DESK REVIEWS | 04.02.02. Other policies and plans that include dementia

DESK REVIEW | 04.02.02. Other policies and plans that include dementia

Yes. There are many policies for older people in Brazil in which dementia is indirectly and sometimes directly integrated into. Examples are:

– The “National Healthcare Policy for Older People” (Política Nacional de Saúde da Pessoa Idosa) that aims to recover, maintain, and promote autonomy and independence of older people (any Brazilian citizen aged 60 years and over) through collective and individual healthcare measures in line with SUS (Brazilian Ministry of Health, 2006b).

– The “National Policy for Primary Care” (Política de Nacional de Atenção Básica) considers changes and updates in the primary care system. The policy emphasizes the importance of the primary care as the main gateway to access the entire public healthcare system (Brazilian Ministry of Health, 2012).

– The “Family Healthcare Strategy” (Estratégia de Saúde da Família) aims to promote quality of life for the Brazilian population and intervene in factors that put health at risk, such as lack of physical activity, tobacco smoking, poor diet, etc. Healthcare teams work closely with people, allowing the professionals to know the person, their family, and the neighbourhood (Brazilian Ministry of Health, 2019c).

– The “It is Better at Home Program” (Programa Melhor em Casa) is a service indicated for people who have temporary or definitive difficulties to leave home and reach a healthcare unit or for people who depend on home-care services. The program aims to provide the patient with care closer to the family’s routine, avoiding unnecessary hospitalizations and reducing the risk of infections (Brazilian Ministry of Health, 2019h). 

The “Technical Guidelines for Implementing a Healthcare Pathway for Integral Health for Older People” (Orientações Técnicas para Implementação da Linha de Cuidado para Atenção Integral à Saúde da Pessoa Idosa) was a document developed to orientate Brazilian states, municipalities, and the Federal District regarding how to provide integral healthcare for older people. The guidelines take in consideration both the identification of older people’s healthcare needs and their functional capacity (Brazilian Ministry of Health, 2018e).

– The “Training Notebook of Primary Healthcare Professionals for Older People’s Health”  (Caderno de Formação – Ação: Capacitação dos Profissionais da Atenção Básica sobre a Saúde da Pessoa Idosa) is used in trainings of primary healthcare professionals and brings educational information about the general health of older people (including information on dementia) (Brazilian Ministry of Health, 2017a).

References:

Brazilian Ministry of Health. (2006b). Política Nacional de Saúde da Pessoa Idosa. Brazilian Ministry of Health.

Brazilian Ministry of Health. (2012). Política Nacional de Atenção Básica. http://189.28.128.100/dab/docs/publicacoes/geral/pnab.pdf

Brazilian Ministry of Health. (2017a). Caderno de Formação – Ação: Capacitação dos Profissionais da Atenção Básica sobre a Saúde da Pessoa Idosa.

Brazilian Ministry of Health. (2018e). Orientações Técnicas para a Implementação de Linha de Cuidado para Atenção integral à Saúde da Pessoa Idosa no Sistema Único de Saúde—SUS. Ministério da Saúde do Brasil.

Brazilian Ministry of Health. (2019c). Estratégia Saúde da Família.

Brazilian Ministry of Health. (2019h). Programa Melhor em Casa.

There are existing programmes and policies under the MoHFW and MSJE that are relevant for persons with dementia and also have scope for inclusion of dementia. These are summarised in Part 3.

Dementia has not been mentioned in other national plans, not even in the national plan of Older People’s Health (Ministry of Health Regulation No. 25/2016 on National Action Plan on Older People’s Health, 2016). However, diabetes and hypertension, two chronic conditions which are risk factors of dementia are covered by the Prolanis program (BPJS Kesehatan, 2014).

References:

BPJS Kesehatan. (2014). Panduan Praktis PROLANIS (Program Pengelolaan Penyakit Kronis)/PROLANIS Guideline. In BPJS Kesehatan.

