Some polyclinics are providing a range of services for dementia patients and their caregivers, hence reducing unnecessary referrals to hospitals
By Ng Wan Ching, The Straits Times, 2 Oct 2014
By Ng Wan Ching, The Straits Times, 2 Oct 2014
Not least because that person becomes increasingly unable to care for himself and slowly becomes almost completely dependent on the caregiver.
And this burden is only going to get greater, here and elsewhere.
Dementia is one of the major causes of disability and dependency among older people.
Worldwide, there are nearly 36 million people with dementia, with more than seven million new cases diagnosed every year, said Dr Lam Pin Min, Minister of State for Health at a World Alzheimer's Day event on Sunday.
As Singapore's population grows older, the prevalence of dementia is expected to increase.
In 2005, there were 22,000 people diagnosed with dementia here, according to a study done in 2006.
Today, there are 38,000 with dementia, with the number set to increase to 92,000 by 2030.
The biggest cost of Alzheimer's and other types of dementia is not expensive medication or therapy, but the care that is needed just to get such patients through everyday living, according to a United States study.
The need to give good care and support, not only to patients but also their caregivers, grows ever more urgent.
Recognising this, the two polyclinic groups - SingHealth and National Healthcare Group - have started initiatives to help make life easier for those with the condition and their caregivers, availing them of the care they need in a primary care setting.
Last year, SingHealth Polyclinics (SHP) and the National Neuroscience Institute (NNI) started a pilot programme called Cognitive Assessment and Rehabilitation (CARe) at SingHealth's Geylang Polyclinic and Outram Polyclinic.
It is run once every two weeks and is designed to develop comprehensive services for patients with dementia.
Its aim is to:
- Provide an early diagnosis of dementia;
- Administer early intervention with appropriate means, either involving medication or not;
- Support patients with appropriate education and counselling; and
- Reduce the level of caregiver stress with counselling and support programmes.Since starting the programme, doctors at the two polyclinics have seen more than 200 patients, referring 70 per cent of them to a hospital for early intervention and further assessment, said Dr Gilbert Tan, a family physician at SHP.
In this scheme, polyclinics evaluate patients who show symptoms of memory impairment or cognitive difficulties and refer them to NNI for further evaluation.
Neurologists from NNI see patients together with family physicians at the polyclinics, said Dr Tan, who is also a senior consultant and assistant director of clinical services at SHP.
Anyone needing further specialised investigations, such as magnetic resonance imagery scans, is referred to the national specialist centre, where patients face an average waiting time of three to five weeks.
Following that, they can continue with routine follow-ups at the polyclinics if their symptoms are mild, said Dr Tan.
This cuts down unnecessary referrals to the hospitals and ensures patients who truly need specialist care get access to it.
The programme also includes dementia education and caregiver training by nurses trained in dementia care, he added.
Polyclinic psychologists provide cognitive evaluation and counselling for both patients and caregivers.
Allied health professionals, such as occupational therapists and speech therapists, will also step in to lend their expertise.
The programme focuses on managing patients younger than 65 who show signs of dementia.
The causes of dementia among patients in this age group are different from those who are elderly, said Dr Tan.
A higher proportion of those in the younger age group have dementia that can be reversed, such as structural brain conditions (brain tumour), chronic alcohol abuse and vitamin B12 deficiency.
They also tend to have a greater social and economic burden as they may still be working and have families to support.
For these patients, there will be a greater need for counselling and social support services.
SUSTAINABLE CARE
An earlier initiative was started by the National Healthcare Group Polyclinics (NHGP) in 2011 to provide integrated care for dementia patients, while working closely with hospital specialist outpatient clinics.
This integrated care service is found at NHGP's polyclinics in Yishun, Ang Mo Kio and Choa Chu Kang, and they work with Khoo Teck Puat Hospital, Tan Tock Seng Hospital and National University Hospital respectively.
Patients who are stable and have been discharged from the hospitals' specialist outpatient clinics are then cared for at the polyclinics.
"We work with the hospitals to ensure that their medical conditions are updated before their appointment at the polyclinic," said Dr Yehudi Yeo, a family physician and consultant at NHGP's Choa Chu Kang Polyclinic.
The patient's relevant records and care plans are sent securely from the hospital to the polyclinic.
Before the patient comes to the polyclinic for his check-up, the hospital geriatricians will discuss his physical conditions and mobility issues with the polyclinic clinicians, said Dr Yeo.
The hospital psychogeriatricians will discuss the extent of the patient's dementia and the therapy needed, he added.
The specialists also provide regular training to the polyclinic's multidisciplinary team, giving input on managing complex cases.
When the patient arrives for his appointment, he will be seen and managed by a team comprising a family physician, a care manager, a psychologist and a medical social worker.
They assess the patient's memory, cognition, behavioural and psychological symptoms of dementia, how able he is at carrying out activities of daily living, the safety aspects of his environment and side effects of his medication.
"Team-based care is crucial in the care of the elderly as they might be suffering from other ailments apart from dementia," explained Dr Yeo.
This collaboration makes transitioning from hospital to primary care seamless and efficient.
It provides a one-stop clinic serving much of the patients' needs so they need not go back to the hospital all the time.
