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Commonwealth Health Partnerships 2015

Dementia in low- and middle-income countries: The case for community care Caroline Kim and Soumitra Pathare Dementia, of which Alzheimer’s disease is the most common form, is an increasingly important global public health issue that demands attention. Root causes of most cases of dementia are unknown and early stages may go undetected. However, in the late stages people can have severe memory loss, as well as loss of reasoning, speech and other cognitive functions. In 2010 an estimated 35.6 million people worldwide had dementia (Prince et al., 2013), with 58 per cent of these living in low- and middle-income countries (LMICs). While the prevalence of dementia is expected to double every 20 years, rates of increase are not uniform. Some LMICs, including India, are predicted to have rates of increase as high as 300 per cent (Ferri et al., 2005), and dementia is the most important independent contributor to disability for elderly people in LMICs (Sousa et al., 2009). Although dementia is a deeply personal condition, it also has high family and societal impacts. It contributes to disability and dependency, and is associated with caregiver strain and stress. Unfortunately, medical assistance and community services for dementia are not always available, especially in LMICs. It is imperative, therefore, for LMICs to devise policies and strategies to meet future need. A variety of approaches are necessary to ensure good quality and universal health coverage for persons with dementia (PWDs); the challenge is for governments to come up with systems that are evidence-based, accessible, delivered effectively, culturally appropriate and cost-effective. Implications for universal health coverage As the population ages and the elderly lose their ability to live independently, there is an increased need for long-term care facilities, with significant associated cost. However, in many LMICs there is no existing infrastructure, or such facilities exist only in the private sector and are largely unaffordable. PWDs live, instead, with family members. This informal care ‘system’ effectively ensures that the elderly do not become wards of the state, but caregivers themselves often shoulder the burden without any support or relief, and the strain placed on them is higher than that experienced by caregivers of persons with only depression or with no diagnosis (Dias et al., 2004). Changing the focus from expensive acute-care facilities to general health promotion, disease prevention and disability management can both take advantage of and provide support to these existing human resources – informal caregivers. When caregiver burden and stress is high there is a decreased quality of life for the PWD, the caregiver and other household members. Furthermore, the care received may not be informed by current medical knowledge – in many cases, family members are unaware that behavioural or psychological problems associated with dementia have a medical basis. For home care to be a part of a universal health care system, it is paramount to provide regular education and assistance for caregivers. Services and programmes for caregivers, including education about dementia and skills training, enhance the ability of family members to care for their loved ones, increase the overall health of the PWDs and reduce demand for institutional care. Education, training and support for caregivers and family members are therefore key to managing dementia. In many LMICs there is a dearth of professionals trained in the area of dementia. This may be due to a lack of specialists, a lack of knowledge among general health professionals or a lack of adequately trained non-medical staff. Front-line health workers at primary care facilities and community-based care centres will need to be trained to recognise and work with PWDs and their caregivers; secondary care facilities will likewise require training for staff members. A small number of specialists will need to be trained to provide supervisory support to team members and direct patient care for acute cases. The sustainable reorganisation of services for PWDs and their caregivers will need new government policy and plans in order to succeed. Some pilot projects have already been conducted (see below), but more research will be necessary so that plans can be scaled up appropriately. Early interventions for prevention Although progression of dementia can be slowed and symptoms can be managed, there is no effective long-term treatment. One area of focus must therefore be prevention. 82 Commonwealth Health Partnerships 2015 Three points of intervention 1. Prevention. Measures can be taken to prevent the onset of dementia and reduce the rate of dementia in the population 2. Reduction. Medical and therapeutic interventions, as well as community-based rehabilitation, can slow the progression of dementia and the onset of disability, and mitigate the effects of disability on daily activities and social participation, so that PWDs are able to care for themselves for longer periods of time and continue to live independently 3. Management. Forms of assistance can include: outreach services, respite care, disability pensions, access to general health care, health information and education (including coping skills and use of physical or memory aids), and shortor long-term care and support. When provided, these can increase the quality of life of the PWDs and their caregivers


Commonwealth Health Partnerships 2015
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