Ministry of Health Regulation No. 25/2016 on National Action Plan on Older People’s Health (Permenkes No. 25/2016 tentang Rencana Aksi Nasional Kesehatan Lanjut Usia 2016-2019). (2016). (Testimony of Ministry of Health Republic of Indonesia).

There is no mention of dementia in any policy document in Kenya whether at national or at county level. It is understood that the mental health policy would also cover people living with dementia as its definition provides a wide realm of potentially eligible people: “older persons especially those without social protection and social networks are often vulnerable to mental disorders” (Ministry of Health, 2015c), page 19.  They should therefore be targeted for mental health interventions.

References:

Ministry of Health. (2015c). Kenya mental health policy 2015-2030: Towards Attaining the Highest Standard of Mental Health. Nairobi, Kenya. https://publications.universalhealth2030.org/uploads/Kenya-Mental-Health-Policy.pdf

 

In Mexico, the National Development Plan (NDP) is the guiding document of the Federal Government in which they describe the national objectives, strategies, and priorities of the integral and sustainable development of the country. It is prepared during the first semester of the six-year term of each federal government and its validity ends with the corresponding constitutional period.

Given that a large proportion live in poverty and without access to social protection system, the National Development Program PND 2019-2024 includes a program for the Welfare of Older Persons, which is based on providing economic support (US $66.61 by month) to women and men over 68 years. However, to date, neither National Health Sector Programs nor National Old Age Health Care Programs have included dementia. Therefore, at the federal level, the issue of dementia is not placed within the national policy.

While Mexico has not yet ratified its adherence, the Inter-American Convention for the Rights of Older Adults includes in its article 19 ‘Rights to Health’ the promotion of the development of specialised integrated social and health care services for older adults with dependency-generating illnesses, including chronic degenerative diseases, Alzheimer’s disease, and other dementias (Organization of American States, 2015).

While ageing issues and older adults have gained importance and have been positioned at the national level as priorities, no specific government sector or Secretariat is responsible for dementia and there are no specific programs for dementia diagnosis and care.

In the previous government administrations, some institutions or programmes included several related activities within their aims to support older adults, for example:

  • National Gerontology Program 2016-2018 (National Institute for the Elderly, INAPAM) (INAPAM, 2016): which focuses on the implementation of public policies to support the wellbeing of older adults.
  • Program to Support Aging 2013-2018 (Programa de Atención al Envejecimiento) (National Centre for Disease Control and Prevention Programs, CENAPRECE): where the first objective was to establish a culture of living healthy, with a gender perspective among older adults, care for chronic diseases and mental health coverage including the detection and diagnosis of memory alterations. However, we found no data about their degree of implementation nor to inform if these were implemented.
  • Specific Mental Health Action Programme 2013-2018 mentions the need for timely detection of mental or behavioural disorders in adults and older adults.
  • Specific Action Programme Psychiatric care 2013-2018 indicates the need to contribute to the deinstitutionalisation of mental health patients with severe cognitive impairment and abandonment.
  • Specific Action Programme Research for Health 2013-2018 only describes the issue of ageing, putting into context the population pyramid that points at ageing and non-communicable diseases.
References:

INAPAM. (2016). Programa Nacional Gerontólogico 2016-2018.

Organization of American States, O. (2015). Inter-American Convention on Protecting the Human Rights of Older Persons (A-70). http://www.oas.org/en/sla/dil/inter_american_treaties_A-70_human_rights_older_persons_signatories.asp

The above mentioned national policies indirectly cover dementia in these areas: risk factors prevention, diagnosis, and treatment (Brazilian Ministry of Health, 2018e).

References:

Brazilian Ministry of Health. (2018e). Orientações Técnicas para a Implementação de Linha de Cuidado para Atenção integral à Saúde da Pessoa Idosa no Sistema Único de Saúde—SUS. Ministério da Saúde do Brasil.

