Better care for people with dementia

15/07/2010
New Straits Times, Sat, Jul 03, 2010

IT can happen to anyone of us here today, as it cuts across ethnicity, gender, education and social status, says Tan Sri Dr Ismail Merican of dementia.

The director-general of Health says dementia is a chronic progressive disease of the brain, resulting in problems with cognition, behaviour and function. Dementia can turn a person into a total stranger.

According to the Delphi Consensus study (2005), there are 24.3 million people with dementia worldwide with 4.6 million new cases every year. That means one new case every seven seconds.

The number of people affected will double every 20 years to 81.1 million by 2040. Most people with dementia live in developing countries (60 per cent in 2001, rising to 71 per cent by 2040). Numbers in developed countries are predicted to increase by 100 per cent between 2001 and 2040.

In other words, Dr Ismail says, for every 20 people, at least one may end up with dementia after the age of 65. Since 2007, the Health Ministry has embarked on a screening programme (including mental health screening) for those above the age of 60.

According to the Global Burden of Disease estimates for the 2003 World Health Report, one person with dementia contributes to 11.2 per cent of years lived with disability in people aged 60 and older.

This is more than the disability caused by stroke (9.5 per cent), musculoskeletal disorders (8.9 per cent), cardiovascular disease (five per cent) and all forms of cancer (2.4 per cent).

Although people with dementia are heavy consumers of health services, direct costs in developed countries arise mostly from community and residential care. In any given year, nearly 20 per cent of older community dwellers have a psychiatric disorder, with estimates increasing to about 90 per cent of older nursing home residents.

However, he adds, family caregivers remain the cornerstone of support for people with dementia.

"Most will experience substantial psychological, practical and economic strain. Dementia care is particularly time intensive, and many caregivers need to cut back on work in order to care for their loved ones," he says.

As the field of dementia has improved over the years, early identification has become potentially useful for the etiologic diagnosis, education of patients and families, and appropriate treatment plan for patients. Yet despite this advancement, recognition of dementia is still low among the primary healthcare workers.

"Training of all the primary health care workers is important in the recognition of this problem. They must know when and whom to refer to, once a person is suspected of having dementia," says Dr Ismail. He says even though neurologists are not on the referral list, they do have an important role to play.

"Certainly a few types of dementia, such as the more complex fronto-temporal lobar dementia and Creutzfeld Jakob Syndrome, may require their expertise."

Dr Ismail says the responsibility of managing people with dementia should not be entrusted to the primary health care providers as it would not be fair to both the patients and the caregivers.

Multidisciplinary team management is required. Ideally there should be close collaboration between the geriatric psychiatry team with the psychiatric, geriatric and internal medicine teams.

He says input is also needed from the rehabilitation services (physiotherapy and occupational therapy), dietician and the nursing staff.

A neuropsychologist or psychologist contributes to a more comprehensive assessment of dementia and to the psychosocial intervention of behavioural problems.

The Ministry is taking this into consideration in its planning of health care services. Its Second Edition of the CPG for the management of dementia was put together by experts in the field in Malaysia, based on the latest scientific evidence.

In the last six years, he says, there has been significant scientific evidence supporting the early detection of dementia in order to make the management of dementia more effective and meaningful.

The new CPG also highlights the collaboration required among the various disciplines in managing dementia sufferers who often have other underlying problems.

"Diagnosis involves physical, neurological and mental assessment. As there are many types of tests available, the new CPG has suggested some easy, simple tests with good accuracy for use," says Dr Ismail.

Based on recent evidence, recommendations are made on the type of blood test and neuroimaging to be used. This will help cut unnecessary costs.

The diagnosis of dementia is deemed inadequate without determining the different etiologies or subtypes of dementia. Current evidence shows that the response to anti-dementia treatment differs according to the subtypes of dementia.

A person with dementia may also have neuropsychiatric problems, so the treatment of this component is equally important.

"Psychological intervention, which should be the first line of treatment for behaviour and emotional problems, need to be person-centred, individualised and tailored to the individual. Medication for control of agitation, aggression and psychosis has shown modest benefits and need to be weighed against the cardiovascular side effects and the higher mortality rate," he adds.