independent and require less health service
support (AIHW, 2015b). As people age, they experience increased frailty and functional decline (Statis-
tics New Zealand, 2013). The risk of co-morbidities, both disease and disability, also increases (AIHW,
2015b). There is very little difference between the rates of disability among males and females, although
rates are higher in females (AIHW, 2014b). Disability here is defined as impairment in functioning, limi-
tation in activities and restriction in participation in major areas of life (AIHW, 2014a).
With increasing life expectancy, there is evidence that the additional years of life are not likely to
be disability free. However, there is a view that morbidity will be condensed into fewer years at the
end of life. Australian data shows the rate of disability increases with age, with nine in ten people aged
90 years and over having a disability (ABS, 2012c). In New Zealand a disproportionate rate of disability
is experienced in people aged 65 and over; with 59 per cent of older people experiencing disability com-
pared with 21 per cent of adults under 65. Maori and Pacific people are the older adults most likely to
experience disability (Office for Senior Citizens, 2015). A particular concern is the increase in dementia
prevalence, with a projected increase to approximately 1.13 million sufferers by 2050 (Warburton &
Savy, 2012). Between 2011and 2013, the main causes of death for older people in Australia were cor-
onary heart disease, dementia and Alzheimer’s disease, cerebrovascular disease, lung cancer and chronic
obstructive pulmonary disease (AIHW, 2015c).
As the general population of Australia and New Zealand is ageing, it is important to recognise that the
older population is ageing concurrently, which presents challenges for maintaining health. It is believed
that an increase in the number of people aged over 85 years will have significant economic and health
service impacts (AIHW, 2015b). This category of older people is the group most likely to experience
dementia (O’Connor & Alde, 2011; Office for Senior Citizens, 2013), with one in four people over the
age of 85 already diagnosed with dementia. This is a major challenge for Australia and New Zealand’s
healthcare systems as these people will require additional support to sustain their health (AIHW, 2015b;
Office for Senior Citizens, 2013). Overall, the need for support and services for older people is greatest
in the last few years of life.
Copyright © 2014. Wiley. All rights reserved.

Community settings
Maintaining the health of older people is a cost-effective measure for older people, services and govern-
ments. To achieve this, the majority of older people receive support informally from their family, friends
and neighbours. Most older people live independently and can continue to do so if they know how to
access services and can access them when needed. To complement informal support, the community
care system provides additional support and services for older people (Productivity Commission, 2011).
The aims of community care include:
•• early detection of health problems
•• prevention and self-management
•• delayed entry into residential care.

12 Caring for older people in Australia

 However, older people are major users of health services and the demand for services currently
exceeds capacity. Given that the population is ageing at an increased rate, it is anticipated demand for
health and social services will also continue to increase (AIHW, 2015b). The Australian government,
through the Department of Health and Ageing, and the New Zealand government, through the Ministry
of Health, fund and provide health services and aged care (Hatcher & Dixon, 2016). Within the com-
munity setting, the first point of contact for older people to access health services is usually their GP. If
it is identified that there is a need for more support and service provision, the Aged Care Assessment
Program (ACAP) is the avenue for access to services and programs for community care. Older people
who require a higher level of care and service provision may be referred to an acute care setting or a
residential care setting.

Role of the general practitioner

Many older people in Australia receive healthcare from their GP, as general practice is the entry and
navigation point of the health system for most Australians (AIHW, 2012a). General practice is funded
nationally and Australians have access to GPs through the Commonwealth Medicare Benefits Scheme
(MBS) (AIHW, 2012a). The use of GP services increases with age and the most common reasons for
appointments with GPs are to get prescriptions, test results or to have a check-up (AIHW, 2012a).
General practitioners are now responsible for the implementation of management programs for
chronic disease, and education for self-management of chronic conditions such as diabetes and car-
diovascular disease. As the incidence of chronic disease increases with the ageing population and
there is a requirement for more support and services (AIHW, 2015b), the role of the GP in assisting
the older person to stay healthy will continue to be very important. Currently, GPs in Australia are
responsible for referral to secondary and tertiary health services. This includes referral of older people
to the ACAP.

Aged Care Assessment Program

The increasing numbers of older people living in the community has led to many requiring assistance to
maintain their health. In 1987 under the ACAP, multidisciplinary Aged Care Assessment Teams (ACAT)
were developed to assess and advise on the provision of services and the requirement for health and
social support (Hatcher, 2010). These teams assess carer stress, social support, the ability for self-care,
and determine the amount of care required as well as needs relating to equipment and home modi-
fication. Prior to the introduction of this program, GPs were responsible for the assessment of older
people and determination of the services or care required.
Besides organising support and care at home, multidisciplinary teams made up of health professionals
also determine whether relocation to residential care is required. The ACAP has assisted in keeping older
people out of residential care and supporting them at home with the provision of home and community
care (Warburton & Savy, 2012).
However, it is important to recognise that although multidisciplinary healthcare teams have been suc-
Copyright © 2014. Wiley. All rights reserved.

cessful in reducing residential care placement, there is inconsistency in referral patterns amongst ACAT
teams (DoHA, 2012a). Inconsistencies lead to differences in the amount and type of community care
received by older people at home, and these impact on their ability to remain living at home. A PHC
model may provide more holistic assessments, better communication and continuity of care across dif-
ferent settings.

