 Hello, and a warm good evening to you all. I'm Stephen Ginsberg, I'm the only man this evening on the webinar last time in this series in July. There's three men and one women, one woman, so we're keeping the gender balance. And looking at the 1500 participants who've registered to join us for tonight. And no surprises, the larger part of the audience are women. So that's always of note when we're talking about carers. So welcome for joining us for tonight's webinar, supporting carers of older people, as well as the viewers who will be watching the recording later. If you hear thunder, it's because up here, they were in a major thunderstorm. I'd like to start by acknowledging and respecting all ancestral lands of Australia's first peoples who represent the oldest surviving living culture on the planet. And I pay my respects to elders past and present. We have an opportunity to co-create a nation that is proud of and embraces Australia's first peoples history, culture, and rights for present and future generations. I'd also like to acknowledge the elders of all the other cultures who live on these lands and respect their knowledge and their wisdom. I'm calling in from Gamoragal country. And if you feel like practicing with the chat facility, you might want to let others know which land and country you are calling in from. So make yourselves comfortable with suitable refreshments and let's get started on what I feel will be a rewarding evening with our panelists. I'm Marika Lynette and Allison. And of course, our imaginary family, Rosa, Phil, and their community of care. This webinar is the result of a unique partnership between the 31 Australian primary health networks and the mental health professionals network, MHPN. In the first in their history, the 31 PHNs have formed a consortium and engaged MHPN to plan, produce, and broadcast three webinars in the next 12 months, focusing on older Australians and mental health. So that was written at the beginning of the series. This is the second of these webinars. The first was in July and was called primary care older persons and mental health, and you can find a recording of that on the MHPN site. And then next year, the last of the three will be exploring aging from a first nations and multicultural perspective. Tonight's panel, I think you've all got bios of them. And they're all wonderful people. That's sounding like Trump. I'm going to get the saxo. And there's the webinar, webinar platform. I'll leave that on for a moment. The resources, including the case study of with the blue button with the biographies and the supporting resources so it's a feedback survey until the end, but do use the chat room. We've already gathered questions that you've sent in before, and we've incorporated those into general questions that will come to in the Q&A section. So these are the learning outcomes. I won't read them to you. I hope we will meet those learning outcomes. And this is where we go first to Marika Contellis, a social worker by training, but importantly also a manager of a social service organization. And I think we'll see that word respect coming up again and again. So thank you, Marika. Thanks so much, Stephen and good evening everyone. It's really nice to be here. I realized that when I was asked to do this that I'm actually officially an old social worker. So there you have it. I have spent some time with our wonderful panel and really unpacked this situation from what we call a social work perspective. As you know, all social workers work from a sort of theory practice theory, and we often talk about respect for the person. We look through the lens of social justice. We're always really quite focused on professional integrity, not unlike other disciplines, of course. But when we look at roses, not roses, but Rosa and Phil's situation, we really need to think about what respect looks like. And the first thing is we really need to acknowledge the long term commitment and love this couple has. We need to recognize Rosa's caring role and her exceptional care of Phil, certainly from my experience, even most recently at CCNB. When you stop and you look a carer in the eyes and you say, you're doing such a wonderful job caring for your husband. Often that just melts a whole load of resistance away. Recognizing and respecting both Rosa's and Phil's intellect and their amazing work contribution and respecting that despite her need to get a knee done, she's actually not ready and she's not confident. So respect is really important. And I use this very complicated model. You give respect, you ultimately get respect. It's not rocket science. The other thing that I would do and what a social worker would do is really look at what's fair and access to information, advice and guidance is absolutely pivotal for Rosa at this time. Don't assume but really seek to understand her reluctance. We often are really quick to say, yeah, look, most carers are reluctant. She doesn't want to leave Phil, etc. We need to understand her options and she certainly does and the potential consequences so she can make informed choices. And you'll all know and understand the whole concept of dignity of risk. And that's what we need to afford Rosa in this situation. You know, this whole thing about professional integrity is often as professionals, we really need to have this considered and sort of self reflected reflections around what our intervention looks like we have to be transparent, etc. My way of working with people, and I certainly have learned this over probably the last decade, not only through my professional experience, but my lived experience as a carer, it takes a village. And there will be better outcomes for Rosa Phil and the extended family Francesca and her kids and her husband are more likely if we take this sort of broader view multidisciplinary approach, which absolutely includes building a community of support around Rosa. So she can continue to care for Phil. I'm hoping to unpack that a little bit this afternoon evening. As we work through, you know, mapping where our roses support. And this is about enhancing her informal and trusted support system. I'm sure