Dementia is the second leading cause of death for Australians aged over 65. More than 421,000 Australians currently live with dementia and this figure is expected to almost double in the next 30 years.

There is ongoing public discussion about whether dementia should be a qualifying illness under Australian voluntary assisted dying laws. Voluntary assisted dying is now lawful in all six states, but is not available for a person living with dementia.

The Australian Capital Territory has begun debating its voluntary assisted dying bill in parliament but the government has ruled out access for dementia. Its view is that a person should retain decision-making capacity throughout the process. But the bill includes a requirement to revisit the issue in three years.

The Northern Territory is also considering reform and has invited views on access to voluntary assisted dying for dementia.

Several public figures have also entered the debate. Most recently, former Australian Chief Scientist, Ian Chubb, called for the law to be widened to allow access.

Others argue permitting voluntary assisted dying for dementia would present unacceptable risks to this vulnerable group.

Australian laws exclude access for dementia

Current Australian voluntary assisted dying laws exclude access for people who seek to qualify because they have dementia.

In New South Wales, the law specifically states this.

In the other states, this occurs through a combination of the eligibility criteria: a person whose dementia is so advanced that they are likely to die within the 12 month timeframe would be highly unlikely to retain the necessary decision-making capacity to request voluntary assisted dying.

This does not mean people who have dementia cannot access voluntary assisted dying if they also have a terminal illness. For example, a person who retains decision-making capacity in the early stages of Alzheimer’s disease with terminal cancer may access voluntary assisted dying.

What happens internationally?

Voluntary assisted dying laws in some other countries allow access for people living with dementia.

One mechanism, used in the Netherlands, is through advance directives or advance requests. This means a person can specify in advance the conditions under which they would want to have voluntary assisted dying when they no longer have decision-making capacity. This approach depends on the person’s family identifying when those conditions have been satisfied, generally in consultation with the person’s doctor.

Another approach to accessing voluntary assisted dying is to allow a person with dementia to choose to access it while they still have capacity. This involves regularly assessing capacity so that just before the person is predicted to lose the ability to make a decision about voluntary assisted dying, they can seek assistance to die. In Canada, this has been referred to as the “ten minutes to midnight” approach.

But these approaches have challenges

International experience reveals these approaches have limitations. For advance directives, it can be difficult to specify the conditions for activating the advance directive accurately. It also requires a family member to initiate this with the doctor. Evidence also shows doctors are reluctant to act on advance directives.

Particularly challenging are scenarios where a person with dementia who requested voluntary assisted dying in an advance directive later appears happy and content, or no longer expresses a desire to access voluntary assisted dying.

Allowing access for people with dementia who retain decision-making capacity also has practical problems. Despite regular assessments, a person may lose capacity in between them, meaning they miss the window before midnight to choose voluntary assisted dying. These capacity assessments can also be very complex.

Also, under this approach, a person is required to make such a decision at an early stage in their illness and may lose years of otherwise enjoyable life.

Some also argue that regardless of the approach taken, allowing access to voluntary assisted dying would involve unacceptable risks to a vulnerable group.

More thought is needed before changing our laws

There is public demand to allow access to voluntary assisted dying for dementia in Australia. The mandatory reviews of voluntary assisted dying legislation present an opportunity to consider such reform. These reviews generally happen after three to five years, and in some states they will occur regularly.

The scope of these reviews can vary and sometimes governments may not wish to consider changes to the legislation. But the Queensland review “must include a review of the eligibility criteria”. And the ACT bill requires the review to consider “advanced care planning”.

Both reviews would require consideration of who is able to access voluntary assisted dying, which opens the door for people living with dementia. This is particularly so for the ACT review, as advance care planning means allowing people to request voluntary assisted dying in the future when they have lost capacity.

This is a complex issue, and more thinking is needed about whether this public desire for voluntary assisted dying for dementia should be implemented. And, if so, how the practice could occur safely, and in a way that is acceptable to the health professionals who will be asked to provide it.

This will require a careful review of existing international models and their practical implementation as well as what would be feasible and appropriate in Australia.

Any future law reform should be evidence-based and draw on the views of people living with dementia, their family caregivers, and the health professionals who would be relied on to support these decisions.

