Date Published: March 28, 2017
Publisher: Public Library of Science
Author(s): Cleusa Pinheiro Ferri, K. S. Jacob
Abstract: In a Perspective, Cleusa Ferri and K. S. Jacob discuss the assessment, recognition, and care of people living with dementia in low- and middle-income countries.
Partial Text: Ageing across the world’s populations is not a homogenous and uniform process. Over the next 15 years, the number of older people is projected to increase by 71% in Latin America and the Caribbean, 66% in Asia, 64% in Africa, 47% in Oceania, 41% in North America, and 23% in Europe . The differences in the base populations and the rates of growth and longevity mean there will be wide variations between regions.
Recent studies have reported a decline in the prevalence of dementia in high-income countries [6,7]. It has been suggested that this decline might be the result of changes in the profile of risk factors for dementia, suggesting that dementia may, at least partially, be preventable. Considering the costs of dementia care, primary prevention is likely to be the cheapest way to reduce the projected impact of dementia in future generations . Evidence for the effectiveness of prevention programs that focus on local contexts and modifiable risk factors needs to be strengthened in order to design effective interventions and appropriate public health policies.
Dementia is under-recognised, underdisclosed, undertreated, and undermanaged, particularly in LMICs, with rates varying between countries . Symptoms of dementia are considered a part of normal ageing in many LMICs and are not perceived as requiring medical care. The lack of awareness and stigma also results in a failure to seek help and treatment . Many caregivers do not complain of problems, although their relatives may have significant cognitive impairment. The high tolerance to such symptoms and disability is often due to families’ low expectations of their older relatives , which results in lower recognition rates, as deterioration of social and occupational functioning is mandatory for a diagnosis of dementia by DSM criteria.
The progressive nature of the disease alters the care needs of people living with dementia over time and requires continual assessment and tailored approaches to changes in clinical problems and presentations . While more responsive and flexible health care models that focus on task shifting and task sharing have been discussed in high-income countries (HICs), the challenges are even more complex with the limited resources in LMICs. The identification of the critical role of local and social determinants to disability  and the paucity of medical interventions to reverse pathology in dementia mandate the need for psychosocial support, accommodation, and nursing care as the main stay of management . The lack of formal and institutional care for dementia in LMICs places a huge burden on relatives and carers.
The relative success of programmes in HICs and their replication in successful projects in LMICs do not necessarily guarantee the possibility of scaling them up or their cost-effectiveness when rolled out to larger populations. The distinctive context of care for older people in LMICs argues for a need to tailor solutions to the prevalent reality. Each country will have to find its best response within the context of its own limitations and possibilities, but it should be based on knowledge of local resources and burden of disease so that its impact can be evaluated and the most effective and sustainable response be delivered.