Australasia


Australia


Eleanor Flynna, Dina Lo Giudiceb and David Amesc


aUniversity of Melbourne, Australia


bRoyal Melbourne Hospital, Australia


cNational Ageing Research Institute, National Ageing Research Institute, Royal Melbourne Hospital, Australia


Australia has three distinct groups of older people: the Anglo-Celtic majority, indigenous Australians and post-war migrants. Patterns of dementia and ageing and expectations of service provision differ between these groups. In June 2010, 35.7% of the 3 million Australians aged over 65 had been born overseas [1]. The majority (60%) of Australia’s population lives in five large cities.


The number of people with dementia in 2011 is estimated to be 266,574 (total population = 22.5 million, 13.5% aged over 65), and that number will undergo a 254% increase by 2050 to 942,624, while the overall population will rise by only one-third [1].


The Australian health and welfare system is complex with three levels of government (federal, state and local) plus private organisations providing services. Medicare (the national universal health insurance system) reimburses part or all of the costs incurred by patients for primary medical care, specialist medical and diagnostic care and pharmaceuticals for ambulatory patients. Residential aged care for eligible people is heavily subsidised by the federal government. Six state and two territory governments provide free hospital care, primarily inpatient, but also some outpatient visits associated with inpatient stays. Funding for public hospitals comes from the federal government by way of grants to the states from funds raised by taxes. About one-third of the population has private health insurance which covers private hospital inpatient care and some inpatient specialist costs. War veterans, predominantly elderly, receive extra health and welfare services. Indigenous Australians are able to access services for those aged at 50 years. Community services (home care and delivered meals) are funded by state and federal governments and tendered out to private and not-for-profit organisations.


In Australia patients see a general practitioner (GP) for initial consultations, who bill their older and pensioner patients only the amount they are reimbursed by Medicare. Patients’ visits to specialists are reimbursed if the patient has been referred by a GP.


The GP is often the first point of contact for a patient or carer seeking help, but many GPs have difficulties with both the diagnosis and management of dementia [2]. Although extra payment is provided to GPs for time spent meeting families or contacting specialised services, this remuneration does not cover the costs.


The state governments provide psychiatric services. The services in the state of Victoria consist of multidisciplinary community Aged Psychiatry Assessment and Treatment Teams (APATTs), which are linked to hospitals and cover all the state’s regions. Patients are assessed at home at the request of the GP, another health worker, family member or other carer. Unlike the Aged Care Assessment Teams (ACATs), the APATTs provide a continuing care and support service to patients to enable them to remain in the community, with beds available for acute aged psychiatry. Old age psychiatry services in other states are variable, but improving.


The ACATs were set up in 1984 and cover all of Australia [3]. Most are co-located with regional bed-based geriatric services. The ACATs are funded by the federal government to ensure that all people referred to residential care actually need it and to assist people to remain at home with support. Referrals are taken from patients, carers and health workers, and assessments are carried out at home or in hospital by multidisciplinary teams. The majority of people assessed by an ACAT have evidence of dementia or other cognitive impairment [4].


In Victoria there are 15 regional Cognitive, Dementia and Memory Services (CDAMS) which provide multidisciplinary assessment of dementia patients and their carers. The aim is to provide integrated services at all levels of the healthcare system. Specialised memory clinics exist in the other capital cities, but none is state-funded and some are privately operated. Attendance at a memory clinic which provides education, counselling and referral to appropriate services improves the quality of life of carers of those with dementia [5].


Each state and territory has a Dementia Behaviour Management Service (DBMAS). These are funded by the national government and provide predominantly telephone advice as well as some rural outreach services.


Many patients with dementia see psychiatrists, neurologists or general physicians for diagnostic workup. Younger and wealthier persons with dementia are more likely initially to be referred to a private specialist. Depending on the specialist’s or the carer’s knowledge of the system, patients may later be referred to publicly funded assessment services.


Cholinesterase inhibitors have been subsidised for people with mild to moderate Alzheimer’s disease since 2001 and are widely used, though the criterion that recipients must show a 2-point rise in Mini Mental State Examination score in the first 6 months of thereapy limits their availability. Memantine is subsidised for a few patients with moderate dementia. As in many other countries, antipsychotics, antidepressants and benzodiazepines are widely and probably overprescribed to people with dementia.


Family and other informal carers provide the bulk of care to persons with dementia. A range of community options is available for patients with dementia to continue living in the community, especially after discharge from hospital or specialist units. Many of these services are part of broader schemes to replace residential care with community care.


Alzheimer’s Australia was set up in 1985 to provide advocacy for those with dementia and their carers. Branches operate in each state and territory, providing counselling, carer groups, educational material and a Dementia Helpline. Its goals include dementia policy development at a federal level, sharing of resources and expertise across Australia and liaison with Alzheimer’s Disease International.


Residential care is provided by a variety of organisations, including state governments, private operators and charitable organisations, which are subsidised and regulated by the federal government. Care is classified as low level (providing meals and assistance with activities of daily living) or high level (providing 24-hour nursing care). Residents requiring an increased level of care can sometimes remain in their current residence with extra services.


