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Over 65s

alternate text 48Caring for someone over the age of 65 can be complex. More chronic health issues are likely to occur in older people, including diabetes, stroke, heart disease, arthritis, high blood pressure, sight and hearing loss, depression, mobility issues and falls.  Dementia External Linkmemory problems are also much more common.

As a Carer, you may be an older person with your own health problems or an adult child juggling a job, a young family and an elderly parent who wants to remain at home.

Below, we outline the who's who of caring for someone Over 65. If at any stage you find the journey confusing or difficult to navigate, please contact us, we are here to help.


Coming into our hospitals

Our hospitals provide a range of different in-patient services for older people and people requiring rehabilitation. These units are staffed with a range of medical, allied health and nursing professionals who are experienced in caring for people over 65 who may have more complex medical problems.

If you are providing most of the care to the person coming into hospital please let the nurse know you are the Carer and to put your name and contact details on the file. Note, your details may already be on file if there has been a previous admission.

Our hospital staff can provide you with information to help you care in the hospital setting and at home.


Who's who of hospital staff

As a Carer you will interact with a variety of hospital staff and it's easy to lose track of who's who. We suggest you keep a notebook and pen handy and if you miss a name, ask the person to repeat it, especially if it is a medical staff member. We have Carer notebooks and pens available in Carer Support. If you need one while in hospital, please let us know.


Medical Staff

Geriatrician - A geriatrician is a specialist doctor who cares for people over the age of 65. Older adults can often have complex health needs and take a variety of medicines.

Geriatricians are specialists in dealing with people who have multiple conditions including dementia and other cognitive impairments, problems with mobility and frailty, incontinence, nutrition, medicines and other medical issues.

Patients with dementia or delirium can be managed in a specialist clinical setting by a skilled workforce to help prevent, diagnose, treat and manage their condition.



Doctors training to become Specialists are called Registrars. They oversee the day-to-day care of the patient and in consultation with the Staff Specialist, make decisions regarding the medical management of patients.  Registrars are in the hospital most of the time and are usually the most accessible person to get a medical update from. Registrars change areas every three to six months so you may deal with different Registrars over a period of time.


Residents and Interns

Interns are doctors in their first year following completion of their university degree. Residents have had at least one year of working in a hospital. They can give you some information but they have limited authority. As part of their training they rotate areas every three months.


Nursing Staff

In hospital wards, most nurses will be either:

  • Registered Nurse (RN) who has completed a university degree.
  • Enrolled Nurse (EN) who has completed a certificate course.
  • Clinical Nurse Educators (CNEs) who work alongside nurses to give them additional education and support.
  • Clinical Nurse Specialists (CNS) or Clinical Nurse Consultants (CNC) specialise in a particular area, e.g. Intensive Care, Aged Care or Cancer Care. They have extensive specialist knowledge and experience.


In the emergency department

It is possible that you will see an aged care CNC or nurse whilst in the emergency department. They will ask you a number of questions to get an accurate background of the person you are caring for. The medical team will use this information to decide whether the person needs to be admitted to a ward or whether they can go home with a follow up service. If they are admitted to the ward, the aged care staff will have arranged for other allied health to be involved in the person's care.


On the ward

If you are admitted to a ward, it may be a specialist aged care ward or a general ward such as surgery, medical or rehabilitation.  Management of each ward is under the direction of a nurse unit manager (NUM) during business hour and a team leader out of business hours. If you have difficulties or queries that the nurses are not able to assist you with, or concerns you wish to raise, you can ask to speak with the ward NUM or Team Leader.



In a rehabilitation ward the allied health team will work closely with the medical and nursing staff to improve the person's function. They may organise a home visit with the person to check that they can manage before being discharged. Any equipment that might be needed will be identified at this time and organised for the person on discharge home.


Allied Health Staff

In hospital wards, you may meet a variety of allied health staff such as:

Social Workers who provide support, counselling and information to patients and their families. They may also assist arrange community services for discharge home

Occupational Therapist (OT) whose role is to see where an illness or disability may prevent a person from being able to perform daily living tasks, for example, taking a shower. An OTs job is to teach a person how to manage tasks again so that they can be independent and safe. OTs may also arrange for home modifications or equipment.