Community care
The Home and Community Care (HACC) program, implemented in 1985 and funded by the Common-
wealth, provides a range of assistance to older people living in the community (Productivity Com­
mission, 2011). HACC is the main provider of community care in Australia. Some of their services
include home help, personal care, ‘meals on wheels’ and centre-based meals, shopping, respite care,
home maintenance and modification, transport and community nursing (DoHA, 2012b).

CHAPTER 1 Healthy ageing and the older person 13

 A component of community care, day care centres provide care during weekdays. Services that
might be provided at day care centres include physiotherapy, occupational therapy, podiatry, diversional
therapy, social work and nursing services. Day care centres also provide a meal and an opportunity for
older people to socialise.
The current system of low-level and high-level community care is currently undergoing major changes
and is being replaced with Home Care Packages. Since 1992, Community Aged Care Packages (CACPs)
have been available for older people with complex care needs so they can remain at home (AIHW, 2015b).
Within this package is the provision of 2–6 hours of care per week, including personal care, cleaning,
cooking and shopping. High-level care packages, known as Extended Aged Care at Home (EACH) pack-
ages, assist older people requiring greater support to stay living at home (AIHW, 2015b). These packages
are for older people who need 8–22 hours of care per week. High-level care packages became available
for older people with dementia; these are known as Extended Aged Care at Home Dementia (EACHD)
packages (AIHW, 2015b). Home Care Packages will provide a level of support from basic to high care.
As the preference of most older people is to stay living at home with support, it is therefore not sur-
prising that the demand for services in the community has continued to increase.

Acute care setting

Older people are major consumers of hospital-based care and the average length of a hospital stay is
7–8 days. In Australia in 2010–2011, 38 per cent of all hospital admissions were over 65 years of age
(AIHW, 2012b). Longer hospital stays are related to complex physical, functional, cognitive and
­psychosocial problems and this highlights the importance of self-management of conditions by the older
person, the prevention of ill health and the promotion of good health.
An effective interface between acute care and the community is essential for the optimisation of health
in older people. In the event of an older person requiring acute hospital care, the transition from hospital
back to home is one that is managed currently through the liaison nurse or case manager to ensure a
level of functional capacity and a reduction of risk of readmission to the acute care setting.

Residential care setting

Older people assessed by the ACAP as unable to continue to live at home are admitted to residential
care. The use of residential care increases with age and is higher for women (Productivity Commission,
2011). Currently, only 6 per cent of older people in Australia and in New Zealand live in residential care
(Miller & Hunter, 2016). They have a high-level dependency. In Australia and New Zealand residential
care settings include dementia-specific sections, some secured for those requiring greater dementia care.
Generally, older people try to avoid relocation to a residential care facility and prefer to remain at home
with high levels of support (Hatcher, 2010).
It is essential for residential care to provide an environment that is homelike. There has been a shift
away from the hospital environment appearance to an environment that mimics a home setting. As the
Copyright © 2014. Wiley. All rights reserved.

residential care facility becomes an older person’s home, it needs to be an environment that is safe and
supportive, matches the needs of the resident and ensures opportunities for the older person, their family
or carer and facility staff to make decisions together. As socialising is important for healthy ageing, resi-
dential care settings should promote participation and foster relationships to avoid loneliness, isolation
and prevent depression.

CRITICAL THINKING

1. What is likely to be the impact on the ageing population from disability and chronic illness?
2. How do community services support older people to remain in the community?
3. To what extent does the current level of health service provision meet the needs of an ageing population?

14 Caring for older people in Australia

 SUMMARY
1.1 Describe the different perspectives on ageing and discuss the diverse characteristics of
older people and how they impact on healthy ageing.
Present-day perspectives focusing on healthy, positive and successful ageing now influence the way
we view ageing and the health of older people. It is generally recognised that older people are not a
homogenous group, and the health and social needs of individuals and communities differ. Despite
this diversity, the marker used for older people in Australia is 65 years. There are many perspec-
tives influencing the complex and multidimensional nature of ageing and the health of older people.
The experience of ageing is influenced by historical and theoretical perspectives and the context
in which older people live their ageing years. The health of an older person is influenced by these
perspectives and the biological, psychological and social factors within the economic and political
context in which they live.
1.2 Explain primary healthcare in terms of how its philosophical and strategic approaches
support healthy ageing.
Primary healthcare is both a philosophy of care and a strategy for healthcare provision for older people.
It focuses on health rather than illness; older people, their families and communities; and self-reliance,
where older people take responsibility for their health. Underpinning PHC as a philosophy are the fun-
damental principles of equity, participation and intersectoral collaboration. These principles provide an
organising framework for approaches to health and healthcare delivery for older people.
1.3 Understand the concept of health and healthy ageing and discuss how the social
determinants of health influence the health of older people.
There are many definitions of health; it is a concept that is individual and subjective. People ­perceive
health differently and the way an older person sees health may be different to the perspective of
others. The demographic characteristics and health and social experiences of older people demon-
strate they are varied and influenced by many factors. Social determinants of health are of particular
significance to a PHC approach.
1.4 Describe how support and services available for older people enhance healthy ageing.
As older people are living longer and the population is ageing, Australia and New Zealand have
made some positive attempts to address requirements for health services and social support. PHC
as a strategy, underpinned by the principles embedded in its philosophy, provides a framework for
health professionals to provide support and services for older people in all settings.