Steven tonight will talk about I know I will, this whole notion of the compassionate community around people at their point of need. We want to support her to understand that her health and her well being will actually help to determine Phil and taking a little bit of control around that's really important. You know, we often talk about assessment and I've got one more minute I think we often talk about assessment. She's like a very less a fair approach to assessing someone's needs. Someone's like Rosa's needs. She's already probably been through assessments. If she's accessing any services or has heard about them. I often ask people what are you miss doing or who do you miss seeing. Tell me about who you can rely on. Who do you trust? What worries you the most? What gives you joy? And what help do you think Phil a new need to stay healthy and healthy at home? And those questions often help unpack and present a whole range of potential interventions. At the end of the day the glue with all practitioners is this thing about trust and trust is about building that relationship. Being reliable actually being really present and showing up when you're with Rosa and Phil but there are no there is no one more important at that point in time. And that's how I've been able to build trust as I've worked with people and I'm sure you've got other techniques yourself. This whole thing is called a systems theory where we look at Rosa's behavior and problems from her perspective in this context of some complexity, which is her carry carrying role and her relationship with her daughter, etc. Ultimately the first step is to make a judgment about what approach will enable trust. And for me that always is the rest is easier. I think I did I did I do well Stephen was that you did brilliantly and and it's interesting. Many years ago, a famous psychiatrist gave a lecture. I went to and she was saying that psychiatrists only prescribed these days. Not true, but she was making a point as she said. Now if you want. If you want to have someone talk to you about your problems, see a social worker, see an occupational therapist, see a psychologist, she must have had a premonition of this, this evening. And she said, trust them all for the meek will inherit the earth. And indeed I think for that for what we're looking at tonight. The three hold the key to the support of the carers and we GPS often, even though the patient client customer citizen is attached to what we say. I always advise them to listen to the real experts who visit people in their homes and really get to know them. So thank you. You sit that scene very well. Next, Lynette. Yeah, and OT certainly have inherited the earth because you're the gatekeepers for a cat. And then it you're going to bring your wealth of the wealth of experience to give us a little idea of what you can do for Rose and Fiddles care. Thank you. Thank you everyone. I'm often asked what do you do. So I thought I'd just stick this one in first. So occupational therapy is a client centered health profession. So we're all client centered and I loved what Marika talked about the questions that she asked as part of her assessment. Very, very similar sort of approach that we would have as well. And the primary goal of occupational therapy is to help people participate in the activities of everyday life, whatever they may be and they will vary from person to person. So the importance of building relationship with Rosa is going to be incredibly important as Marika hinted at and in order for us to determine what those activities of daily life are and what has the most meaning for Rosa. So we tend to operate by working with people and communities to enhance engagement in the occupation that people want to do what they need to do or what they are expected to do. So occupational therapy is really about doing stuff. And sometimes that means modifying what it is you do or how you do it or modifying the environment to better support the occupations that you can do. So that's a bit of a potted version of what an occupational therapist does because we work with all sorts of people. In this instance, we're talking about an older carer that that same definition holds true for a range of different areas where occupational therapists work. So the sort of model I use is called the person environment occupation model. As I said before, occupational performance is what we're interested in so people being able to do things. So my first thought by looking at the case study was to think about, well, what about the person who is Rosa? So we have a few clues in the case study we were given. So she's very much centered on successfully caring for Phil and that appears to be her primary role. And we have a few other sort of notes about her condition from the case study as well. We think about the environment. We don't know much about the home. We don't know much about the physical aspect of the home at all other than it's got lots of Phil's papers in it. So for me, I would really want to do a home visit in order to sort of gather that sort of information. Her garden is precious to her, but she may well have had to deal with the change a little bit. There's also, sorry, there's lightning and stuff outside and I can hear it. There's also limited support from her daughter or the amount of support has changed. She seems to have some support from her neighbour, Nelly. But as Marika said, that whole community of support needs to be addressed. And now she's been put in a position where she's having to navigate a whole bunch of services. And ACAT was mentioned and the money aged care website and everything is probably enough to send most older people who are feeling a bit vulnerable to start with into a head spin. So there are some issues with just being a user of health services as well. So that's all part of the environment. And then the occupations that she engages in, as I said earlier, I think her carer role is her key occupation at the moment. And it seems to be to the exclusion of lots of other things like looking after herself, being a self-maintainer. She also had a previous role supporting Phil's career and she was