Dementia is on the rise, partially due to an aging population and better healthcare support services that promote longevity.
In Singapore, The Institute of Mental health conducted the Well-Being of Singapore Elderly (WISE) study which estimates that 1 in 10 people over the age of 60 suffers from cognitive impairment, and the risk increases with age.
What is Dementia?
Dementia, in a nutshell, describes a person who needs care and assistance in their daily lives due to the deterioration of memory, ability to understand, and behavioural disturbances.
It’s Not Just About the Dementia Patient
Dementia isn’t a singular health issue for the patient- it affects the patient’s family too.
Dementia can occur earlier in life as well. I have seen patients in their forties with moderate to advanced Dementia, losing the power to talk, or complete everyday activities we take for granted. It can be devastating to a family unit. They have to take into consideration such as financial and legal deputyship concerns that go beyond healthcare.
Patients are often diagnosed early with self-reported memory difficulties. Their family member could have observed a change and increased difficulty of the patient to perform the activities of daily living. This scenario allows the patient and family to seek medical support and professional help early.
For family caregivers of patients who refuse to accept help despite facing difficulties in their daily lives, it is challenging to bring these groups of people to seek medical attention early.
Every Patient with Dementia is Different
Dementia manifests itself differently in every patient and they do not have a similar clinical and functional progression.
Some patients with behavioural symptoms are often misdiagnosed. For example, Frontotemporal Dementia is often misdiagnosed as a psychiatric condition and Dementia with Lewy Bodies is often misdiagnosed as Parkinsonian disease, a neurological condition.
Treatment Options for Dementia
Management and treatment plans can differ depending on the specific needs of the individual.
Pharmaceutical Treatments
Pharmaceutical treatment usually includes Cholinesterase inhibitors such as Aricept or Exelon. These medication increases certain chemicals (neurotransmitters) in certain parts of the brain involved in memory.
Another medication, Memantine, affects other chemical messengers in the brain which promotes learning and memory as well.
These medications are used to slow down and stabilise the progression of Alzheimer’s type Dementia, rather than other types of Dementia such as Vascular type.
Some patients with Dementia may also have depression or agitation. Psycho-geriatricians may also prescribe antidepressants like Remeron or Lexapro, or mood stabilizers like Epilim. A combination of various psychotropic medications is used to support the patients and their caregivers.
Non-Pharmaceutical Treatments
Non-pharmaceutical support such as occupational therapy, physiotherapy, and speech therapy (for the more advanced stage) are often extremely helpful. Strategies to safely cope with dementia at home will be discussed during such sessions to allow for more meaningful interactions and easier day-to-day living.
Some other alternative therapies like music, reminiscence and pet therapy are often underutilised. In my opinion, they are very useful treatment options to attempt and they have no known side effects.
Using Technology to Support Patients with Dementia
Technology is increasingly being used to support patients with dementia and their families. Different stages of dementia require different support and these support caters to different domain of needs.
The different domain of needs can be grouped as follow:
- memory
- speech
- physical
- behavioural
- emotions
Technology can also be divided into:
- Those that support the patients
- Those that support the caregivers or the service providers.
Technology can range from modification or simplification of existing day-to-day devices, such as:
- a talking clock
- pill reminders
- phones with big buttons
- showing pictures of the family members with pre-inserted phone numbers
- artificial intelligence like Chat Yourself- an award-winning prototype system that allows older adults with cognitive impairment to chat with an A.I. chatbot. The system holds customised data pertaining to the patient and will be reminded of their day-to-day needs. Chat Yourself is developed by Italia Longeva.
Here in Singapore, a smartphone application called “Dementia Friends” was developed to support older adults who may wander and get lost. It works by getting members all over the island to keep a lookout if any of the cognitively impaired adults are lost.
Effects of Dementia on Caregivers
Caregiver stress is very common. Caregivers of more advanced dementia and dementia patients who are more dependent may experience physical strain. This can be worsened if there are no community resources like elder sitting or nursing aids available.