KEY TERMS
Aged care assessment program (ACAP) a cooperative working arrangement comprising
multidisciplinary teams designed to assess and advise older people and their families about the
Copyright © 2014. Wiley. All rights reserved.

provision of services and available support

Equity the redistribution of resources to address the determinants of health and enhance the health and
wellbeing of all older people
Health a resource used for everyday living
Health promotion an approach designed to enable older people to positively maintain and improve
their health individually or at a community level
Healthy ageing the ability of the older person to develop, maintain or adapt in order to function
optimally mentally, physically, socially and economically
Intersectoral collaboration the collective action of all sectors — not just the healthcare sector — to
enhance the health of older people
Older people people aged 65 and older in developed countries, or 60 and older in developing countries

CHAPTER 1 Healthy ageing and the older person 15

Another random document with
no related content on Scribd:
six. “Well,” replied Mr. Lincoln, “I have been so busy to-day that I
have not had time to get a lunch. Go in and sit down; I will be back
directly.”
Mr. Ford made the young woman accompany him into the office,
and when they were seated, said to her: “Now, my good girl, I want
you to muster all the courage you have in the world. When the
President comes back he will sit down in that arm-chair. I shall get up
to speak to him, and as I do so you must force yourself between us,
and insist upon his examination of your papers, telling him it is a
case of life and death, and admits of no delay.” These instructions
were carried out to the letter. Mr. Lincoln was at first somewhat
surprised at the apparent forwardness of the young woman, but
observing her distressed appearance, he ceased conversation with
his friend, and commenced an examination of the document she had
placed in his hands. Glancing from it to the face of the petitioner,
whose tears had broken forth afresh, he studied its expression for a
moment, and then his eye fell upon her scanty but neat dress.
Instantly his face lighted up. “My poor girl,” said he, “you have come
here with no governor, or senator, or member of congress, to plead
your cause. You seem honest and truthful; and”—with much
emphasis—“you don’t wear ‘hoops’; and I will be whipped but I will
pardon your brother!”
Among the applicants received on another occasion by the
President, was a woman who had also met with considerable
difficulty and delay in getting admission to him. She said that her
husband had been arrested some months before and sent to the
“Old Capitol” prison; that he had not been “tried,” and could not learn
as he was likely to be; and she appealed to the President as a
husband and father to interfere and order an immediate trial. Mr.
Lincoln said he was sorry this could not be done,—adding that such
cases were much like the different sacks of grain at a country grist-
mill, all “waiting their turn to be ground,” and that it would be unfair
for the “miller” to show any “partiality.” The woman left, but the next
day appeared again before him. Recognizing her, Mr. Lincoln asked
if anything “new” had happened. “No,” replied the woman; “but I have
been thinking, sir, about what you said concerning the ‘grists,’ and I
am afraid mine will get ‘mouldy’ and ‘spoil’ before its turn comes
around, so I have come to ask, Mr. President, that it may be taken to
some other ‘mill’ to be ground.”
Mr. Lincoln was so much amused at the wit and shrewdness of
the request, that he instantly gave the woman an unconditional
discharge for her husband.
 LXXIV.
“Good morning, Abe!” was the greeting addressed to the
President, as we sat together in his office one morning,—he
absorbed at his desk, and I with my pencil. I looked up in
astonishment at the unaccustomed familiarity.
“Why, Dennis,” returned Mr. Lincoln, “is this you?”
“Yes, Abe,” was the rejoinder; “I made up my mind I must come
down and see you once while you were President, anyhow. So here I
am, all the way from Sangamon.”
Sitting down, side by side, it would have been difficult for one
unfamiliar with democratic institutions to tell, by the appearance or
conversation, which was the President and which the back-
countryman, save that from time to time I overheard the man
addressed as “Dennis” refer to family trials and hardships, and
intimate that one object of his journey so far, was to see if his old
friend “could not do something for one of his boys?”
The response to this was: “Now, Dennis, sit down and write out
what you want, so that I can have it before me, and I will see what
can be done.”
I have always supposed that this was “Dennis Hanks,” the early
companion and friend of Mr. Lincoln; but my attention at the time
being diverted, the matter passed out of my mind, and I neglected
subsequently to inquire.
About this period—it may have been the following evening—the
house was thrown into an uproar by a performance of little “Tad’s.” I
was sitting in Mr. Nicolay’s room, about ten o’clock when Robert
Lincoln came in with a flushed face. “Well,” said he, “I have just had
a great row with the President of the United States!”
 “What?” said I.
“Yes,” he replied, “and very good cause there is for it, too. Do
you know,” he continued, “‘Tad’ went over to the War Department to-
day, and Stanton, for the fun of the thing,—putting him a peg above
the ‘little corporal’ of the French Government,—commissioned him
‘lieutenant.’ On the strength of this, what does ‘Tad’ do but go off and
order a quantity of muskets sent to the house! To-night he had the
audacity to discharge the guard, and he then mustered all the
gardeners and servants, gave them the guns, drilled them, and put
them on duty in their place. I found it out an hour ago,” continued
Robert, “and thinking it a great shame, as the men had been hard at
work all day, I went to father with it; but instead of punishing ‘Tad,’ as
I think he ought, he evidently looks upon it as a good joke, and won’t
do anything about it!”