quite active. There's a whole list of things that she used to do which are probably not happening as often anymore. And she's now having to focus on caring for Phil partly because he needs a lot of supervision. So I'd be a bit concerned about that because I've done some research about what the burden of caring is for older people. If their partner with dementia has any sort of self-care needs. So that's a red flag for me. It makes me wonder if she drives. We don't know that. It makes me wonder how she gets out of the house to do her shopping, whether she can actually leave Phil, or whether there's anyone that can sit with him if she has to go out and do something. There are quite a few red flags there for me. So as I said earlier, my potential intervention would be to go and meet Rosa and Phil and try to build a relationship with her. And a lot of relationships take several home visits to develop. So the idea that you can get it all sorted out in one, it is rather unrealistic. So it may require a sort of ongoing sort of relationship building exercise. But I'd want to have a chat to Rosa to work out what sorts of self-care things she's having difficulty with. Any tasks at home she's having difficulty with. Like the case study did mention that she's not presenting herself very well. So that would put a few red flags up for me. And she's obviously got issues with her knee. And even pre any idea of surgery, there'd be a whole heap of things we can do to make transfers easier for her at home. And post-surgery, she would definitely need some assistance with that. And identification of any sort of home hazards. I mean, we're only told about the clutter, but there could be any range of falls related hazards in the home. So that would be an obvious thing to have a look at. There are also some really good programs available. One that I know of particularly is the tailored activity program, which is a program for people with dementia and their carers to try and re-engage the person with dementia into activities that they find enjoyable. And that can offer some respite and relief to the carer as well. So there's a reference there if anyone's interested in that. So I think that's it from me. Oh no, how to get hold of an occupational therapist. So I believe there's quite a few GPs on this call. So an occupational therapist is, as Stephen mentioned, often involved in ACAT assessments and would make recommendations for both Rose and Phil. But that depends whether or not the GP gets as far as making an ACAT referral with Rose's permission. GPs can also get occupational therapists involved through a chronic disease management program for Rose, especially for falls prevention. So I would expect them to include an OT and a physio. And local community health centers run by the local health districts normally employ occupational therapists as well. So there are a variety of ways you can get hold of someone that might be able to help. Okay, I think that's me now, Stephen. Well, that's some of you. Only some. It's a lot more information you've got there. And I can't think how many times I've said, borrowing from the ever popular TV series called The Midwife, call the OT. Because really there are situations that are absolutely perfect for the tasks that you can do. It's a problem, isn't it, when families haven't been able to get an ACAT assessment and given the waiting list for packages. That's the routine. We'll maybe come to mention a little bit about that later. So thank you for that. Now, last but not least, Alison, to give some insight into the psychological and emotional care of a carer's needs, particularly Rosa, and how we can try and meet those needs. Thank you, Alison. Thank you, Stephen. Hi, everyone. It's a pleasure to be here. It may surprise you all, but I won't necessarily just stick to the topic of emotional and psychological support. So this first slide really is just a representation of what everyone's been describing in terms of the holistic care that we all like to deliver. And the assumptions I think we can all make are that Rosa is a really loving wife intent on keeping Phil at home. We can also assume from the story that she believes that she can actually do this on her own. So that's a really interesting one and quite common. Also, I'm assuming that Rosa is putting herself second and Phil first, which is also incredibly common in that cohort and for all of our mothers particularly. So the risks for both Rosa and Phil, in my opinion, are quite high in this scenario. And when I'm talking about risks, I'm particularly talking about the risk of carer burnout and also the risk of Phil prematurely going into hospital and or going into an aged care facility, which is the exact opposite of what Rosa is trying to achieve. So weighing up where to begin is this visual slide trying to capture what my brain does. So there's actually multiple reasons why a carer will refuse help. Often it's lack of knowledge about dementia. They actually don't realise that it's impossible for one person to continue to look after someone with dementia on their own. I have never seen a carer succeed and that's many thousands of examples. Often it can be to do with fear, sometimes pride. Other people are more deserving as a common one, particularly from females. And I had one the other day where the husband didn't disclose what was going on to a cat because he didn't want to ruin his wife's reputation, even though it was actually a symptom of dementia. So the risk assessment, as I said, is also important in terms of physical risks for both of them, medical risk, emotional risk as well. And a lot of the risks are unnecessary. So this isn't about the conversation about dignity of risk, this is about... And I've just put a note in there that stress and burnout can actually really impede a person's ability to take information in. So just keep that in mind when we're trying to educate people. So it's important to really appreciate where what Rose's understanding is, her attitude and also her responsibilities in terms of where Phil's dementia is up to. So the next slide is just a different way of looking at what everyone's been talking