More often, due to behavioural disruptions, the mental health of caregivers can also be affected. Mental distress experienced by families is a common reason why Dementia patients are institutionalised into Dementia Care Homes.
Financial Support for Dementia Patients
Apart from medical and care-giving support, financial support is crucial as well. Dementia is not a deadly disease. However, it is a prolonged commitment to care for such an individual. Life-sustaining treatment decisions like artificial tube feeding for advanced dementia can very much prolong the duration of care by decades.
Financial planning, hence, is a crucial part of the management plan.
Insurance
The usual insurance such as hospitalisation or life plans is sadly unsuitable to insure the needs of the individual with dementia.
The only types of insurance in Singapore that covers such disability are
ElderShield from the Central Provident Funds (CPF)
IDAPE scheme from the Agency of Integrated Care. However, with a pay-out of $250 to $400 monthly only for up to 72 months, coverage is inadequate.
A study published locally in 2016 in the Journal of Alzheimer’s Disease estimates the annual cost per person at S$10,245 per year in Singapore.
Comparing this figure with the pay-outs of the types of insurance available, the basic coverage is inadequate to cover the medial estimated cost.
CareShield Life, an upgraded version of ElderShield was launched in 2020. It has higher pay-outs with lifelong support and it is a step closer to close the monetary gap. However, the basic plan might not be sufficient coverage as well.
ElderFund, an upgraded policy to IDAPE was launched in February 2020 and it provides long time pay-outs but capped at $250 monthly.
Managing the Assets of a Patient with Dementia—Legal Deputyship
I see many seniors with cognitive issues having trouble with their banking or housing needs regularly.
Many of our older adults may not be aware of the Lasting Power of Attorney- “a legal instrument that allows an individual to voluntarily appoint another person to act and make decisions on their behalf should they lose their mental capacity”- and have never done such documentations.
When they are demented and do not have the mental capacity to manage their own funds or property, the family might be stuck when they are required to help their loved ones manage their money or property. A typical example will be as such:
- Mrs A, an 88-year-old lady has lived in her 2 room Housing and Development Board (HDB) flat in Tanglin Halt Road all her life.
- She lost her husband awhile back from natural causes and now lives with her foreign domestic caregiver.
- She has advanced dementia and is mainly bed-bound and on a nasogastric tube feeding.
- The HDB flat is still under her name to date.
- HDB informed Mrs A about the impending Selective En-Bloc Redevelopment Scheme (SERS) and will be relocating her to a nicer and newer HDB.
- However, due to her lack of mental capacity and no previous appointment of a deputy, Mrs A was not able to consent to the exercise.
- Hence, Mrs A’s family was initially stuck on the course of action.
Without an appointment of a donee in the Lasting Power of Attorney documentation, Mrs A’s family will have to apply for her deputyship via the lawyers at the Family Justice Courts.
Time, effort, and costs for the legal fees will be incurred. Although the Family Justice Courts have started a simpler and cost-effective version of self-filing using IFAMS, such deputyship power may still have to go through a lawyer-assisted court process.
Pastoral Care for Dementia Caregivers
Lastly, pastoral care can be overlooked sometimes.
Long-term caregivers may experience difficulty adjusting following the death of the patient whom they have cared for over many years. With Singaporeans living in more isolated and smaller family units, getting support from the community might be less accessible in some cases.
Hence, proper pastoral care services can make a huge difference.
Conclusion
In summary, Dementia presents a multi-faceted challenge for the patient and their family. To navigate the many challenges, planning should start when the patient is still cognitively sound.
Apart from signing the Lasting Power of Attorney, another useful planning tool to add will be Advance Care Plan. Advance Care Planning (ACP) is the process of planning for future healthcare options through a series of voluntary and non-legally binding conversations with your family and doctors. In an ACP discussion, patients are guided to understand, reflect upon, and discuss their goals, values, and beliefs. They are then led to indicate their preferences with regard to their future healthcare treatments.
If you are a caregiver of a patient with dementia and you are applying for IDAPE/ElderShield/ElderFund, or you are in need of a Mental Capacity Assessment, visit Lotus Eldercare’s website.