“Tad,” however, presently went to bed, and then the men were
quietly discharged. And so it happened that the presidential mansion
was unguarded one night, at least, during the war!
The second week in July the whole country, and Washington in
particular, was thrown into a fever of anxiety by the rebel raid upon
that city under Early and Breckinridge. The night of Sunday, the 10th,
I have always believed the city might have been captured had the
enemy followed up his advantage. The defences were weak, and
there were comparatively but few troops in the city or vicinity. All day
Monday the excitement was at the highest pitch. At the White House
the cannonading at Fort Stevens was distinctly heard throughout the
day. During Sunday, Monday, and Tuesday, the President visited the
forts and outworks, part of the time accompanied by Mrs. Lincoln.
While at Fort Stevens on Monday, both were imprudently exposed,—
rifle-balls coming, in several instances, alarmingly near!
The almost defenceless condition of the city was the occasion of
much censure. Some blamed General Halleck; others General
Augur, the commander of the Department; others the Secretary of
War; and still others the President.
Subsequently the rebel force returned to Richmond almost
unharmed. I saw no one who appeared to take this more to heart
than Mrs. Lincoln, who was inclined to lay the responsibility at the
door of the Secretary of War.
Two or three weeks later, when tranquillity was perfectly
restored, it was said that Stanton called upon the President and Mrs.
Lincoln one evening at the “Soldiers’ Home.” In the course of
conversation the Secretary said, playfully, “Mrs. Lincoln, I intend to
have a full-length portrait of you painted, standing on the ramparts at
Fort Stevens overlooking the fight!”
“That is very well,” returned Mrs. Lincoln, very promptly; “and I
can assure you of one thing, Mr. Secretary, if I had had a few ladies
with me the Rebels would not have been permitted to get away as
they did!”
 LXXV.
It was not generally known before the publication of Dr. Holland’s
biography of Mr. Lincoln, that he was once engaged in a “duel,”
although a version of the affair had been published previous to his
biographer’s account of it, which, however, the few who saw it were
disposed to regard as a fabrication.
One evening, at the rooms of the Hon. I. N. Arnold, of Illinois, I
met Dr. Henry, of Oregon, an early and intimate friend of Mr.
Lincoln’s. Mr. Arnold asked me in the course of conversation if I had
ever heard of the President’s “duel” with General Shields? I replied
that I might have seen a statement of the kind, but did not suppose it
to be true. “Well,” said Mr. Arnold, “we were all young folks together
at the time in Springfield. In some way a difficulty occurred between
Shields and Lincoln, resulting in a challenge from Shields, which was
at length accepted, Mr. Lincoln naming ‘broadswords’ for weapons,
and the two opposite banks of the Mississippi, where the river was
about a mile wide, for the ‘ground.’”
Dr. Henry, who had listened quietly to this, here broke in, “That
will do for a ‘story,’ Arnold,” said he, “but it will hardly pass with me,
for I happened to be Lincoln’s ‘second’ on the occasion. The facts
are these. You will bear me witness that there was never a more
spirited circle of young folks in one town than lived in Springfield at
that period. Shields, you remember, was a great ‘beau.’ For a bit of
amusement one of the young ladies wrote some verses, taking him
off sarcastically, which were abstracted from her writing-desk by a
mischievous friend, and published in the local newspaper. Shields,
greatly irritated, posted at once to the printing-office and demanded
the name of the author. Much frightened, the editor requested a day
or two to consider the matter, and upon getting rid of Shields went
directly to Mr. Lincoln with his trouble.
 “‘Tell Shields,’ was the chivalric rejoinder, ‘that I hold myself
responsible for the verses.’ The next day Mr. Lincoln left for a distant
section to attend court. Shields, boiling over with wrath, followed and
‘challenged’ him. Scarcely knowing what he did, Mr. Lincoln
accepted the challenge, seeing no alternative. The choice of
weapons being left to him, he named ‘broadswords,’ intending to act
only on the defensive, and thinking his long arms would enable him
to keep clear of his antagonist.
“I was then a young surgeon,” continued Dr. Henry, “and Mr.
Lincoln desired me accompany him to the point chosen for the
contest,—‘Bloody Island,’ in the Mississippi, near St. Louis,—as his
‘second.’ To this I at length consented, hoping to prevent bloodshed.
On our way to the ground we met Colonel Hardin, a friend of both
parties, and a cousin of the lady who was the real offender.
Suspecting something wrong, Hardin subsequently followed us,
coming in upon the party just as Lincoln was clearing up the
underbrush which covered the ground. Entering heartily upon an
attempt at pacification, he at length succeeded in mollifying Shields,
and the whole party returned harmoniously to Springfield, and thus
the matter ended.”
This version of the affair coming from an eye-witness is
undoubtedly in all respects correct. It subsequently came in my way
to know that Mr. Lincoln himself regarded the circumstance with
much regret and mortification, and hoped it might be forgotten. In
February preceding his death a distinguished officer of the army
called at the White House, and was entertained by the President and
Mrs. Lincoln for an hour in the parlor. During the conversation the
gentleman said, turning to Mrs. Lincoln, “Is it true, Mr. President, as I
have heard, that you once went out to fight a ‘duel’ for the sake of
the lady by your side?”
“I do not deny it,” replied Mr. Lincoln, with a flushed face; “but if
you desire my friendship you will never mention the circumstance
again!”
 LXXVI.
In August following the rebel raid, Judge J. T. Mills, of Wisconsin,
in company with ex-Governor Randall, of that State, called upon the
President at the “Soldiers’ Home.”
Judge Mills subsequently published the following account of the
interview, in the “Grant County (Wisconsin) Herald”:—