about in terms of someone moving from carer burnout into the carer being able to thrive and looking at mitigating risk by putting in supports and targeting specific behaviors and psychological symptoms of dementia and educating the carer of various principles. This is another way of looking at that holistic care that we're all trying to achieve. So with Rosa in the centre there, this is about appreciating her on every level possible and appreciating the informal and formal support, of course, as well as her medical health needs and pretty much using anything and everything we can to create that network around Rosa. And this last screen is the most important from my perspective and this is how I view whenever I'm working with a carer of someone with dementia because it's actually impossible to do the one person without the other. So it's about knowing the carer and asking, just being curious about them and also knowing the person with dementia. And a lot of that information often comes from the carer as well as meeting the person themselves. Home visits are gold, so that was an OT that actually taught me that in the early days of ACAT, so thanks to the OT. And also having a really good understanding of dementia, it would again be nigh on impossible to really help this couple without understanding the ins and outs and the nuances of the dementia itself. And just that pyramid there tends to be the order I do things in, which is that rapport building first and then fine tuning. And then once everyone's settled, that's when it tends to be the best time to address that grief and loss. So that's it from me for now. Thank you. That's absolutely fantastic. I would agree totally that home visits are gold. My dad taught me that he was a GP in a suburb of London. And unfortunately in Australia, the figures show that home visits by GPs have cailed right off except in country areas. So we really do have to work as a team relying on you in your disciplines to be the eyes and ears. Digital solutions probably won't solve it, even though there's interest in the digital solution. So maybe if I go back to Marika so that we do it in order and just do a starter question. Marika, how can how can we involve Francesca in the conversation about care and support and indeed nearly the neighbor. And as Alison said, it takes a village and I think that's probably what you were referring to when you spoke about compassionate communities. Especially there's a definition going around of compassion, which is empathy and action. So compassion is two softer words sometimes for healthcare professionals. Empathy we all should have, but we like a bit of action. So would you like to pick up there Marika and then you other two just feel free to join a conversation at this stage. Sure, sure. I think it's a really good question. I think again from we need to see Rosa and Phil in context and in context of all the strengths that they have to continue to live at home safely and happily irrespective of the dementia, irrespective of the bad knee, irrespective of the garden, needing tending or whatever, whatever other challenges they are. I think in order to involve Francesca again, the key is to build trust with Rosa. She is the gatekeeper to wellness for both her and to Phil. I would certainly want to establish that trust, whatever that looks like, absolutely a home visit is the way to go. Conversation, sharing of knowledge, sharing of experiences that will then allow that front door to open just a little bit. She's absolutely legit to involve daughters. I know in my circumstance, I'm a very involved daughter, but my dad's the primary carer. And for a long time, his major issue was he didn't want people to see my mum bumbling and not being able to find her words. He didn't want to her to be embarrassed because of her memory loss or her agitation. And as a response to that is he didn't want to include others or seek help in the many ways didn't even want to see some of that external informal network because it was really putting my mum on show that she wasn't well. And in Rosa's case, her hesitation is, you know, Phil was a successful man. She supported him. He was clever. He had an amazing career. She might not want everyone to see that his dementia is making him behave differently. So I would want to really work with her over, you know, a couple of home visits and then say, look, how about we have a chat to Francesca and see what she thinks. I'm not sure what my other colleagues on the panel would also add to that. Go for it, you two. Well, on behalf of Rosa, I think the first it's Alison here. I think the first thing she would say is, oh no, Francesca is way too busy. So because she's in the story it said that earlier in the year, she's pulled back. And so I'm not sure that would work immediately, but I agree with everything else. It's all about that rapport, isn't it? And understanding why Rosa's saying no and thinking that she can do it on her own. I often find that it is just truly a genuine lack of understanding from the public about dementia. Everyone says that they know what dementia is, but when it comes to the crunch, I really feel... I'm pretty straightforward with people and I come straight out and let them know that in all of my years I have never, ever seen a carer manage to do it on their own. So I use that trade-off for them and say, if your goal is to keep Phil at home, then this is the only way to do it. And I work from leveraging that. Absolutely, yes, very much. Lynette, is your microphone working? No, something's dropped out there. I'll just carry on while the tech people behind fix things up. But yes, I absolutely agree and this is what you were saying. It takes a village, beautiful daughters all very well when they can do the duty as it were. And I love it that there's an organization called Beautiful Daughters to stand in when the beautiful daughters can't. And why should they be expected to? In that compassionate communities model, there's a saying goes around, what's in the lada? So when we go into the lada, we don't think there's anything there and it's just Rosa and Phil and maybe a pet. We try and see maybe