DESK REVIEWS | 07.02.01.02. Does the country have any of the following:

DESK REVIEW | 07.02.01.02. Does the country have any of the following:

Usually, the GP refers those he/she suspects that have dementia to a specialist (psychiatrist, neurologist, or geriatrician) under secondary care, but may opt to conduct neuropsychological tests, as well as ask for the blood tests and tomography directly if possible.

Generally, a GP refers the person to a specialist (neurologist/psychiatrist).

PERDOSSI has developed a diagnostic protocol for primary care. In addition, from 2019 onwards primary care centres have to adopt a screening approach by the Ministry of Health’s regulation no. 4/2019 on Minimum Standard of Service. The document states that all people aged 60 years old or above should receive an annual check of blood glucose and cholesterol level, Geriatric Depression Scale, Abbreviated Mental Test, Instrumental Activities of Daily Living (Ministry of Health Regulation No. 4/2019 on Technical Standard to Fulfill Quality of Basic Service in Minimum Standard of Healthcare Service (Permenkes No. 4/2019 Tentang Standar Teknis Pemenuhan Mutu Pelayanan Dasar Pada Standar Pelayanan Minimal Bidang, 2019).

References:

Ministry of Health Regulation no. 4/2019 on Technical Standard to Fulfill Quality of Basic Service in Minimum Standard of Healthcare Service (Permenkes no. 4/2019 tentang Standar Teknis Pemenuhan Mutu Pelayanan Dasar pada Standar Pelayanan Minimal Bidang). (2019). (Testimony of Ministry of Health Republic of Indonesia).

Diagnosis for dementia is made by a medical officer at referral county hospitals, but as a secondary condition. Often, diagnosis is received late, following admission to inpatient care diagnosis because the primary complaint at the outpatient clinic is dementia unrelated and the dementia symptoms are mostly identified during inpatient care (Musyimi et al., 2019).

References:

Musyimi, C., Mutunga, E., & Ndetei, D. (2019). Stigma and dementia care in Kenya: Strengthening Responses to Dementia in Developing Countries (STRiDE) Project. In World Alzheimer Report 2019: Attitudes to dementia (pp. 121–122). London, UK: Alzheimer’s Disease International. https://www.alzint.org/u/WorldAlzheimerReport2019.pdf

Not as part of any public health or social security institutions. Most people with a diagnosis obtains it from private services/specialists.

This may be done, but there is no standard protocol. The neurologist or geriatrician is likely to do this during consultation. For the prescription of free anticholinesterase the specialist has to do the CDR (severity) and MMSE (cognition), but nothing regarding BPSD.

Specialists are equipped to assess people with dementia that are exhibiting psychological symptoms and challenging behaviours. The Clinical Practice Guidelines published by the Indian Psychiatric Society (IPS) (initially in 2007 and revised in 2018) contains a protocol for identification and management of challenging behaviours through pharmacological and non-pharmacological interventions (Shaji et al., 2018). For example, it provides an overview of the drugs recommended for management of behavioural and psychological symptoms of dementia (Shaji et al., 2018).

Non-pharmacological interventions for behavioural and psychological symptoms of dementia have been identified as a key intervention in dementia care. It is recommended for psychological interventions to be explored first before administering pharmacological therapies (Shaji et al., 2018). These psychological interventions have been found to work best when individually tailored to the patient (person-centred care) (Shaji et al., 2018). Cognitive stimulation programmes are beneficial in improving and maintaining the functionality for Activities of Daily Living (ADL). Other interventions like reality orientation and reminiscence therapy are also recommended (Shaji et al., 2018).

References:

Shaji, K.S., Sivakumar, P.T., Rao, G.P., Paul, N., (2018). Clinical Practice Guidelines for Management of Dementia. Indian J. Psychiatry 60, S312–S328. https://doi.org/10.4103/0019-5545.224472

An assessment for behavioural and psychological symptoms of dementia (BPSD) is not routinely performed among older people or people who have been diagnosed with dementia. The Ministry of Health is currently planning a guideline for primary care, and this might include the Neuropsychiatric Inventory (NPI) to assess BPSD. The NPI, however, is commonly used for assessment in memory clinics.

Similar to diagnosis, management is provided at referral county hospitals by psychiatric nurses and psychologists in counties where psychologists are integrated within the health system.

Not as part of public or social security services and no information is available from any private (profit or non-profit) services that offer these services. Some specialists could offer these, but no information is available publicly that we could document.

Yes, but not specifically for people living with dementia.

There are a few dementia activities centres and day-care centres in the country that provide cognitive stimulation and support functional rehabilitation for people with dementia.