* * * * *

“The Governor addressed him: ‘Mr. President, this is my friend

and your friend Mills, from Wisconsin.’
“‘I am glad to see my friends from Wisconsin; they are the
hearty friends of the Union.’
“‘I could not leave the city, Mr. President, without hearing
words of cheer from your own lips. Upon you, as the
representative of the loyal people, depend, as we believe, the
existence of our government and the future of America.’
“‘Mr. President,’ said Governor Randall, ‘why can’t you seek
seclusion, and play hermit for a fort-night? it would reinvigorate
you.’
“‘Aye,’ said the President, ‘two or three weeks would do me
good, but I cannot fly from my thoughts; my solicitude for this great
country follows me wherever I go. I don’t think it is personal vanity
or ambition, though I am not free from these infirmities, but I
cannot but feel that the weal or woe of this great nation will be
decided in November. There is no programme offered by any wing
of the Democratic party but that must result in the permanent
destruction of the Union.’
 “‘But Mr. President, General McClellan is in favor of crushing
out the rebellion by force. He will be the Chicago candidate.’
“‘Sir,’ said the President, ‘the slightest knowledge of arithmetic
will prove to any man that the rebel armies cannot be destroyed by
democratic strategy. It would sacrifice all the white men of the
North to do it. There are now in the service of the United States
near two hundred thousand able-bodied colored men, most of
them under arms, defending and acquiring Union territory. The
democratic strategy demands that these forces should be
disbanded, and that the masters be conciliated by restoring them
to slavery. The black men who now assist Union prisoners to
escape are to be converted into our enemies, in the vain hope of
gaining the good-will of their masters. We shall have to fight two
nations instead of one.
“‘You cannot conciliate the South if you guarantee to them
ultimate success; and the experience of the present war proves
their success is inevitable if you fling the compulsory labor of
millions of black men into their side of the scale. Will you give our
enemies such military advantages as insure success, and then
depend on coaxing, flattery, and concession, to get them back into
the Union? Abandon all the posts now garrisoned by black men;
take two hundred thousand men from our side and put them in the
battle-field or cornfield against us, and we would be compelled to
abandon the war in three weeks.
“‘We have to hold territory in inclement and sickly places;
where are the Democrats to do this? It was a free fight, and the
field was open to the War Democrats to put down this rebellion by
fighting against both master and slave long before the present
policy was inaugurated.
“‘There have been men base enough to propose to me to
return to slavery the black warriors of Port Hudson and Olustee,
and thus win the respect of the masters they fought. Should I do
so, I should deserve to be damned in time and eternity. Come
what will, I will keep my faith with friend and foe. My enemies
pretend I am now carrying on this war for the sole purpose of
Abolition. So long as I am President, it shall be carried on for the
sole purpose of restoring the Union. But no human power can
subdue this rebellion without the use of the emancipation policy,
and every other policy calculated to weaken the moral and
physical forces of the rebellion.
“‘Freedom has given us two hundred thousand men raised on
Southern soil. It will give us more yet. Just so much it has
subtracted from the enemy, and instead of alienating the South,
there are now evidences of a fraternal feeling growing up between
our men and the rank and file of the rebel soldiers. Let my
enemies prove to the country that the destruction of slavery is not
necessary to a restoration of the Union. I will abide the issue.’
“I saw that the President was a man of deep convictions, of
abiding faith in justice, truth, and Providence. His voice was
pleasant, his manner earnest and emphatic. As he warmed with
his theme, his mind grew to the magnitude of his body. I felt I was
in the presence of the great guiding intellect of the age, and that
those ‘huge Atlantean shoulders were fit to bear the weight of
mightiest monarchies.’ His transparent honesty, republican
simplicity, his gushing sympathy for those who offered their lives
for their country, his utter forgetfulness of self in his concern for its
welfare, could not but inspire me with confidence that he was
Heaven’s instrument to conduct his people through this sea of
blood to a Canaan of peace and freedom.”
 LXXVII.
No reminiscence of the late President has been given to the
public more thoroughly valuable and characteristic than a sketch
which appeared in the New York “Independent” of September 1st,
1864, from the pen of the Rev. J. P. Gulliver, of Norwich,
Connecticut:—
“It was just after his controversy with Douglas, and some months
before the meeting of the Chicago Convention of 1860, that Mr.
Lincoln came to Norwich to make a political speech. It was in
substance the famous speech delivered in New York, commencing
with the noble words: ‘There is but one political question before the
people of this country, which is this, Is slavery right, or is it wrong?’
and ending with the yet nobler words: ‘Gentlemen, it has been said
of the world’s history hitherto that “might makes right;” it is for us and
for our times to reverse the maxim, and to show that right makes
might!’
“The next morning I met him at the railroad station, where he
was conversing with our Mayor, every few minutes looking up the
track and inquiring, half impatiently and half quizzically, ‘Where’s that
‘wagon’ of yours? Why don’t the ‘wagon’ come along?’ On being
introduced to him, he fixed his eyes upon me, and said: ‘I have seen
you before, sir!’ ‘I think not,’ I replied; ‘you must mistake me for some
other person.’ ‘No, I don’t; I saw you at the Town Hall, last evening.’
‘Is it possible, Mr. Lincoln, that you could observe individuals so
closely in such a crowd?’ ‘Oh, yes!’ he replied, laughing; ‘that is my
way. I don’t forget faces. Were you not there?’ ‘I was, sir, and I was
well paid for going;’ adding, somewhat in the vein of pleasantry he
had started, ‘I consider it one of the most extraordinary speeches I
ever heard.’
 “As we entered the cars, he beckoned me to take a seat with
him, and said, in a most agreeably frank way, ‘Were you sincere in
what you said about my speech just now?’ ‘I meant every word of it,
Mr. Lincoln. Why, an old dyed-in-the-wool Democrat, who sat near
me, applauded you repeatedly; and, when rallied upon his
conversion to sound principles, answered, “I don’t believe a word he
says, but I can’t help clapping him, he is so pat!” That I call the
triumph of oratory,—