if Francesca can't be the person who helps. Does she know anyone who's close enough? I've known situations where someone goes through the phone book with the family and says, well, you know, maybe they would enjoy helping coming around. What would you feel about it? I'm sorry, Steven, I'm sorry to cut across you. I think that's a really good point. And one of the things that I've often used is that what's in the lada and people couldn't possibly ring my cousin. You know, she's busy with her own children and family and husbands unwell and blah, blah, blah. I often ask carers, well, tell me when you supported somebody, when somebody needed help and you were there. And they often say, well, you know, I used to deliver meals to Mellie and I can't quite do that. I used to go down to the University of the Third Age and I always used to make the sandwiches because I know there were two people there that never ate. And slowly they begin to see the role that they played in helping people go right. And that sometimes allows people to become a little bit more accepting of, well, you know, maybe I can ask Mellie to just pop in, sit with Phil, duck down to the shop or go and get an x-ray. Maybe I can do that. Lynette, are you back on with us? No, I don't think she can hear us all. I think that storm over Sydney has wrecked a few connections, but at least we've got your audio, Marika. So, Alison, I'm coming back to you. There's quite a lot of conversation in the chat room about carer burden and the guilt or shame of not coping as a carer. Do you want to just, you know, people really talk about it? And perhaps that also leads to the next question, which is abuse by carer or to the carer? Yes, I'm happy to talk to this and it's actually, again, something I sort of, my main thing, a main role that I do. So carer burden, most people will be aware the literature is very firm. It's really dangerous for them medically, physically, psychologically. There's no doubt that it actually makes carers sick. So it is, in my opinion, a high risk and, as I said, an unnecessary one. Certainly, in terms of doing that risk assessment, the preferable time to put in support, by the way, for someone with dementia is on diagnosis, or if I had my way even pre-diagnosis, during diagnosis and after, not four years later, you know, because they've been travelling OK. That education needs to begin much earlier in the piece, otherwise we end up with many cases of Rosa and Phil. And the carer emotional rollercoaster is a really interesting one. And again, everything that the other girls said about validating and respecting that carer as a person really melts them and really sort of gets you a long way with about 95% of them. It's just understanding why they're making those decisions, educating them. But once you build that rapport, that's when they start disclosing some other stuff. So they're either having, you know, they try to be perfect, and then when they're not. So Rosa would get cross at Phil and she snaps at him, and then afterwards she'll feel guilty. And then she'll beat herself up that she's not being good enough. The other scenario is if you've got a carer who's really burnt out, they actually probably will be snapping at the person with dementia. They will be likely yelling at them. I had one the other week where the son was raising his voice at mum because mum not only was deaf, but very, very repetitive with very little comprehension that no one had checked in with the son. No one had educated him, asked him if he was okay, validated the role that he was playing in looking after his mum. So I was concerned somebody may walk into that scenario and accuse that son of abuse when indeed this son was a dedicated son who literally had dedicated his retirement to looking after mum. And it was more a case of I felt that we as a community have let them down in that we haven't provided timely supports in a way that he could move from carer burnout into thriving so that he could go back and play his bowls and have his life as well as have his mum be safe and sound and living her best life. To me it's all about education and supports and it's to get in early and it's probably a good time to mention that I'm thrilled that Dementia Australia, so this will apply for everyone listening, now has a brand new service that is a post-diagnostic support service and I've attached the information to the resources. I certainly intend to refer pretty much everybody as soon as we give them a diagnosis. So let's all do the same and then we'll overwhelm the service and then they'll need more funding. Good idea Allison, good idea. I'd like to say the PH, oh yes, go ahead Roryka. Sorry again Stephen. Thank you for that Allison because I think that's really important messages. One of the things that we all do as professionals or support people of particularly of carers is support them to transition into their next bit in their life and ultimately when you're caring for someone you're actually moving through a transition. You're transitioning your relationship with that person. You're transitioning your role. You're transitioning your circumstances. You're having people in your home that you don't actually know. In Rosa's circumstances, I mean there could be cultural issues around that. There's certainly issues around, I don't want anyone to come into my home. I certainly don't want anyone to come into my home and see my messy house or come into my bathroom. I mean that is very intimate and very, very invasive no matter how critical that service is. So being really mindful that we are helping people through transitioning to the next stage. And in Rosa's case and in fact in many carers case, they're really trying to understand this whole thing that they're doing caring for their loved one and they're grieving. They're constantly grieving. For those of us who are parents, I remember a nurse told me once, a baby health nurse said, Marika, parenting is this never ending journey of grief. And I said, oh that sounds terrible. And she said, no you think about it. You know, you grieve about being pregnant and then the baby is born and you grieve about the baby no