Medical education has undergone expansion and change in the last two decades with both graduate and undergraduate entry courses available. Nursing and allied health education is university based. All clinicians are expected to undertake continuing professional education, which gives opportunities for academics to provide education on dementia assessment and management.


There is an expectation by both professionals and carers that there will be a continuation of the improvements in services for dementia patients seen in the last 20 years. All levels of government have acknowledged the demographic realities of a large increase in the older population and therefore of increasing numbers of dementia patients. The costs of providing world-class services to a rapidly growing elderly population may constrain further improvements and even the maintenance of services, but to date this has not been the case. The future of dementia care may depend as much on continued trade and business success as on the expertise of our professionals.



References


1. Deloitte Access Economics (2011) Dementia Across Australia: 2011–2050. Canberra: Alzheimer’s Australia.


2. Brodaty H, Howarth GC, Mant A, Kurrle S (1994) General practice and dementia: a national survey of Australian GPs. Medical Journal of Australia 160:10–14.


3. Howe A (1997) From states of confusion to a National Action Plan for Dementia Care: the development of policies for dementia care in Australia. International Journal of Geriatric Psychiatry 12:165–171.


4. LoGiudice D, Waltrowicz W, McKenzie S, Ames D, Flicker L (1995) Dementia in patients and carers referred to an Aged Care Assessment Team, and stress in their carers. Australian Journal of Public Health 19:275–280.


5. LooGiudice D, Waltrowicz W, Brown K, Burrows C, Ames D, Flicker L (1999) Do memory clinics improve the quality of life of carers? A randomised trial. International Journal of Geriatric Psychiatry 14:626–632.




China


Xin Yu and Huali Wang


Institute of Mental Health, Peking University, China



Epidemiology and burden of dementia in China


A population census conducted in 2010 showed the proportion of people over 65 growing from 4.9% in 1982 and 7.0% in 2000 to 8.9% in 2010, so in 2010 the population aged over 65 amounted to 118.8 million [1]. The prevalence of dementia is approximately 5% [2,3]. Therefore, it is estimated that there are approximately 6 million persons living with dementia in China, with Alzheimer’s disease (AD) being the most common subtype [2]. The 10/66 Dementia Research Group reported the incidence of dementia in China as 24.0 per 1000 person-years. Although it is difficult to assess the contribution of dementia to mortality, the hazard ratio (HR) calculated was 3.02 (95% CI 2.13–4.28) in urban China and 3.59 (95% CI 2.47–5.21) in rural China [4].


In an observational cross-sectional study in a memory clinic, Wang et al. reported that caregiver time varied dramatically across different stages of dementia. For example, the caregiver time on personal activities of daily living (PADL) recorded using the Resource Utilization in Dementia (RUD) scale was 25 hours per month in mild cases and 172 hours per month in severe cases [5].



Ageing service policies


At the WHO/China Mental Health Awareness Event held in 1999 in Beijing, Dr Brundtland, former Director-General of the World Health Organisation, stated that mental health should be listed as a health priority in China. Dementia would be a great challenge to China as a simple consequence of demography and increase in life expectancy due to better physical health [6]. In 2001, Jiang Zemin, former President of the Peoples’ Republic of China, in his response to Dr. Brundtland, reassured that promoting mental health care and reducing stigma against mental disorders are extremely important for the socioeconomic development of the country [7].


Following this response, national mental health action plans have been implemented in the past decade [8]. In the latest national mental health plan increasing public awareness, knowledge of mental health problems and improving early detection and intervention of dementia and depression are still listed as priorities [9]. In addition to these national mental health policies, a series of national ageing development plans have been released by the National Ageing Committee since the early 1990s [10]. The latest 12th five-year (2011–2015) National Plan for Ageing Development explicitly urges the whole society to promote mental health and psychological well-being of the elderly [11]. These social policies and documents have provided new guidance for social and other services for the elderly, closely related to mental health care. Notably, in 2006, in the White Paper on China Ageing Development, the State Council recognised the significant increase of the ageing population and its implications for long-term care [12].


By 2011 universal health insurance coverage was achieved through the implementation of a social medical insurance system, including the urban employee basic medical insurance (UEBMI), the new rural cooperative medical system (NRCMS) and the urban resident basic medical insurance system (URBMI). The universal health insurance coverage is particularly beneficial for rural dwelling elderly and those who have never been employed. These policies provide a great opportunity to develop a culturally appropriate mental healthcare delivery system in China, which integrates with the social and medical service system.



