Research Article: Packages of Care for Dementia in Low- and Middle-Income Countries

Date Published: November 3, 2009

Publisher: Public Library of Science

Author(s): Martin J. Prince, Daisy Acosta, Erico Castro-Costa, Jim Jackson, K. S. Shaji, Vikram Patel

Abstract: In the fifth in a series of six articles on packages of care for mental disorders in low- and middle-income countries, Martin Prince and colleagues discuss the treatment of dementia.

Partial Text: Dementia is a chronic organic brain syndrome, characterised by progressive impairment of multiple cortical functions, including memory, learning, orientation, language, comprehension, and judgement. Diagnosis requires decline in cognitive function and independent living skills (Box 1) [1]. However, for carers and people with dementia, the behavioural and psychological symptoms of dementia (BPSD) affect most quality of life, are an important cause of carer strain [2], and a common reason for institutionalisation [3]. Alzheimer’s disease, vascular dementia, dementia with Lewy bodies, and frontotemporal dementia are the most common dementia subtypes, but mixed pathologies may be the norm [4]. Some rare causes (subdural haematoma, normal pressure hydrocephalus, hypercalcaemia, and deficiencies of thyroid hormone, vitamin B12, and folic acid) can be treated. Otherwise, the progressive course of dementia cannot be altered, but symptomatic treatments and support can be helpful.

The principal goals of management of dementia are: early diagnosis; optimization of physical health, cognition, activity, and wellbeing; detection and treatment of BPSD; and the provision of information and long-term support to carers. The evidence base for dementia care comes, overwhelmingly, from HICs (Table 1). All the studies discussed below refer to HICs, unless otherwise specified.

The mechanisms by which effective dementia care treatments may be delivered in LMIC settings are summarized in Table 2.

On the basis of our review, we have proposed a package of care for LMICs that considers the availability of resources for the detection, diagnosis, and treatment of dementia in this setting. In Table 3, the main features of this package are compared with typical recommendations for well-resourced HIC settings. To improve care for dementia in LMICs, we propose that the basic package of care should focus upon diagnosis coupled with information, regular needs assessments, physical health checks, and carer support. This package should be extended to include carer training, respite care, and assessment and treatment of BPSD where possible. We suggest that that care can best be delivered by trained primary care teams, with a paradigm shift towards chronic continuing care and community outreach. Practice-based care coordinators are an essential component of this package, ideally working within a collaborative-care framework. Finally, we note that care delivery will be more efficient when integrated with that of other chronic diseases, and more broadly based community-support programs for the elderly and disabled.



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