longer breastfeeding. You grieve about the toddler becoming independent. You grieve about them moving on to school. I remember when my little one went to Kindie, that was horrific. For me, he had a great time. You grieve about them becoming teenagers, adults, leaving home. And I guess in many ways when you're caring for someone, whether it's a partner or a child or a sibling, you have this grieving stage of the relationship you've had in the past. And that manifests its way in a whole range. You know, people being angry and pissed off with the care worker that comes in, people being withdrawn, being resistant. So getting to know that is really important. I think that's where the role of a psychologist is really important, Alison. Very good evidence that if we recognize anticipatory grief, this will help the bereavement burden greatly. So absolutely, there are now psychological services that primary health networks can commission for emotional well-being for older people, both in the aged care facilities and since COVID into the community. So that might give us, with a limited workforce of gero-psychologists, might give us a little more workforce to be able to visit people with this care burden. I'm working on that workforce issue, Stephen. But also, it is social workers as well that are well-versed to be working on those emotional sort of factors and the social determinants of health. In fact, I'm a firm believer in all, you know, the full multidisciplinary suite. And from a dementia-specific lens, I believe that all of our disciplines can actually be well-versed in all of our roles. And particularly the core roles of OT, social work and psychology. So that worked well tonight, supporting the GP. And that's the model that I would love to see out in the community to actually keep people out of hospital and to, you know, keep people at home as long as possible. So I want to put a sort of a pointy little question force to everyone though. What do we do with the urgent risks? Because we're focused on Rosa, but what about the fact that Phil is wandering? And we don't know, for example, if she's still trusting him to take his own medications. He's got high blood pressure, so he's likely on a high-potensive medication. Is he mucking that up, or is she at least in charge of that? So again... Well, Lynette, what do you think? Because you've not had enough options because your audio went... I'm sorry, I'm sorry. I had a clap of lightning and I disappeared. I mean, really, the situation needs to be looked at as it evolves and unravels when you do actually see the person. I mean, I think it would be really hard to identify what the issues might be with Phil without doing the home visit that's gold and actually spending some time with him in his own environment where he would be most comfortable. I think it would be very hard to work out what you could do in a consulting room, for instance, when Phil and Rosa come to see a GP. I think it would be very difficult to make an evaluation of his behaviour or his status. I mean, I'm very concerned that Rosa might not be able to leave the house or leave him and what some of the issues might be and whether or not she has to go everywhere with him to sort of, I don't know, whoop, the dog. I don't know what else has to happen without having a chat and finding out what the routines are for them as a couple. Even at Sanders though, Francesca might not be around so much to do shopping and things like that. I don't know if they have a computer. I would expect they probably do if Phil has had an academic life. I would expect them both to be familiar with a computer in which case there are ways you could get around having to go to the shops thing. But I would imagine that there would be an issue for Rosa just needing to be around him all the time and not being able to have a shower, for instance, herself and all of that sort of thing. I'm wondering if you as the eight cat specialist, assuming that they're given the golden real of a level four package where we're making many assumptions here. How far in your experience does that go in getting enough support to support her and keep him at home? And is it possible to keep him at home without bringing in community support in the terms that Marika was talking about and it takes a village Allison's phrase. What does a level four package realistically offer them? Maybe people, participants who don't really know about what some of these level packages give, but they certainly would give respite for Rosa. Absolutely, but a lot depends on, again, as somebody else is saying, how adverse they are to having lots of people they don't know in their home. You see that will be a major hurdle as well as even if they got to the point where Rosa would accept some help. It might be baby steps first so that that trust can build up. You can have success with a small improvement and then build on that to a slightly larger amount of help. I think going from zero to level four might be a little bit of a difficult thing for Rosa to cope with or adjust to. Lynette Luckworth for us, the system has an 18 month wait on level four packages. I know, I was then going to say all the trust things then become difficult. You could get them to agree to this and then say, well, actually you won't hear from anyone for ages. So this is the wicked problem, isn't it? Because the Royal Commission has assessed that more people are going to want to spend more time at home and yet we've got this 18 month lag on the packages. So a word to everyone out there, just get everyone registered for that package. Call Lynette and her team, get the ACAT assessment done and then see there's plenty of time in that 18 months that if it's not in there, like the insurance policy, unfortunately it will be residential care. So and I think knowing dementia well, Phil actually already has a moderate stage dementia. And I don't think as much as I respect that it takes time to sort of build rapport with Rosa, I think there is some urgency here in terms of getting a combination of formal and informal support. Pretty much I tend to use whatever's available. If he had a mild dementia and his