Ben White, Professor of End-of-Life Law and Regulation, Australian Centre for Health Law Research, Queensland University of Technology; Casey Haining, Research Fellow, Australian Centre for Health Law Research, Queensland University of Technology; Lindy Willmott, Professor of Law, Australian Centre for Health Law Research, Queensland University of Technology, Queensland University of Technology, and Rachel Feeney, Postdoctoral research fellow, Queensland University of Technology

This article is republished from The Conversation under a Creative Commons license. Read the original article.

People have a pretty intuitive sense of what is healthy – standing is better than sitting, exercise is great for overall health and getting good sleep is imperative.

However, if exercise in the evening may disrupt our sleep, or make us feel the need to be more sedentary to recover, a key question emerges – what is the best way to balance our 24 hours to optimise our health?

Our research attempted to answer this for risk factors for heart disease, stroke and diabetes. We found the optimal amount of sleep was 8.3 hours, while for light activity and moderate to vigorous activity, it was best to get 2.2 hours each.

Finding the right balance

Current health guidelines recommend you stick to a sensible regime of moderate-to vigorous-intensity physical activity 2.5–5 hours per week.

However mounting evidence now suggests how you spend your day can have meaningful ramifications for your health. In addition to moderate-to vigorous-intensity physical activity, this means the time you spend sitting, standing, doing light physical activity (such as walking around your house or office) and sleeping.

Our research looked at more than 2,000 adults who wore body sensors that could interpret their physical behaviours, for seven days. This gave us a sense of how they spent their average 24 hours.

At the start of the study participants had their waist circumference, blood sugar and insulin sensitivity measured. The body sensor and assessment data was matched and analysed then tested against health risk markers — such as a heart disease and stroke risk score — to create a model.

Using this model, we fed through thousands of permutations of 24 hours and found the ones with the estimated lowest associations with heart disease risk and blood-glucose levels. This created many optimal mixes of sitting, standing, light and moderate intensity activity.

When we looked at waist circumference, blood sugar, insulin sensitivity and a heart disease and stroke risk score, we noted differing optimal time zones. Where those zones mutually overlapped was ascribed the optimal zone for heart disease and diabetes risk.

You’re doing more physical activity than you think

We found light-intensity physical activity (defined as walking less than 100 steps per minute) – such as walking to the water cooler, the bathroom, or strolling casually with friends – had strong associations with glucose control, and especially in people with type 2 diabetes. This light-intensity physical activity is likely accumulated intermittently throughout the day rather than being a purposeful bout of light exercise.

Our experimental evidence shows that interrupting our sitting regularly with light-physical activity (such as taking a 3–5 minute walk every hour) can improve our metabolism, especially so after lunch.

While the moderate-to-vigorous physical activity time might seem a quite high, at more than 2 hours a day, we defined it as more than 100 steps per minute. This equates to a brisk walk.

It should be noted that these findings are preliminary. This is the first study of heart disease and diabetes risk and the “optimal” 24 hours, and the results will need further confirmation with longer prospective studies.

The data is also cross-sectional. This means that the estimates of time use are correlated with the disease risk factors, meaning it’s unclear whether how participants spent their time influences their risk factors or whether those risk factors influence how someone spends their time.

Australia’s adult physical activity guidelines need updating

Australia’s physical activity guidelines currently only recommend exercise intensity and time. A new set of guidelines are being developed to incorporate 24-hour movement. Soon Australians will be able to use these guidelines to examine their 24 hours and understand where they can make improvements.

While our new research can inform the upcoming guidelines, we should keep in mind that the recommendations are like a north star: something to head towards to improve your health. In principle this means reducing sitting time where possible, increasing standing and light-intensity physical activity, increasing more vigorous intensity physical activity, and aiming for a healthy sleep of 7.5–9 hours per night.

Beneficial changes could come in the form of reducing screen time in the evening or opting for an active commute over driving commute, or prioritising an earlier bed time over watching television in the evening.

It’s also important to acknowledge these are recommendations for an able adult. We all have different considerations, and above all, movement should be fun.

Christian Brakenridge, Postdoctoral research fellow at Swinburne University Centre for Urban Transitions, Swinburne University of Technology

This article is republished from The Conversation under a Creative Commons license. Read the original article.