Puskesmas santun lansia (geriatric friendly Puskesmas) provide promotive, preventive, curative, and rehabilitative services including psychosocial therapy services in rehabilitative sectors (Zakiah, 2017). The services consist of psychological health services and cognitive activities for older people, which aim to support older people in preserving their functional abilities and independency (Aistyawati, 2016).

References:

Aistyawati, I. (2016). Analisis Implementasi Kebijakan Program Puskesmas Santun Lanjut Usia di Puskesmas Mijen Kota Semarang. Administrasi Publik.

Zakiah. (2017). Puskesmas Santun Lansia. https://www.slideshare.net/dr_Qiqi/puskesmas-santun-lansia-76504165

Yes, but not specifically for people living with dementia.

Dementia organisations like NMT and private attender agencies like Portea, Life Circle Elder Care and more, run home-based care programs primarily in urban areas where paid attenders are available to support home-based care. There are also a few day-care services offered by organisations including ARDSI.

This is often provided by family members.

Yes, they are beginning to be implemented, but not specifically for people living with dementia.

Less than 1% of patients have access to palliative care in India and existing services are predominantly available for persons living with cancer (Rajagopal et al., 2015). The state of Kerala is an exception with a large community-based model for palliative care (Kumar, 2007).

Recently, the Ayushman Bharat-Health and Wellness Centres are working on expanding the range of care services provided at a primary level including elderly and palliative care services which are relevant to persons with dementia (MoHFW, 2019).

References:

Kumar S. K. (2007). Kerala, India: a regional community-based palliative care model. Journal of pain and symptom management, 33(5), 623–627. https://doi.org/10.1016/j.jpainsymman.2007.02.005

Ministry of Health and Family Welfare (2019). Ayushman Bharat: Health and Wellness Centre.

Rajagopal, M. R. (2015). The current status of palliative care in India. Cancer Control, 22, 57-62. Available from: http://www.cancercontrol.info/wp-content/uploads/2015/07/57-62-MR-Rajagopal-.pdf

 

Palliative care was first established in Indonesia in 1992. Expansion of programmes has been slow as services are concentrated in big cities (Putranto et al., 2017), leading to a lack of palliative care services in community-based and primary healthcare facilities. An example of palliative care in community-based service can be found in the Puskesmas Balongsari in Surabaya, East Java. A team of medical doctors, psychologists, nurses, and volunteers provides Palliative care services in the outpatient setting on Mondays and Wednesdays (Saleh et al., 2008). However, this is not dementia specific. Palliative care in Indonesia is mostly linked to cancer (Putranto et al., 2017) and in general is regulated by the Ministry of Health (Kementerian Kesehatan Republik Indonesia, 2007). There continues to be a lack of research evidence and initiative towards developing palliative care for people with dementia in Indonesia.

References:

Kementerian Kesehatan Republik Indonesia. (2007). Minister of Health Decree 812/2007 on Palliative Care Policy (Keputusan Menteri Kesehatan Republik Indonesia No. 812/2007 tentang Kebijakan Perawatan Paliatif).

Putranto, R., Mudjaddid, E., Shatro, H., Adli, M., & Martina, D. (2017). Development and challenges of palliative care in Indonesia: role of psychosomatic medicine. BioPsychoSocial Medicine.

Saleh, M. S., Danantosa, T., & Kusumawardhani, C. (2008). Perawatan Paliatif di Puskesmas Balongsari Surabaya: Upaya Mendekatkan Layanan Rawat Jalan Kepada Pasien Kanker Stadium Lanjut.

These are provided at referral county and private hospitals by mostly psychologists (only in Makueni County for public health facilities) and/or social workers in addition to doctors and nurses team (Hospice Care Kenya, 2018; International Association for Hospice & Palliative Care, 2019). Not all county hospitals have put in place the scheme of service for social medical workers. The medical social workers are supposed to contribute to improvement of health care services and provide counseling to patients and relatives in institutions/hospitals, psychosocial rehabilitation, home based care, and placement of patients. Other roles include providing support services to curative/hospital based, primary, preventive and promotive programmes, and activities (Republic of Kenya, 2009). Private hospitals e.g., the Aga Khan University Hospital have also social workers in their palliative care team (International Association for Hospice & Palliative Care, 2019). In most cases, people with dementia receive these services especially those at advanced stages.