“When you convince a man against his will,

Though he is of the same opinion still.”

Indeed, sir, I learned more of the art of public speaking last evening
than I could from a whole course of lectures on Rhetoric.’
“‘Ah! that reminds me,’ said he, ‘of a most extraordinary
circumstance which occurred in New Haven the other day. They told
me that the Professor of Rhetoric in Yale College,—a very learned
man, isn’t he?’
“‘Yes, sir, and a fine critic too.’
“‘Well, I suppose so; he ought to be, at any rate,—they told me
that he came to hear me, and took notes of my speech, and gave a
lecture on it to his class the next day; and, not satisfied with that, he
followed me up to Meriden the next evening, and heard me again for
the same purpose. Now, if this is so, it is to my mind very
extraordinary. I have been sufficiently astonished at my success in
the West. It has been most unexpected. But I had no thought of any
marked success at the East, and least of all that I should draw out
such commendations from literary and learned men. Now,’ he
continued, ‘I should like very much to know what it was in my speech
you thought so remarkable, and what you suppose interested my
friend, the Professor, so much.’
“‘The clearness of your statements, Mr. Lincoln; the
unanswerable style of your reasoning, and especially your
illustrations, which were romance and pathos, and fun and logic all
welded together. That story about the snakes, for example, which set
the hands and feet of your Democratic hearers in such vigorous
motion, was at once queer and comical, and tragic and
argumentative. It broke through all the barriers of a man’s previous
opinions and prejudices at a crash, and blew up the very citadel of
his false theories before he could know what had hurt him.’
“‘Can you remember any other illustrations,’ said he, ‘of this
peculiarity of my style?’
“I gave him others of the same sort, occupying some half-hour in
the critique, when he said: ‘I am much obliged to you for this. I have
been wishing for a long time to find some one who would make this
analysis for me. It throws light on a subject which has been dark to
me. I can understand very readily how such a power as you have
ascribed to me will account for the effect which seems to be
produced by my speeches. I hope you have not been too flattering in
your estimate. Certainly, I have had a most wonderful success, for a
man of my limited education.’
“‘That suggests, Mr. Lincoln, an inquiry which has several times
been upon my lips during this conversation. I want very much to
know how you got this unusual power of “putting things.” It must
have been a matter of education. No man has it by nature alone.
What has your education been?’
“‘Well, as to education, the newspapers are correct; I never went
to school more than six months in my life. But, as you say, this must
be a product of culture in some form. I have been putting the
question you ask me to myself, while you have been talking. I can
say this, that among my earliest recollections I remember how, when
a mere child, I used to get irritated when any body talked to me in a
way I could not understand. I don’t think I ever got angry at anything
else in my life. But that always disturbed my temper, and has ever
since. I can remember going to my little bedroom, after hearing the
neighbors talk of an evening with my father, and spending no small
part of the night walking up and down, and trying to make out what
was the exact meaning of some of their, to me, dark sayings. I could
not sleep, though I often tried to, when I got on such a hunt after an
idea, until I had caught it; and when I thought I had got it, I was not
satisfied until I had repeated it over and over, until I had put it in
language plain enough, as I thought, for any boy I knew to
comprehend. This was a kind of passion with me, and it has stuck by
me; for I am never easy now, when I am handling a thought, till I
have bounded it North, and bounded it South, and bounded it East,
and bounded it West. Perhaps that accounts for the characteristic
you observe in my speeches, though I never put the two things
together before.’
“‘Mr. Lincoln, I thank you for this. It is the most splendid
educational fact I ever happened upon. This is genius, with all its
impulsive, inspiring, dominating power over the mind of its
possessor, developed by education into talent, with its uniformity, its
permanence, and its disciplined strength,—always ready, always
available, never capricious,—the highest possession of the human
intellect. But, let me ask, did you prepare for your profession?’
“‘Oh, yes! I “read law,” as the phrase is, that is, I became a
lawyer’s clerk in Springfield, and copied tedious documents, and
picked up what I could of law in the intervals of other work. But your
question reminds me of a bit of education I had, which I am bound in
honesty to mention. In the course of my law-reading, I constantly
came upon the word demonstrate. I thought at first that I understood
its meaning, but soon became satisfied that I did not. I said to
myself, “What do I mean when I demonstrate more than when I
reason or prove? How does demonstration differ from any other
proof?” I consulted Webster’s Dictionary. That told of “certain proof,”
“proof beyond the possibility of doubt;” but I could form no idea what
sort of proof that was. I thought a great many things were proved
beyond a possibility of doubt, without recourse to any such
extraordinary process of reasoning as I understood “demonstration”
to be. I consulted all the dictionaries and books of reference I could