In the Prolanis programme, dementia is not specifically mentioned. However, it addresses the risk reduction aspect (by managing diabetes and hypertension) (BPJS Kesehatan, 2014).

References:

BPJS Kesehatan. (2014). Panduan Praktis PROLANIS (Program Pengelolaan Penyakit Kronis)/PROLANIS Guideline. In BPJS Kesehatan.

The National Ageing Program of Attention 2013-2018 developed by the CENAPRECE predominantly focused on the screening of alterations of memory problems with the application of the Mini-mental (Folstein et al., 1975). The indicator of compliance was the coverage of mental health in the detection of alterations of memory (numerator: total number of detections carried out through the Mini-mental / denominator: population of 60 years and more) by 100. The information was planned to be captured by the National Health Information System (Sistema Nacional de Información en Salud) at the Ministry of Health. However, no official estimates for this indicator have been reported so far.

References:

Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12(3), 189–198. https://doi.org/10.1016/0022-3956(75)90026-6

Yes, there some dementia-specific documents at subnational levels. We could identify four of them. They are the law 6.926 in the Federal District (Federal District Government, 2021), the PL 131/2018 in the state of Rio Grande do Sul (Projecto de Lei n131/2018, 2018), the PL 769/2019 in the municipality of São Paulo (São Paulo Chamber of Deputies, 2019), and the PL 12/2020 in the city of Novo Hamburgo (Novo Hamburgo Municipal Chamber, 2020). They relate to policy for prevention, treatment, and support for people living with Alzheimer’s disease and other dementias and their family carers.

Besides, there are some policy documents that include strategies to improve the quality of care and accessibility to mental health services for older people in general, with dementia being explicitly cited as one of the conditions included. These documents are the State of Paraná Plan for Older People (Paraná Government, 2014), the State of Pará Plan for Older People (Pará Government, 2017) and the Municipality of São Paulo Healthcare Plan (São Paulo City Hall, 2015). Even though no documents exist for dementia specifically, the municipality of São José dos Campos, for example, offers dementia training for doctors, nurses, and dentists. This training is based on discussions of dementia-related clinical cases with a multidisciplinary team. Furthermore, there is an “Ageing Workshop” for training health community agents and nursing assistants in an array of topics relating to ageing, including dementia also in São José dos Campos. In Brazil there are 5,570 municipalities which are decentralised from the federal government; thus, it is possible that other unknown local initiatives exist.

References:

Federal District Government. (2021). LEI No 6.926—Política distrital para prevenção, tratamento e apoio às pessoas com doença de Alzheimer e outras demências. https://www.tjdft.jus.br/institucional/relacoes-institucionais/arquivos/lei-no-6-926-de-02-de-agosto-de-2021.pdf

Novo Hamburgo Municipal Chamber. (2020). Projeto de Lei Municipal 12/2020—Novo Hamburgo. Camara Municipal. https://portal.camaranh.rs.gov.br/pm3/informacao_e_conhecimento/noticias/novo-hamburgo-podera-ter-politica-de-enfrentamento-ao-alzheimer

Paraná Government. (2014). Plano Estadual dos Direitos da Pessoa Idosa do Paraná: 2015 a 2018. http://www.cedi.pr.gov.br/arquivos/File/2015/publicacoes/Plano_Estadual_Idoso_publicado.pdf

Paraná Government. (2017). Plano Estudual de Atendimento à Pessoa Idosa: 2016-2019.

São Paulo Chamber of Deputies. (2019). Projeto de Lei da Câmara Municipal de São Paulo, n 769, de 2019. https://splegisconsulta.camara.sp.gov.br/Pesquisa/DetailsDetalhado?COD_MTRA_LEGL=1&COD_PCSS_CMSP=769&ANO_PCSS_CMSP=2019

São Paulo City Hall. (2015). Plano Municipal de Saúde de São Paulo 2014-2017. City Hall of Sao Paulo.