cognitive screening scores were like 26 out of 30, but keep in mind this is a very bright man, so he's had further to fall. And the fact that he's now scoring 16 out of 30 means that he's actually really quite a long way along. She's already neglecting herself and may end up with her own. Probably no one's educated her that feels at higher risk of delirium. Any number of things can go wrong. So yeah, any sort of reluctance on Rosa's part, I tend to combat if you like with the risk of not being able to keep him at home. I'll show my my English heritage comes from the Latin cure, cure. And I think we often think that good care will will cure the situation. But unfortunately, sometimes what we hope for doesn't happen and a family sometimes expect that from residential care. Probably got lower expectations of care at home, but can still have very high expectations. How do we deal with some of those higher expectations of family members who think that the formal carers can can do do miracles. Do you encounter that any anyone on the on the panel working with the families. You're nodding when I'm not sure if your audience I'm trying to think of specific examples. But yes, one of the people with very unrealistic expectations. Yes, yes. And I think that's part of our task is to say that, you know, there isn't a cure for this. We so expect modern medicine to be able to cure everything. And yet, of course, aging grief loss are not curable. So I'm not telling anyone in this in this wise audience anything they don't know. It's just we are often faced with that challenge. Interestingly, the research showed that a large proportion of the population don't realize that dementia will kill you. So it's actually leans the other way that they're not they don't realize. You know, so that's it. That was really interesting to me and again reinforces that need to educate. I was just wondering if there was a question. I think from one of the GPs about when when their patient or the family of their patient doesn't disclose any of these problems. What what are they meant to do? And I just was quickly going to say that even though every individual is different. Again, having a solid knowledge base of dementia and just using simple screening tools can be a really good indicator in terms of what risks match up with what degree of cognitive impairment. So those scores when they're getting quite bad typically mean that they won't be taking their medications correctly that they might be at risk of when they're driving and those sort of things. But again, I think sometimes GPs in the consult room with limited time, I think it must be really tough. It's not like you can press people and if if like most scenarios, the person with dementia continues to visit on their own. And and one of the main symptoms of dementia for most of the main dementias is lack of insight. Then there is no information forthcoming. And I think that that's a really tricky one. So I think these new services where they're dementia specific services that we as a community can introduce on diagnosis is a probably a beautiful and compassionate way of getting around some of those symptoms as they emerge. Because to me that's the biggest wicked problem probably for GPs is you can't sit there and talk to a person about their symptoms when their main symptom is loss of insight. Because it's actually quite cruel. We don't grab them by the shoulders and go remember you've got dementia and therefore that means. So yeah, I'm quite hopeful that new sort of methods that we've been speaking about that have stemming from the Royal Commission discussion. Multidisciplinary teams, community based teams with the GP as the lead could quite beautifully address many of these issues in the future. I'm quite optimistic about it. I'm going to interrupt there and I'm just going to challenge us all a little bit. It's Marika here again. You know, the purpose of this session was really to focus on the carer and the mental health of the carer. And what we often do is always pivot our attention on the person that is being cared for. I know you're shaking your head not suggesting that we've done that. And it's like it's a little bit like a chicken or egg is like we can't really address the mental health of the carer without addressing the care needs, the diagnosis, the intervention of the person that needs caring. But often a carer is saying, look, you know, he's had everything and I've hid behind that. What about me? Am I someone even if I'm not caring for Phil? And often it's, you know, carers themselves like to say, look, don't worry about me. I'm absolutely fine. As indeed Rosa has, I'm not so, you know, Phil, Phil, Phil. But I think we need to get in and understand and of course the GP does not have the time. And in this instance, the GP was fantastic in sort of saying, hey, I didn't even realise I was your GP. Let's go get an x-ray. But doesn't have that time. So again, I'm going to go back to this compassionate community that is around Rosa. How do we use them to lift her up to really say, Rosa, you are just as important and without you and your wellbeing. Let's just focus on you for a second. Let's just focus on you. And I think, you know, Steven, you asked a question earlier is how do we involve and engage Francesca and her, her now, you know, year 12 daughter and nearly the neighbour and other people. How do we engage them in a non-intrusive way? Obviously, education is really important. That's the insight stuff that we've just been talking about. Really important. Phil may have lost some insight. But how do we engage and support Rosa to educate the people around her? Look, Phil's got diabetes diagnosed with dementia. He's still Phil and I'm still Rosa. But this is what he's likely to behave like, you know. And I think we need to turn our attention to Rosa as an individual just for a little bit in really looking at caring for her and some of those questions I put up earlier is, you know, what gives you joy, Rosa? Who do you trust? Who do you miss? You know, it might be like, you know, I really miss Helen down at the Bolo when I used to play bowls every Tuesday. I haven't seen her