It is "not sustainable" to always have the patient return to specialist outpatient clinics, said Dr Yeo. "Caregivers feel the emotional burden and making trips to the hospital can be time-consuming."
Caring for patients in a community setting, with patients and caregivers getting advice and support from the multidisciplinary team, makes it a more sustainable effort in the long run, he added.
HELP FOR CAREGIVERS
Challenges that commonly crop up for Alzheimer's patients with include functional decline - for example, becoming unable to care for oneself - and behavioural changes, such as not sleeping at night and getting lost in public places.
In severe cases, patients may not even recognise their loved ones and caregivers, which makes caring for them even more challenging.
It is recognised that caregivers play a pivotal role in the care of patients with Alzheimer's disease and it is therefore important they know how the disease will progress and what its complications are.
During consultations, doctors at the two SingHealth polyclinics look out for signs of stress and burnout in the caregivers and provide appropriate advice.
They can also be referred to see medical social workers, who can help them get assistance from community resources that are available, said Dr Tan.
At NHGP, caregivers are taught coping techniques and strategies on handling disruptive behaviour in those with Alzheimer's.
As a last resort, when caregivers are near their breaking point, the doctors would prescribe some medication on a short-term basis to calm the patient and give the caregiver some respite, said Dr Yeo.
Caregivers can also contact the Alzheimer's Disease Association to join its support group, where they can share and learn from the experiences of other caregivers, he added.
When a father becomes forgetful
By Ng Wan Ching, The Straits Times, 2 Oct 2014
By Ng Wan Ching, The Straits Times, 2 Oct 2014
Looking back, the first signs that all was not well with her father were the strange ramblings.
He talked about returning his home to unspecified persons and would mention there were people outside his Housing Board flat.
Madam S and her siblings brushed the odd behaviour off and attributed it to old age.
Her father also appeared confused and often did not make sense.
"He would give you a wrong account of things," said Madam S.
She mentioned it to the polyclinic doctor at Choa Chu Kang when she took her father there for another medical issue. The polyclinic had just begun its Alzheimer's programme.
"We got an appointment to see a geriatrician quite quickly," she said.
Her father was diagnosed with moderate Alzheimer's early last year.
But convincing her father - a widower in his 80s who lived by himself with a domestic helper - that he had dementia was a challenge.
While Madam S had employed the domestic helper to look after him, he clung on to his independence and wanted to go out on his own. He also refused to use a walking stick, preferring an umbrella to aid his walking instead.
One day, he fell down when he was outside. A passer-by called an ambulance to take him to the hospital. Fortunately, he was not badly hurt.
Six months later, he fell again, this time suffering a cut on his hand which needed stitches.
But still he refused to stay at home. Madam S had no choice but to ask the domestic helper to follow him at a distance to keep an eye on him. "It was like playing private eye," she said.
MORE FRAIL NOW
This year, his condition worsened. He is much more frail and does not go out on his own any more. He does not always recognise his three children or know them by name.
A set of new challenges now face Madam S and her siblings.
Their father may brush his teeth six times a night or eat breakfast multiple times in a day.
He is also getting more stubborn and can be extremely unwilling to cooperate with his caregivers.
"We would spend a lot of time trying to coax him to do the necessary things for everyday living, but after an hour, we could still be at square one," said Madam S.
He also does not sleep very much and is always awake from 3am to 5am.
Therefore, Madam S has hired a second domestic helper to look after him. "He tries to telephone us when he is awake in the early hours of the morning," she said.
So, the second helper stays awake during those hours to keep an eye on him and try to distract him from calling his children.
She also helps him to the toilet and makes sure he does not fall.
Madam S has also told the helpers to reduce his quantity of food so he does not put on too much weight.
"During Chinese New Year, we realised that he ate six mandarin oranges in a row. Now we keep a closer eye on what he eats."
She is thankful that her siblings help out and that she can get most of the medical care her father needs at the polyclinic.
"When we were going to and from the hospital after he hurt himself falling, it was stressful. It took us about half an hour to get there and the wait to see the doctor was long, compared with just 10 minutes to get to the polyclinic, where the wait to see the doctor was shorter too," she said.
Advice from the polyclinic on how to look after her father has also helped.
Said Dr Yehudi Yeo, a family physician and consultant at Choa Chu Kang Polyclinic: "There is no ideal way to address disruptive behaviour. Caregivers need to be creative and customise solutions."
That means they need to know the patient well, understand his preferences and other health conditions, as well as his life stories, he said.
In trying to persuade the patient to shower, for instance, they can paint it as a pleasant scenario or even say it is a massage therapy session and play soft music in the background.
Or, if the patient likes to throw things out of the window, change the physical environment by fitting mosquito mesh on the window grills, he added.
One of the biggest challenges Madam S faces with her father is his temper.
"He cannot control his temper when he does not get what he wants. I get concerned because his face will turn very red," she said.
She told the polyclinic doctor who prescribed her father with mood moderation medication.
"He's much calmer now," she said.
There will be many more challenges ahead, but she is comforted by the thought that help is nearby at the polyclinic.
Related
No comments:
Post a Comment