References:

Hospice Care Kenya. (2018). Paving the way for universal access to palliative care in Kenya.  https://www.hospicecarekenya.com/other-news/paving-the-way-for-universal-access-to-palliative-care-in-kenya/

International Association for Hospice & Palliative Care. (2019). Global directory of palliative care services and organizations. https://hospicecare.com/global-directory-of-providers-organizations/

Republic of Kenya. (2009). Scheme of Service for Medical Social Workers. Permanent Secretary Ministry of State for Public Service, Office of the Prime Mininster. Nairobi, Kenya. https://www.health.go.ke/wp-content/uploads/2015/09/SCHEME%20OF%20SERVICE%20FOR%20MEDICAL%20SOCIAL%20WORKERS.PDF

 

In Mexico, the inclusion within the Federal Legislation, of palliative care for individuals with terminal conditions took place in 2009, specifying the need to attend the care of those individuals “with illnesses that have no cure and are in an irreversible condition of health deterioration”, but people with dementia are not included as a specific group. However, very little advances have been made and public services for palliative care are almost inexistent. No private services offering support for palliative care could be identified and only two non-profit organisations in the country were identified providing these support services for any individual/illness.

Yes, but not specifically for people living with dementia.

The Rights of Persons with Disabilities Act 2016, states that a disability assessment can be conducted to assess cognitive impairment for people with chronic neurological disorders. Based upon the results of this assessment, a nominal state pension can be received from the government (Government of India, 2016). Other schemes are listed in Part 9.

References:

Government of India. (2016). The Rights Of Persons With Disabilities Act. THE GAZETTE OF INDIA EXTRAORDINARY PART II.

The Ministry of Health recognises the need of a public financial insurance system specific for dementia and LTC services through the national dementia plan. Although this has not been implemented, financial aid for older people (regardless of a dementia diagnosis) in healthcare services cost has been regulated by Government Regulations (Pemerintah Pusat Republik Indonesia, 2004) and data shows that Puskesmas Santun Lansia provide lower cost geriatric services than those provided in standard Puskesmas (Indriati et al., 2013).

Furthermore, according to the 2019 older people services programme, several people in Indonesia were to benefit from social and financial protection schemes in 2019. These schemes were not specifically for people with dementia.

These include:

  • ASLU: to reach 30,000 people with the value of assistance is Rp 200,000 × 12 months per older person.
  • Home care: to reach 20,000 older people with assistance valued to IDR 2,000,000 per person.
  • Family support: to reach 7,000 people.
  • Social Assistance through Social Welfare Institutions Seniors/Asistensi Sosial Melalui Lembaga Kesejahteraan Lanjut Usia (LKS-LU), targeting 2,655 people.
  • Older people who received social services through Case Response Target in 2019: 8,390 people.
  • Other supporting activities including development of age-friendly neighbourhood and day care services.
  • Progres LU (Program Rehabilitasi Sosial Lanjut Usia) aimed to help older people to rehabilitate and develop their social functioning ability. Progres LU consists of:
    • non-cash assistance worth Rp. 200,000 per person per month,
    • social care within families/community halls, in the form of social assistance of Rp. 1,200,000 per person per year through LKS-LU,
    • support for relatives who are taking care of older people, in the form of non-cash social assistance of Rp. 3,000,000 per person per year,
    • therapy, in the form of social assistance Rp. 1,350,000 per person per year through LKS LU,
    • Social Professional Assistant for Seniors: for community social workers who coordinate and assist in older people social rehabilitation programs at all levels (national, provincial, district/city-level, rehabilitation centres). For paid Social Assistant for older people, the payment is Rp. 2,500,000 per person per month.
  • Other technical support related to main activities in the program.
  • Support for Accessibility for older people through Pemenuhan Hak Hidup Layak (Fulfillment of the Right to Decent Living), in the form of social assistance for older people in emergency situation with a value of Rp 750,000 per person, and Bimbingan dan Dukungan Aksesibilitas (Guidance and Accessibility Support), in the form of social assistance for older people experiencing barriers to mobility and accessibility with value in the amount of Rp. 750,000 per person (Badan Pusat Statistik, 2019b).
References:

Badan Pusat Statistik. (2019b). Statistik Penduduk Lanjut Usia di Indonesia 2019. xxvi + 258 halaman.

Indriati, S., Oktarina, D., Santoso, K., Sikoki, B. S., & Sine, J. J. (2013). Forum Nasional IV Jaringan Kebijakan Kesehatan Penilaian Kepatuhan terhadap Standar Kebijakan Nasional untuk Pelayanan Kesehatan Lansia di Yogyakarta: Pelayanan kesehatan vs lanjut usia.

Pemerintah Pusat Republik Indonesia. (2004). Undang-Undang No. 43 Tahun 2004. https://peraturan.bpk.go.id/Home/Details/66188

Only those above 65 years who are poor and vulnerable and none of their household members is receiving pension, regular income, or gainful employment, are entitled to cash transfers (Kshs. 4000) every two months. Those below the age of 65 years who have dementia and are classified as persons with severe disability, are also entitled to similar cash transfer. A person is required to enroll only for one of the schemes even if they qualify for both. Further details on cash transfer schemes are described in part 9 (social protection for people with dementia).