transition into care homes. Such interventions may be more effective early in the disease course. Support groups for people with dementia, acetylcholinesterase inhibitors and cognitive stimulation to improve cognitive function, and behavioural interventions for depression are effective interventions in earlystage dementia (Prince, Bryce and Ferri, 2011). While early diagnosis and intervention is likely to be cost-effective in HICs, assuming delayed or averted transfer into costly institutional care settings, the cost-effectiveness of scaling up diagnosis and care in LMICs is unknown. However, the psychological and economic strain on caregivers is substantial and compensatory benefits practically non-existent. There are considerable challenges in achieving acceptable levels of coverage and access to care. Currently, people with dementia receive a diagnosis late in the disease course, if at all; around half of those affected are not diagnosed in HICs, the proportion falling to below ten per cent in LMICs where awareness is even lower (Ibid). Since dementia is very often comorbid with depression and physical impairments (including undernutrition, reduced mobility, pain, hearing and vision problems, and incontinence), horizontally structured comprehensive assessment and intervention targeting frailty and dependence is likely to be the best and simplest approach to increase coverage of care for older people with dementia and mood disorders. The World Health Organization Department of Ageing and Lifecourse is currently developing a novel intervention approach (WHO-COPE)2 comprising: a) Community case finding of frail dependent older adults by community health workers (CHWs) b) Structured comprehensive home-based assessment of mental, cognitive and physical impairments, care arrangements and carer strain c) Evidence-based interventions for low mood, confusion, behaviour disturbance, undernutrition, reduced mobility, incontinence, low vision and hearing problems Conclusion: Equity in health care The worldwide epidemic of chronic disease is, to a large and increasing extent, concentrated in older people and people living in LMICs. The association between biological age, morbidity and loss of function underpins the link between population ageing and increasing burden; however, this association is neither constant nor immutable, leaving much scope for intervention to promote health and prevent disease in older people. The fitness for purpose of health services and systems for older adults and their complex, interacting, chronic medical and social difficulties is open to question. Multimorbidity increases sharply with age, and therefore care coordination is essential. ‘Frailty’ provides an attractive theoretical framework within which practitioners can devise holistic assessment and treatment of older people with complex comorbidities in a structured way (Lacas and Rockwood, 2012). Packages of care for people with dementia (and other priority mental and neurological disorders, including depression) have been developed by WHO as part of their Mental Health Gap Action Plan3. As yet, these have not been taken up, implemented or evaluated for older people. Such single-condition, vertical A g e i n g a n d d i s e a s e b u r d e n s programmes may have limited appeal to policy-makers, who struggle to provide equitable access even to basic age-appropriate medical care for frail and dependent older people. The Madrid International Plan of Action on Ageing called for the elimination of social and economic inequalities in access to health care and the development of health care and long-term care to meet the needs of older people. To achieve these needs, age discrimination should be countered and the challenges posed by multimorbidity and frailty addressed. Endnotes 1 Seismic shifts in the burden of disease between WHO 2004 estimates (WHO, 2008) and the IHME 2010 estimates (Murray et al., 2010) have been neither highlighted nor explained. Findings from the original Lancet Series on Ageing (2014) review on which this article is based show that, in older people for whom the discrepancies were most striking, the burden of dementia has been cut by half and that of visual impairment by two-thirds, while the burden of musculoskeletal disorders has nearly quadrupled. This result is due to changes in disability weights rather than in the estimates of the frequency of these disorders. Disability weights will be affected by choice of respondents used to measure them, the information provided about the health states and the way that the questions are framed. WHO global burden of disease weights (WHO, 2004) were measured through a consensus of international experts, whereas the Institute for Health Metrics and Evaluation (IHME) weights portrayed judgements of the general public (Salomon et al., 2012). IHME weights link to relative health rather than relative disability, and the extent to which the IHME global burden of disease notion of health loss maps on to conventional notions of disability and dependence is open to question. 2 See www.who.int/ageing/about/who_activities/en/index1.html Accessed 13 April 2014. 3 See www.who.int/mental_health/mhgap Accessed 13 April 2014. References ADI (Alzheimer’s Disease International), 2013. The Global Impact of Dementia 2013–50. London: ADI. Albanese, E., Liu, Z., Acosta, D. et al., 2011. ‘Equity in the delivery of community healthcare to older people: Findings from 10/66 Dementia Research Group cross-sectional surveys in Latin America, China, India and Nigeria’. BMC Health Services Research, 11, pp. 153. Barnes, D. E. and Yaff, K., 2011. The projected effect of risk factor reduction on Alzheimer’s disease prevalence. The Lancet Neurology, 10, pp. 819–828. Brown, M. L., Goldie, S. J., Draisma, G., Harford, J. and Lipscomb, J., 2006. ‘Health service interventions for cancer control in developing countries’. In: D. T. Jamison, J. G. Breman, A. R. Measham et al., eds, 2006. Disease Control Priorities in Developing Countries. Second edition. Washington, DC: World Bank. Feenstra, T. L., van Genugten, M. L., Hoogenveen, R. T., Wouters, E. F. and Rutten-van Mölken, M. P., 2001. ‘The impact of aging and smoking on the future burden of chronic obstructive pulmonary disease: A model analysis in the Netherlands’. American Journal of Respiratory and Critical Care Medicine, 164, pp. 590–596. Fletcher, A. E., 2010. ‘Free radicals, antioxidants and eye diseases: Evidence from epidemiological studies on cataract and agerelated macular degeneration’. Ophthalmic Research, 44, pp. 191–198. Commonwealth Health Partnerships 2015 45
Commonwealth Health Partnerships 2015
To see the actual publication please follow the link above