find, but with no better results. You might as well have defined blue
to a blind man. At last I said, “Lincoln, you can never make a lawyer
if you do not understand what demonstrate means;” and I left my
situation in Springfield, went home to my father’s house, and stayed
there till I could give any proposition in the six books of Euclid at
sight. I then found out what “demonstrate” means, and went back to
my law-studies.’
“I could not refrain from saying, in my admiration at such a
development of character and genius combined: ‘Mr. Lincoln, your
success is no longer a marvel. It is the legitimate result of adequate
causes. You deserve it all, and a great deal more. If you will permit
me, I would like to use this fact publicly. It will be most valuable in
inciting our young men to that patient classical and mathematical
culture which most minds absolutely require. No man can talk well
unless he is able first of all to define to himself what he is talking
about. Euclid, well studied, would free the world of half its calamities,
by banishing half the nonsense which now deludes and curses it. I
have often thought that Euclid would be one of the best books to put
on the catalogue of the Tract Society, if they could only get people to
read it. It would be a means of grace.’
“‘I think so,’ said he, laughing; ‘I vote for Euclid.’
“Just then a gentleman entered the car who was well known as a
very ardent friend of Douglas. Being a little curious to see how Mr.
Lincoln would meet him, I introduced him after this fashion:—‘Mr.
Lincoln, allow me to introduce Mr. L——, a very particular friend of
your particular friend, Mr. Douglas.’ He at once took his hand in a
most cordial manner, saying: ‘I have no doubt you think you are right,
sir.’ This hearty tribute to the honesty of a political opponent, with the
manner of doing it, struck me as a beautiful exhibition of a large-
hearted charity, of which we see far too little in this debating,
fermenting world.
“As we neared the end of our journey, Mr. Lincoln turned to me
very pleasantly, and said: ‘I want to thank you for this conversation. I
have enjoyed it very much.’ I replied, referring to some stalwart
denunciations he had just been uttering of the demoralizing
influences of Washington upon Northern politicians in respect to the
slavery question, ‘Mr. Lincoln, may I say one thing to you before we
separate?’
“‘Certainly, anything you please.’
 “‘You have just spoken of the tendency of political life in
Washington to debase the moral convictions of our representatives
there by the admixture of considerations of mere political
expediency. You have become, by the controversy with Mr. Douglas,
one of our leaders in this great struggle with slavery, which is
undoubtedly the struggle of the nation and the age. What I would like
to say is this, and I say it with a full heart, Be true to your principles
and we will be true to you, and God will be true to us all!’ His homely
face lighted up instantly with a beaming expression, and taking my
hand warmly in both of his, he said: ‘I say Amen to that—Amen to
that!’
“There is a deep excavation in the rock shown to visitors, among
the White Mountains, into which one of the purest of the mountain
streams pours itself, known as ‘The Pool.’ As you stand by its side at
an ordinary time you look down upon a mass of impenetrable green,
lying like a rich emerald in a setting of granite upon the bosom of the
mountain. But occasionally the noon-day sun darts through it a
vertical ray which penetrates to its very bottom, and shows every
configuration of the varied interior. I felt at that moment that a ray
had darted down to the bottom of Abraham Lincoln’s heart, and that I
could see the whole. It seemed to me as beautiful as that emerald
pool, and as pure. I have never forgotten that glimpse. When the
strange revocation came of the most rational and reasonable
proclamation of Fremont,—‘The slaves of Rebels shall be set free,’—
I remembered that hearty ‘Amen,’ and stifled my rising
apprehensions. I remembered it in those dark days when McClellan,
Nero-like, was fiddling on James River, and Pope was being routed
before Washington, and the report came that a prominent Cabinet
Minister had boasted that he had succeeded in preventing the issue
of the Emancipation Proclamation; I said: ‘Abraham Lincoln will
prove true yet.’ And he has! God bless him! he has. Slow, if you
please, but true. Unimpassioned, if you please, but true. Jocose,
trifling, if you please, but true. Reluctant to part with unworthy official
advisers, but true himself—true as steel! I could wish him less a man
of facts, and more a man of ideas. I could wish him more stern and
more vigorous: but every man has his faults, and still I say: Amen to
22
Abraham Lincoln!”
 LXXVIII.
The Hon. Orlando Kellogg, of New York, was sitting in his room
at his boarding-house one evening, when one of his constituents
appeared,—a white-headed old man,—who had come to
Washington in great trouble, to seek the aid of his representative in
behalf of his son. His story was this: “The young man had formerly
been very dissipated. During an absence from home a year or two
previous to the war, he enlisted in the regular army, and, after
serving six months, deserted. Returning to his father, who knew
nothing of this, he reformed his habits, and when the war broke out,
entered heart and soul into the object of raising a regiment in his
native county, and was subsequently elected one of its officers. He
had proved an efficient officer, distinguishing himself particularly on
one occasion, in a charge across a bridge, when he was severely