in over 12 months. We don't know. Well, how about we call Helen? How about you call Helen? There's a goal for you. Let's call Helen. So again, I mean, this session is really looking at us understanding the mental health challenges of caring. And of course, of course, it's difficult to separate that from the person that they cared for. But we need to be able to focus our attention on Rosa, obviously interdependently with Phil, but really focusing on her and what's important to her. To me, you've probably just highlighted, Marika, the reason why a dementia-specific workforce is essential because it is impossible to do one without the other. And if a carer is getting to the point where they're saying, what about me? I consider that we're doing it wrong. So because my entire focus, I have many families saying to me, oh, I thought you'd be working with Dad. And I'm like, no. The entirety, even though I assist with diagnosing dementia, almost the entirety of the work that I do is with the carer and is about the carer. So certainly that shouldn't be mistaken. But at the same time, I can't help Rosa get back to gardening and bridge if the reality is that Phil can't be left home alone because he's going to burn the house down or he's going to wander onto the highway. So I find that description, what you said, it's exactly true. And that therein lies the skill is that when you come on board with a case that's at this stage with no support, it's a juggling act. I actually find that I have to do several things within that first session. Pretty much a little bit of everything, a little bit of validation, a little bit of risk assessment, a little bit of checking in with her education and cramming it all in because there's no one thing less important than the other. To me, that's always been the hardest skill of all. And I even find that I do a little nod to grief and loss. And for some who are ready, I flag that and say, that is there. There's no time to get to it at the moment, but just flagging with them. That is also that anticipatory grief. So yeah, it's just naming it. Just naming it. Well, we need to clone you about 10,000 times, don't we? To deal with the challenge of the numbers of people who are going to need those kinds of services. So that's great. Can I just ask you, Lynne, in the TV panel shows, they ask for a two minute summary of how you feel things have gone in terms of looking at Rosa's situation. Well, I think Marika and Alison have covered all the caring and social and psychological components really clearly. I guess what I'm concerned about as an OT would be to make sure that Rosa is able to mobilize and transfer and undertake her own self care as well as fill self care safely with a gammy knee and osteoarthritis that she might have in other joints, not just the knee. It's only because she fell that the knee turned into a problem. And there would be a whole range of things we could look at to try and prevent her falling and fill falling as well for that matter in her home. Yes, yes. It's important because that's what does send you to hospital and then again into quick fractured femur and off you go, yes. Then the bubble of care after that. That's right. So let's try and keep all the roses and fills at home. And I think we've got to the stage which I want to thank you three for what you've contributed. It's always too short, but I think you've summed up beautifully many of the issues that we face and many of the solutions that are out there. One of the themes that came out of the last webinar was hope. So I think if we share that hope with Rosa and Phil and all those like them, that will be helpful. So thank you to our engaged audience and for all of your entries into the chat box. Of course we haven't answered all of your questions, but maybe there'll be more more opportunities down the track. Perhaps the take home message is one of hope and respect and the wish that the needs of the kind carers of our nation will continue to be met by all in the community, including animals. For you pet lovers, they play a very important part as do televisions and their informal carers too. And by all the professionals working together collaboratively and assertively across all of our disciplines. So I'll just move the there is a supporting resources tab on your screen and you'll be sent a recording of tonight's webinar as an email. And there are also, I should say, many excellent past webinars available on the MHPN website. Local networking. I had a great personal experience with this part from these webinars with the support of the MHPN team and our PHN in Sydney North. So we've been running meetings now for a couple of years for the same sort of audiences is here tonight. I think we've mostly got is about 100 people squashed into a room, obviously more for the webinars addressing issues which have ranged from First Nation elder well being to BPSD to addictions, mood, medication. Talks from art and music therapists, and we've even been able to screen a couple of outstanding documentaries. So I really do encourage you to contact MHPN either in the in the feedback at the end or just by calling them start one in your area. And these are the kinds of discussions that you can have in every area there are wonderful social workers, occupational therapists and gyro psychologists, counselors, community members. So MHPN is incredibly supportive in setting up one of these networks. So I really do encourage you to do that. And by way of this great partnership between the 31 PHN and MHPN. The final webinar in this series next year, as I said, we'll explore aging from a First Nations and multicultural perspective. So don't forget to fill in the exit survey. That's the most important thing, most important job for me tonight. And so thank you for putting up with the thunderstorm, but I do think it was a good metaphor, expect the unexpected. And so good night to all and don't forget to care for yourselves. You can't care for others unless we all care for ourselves. Thank you for your participation and I look forward to seeing you in the new year. Keep your eye out for the announcement of the next webinar. Thank you.