Physiotherapist (Physio) who sees a patient after surgery, or if they have a longer term illness or disability, to help address mobility issues. They also educate people to understand the importance of exercise and to increase mobility and strength. Physios assess a patient's need for mobility aids and organise follow-up appointments with the post-discharge clinics.

Speech Pathologists who assess, treat and provide a management plan for patients with communication disorders. Surgery, disease or brain injury may cause physical problems, i.e. eating or swallowing.

Dietitians ensure that patients receive the correct diet and nutrition. Ask to speak to the dietician if you have any concerns. Dietitians work closely with Speech Pathologists for patients who have swallowing difficulties and it is important for Carers to be involved too. If you are concerned that your relative is not eating, please speak with the Dietitian or RN.


Aged Care Assessment Team (ACAT)

Older patients who need residential care, respite care or community care packages are assessed by ACAT who determines their eligibility, level of care required and advises of options. Consent to aged residential placement is always discussed with the patient and their family/Carer. ACAT will only see the person on the ward if they need residential care. Assessment for community packages will only happen when the person is at home.



Pharmacists review medications and work closely with doctors prescribing medications. It is important that you advise them of all medications and supplements being taken. If you dispense medications for your family member please ensure you have a list of medications with you when coming in to hospital.

Chaplains are available to support people in times of crisis, anxiety, suffering, grief, loss and death. They are non-denominational. Staff can arrange a chaplain for you.



Interpreters are available in our hospitals. Ask staff if an Interpreter is required.


Does the person you care for have memory or cognitive problems?

The PDF iconCommunication and Care Cues form enables our staff to recognise and provide patient-centered care to meet the individual needs of patients with memory and cognitive problems whilst they are in hospital.

Filling out the Communication and Care Cues form will help us keep the person you care for settled while they are in hospital. For example, “John takes a walk each evening, he gets upset if he doesn't get his walk."

Your knowledge and expertise of caring, especially in regards to communication and behaviour, is an important link for us.  Please fill out this form (hyperlink) and give it to nursing staff so it can go on the medical file. If you have completed this form on a previous admission, it should already be part of the medical record.


Helping out in hospital


If your family member struggles to feed themselves, we are happy for you to assist. Please let nursing staff know so they can ensure the bed is at the right height for you and explain anything else you need to know. 

If you notice a behaviour that is unusual in your family member this could be a result of delirium and it is important you discuss this with nursing staff as soon as you notice any changes.

Staying overnight in hospital

If the person you care for with a cognitive impairment is unsettled and you think it will help for you to stay overnight, our Carers @ the Bedside program can help. Please discuss this with the nursing staff.

If your family member is unsettled and trying to get up out of bed, please talk to nursing staff about your concerns.


Advance Care Directives (ADO)

An Advance Care Directives is important. It is a formal written record of wishes, preferences and instructions about future medical treatment. An ADO plays a critical role in reducing stress for you and the family when the person you care for is unable to make decisions.

If the person you care for has one, please bring it with you to hospital and ensure doctors have a copy. We recommend you have duplicate copies at home.  For more information on Advance Care Directives please see our Legal Information for Carers page.


Leaving hospital with someone Over 65


Referrals to services or Home Care packages on discharge

Upon discharge from hospital, you may be referred by nursing, allied health or medical staff to community health and other community services including:


APAC – Acute Post-Acute Care

APAC enables patients to have hospital care at home. For example, a patient who has had a stent operation may go home and a doctor (a specialist or GP) and nurse will visit them to oversee their care and carry out any further treatment. APAC team members include nurses, doctors, physiotherapists, occupational therapists and social workers.

Rehabilitation Discharge Team (RDT – Hornsby hospital only)

This team comprises of nursing, physios and OTs. It may be decided that the person can received some allied health in the home rather than be admitted to the rehabilitation ward. This service doesn't charge and comes from the hospital. They can provide some therapy to the person for up to four weeks, around two - three times a week. They will refer on to another service if required at the end of the four weeks.


Northern Sydney Home Nursing Service

Once discharged some patients will require the care of our local community nursing service. This will be arranged by hospital staff, or if required in the community, by your GP.


Discharge packages

Some patients need support to return home. Medical and nursing staff will discuss this with you and the social worker before arranging the care.


