Worldwide the population is ageing, with this longevity bringing a range of issues to the individuals, their families and the community. Normal ageing involves physical, cognitive and social changes, “some of which can be anticipated and managed, some requiring support and others involving care, especially when capacity declines or when one or more chronic diseases add to the complexity of a person’s needs”[1]. The World Health Organisation (WHO) has identified a range of musculoskeletal condition risk factors (including inadequate physical activity, obesity, smoking and poor nutrition) as prevalent across the lifespan from adolescence through to older age, although the prevalence increases with age [2]. A recent Interim Report of the Royal Commission into Aged Care Quality and Safety in Australia itemised a broad range and prevalence of adverse health conditions associated with ageing, including “dementia, mental illnesses such as anxiety and depression, as well as physical diseases like diabetes and arthritis leading to increased frailty: bones become brittle, balance becomes less certain, posture more adversely affected” [1] For older people disconnection from their homes and supportive community networks, can further exacerbated these characteristics [3]. These combined factors lead to huge financial costs associated with managing these ailments, adding a further burden to older adults, their families and the healthcare system [4]. In Australia, the burden of age-related disability and illness is expected to keep increasing as the current population ages, with the escalating economic costs of managing chronic conditions having exceeded the 2018 estimate of $320 billion [5]. In summary, the health and economic effects of ageing are broad ranging with adverse impacts at an individual, societal, national, and international level.
To address these challenges, measures to prevent adverse health impacts and promote positive health outcomes are advocated [6, 7]. Research into the clinical consequences of ageing has occurred [7] with the WHO highlighting a range of prevention and management strategies that include non-pharmacological interventions such as exercise, weight management, psychological therapies, pharmacological therapies as well as specialist and/or surgical care [2, 8]. Related research into how to manage the complex health issues associated with ageing has advocated a multidisciplinary approach to the needs of older people that are often complicated by multiple chronic comorbidities, polypharmacy and long-standing opioid and/or sedative use [9, 10]. Despite this research, focus has remained on mono-disciplinary and mono-modal approaches that typically concentrate on one discipline or approach and one loci of impact that singles a body part. This has led to research that is advocating a move from a silo to a synergy approach [11]. A synergy approach requires a more holistic combination of personal, physical, mental health, dietary and lifestyle patterns as well as psychological, social and medical responses and support for healthy ageing of older people [12, 13]. This might include a combination of manual therapy and exercise plus improved dietary patterns to actively engage the older person in self-care to improve their mobility, reduce frailty and promote quality of life [12]. It may also include support for self-help and group exercise regimes that can assist in promoting movement, strength, flexibility and social engagement to empower older people to develop their health and wellness. It may include a combination of Eastern and Western approaches to support their wellbeing. Chinese Medicine, for example, highlights the importance of physical activities, such as Yoga and Tai Chi, to promote cardiovascular fitness and muscle strength, improve balance and prevent falls. A study [14] reported both Tai Chi and Yoga promotes physical exercise and opportunities for older persons as a means to enhance their quality of life through interaction between an ageing persons’ physical, emotional and intellectual wellness.
Formal aged care supports differ between countries. In Australia, services are provided to those who can no longer live independently and care for themselves. These services vary from support provided in the older person`s own home, or through the community, or in group homes, or in purpose-built residential facilities [1]. In-home assistance may include clinical care as well as personal care and help with everyday living activities. In residential settings, intensive care is provided to people with greater physical or cognitive problems or general frailty. A recent Royal Commission into Aged Care Quality and Safety in Australia highlighted the need for Residential Aged Care Facilities to adopt more interdisciplinary, consumer-driven approaches engaging residents in “meaningful sociocultural activities that promote wellbeing and quality of life rather than simply relying on more traditional top-down prescriptive/pharmacological approaches” [1]. Such a holistic approach has implications for how to achieve integration between these services. The next section provides an example of how chiropractic and osteopathic services can be integrated with medical and traditionally available clinical services as a contribution to more integrated pathways to healthy ageing.
Implications for chiropractors and osteopaths
As primary health care practitioners, chiropractors and osteopaths play an important role in health promotion and injury prevention. Chiropractic and osteopathic procedures have been described as safe and effective in managing the burden of musculoskeletal conditions, in reducing pain and in improving mobility of ageing persons [15, 16]. Chiropractors centre their practice on the diagnosis, management and prevention of mechanical disorders of the musculoskeletal system, and their effects on general health. Osteopaths are also trained in manual therapies, exercise prescription and other evidence-based techniques to help patients manage their musculoskeletal condition(s). The Code of Conduct for chiropractors and osteopaths emphasises the importance of person-centred, evidence-based, multidisciplinary approaches [17]. Chiropractors and osteopaths each provide management strategies, including the care of acute injuries (sprains or strains) together with the provision of exercise therapy, rehabilitation, and chronic pain management. Chiropractors, for example, can provide low-force manipulation, soft tissue (massage) therapy to alleviate pain through a non-pharmacological approach as well as being trained to communicate and collaborate with other health care professions to co-manage the patient with other modalities or appropriate referral as needed [18]. Thus, these services are potentially valuable additions in addressing musculoskeletal issues facing older people. The Australian Professional Association for osteopathy states that “the aged care industry needs osteopaths and other allied health professionals to continue to work with other primary care professionals to help manage the projected increase in demand” [19]. The focus is on integrating dietary, lifestyle and rehabilitation approaches to patient care to complement existing services provided by geriatric care teams [19].
In Australia, research has identified that seventy-four percent of chiropractors regularly see older people in private practice, while 12% of chiropractic patients have been identified as older people [20]. Given the ability of chiropractors and osteopaths to care for older people, and evidence that older people attend chiropractors in private practice, it is interesting that chiropractic and osteopathic services are under-represented in Residential Aged Care. This is particularly the case in comparison to medical and mainstream clinical services provided by medical doctors and nurses [15, 20], as well as allied health care such as physiotherapy, podiatry and occupational therapy. Among explanations for this is recognition of the complexity involved in adopting different ways of working required for a more integrated approach. What is recommended is a more holistic environment in which a supportive context, culture, and new mental paradigm exists in which separate disciplines recognise and respect the expertise and value of the contribution of each discipline [21].
This paper presents the findings of an empirical case study of an intervention in a Residential Aged Care facility in Australia in which chiropractic and osteopathic services were added to the existing medical, nursing and physiotherapy services. The intervention was guided by an ecosystem based in six tenets of a distributed leadership approach that supports collaboration for change. It was hoped that this would provide lessons learnt upon which actions could be used to guide more integrated pathways to healthy ageing.