Research shows that education, literacy, verbal fluency, social class, socio-economic status, financial stress and motor sequencing are variables that effect the onset of dementia (the ‘cognitive reserve hypothesis’; Lund et al., 2010; Scazufca et al., 2008). Associations have also been found between dementia and poor nutrition, food insecurity, place of birth (rural vs urban) and early life brain development. Older adults exposed to five or six unfavourable factors are more than seven times more likely to develop dementia than those with no risk factors (Scazufca et al., 2008), suggesting a cumulative effect; there is therefore a strong incentive to reduce such risk factors. Smoking, hypertension, high cholesterol and diabetes are also associated with an increased risk of dementia, particularly non-Alzheimer’s dementia (Whitmer et al., 2005). Preventative measures must start early and social policies are key. Recent research, done in middle-income countries, has confirmed the protective effect of education and literacy against dementia (Prince et al., 2012). One strategy, then, is to increase literacy and education to reap future health benefits. Pre- and post-natal programmes for young children and mothers targeting nutrition and developmental activities can also be augmented with the goal of dementia prevention in mind. Food security programmes can be re-assessed in the light of health and ageing. Lifestyle factors, such as a healthy diet, moderate alcohol intake, non-smoking and regular physical activity, also appear to be protective (Akinyemi et al., 2013; Etgen et al., 2011) and should be promoted not only throughout the life course but also with programmes directed at the elderly, with the advantage of protecting not only from dementia onset, but also other long-term health problems. Finally, steps can be taken to ensure that rural areas, where there is highest risk, benefit from such programmes on an equal basis with urban areas. Community-based services and education for caregivers In the majority of LMICs, specialist resources are scarce or simply unavailable. Trained non-medical workers can provide culturally appropriate and diverse services at a low cost, and with the supervision and guidance of a specialist whenever medicalised interventions are necessary. This is precisely what was done in Goa, India, with care recipients showing clear benefits (Dias and Patel, 2009). In the Goa study, each geographical area was treated by a ‘community team’ comprised of two home care advisors – lay workers with no formal medical training. These were trained in an intensive one-week session that included learning about listening, counselling, stress management and health advice for common complaints. Their tasks included basic education about dementia and common behavioural issues; providing information about management of dementia; general support to the caregiver, including assistance with daily activities where appropriate; providing referrals to doctors or psychiatrists where warranted; networking between families for peer support; and advising about available government social support schemes. Minimum visit frequency was once fortnightly, over a period of six months. A lay counsellor met with each home care advisor also fortnightly, to provide support. Only one specialist – a psychiatrist – was required, on a part-time basis, to confirm diagnosis, meet with the homecare D eme n t i a i n l ow- a n d mi d d l e - i n c ome c o u n t r i e s advisors twice monthly and have follow-up visits with the PWD where medicalised treatment was deemed necessary. The key objectives of the programme were to improve the family and caregiver knowledge base, to provide emotional and other support, to maximise caregiving resources and to improve caregiving skills, thereby increasing the quality of life and care for both the PWD and the caregiver. This intervention also resulted in reduced caregiver burden, as well as less mental stress and distress. Another study performed in the Netherlands found that homebased short-term (ten hours over five weeks) interventions by an occupational therapist were not only cost effective, but yielded significant and clinically relevant improvements for the PWDs (Graff et al., 2008). The occupational therapist trained caregivers in problem solving, coping, supervision and strategies to assist the PWDs to sustain personal autonomy and social participation. PWDs, in turn, were trained in compensation skills and the use of aids, and in how to optimise individual skills to improve their ability to conduct daily activities. Both were counselled on how to modify the home and environment. One key lesson from both studies is the importance of enhancing existing resources – such as family members – through education about dementia and stress relief/coping strategies. Another is that providing PWDs with knowledge of how to improve their own ability to complete daily tasks as much as possible has a clinically significant positive effect. Finally, educating the greater community about dementia and creating networks of caregivers also assisted PWDs and their families. Conclusions and recommendations Focus on prevention Countries can focus on preventing dementia by creating policies and programmes that reduce societal risk factors, such as poor early childhood development, poor nutrition and food insecurity, while increasing societal protective factors against dementia, such as rates of education and literacy, by providing educational opportunities to all and promoting healthy lifestyle choices, such as healthy eating, moderate alcohol intake, non-smoking and regular physical activity. Focus on reducing the burden of disabilities Policies and programmes should also provide rehabilitation or therapeutic services in the community and the home, reducing the social isolation of PWDs. Support must be given to informal caregivers, such as family members, through respite care programmes, caregiving pension credits or monies, access to subsidies, training and home-based assistance; to PWDs by providing social pensions for the elderly and access to formal homecare and outreach services; and non-governmental and community-based organisations that provide assistance to PWDs and caregivers. The burden of disabilities can also be reduced by ensuring the availability of essential drugs, where necessary, for treatment of dementia and associated behaviours and symptoms. Focus on education and training Education and training must be provided for informal caregivers on how to care for PWDs, manage behavioural or psychological Commonwealth Health Partnerships 2015 83
Commonwealth Health Partnerships 2015
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