TRANSPAC – The Transition Care Program

Transpac is a short-term program for ATSI and frail older people being discharged from hospital. It provides a package of services that includes nursing support, personal care, domestic assistance and low intensity therapy i.e. physiotherapy, occupational therapy, social work and speech pathology. It enables a person to have the opportunity to continue their recover and regain their independence at home, rather than enter residential care prematurely. Packages are goal-oriented and time limited to a maximum of 12 weeks.



ComPacks is a community care package for people over 65 being transferred home from hospital. It can help patients regain independence and manage a safe return home. The package is available for up to six weeks for any adult who is assessed as needing two or more community services after discharge from hospital, i.e. personal care, housekeeping, transport to medical appointments and social support. Referrals for both of these packages are made through our hospital social workers. If you feel you will need help at home, please speak with a social worker well before discharge.


How do I get Community Care from Home?


My Aged Care

My Aged Care is the new one-stop shop for all aged care services in Australia. It is available for people over age 65 and Aboriginal and Torres Strait Islander people over the age of 50.

The first thing to do is call My Aged Care on 1800 200 422 where you will speak to an intake officer. You will be asked questions about your health, areas of need, what supports you have in your life, your Medicare number and other personal details. Carers are also able to talk with the intake officer about carer stress and other carer support needs. 

You can also visit the My Aged Care websiteExternal Link for information on the different types of supports and services available.

It is important to note that after registering you will need to have an assessment. The assessment is a conversation with a qualified My Age Care assessor.  It is important not to become too anxious or worried about the assessment, instead see it as a good opportunity to talk about and plan for your health and support needs. The My Aged Care Assessor will contact you to arrange an appointment time.

My Aged Care will explain:

  • The different aged care services available
  • Programs that support older people to continue living at home:
  • Your eligibility
  • Matching the right local services with your needs (you are able to select your own service provider)
  • Checking any compliance issues with services you're considering
  • Cost of your aged care services, including fee estimators
  • Respite Care
  • End of Life care at home
  • Transition Care (for older people who have been in hospital and need support to recover)
  • Aged care homes 

My Aged Care information is available in all languages. Call them on 1800 200 422 or visit their websiteExternal Linkand select your language for translated information.


Respite Care

Respite allows both you and the person you care for to take a break, to connect socially, to meet and talk with other people. It comes in many forms - from family or friends or more formally through a home, community or residential respite service.

It is important to make time for yourself. You may find taking a break difficult at first but it's important you do. Taking a break allows you to have a rest from your caring role and to maintain some independence whilst knowing the person you care for is being properly looked after. Some carers choose a day a week, others a few hours every now and then. It can be useful to begin with short breaks and increase them over time. The type of respite care you need will depend entirely on your own unique situation - what suits you and the person you care for. Types of respite include:

  • In-home respite – A respite carer comes to your home
  • Residential respite – Care in an aged care facility while you recharge
  • Centre-based respite – Usually held during the day at a community facility providing group activities in a social setting.

It's good to remember that respite care is only for a short period of time and regular breaks are important for you. It is also worth remembering that respite can be accessed for your loved one, if you need a period of hospitalisation yourself and cannot be at home to provide care.


Concerned about your hearing, or of the person you care for?

Did you know you can book in for a free hearing check if you are a pension card holder? There are more than 490 Locations nationwide. Call 131 797 or visit their website.External Link

Stepping On is a free, exciting and friendly community-based falls prevention program for seniors. It is designed to build knowledge, strength and confidence to prevent falls and stay active and independent.


Aged Care Problems and complaints

If you have a concern or complaint that you have not been able to resolve by talking with your service provider, the Aged Care Quality and Safety Commission can support you with information and options, to resolve your concern with the service provider.

When you contact them, we will listen to you and ask questions about your concern to help them understand the issues and your expectations. They will then let you know if your concern or complaint is an issue that we can help you with.

You can contact them by phone on 1800 550 552 (9am-5pm, Mon-Fri) or visit their website at Aged Care Complaints CommissionerExternal Link



Interpreters are available and you have the right to use one. If you are in hospital ask the staff to arrange an interpreter for you. If you need to talk to a Community Health Centre or Community Service Provider, call the Telephone Interpreting Service on 13 14 50.


Key Links:


Further assistance

We have a wide range of information to help you in your caring role, including help with:


Call Carer Support 

If you live in the Northern Sydney region and would like more advice about your caring situation, please call us on 9462 9488