wounded,—his colonel being killed by his side. Shortly after this, he
came in contact with one of his old companions in the ‘regular’
service, who recognized him, and declared his purpose of informing
against him. Overwhelmed with mortification, the young man
procured a furlough and returned home, revealing the matter to his
father, and declaring his purpose never to submit to an arrest,—‘he
would die first.’” In broken tones the old man finished his statement,
saying: “Can you do anything for us, Judge?—it is a hard, hard
case!” “I will see about that,” replied the representative, putting on
his hat; “wait here until I return.” He went immediately to the White
House, and fortunately finding Mr. Lincoln alone, they sat down
together, and he repeated the old man’s story. The President made
no demonstration of particular interest until the Judge reached the
description of the charge across the bridge, and the wound received.
“Do you say,” he interrupted, “that the young man was wounded?”
“Yes,” replied the congressman, “badly.” “Then he has shed his blood
for his country,” responded Mr. Lincoln, musingly. “Kellogg,” he
continued, brightening up, “isn’t there something in Scripture about
the ‘shedding of blood’ being ‘the remission of sins?’” “Guess you
are about right there,” replied the Judge. “It is a good ‘point,’ and
there is no going behind it,” rejoined the President; and taking up his
pen, another “pardon”—this time without “oath,” condition, or reserve
—was added to the records of the War Office.
“Among a large number of persons waiting in the room to speak
with Mr. Lincoln, on a certain day in November, ’64, was a small,
pale, delicate-looking boy about thirteen years old. The President
saw him standing, looking feeble and faint, and said: ‘Come here, my
boy, and tell me what you want.’ The boy advanced, placed his hand
on the arm of the President’s chair, and with bowed head and timid
accents said: ‘Mr. President, I have been a drummer in a regiment
for two years, and my colonel got angry with me and turned me off. I
was taken sick, and have been a long time in hospital. This is the
first time I have been out, and I came to see if you could not do
something for me.’ The President looked at him kindly and tenderly,
and asked him where he lived. ‘I have no home,’ answered the boy.
‘Where is your father?’ ‘He died in the army,’ was the reply. ‘Where is
your mother?’ continued the President. ‘My mother is dead also. I
have no mother, no father, no brothers, no sisters, and,’ bursting into
tears, ‘no friends—nobody cares for me.’ Mr. Lincoln’s eyes filled
with tears, and he said to him, ‘Can’t you sell newspapers?’ ‘No,’
said the boy, ‘I am too weak; and the surgeon of the hospital told me
I must leave, and I have no money, and no place to go to.’ The
scene was wonderfully affecting. The President drew forth a card,
and addressing on it certain officials to whom his request was law,
gave special directions ‘to care for this poor boy.’ The wan face of
the little drummer lit up with a happy smile as he received the paper,
and he went away convinced that he had one good and true friend,
23
at least, in the person of the President.”
No incident of this character related of the late President, is more
profoundly touching in its tenderness and simplicity than that given to
me the last evening I passed at the White House, in the office of the
 24
private secretary, by a resident of Washington, who witnessed the
scene.
“I was waiting my turn to speak to the President one day, some
three or four weeks since,” said Mr. M——, “when my attention was
attracted by the sad patient face of a woman advanced in life, who in
a faded hood and shawl was among the applicants for an interview.
“Presently Mr. Lincoln turned to her, saying in his accustomed
manner, ‘Well, my good woman, what can I do for you this morning?’
‘Mr. President,’ said she, ‘my husband and three sons all went into
the army. My husband was killed in the fight at ——. I get along very
badly since then, living all alone, and I thought I would come and ask
you to release to me my oldest son.’ Mr. Lincoln looked into her face
a moment, and in his kindest accents responded, ‘Certainly!
certainly! If you have given us all, and your prop has been taken
away, you are justly entitled to one of your boys!’ He immediately
made out an order discharging the young man, which the woman
took, and thanking him gratefully, went away.
“I had forgotten the circumstance,” continued M——, “till last
week, when happening to be here again, who should come in but the
same woman. It appeared that she had gone herself to the front, with
the President’s order, and found the son she was in search of had
been mortally wounded in a recent engagement, and taken to a
hospital. She found the hospital, but the boy was dead, or died while
she was there. The surgeon in charge made a memorandum of the
facts upon the back of the President’s order, and almost broken-
hearted, the poor woman had found her way again into Mr. Lincoln’s
presence. He was much affected by her appearance and story, and
said: ‘I know what you wish me to do now, and I shall do it without
your asking; I shall release to you your second son.’ Upon this, he
took up his pen and commenced writing the order. While he was
writing the poor woman stood by his side, the tears running down her
face, and passed her hand softly over his head, stroking his rough
hair, as I have seen a fond mother caress a son. By the time he had
finished writing, his own heart and eyes were full. He handed her the
paper: ‘Now,’ said he, ‘you have one and I one of the other two left: