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Public health interventions – dementia

By Brianan Jones
Bachelor of Public Health,
University of Canberra

An estimated 322,000 Australians had dementia in 2013. Based on projections of the country’s population, ageing and growth, the number of people with dementia will reach almost 400,000 by 2020 and around 900,000 by 2050 (AIHW 2013). The care and management of people with dementia is one of the largest challenges facing the global population (World Health Organisation [WHO] and Alzheimer’s Disease International [ADI] 2012, cited in Leach and Hicks 2013).

This essay will briefly define dementia and highlight its significance as a public health issue in Australia. In addition it will demonstrate that dementia is an international public health issue and the worldwide policy response, which will provide context to discuss and analyse Australia’s history of policy addressing dementia. The application of the worldwide policy is in context to both State and Territory and Federal policy. To conclude, this essay will define public health and illustrate its role in tackling the dementia epidemic.

Dementia is not a single specific condition; it is a term used to describe the symptoms of a large group of illnesses which cause a progressive decline in a person’s functioning (Alzheimer’s Australia 2005; AIHW 2013). It is characterised by the impairment of brain functions including, a loss of memory, intellect, rationality, social skills and emotional reactions and is usually of gradual onset, progressive and irreversible. There are many different forms of dementia and each has its own cause and symptoms, the most common include Alzheimer’s disease, vascular dementia and Dementia with Lewy Bodies. Dementia affects mostly older people; however it is not a normal part of ageing. At present there is no prevention or cure for most forms of dementia, therefore support is vital for people with dementia and the help of families and carers can make a positive difference (Alzheimer’s Australia 2005).

As discussed above, Australia is not alone in its fight against dementia, with currently 35.6 million people worldwide estimated to be living with dementia in 2010. International policy context and specific country context are crucial when understanding the development of dementia plans. In 2004, Japan hosted the 20th International Conference of Alzheimer’s Disease International (ADI) in Kyoto. At the conference, the ADI members developed the Kyoto Declaration, which established 10 recommendations to assist in combating dementia (Access Economics 2006; cited in Alzheimer’s Australia 2011). In 2006, Alzheimer’s Europe and its member organisations released the Paris Declaration which called upon the European Union, WHO, the Council of Europe and national governments to recognise Alzheimer’s disease as a major public health challenge and to develop European, international and national action programs (Alzheimer’s Europe 2012; cited in Alzheimer’s Australia 2011). As a result a number of countries have produced national strategies or plans to address dementia, including; England, France, South Korea, Norway, Scotland, Denmark, Japan, Canada, Netherlands, the US and Australia. The Kyoto Declaration, prepared by ADI, set out the range of areas of focus in framing a dementia plan. The Paris Declaration went further, stating the shared political, public health, research, medical, care, social support, legal and ethical priorities of responding to dementia (Alzheimer’s Europe 2009, cited in Alzheimer’s Australia 2011). Both declarations have provided the foundations of development for many international dementia plans.

In 2005 the Australian Government committed $320 million in funding over five years to the Dementia Initiative (formally known as Dementia – A National Health Priority) (Alzheimer’s Australia 2013; AIHW 2012; Department of Health 2005). This initiative aimed at supporting people with dementia and their carers through the implementation of three measures: the establishment of high-level community care places specifically for people with dementia; new training programs for health professionals, carers and community workers; and additional research, improved care initiatives and early intervention programs (AIHW 2012). The initiative was a landmark for people living with dementia because it recognised the scale of the problem and its impact on the quality of life of Australians. According to Alzheimer’s Australia, at the end of the five years both major government parties supported continuing the initiative; however in the 2011-12 budget the Australian Government terminated the initiative.

In 2010 Alzheimer’s Australia published an evaluation of the Dementia Initiative by [the then] Minister for Mental Health and Ageing, Mark Butler. The evaluation reported the Dementia Initiative achieved much of its promise and has shown positive returns on the Australian Government’s investments through providing a substantial contribution to support people living with dementia and their carers and through lifting the profile of dementia in Australia. However, the evaluation also makes clear the Dementia Initiative falls short of the actions needed to combat the dementia epidemic in key areas. These include lack of communication strategy or action on primary care. Alzheimer’s Australia (2010) has also suggested the initiative failed to address other key areas such as acute care, end of life care, dementia risk reduction, and cutting edge research into the cause and prevention of dementia. In addition, there has been no recognition of the lack of access to age-appropriate services for those with younger onset dementia.

In January 2005, the Australian Health Ministers jointly agreed to develop the National Framework for Action on Dementia 2006-2010 (The Framework or NFAD) to provide an opportunity to create a strategic, collaborative and cost-effective response to dementia across Australia (Australian Health Ministers Conference [AHMC] 2006). The Framework was developed in consultation with Australian Community Services and Aged Care Ministers, but also people with dementia, their carers, families, the peak bodies that represent them, key stakeholders and service providers. It focuses on outcomes that can be best achieved nationally, with the cooperation of the Australian, State and Territory Governments, rather than on any individual jurisdiction’s initiatives. The Australian Health Ministers identified five priority areas in The Framework: care and support services; access and equity; information and education; research; and workforce and training strategies. These priority areas are fundamental to the quality of life of people with dementia as well as having the potential to yield the greatest benefits from the adoption of a national approach (AHMC 2006). However, whilst these priority areas are the collective responsibility of all governments, either the Australian Government or States and Territories will take the lead for key priorities for which they are primarily responsible.

For example, the Australian Government has primary responsibility for residential aged care, and State and Territory Government are primarily responsible for acute care services (AHMC 2006). The Framework will help to coordinate existing dementia care and support activities, share ideas and develop a more responsive service system through the provision of a structure that brings together Australian, State and Territory Governments while maintaining flexibility in service delivery (AHMC 2006).

In addition to The Framework, all Australian States and Territory Governments have implemented or are developing their own plans and actions to address dementia. The ACT has developed The Health Action Plan 2002 and the Clinical Services Plan which, in conjunction, are promoting healthy ageing, services for the frail aged and older people with cognitive impairments as priorities for health services. NSW has developed Future Plans, the second NSW dementia strategy and a collaborative plan between NSW Health and NSW Department of Ageing, Disability and Home Care. The Northern Territory has undertaken a number of initiatives, including a validation project for the Kimberly Indigenous Cognitive Assessment tool and reviewing local polices for Age Care Assessment Teams. South Australia is currently developing a State Dementia Plan. The Tasmanian Dementia Care Plan 2000 and Beyond is currently being reviewed. Victoria has developed the Pathways to the Future, 2006 and Beyond – Dementia Framework for Victoria. Lastly, Western Australia has the Dementia Action Plan 2003-2006. State and Territory Government policy can address the dementia needs of their population more accurately than national policy however, whilst maintaining focus on key priorities of The Framework.

In April 2012, the Australian Government published its Living Longer Living Better aged care reform package along with $3.7 billion of funding over five years and a promise to build a better, fairer and more nationally consistent aged care system. Within this package, the Government has promised to provide $268.4 million over five years to tackle the nation’s dementia epidemic. The action means and funding are broken up as follows:

  • $41.3 million to supporting people with dementia across the health system through expanding the Dementia Behaviour Management Advisory Service into acute and primary care settings and through supporting primary health care providers to undertake more timely dementia diagnosis. GPs and practice nurses will receive training and education programs and improved support to help them better diagnose dementia.
  • $41.0 million to better care for older Australians with behavioural problems associated with severe dementia in residential care through giving providers an additional $5789 per year, on top of normal subsidies to support people with severe dementia and to provide staff with improved training, guidelines and procedures to ensure best practice by aged care providers.
  • $123.3 million to better care for older Australians with dementia in Home Care Packages through establishing the new Dementia Supplement will increase funding by 10 per cent to recognise the higher costs of caring for people with dementia.
  • $39.2 million to improving acute care services for people with dementia, better identification, better coordination and better support systems will be developed and trialled to enable safe and appropriate hospital services.
  • Lastly, $23.6 million to improve support for people with younger onset dementia and enable better coordinated care and support. In addition, the Australian Government will recommend to State and Territory Health Ministers that dementia be recognised as the ninth national Health Priority Area. This will help drive collaborative efforts aimed at tackling dementia at a national, local and state and territory levels.

On 10 August 2012 the Australian Health Ministers recognised dementia as the ninth National Health Priority Area (AIHW 2013). According to the Australian Government this will help focus attention and effort on dementia, drive collaborative efforts aimed at tackling dementia at national, local and state and territory government levels, support collaboration with non-government organisations, health experts, clinicians and consumers and enhance recognition of current and proposed work undertaken as part of the NFAD (AIHW 2013).

In August 2013, prior to the September Federal Election, the Coalition released their policy to Boost Dementia Research. To accompany the policy was the promise of a further $200 million over five years to Australian scientists and medical researchers working on ways to prevent or cure dementia (Loughnane 2013). The boost to funding dementia research will endeavour to: expand capacity in dementia research by supporting new researches to commence work on key challenges; prioritise additional funding for dementia research projects; translate research into better care for dementia patients; and invest in vital dementia research infrastructure. The coalition will work with the National Health and Medical Research Council (NHMRC) and the Australian Research Council to boost the number of Early Career Research Fellowships, Postgraduate Scholarships, Career Development Scholarships and Future Fellowships for dementia research (Loughnane 2013). The $200 million provided will be quarantined for dementia-related research and coordinated through the NHMRC. It’s important to note, this funding is in addition to the Government’s commitments to dementia through the Living Longer Living Better reforms (Loughnane 2013).

Public health involves the organised response by society to improve and promote health of populations (Duckett & Wilcox 2011; McMurry & Clendon 2011). Public health initiatives are based on population-level data and typically involve measurement and surveillance, and development of evidence-based strategies to either prevent or overcome disease. The aim is to protect health, prevent illness, injury and disability and promote health including encouraging healthy behaviours and building healthier communities (Duckett & Willcox 2011). Therefore, all of the above policies and actions are public health initiatives as they are society’s response to improve and promote health of populations through managing and preventing dementia.

In 2012 WHO and Alzheimer’s Disease International developed the report Dementia: a public health priority. The purpose of this report is to raise awareness of dementia as a public health priority, to articulate a public health approach and to advocate for action at international and national levels (WHO 2012). Currently, there is lack of awareness and understanding of dementia in most countries, resulting in stigmatisation, barriers to diagnosis and care, and impacting caregivers, families and societies physically, psychologically and economically (WHO 2012). The report identifies priority areas of action required within policy and planning in order to address these concerns. They include raising awareness, timely diagnosis, commitment to good-quality continuing care and services, caregiver support, workforce training, prevention and research (Alzheimer’s Australia 2013). The report is expected to facilitate governments, policy-makers and other stakeholders to address the impact of dementia as an increasing threat to global health. It is hoped that the report will promote dementia as a public health and social care priority worldwide (WHO 2012).

This paper has identified the challenges associated with the care and management of dementia within Australia and internationally. It has demonstrated the Australian policy struggle from 2005 to current which has been complicated by limited funding, change in priorities and change in government. It highlighted the Australian Government’s achievement in being the first nation to make dementia a national health priority and the advancement of integrated state and federal policy to address dementia.

In conclusion, dementia has a devastating impact on the individuals, their families, their communities and national health systems, therefore dementia must remain a public health priority for not just governing bodies but all Australians.

References

Alzheimer’s Australia (2005 July) What is Dementia?

Alzheimer’s Australia (2010 November 5) Evaluation of Dementia Initiative.
Retrieved from: http://www.fightdementia.org.au/common/files/NAT/20101105_Nat_SUB_CommentsLAMAEval.pdf

Alzheimer’s Australia (2011 October) National Strategies to Address Dementia.
Retrieved from: http://www.fightdementia.org.au/common/files/NAT/20111410_Paper_25_low_v2.pdf

Alzheimer’s Australia (2013) Dementia: A Public Health Priority. Retrieved from: http://campaign.fightdementia.org.au/dementia-a-public-health-priority/

Alzheimer’s Australia (2013). Fight Dementia Campaign. Retrieved from: http://www.fightdementia.org.au/common/files/NAT/20120410_FightDementiaActionPlan.pdf

Australian Health Ministers Conference (2006 May) National Framework For Action On Dementia 2006-2010. North Sydney, NSW: NSW Department of Health.

Australian Institute of Health and Welfare (AIHW) (2012). Dementia in Australia. Canberra, ACT: Australian Institute of Health and Welfare.

Australian Institute of Health and Welfare (2013). Dementia. Retrieved from: http://www.aihw.gov.au/dementia/
Department of Health (2005 May 10) Budget 2005-2006 Ageing 1. Retrieved from: http://www.health.gov.au/internet/budget/publishing.nsf/Content/health-budget2005-hbudget-hindex.htm

Department of Health and Ageing (2012 April 20) Living Longer Living Better. Canberra, ACT: Commonwealth of Australia.

Duckett S, Willcox S (2011). The Australian Health Care System (Fourth Edition). South Melbourne, VIC: Oxford University Press.

Leach K, Hicks A (2013) The Nurse’s Role in Closing the Diagnostic Gap for People with Dementia. British Journal of Community Nursing 18 433-440.
Loughnane B (2013 August) The Coalition’s Policy to Boost Dementia Research. Barton: ACT.

McMurray A, Clendon J (2011). Community Health and Wellness (Fourth Edition). Chatswood, NSW: Elsevier Australia.

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