A dementia specific initiative has been operating in Kerala since 2014 (a state in South India). The Department of Social Welfare, Government of Kerala, and the Kerala State Social Security Mission (KSSM) with ARDSI as its knowledge partner, have been jointly implementing the Kerala State Initiative on Dementia (KSID).

This initiative has the following mandates (Social Justice Department and ARDSI, 2014):

  • Creating comprehensive dementia awareness in the community (information, education and communication materials and website content prepared/developed and disseminated by ARDSI) (Social Justice Department and ARDSI, 2014),
  • Equipping social and health care personnel with the skills required to provide dementia care (ARDSI currently provides training to the personnel on dementia Care) (Social Justice Department and ARDSI, 2014),
  • Establishing memory clinics in medical colleges for early diagnosis and intervention (ARDSI has published memory clinic guidelines) (Social Justice Department and ARDSI, 2014),
  • Establishing Model Dementia Day Care and Full-time Care Centres in all districts (one each functional at Cochin and Trissur districts of Kerala) (Social Justice Department and ARDSI, 2014),
  • Setting up telephone helpline services for dementia information and support (ARDSI has set up a Dementia National Help Line at Cochin) (Social Justice Department and ARDSI, 2014)
  • Developing protocols for the diagnosis, treatment, and care of the dementia (ARDSI has developed standard operating procedures for Day care centres and full-time Dementia care centres) (Social Justice Department and ARDSI, 2014).
References:

Social Justice Department and ARDSI (2014). Kerala State Initiative on Dementia. Alzheimer’s Disease International.

There have not yet been many dementia-specific documents, although age-friendly policies have been implemented at regional levels. A good example of a specific regional policy is the dementia-friendly village of Ketewel in Bali (Radha, 2018). There are also clinical guidelines on diagnosis and management of dementia issued by the Indonesian Neurologists Association (PERDOSSI) in 2015 (PERDOSSI, 2015).

References:

PERDOSSI. (2015). Panduan Praktik Klinik: Diagnosis dan Penatalaksanaan Demensia. PERDOSSI.

Radha, W. (2018). Penuhi hak lanjut usia, TP PKK Prov. Bali Dorong Pemberdayaan Lansia melalui Kegiatan Produktif. MetroBali. http://metrobali.com/penuhi-hak-lanjut-usia-tp-pkk-prov-bali-dorong-pemberdayaan-lansia-melalui-kegiatan-produktif/

Dementia is framed as a serious condition that may lead to a physically and psychologically dependent-life, with high impact in the quality of life of family carers (Brazilian Ministry of Health, 2018e).

References:

Brazilian Ministry of Health. (2018e). Orientações Técnicas para a Implementação de Linha de Cuidado para Atenção integral à Saúde da Pessoa Idosa no Sistema Único de Saúde—SUS. Ministério da Saúde do Brasil.

 

Dementia is discussed in a clinical context in PERDOSSI’s clinical practice guideline. This guideline advises on promotion, prevention, diagnostic, and treatment aspects of dementia starting from the primary care level up to the third-level referral. It was developed based on adapting existing guidelines from other countries (including Singapore, Malaysia, Philippines, and the UK) to the local context, and was planned to be renewed in 2017 (PERDOSSI, 2015). However, to the best of our knowledge, there are no updated versions of the guideline or of other clinical guidelines publicly available.

References:

PERDOSSI. (2015). Panduan Praktik Klinik: Diagnosis dan Penatalaksanaan Demensia. PERDOSSI.

Dementia appears to be falling under the realm of mental health; however, no specific mention has been made in the mental health policy (Ministry of Health, 2015c)

References:

Ministry of Health. (2015c). Kenya mental health policy 2015-2030: Towards Attaining the Highest Standard of Mental Health. Nairobi, Kenya. https://publications.universalhealth2030.org/uploads/Kenya-Mental-Health-Policy.pdf