Guidelines on dementia care


There are two major sets of guidelines on the management of dementia. One was developed by the Chinese Society for Psychiatry (CSP) and the other by a professional group on cognitive impairment under the auspices of the Chinese Society for Neurology (CSN) [13,14]. Usually in China, one randomised controlled trial (RCT) with positive results is sufficient for drug registration and approval by our State Food and Drug Administration (SFDA): there are few RCTs designed to test the effectiveness of anti-dementia agents further, once these are approved for the treatment of AD. Therefore, the evidence described in both sets of guidelines is mostly adapted from trials conducted in other countries. Guidelines released by the European Federation of Neurological Societies, the American Psychiatric Association and the American College of Physicians (ACP) were the main sources of guidelines on dementia and cognitive impairment by CSN. Due to limited local evidence on dementia care in China, the CSP working group aimed to introduce certain standards for dementia care, including reducing risk factors, early detection of clinical features, introducing timely pharmacological and non-pharmacological interventions and care for people with dementia. The CSP guidelines place a strong focus on home care and long-term residential care for people with dementia and set an optimal framework for dementia care. However, more local evidence on dementia care is needed to develop evidence-based guidelines appropriate for China.


Another concern is the lack of efficient or effective ways to monitor physicians’ performance, making it difficult to estimate how either dementia guideline is being applied in routine clinical practice. The inadequate implementation of dementia guidelines may result in extra barriers to access dementia care services.



Service resources for dementia care


People with cognitive impairment usually seek medical help from neurologists, psychiatrists or geriatricians. In the past decade, widespread public health education has contributed to an increased awareness of cognitive impairment among the general population. Now more and more people living with cognitive impairment and early dementia are seen in memory clinics. However, there is no specific certification requirement for subspecialty training in dementia and cognitive impairment, and the quality of care may vary across different areas. A national psychogeriatric service resource survey conducted in 2004 found there were only 93 hospitals providing a ‘mental health service for the elderly’. The number of psychiatrists and psychiatric nurses providing elderly mental health care were too few. There were no social workers at all in the field of dementia care. These findings suggest that there is a great paucity of service resources for people with mental disorders, including dementia [15]. This is contrasted with the great demand for quality mental health care for the elderly. In addition to the implementation of continuous medical education programmes (CME), which have educated hundreds of physicians, the Peking University Institute of Mental Health initiated a subspecialty training programme in geriatric psychiatry. It is expected that this initiative will increase the availability of subspecialty training and will ultimately be scaled up in the whole country, so that there will be more well-trained psychogeriatricians delivering elderly mental health programmes.


Despite limited resources Chinese experts have provided and continue to provide valuable diagnostic services and care for people with dementia, as well as carrying out significant research. Memory clinics have been set up in major cities, providing diagnosis, treatment and management for people with dementia. In cities, such as Beijing, Guangzhou, Shanghai and Hangzhou, medical professionals also try to ensure dementia caregiver support groups are available. The caregiver support group at the Peking University Institute of Mental Health provides group intervention for caregivers of people with dementia. AD centres and collaborative networks are formed by well-established institutions, such as the national collaborative network for early diagnosis and research of dementia directed by the Peking University Institute of Mental Health. Meanwhile, institutions with a high scientific reputation have been and are involved in collaborative AD projects with international academic and scientific institutions. For example, in collaboration with Harvard Medical School, the development of the AD Care and Research Centre at the Peking University Institute of Mental Health was funded by the National Institute of Health in the USA. More than 10 hospitals have been enrolled as participating sites for several global AD trials. Investigators may also receive funding from the Ministry of Science and Technology, the Natural Science Foundation of China and some other research funding agencies. Investigators at universities, academic and research institutions carry out basic research on the neurobiological mechanism of AD and mild cognitive impairment (MCI).


Currently, care for the elderly primarily depends on family care and community-based social services, while private care may not be affordable to the majority of the elderly population. Therefore, in addition to hospital services, family and neighbourhood communities are still considered as the optimal setting for care and one of the key components of mental healthcare delivery. As is the Chinese tradition: a feeling of duty as the exemplary attitude for children and filial obligation and reciprocity are the two major philosophical underpinnings of caring for the elderly in China [16]. The newer entity of a National Ageing Committee has declared the importance and urgency of building elderly friendly communities and home-care service systems [17].


These strategies may to some extent urge our society to be engaged in the community-based services for the elderly. However, it will take a long time to reach a high-level readiness in the community. Community understanding and responsiveness at the very earliest stage and public awareness of mental health problems in general have been quite low [18]. With collaborations between academic institutions and several organisations, for example, Alzheimer’s Disease Chinese (ADC, an ADI member), the Beijing Cuncaochunhui Mental Health Service Center (NGO) and the Chinese Alzheimer Project (NGO), efforts on raising awareness of mental health problems, such as dementia and depression, have met with considerable public acceptance, including among community-dwelling elderly, nursing home residents, college students, social welfare staff and the media.


In recent years, the issue of long-term care has been identified as one of the major concerns in dementia care. In addition to nursing homes established by the government, several privately owned nursing homes have been set up in cities such as Beijing and Shanghai. However, staff seldom receive training in professional caregiving skills for people with dementia. Therefore, improving the quality of dementia nursing care is critically important. The China Alzheimer Project (CAP) and ADC are collaborating in an online training programme for good quality dementia care which was launched in the autumn of 2012.

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Sep 8, 2016 | Posted by in GERIATRICS | Comments Off on Australasia

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