Mental health care for older people: what role for primary care?

In 1990, 58 percent of the world's population aged 60 years and over lived in developing countries. By 2020 this will rise to 67 percent. In developing countries the number of people over 60 will increase by 200 percent compared to 68 percent in the developed world. This will be accompanied by unprecedented economic growth and changes in social structures and the pattern of family life. How will these changes affect the care and support of older people with mental health conditions?

Dementia and major depression are two of the leading contributors to disease in older people. Dementia, most commonly caused by Alzheimer's disease is characterised by a progressive loss of intellectual abilities, typically leading to death five to seven years after diagnosis. Worldwide, dementia alone accounts for 11 percent of years lived with disability. This is more than stroke (10 percent), cardiovascular disease (5 percent) and all forms of cancer (2 percent).

In developing countries, older people often live in large family households where caregiving roles and responsibilities may be shared. Nevertheless, family caregivers experience psychological and economic strain. Furthermore, traditional family structures are under threat from changing attitudes towards older people, the education and employment of women, migration, declining fertility, and HIV/AIDS, which has 'orphaned' elderly parents and children. Without state provision, family support for older people may fail.

Primary health care does not meet the needs of the elderly mentally ill, who need a diagnosis, a comprehensive home-based needs assessment, and longer term monitoring and care. Instead they tend to receive a clinic-based service orientated to the diagnosis of 'treatable' physical conditions. In poorer countries, perhaps because of the inadequacy of government services, families of people with dementia are paradoxically more likely to resort to expensive private medical services.

Governments have sought to bolster family care through legislation or fiscal or social incentives. Instead, wider access to pensions would increase self-reliance, and compensatory benefits for caregivers and older people with mental disabilities would do much to redress their economic disadvantage.

Clinical interventions are available for a number of conditions. For late-life depression, antidepressants and multidisciplinary 'stepped care' have proved effective. For dementia, education and training for caregivers, behavioural management strategies for symptoms such as wandering and agitation, and the new anticholinesterase drugs for improving cognitive function have been successful. Although the evidence supporting these interventions comes from developed countries, there is no reason that findings cannot be broadly applied.

Evidence indicates that effective solutions must be based upon primary care, and should include:

• More training in the basic curriculum for primary care staff, which will help move beyond a policy focus on simple curative interventions. Much can be done by extending the role of generic multi-purpose health workers who already work in the community.
• Good quality residential care: important for those with little or no family support. Developing effective systems of registration and inspection, training for care workers, and provision of medical services are equally important.
• Tackling the lack of awareness and understanding of dementia as a brain disease so families can seek help and receive support from health services. Alzheimer's disease associations, such as Alzheimer's Disease International, create a framework for positive engagement between clinicians, researchers, caregivers and people with dementia. They raise funds, disseminate information and act as advocates with governments, policy-makers and the media.

The resource implications for chronic disease management are enormous. Developed countries have seen increasing proportions of their health budgets consumed in this way. Developing countries will be profoundly affected. The only question is the extent to which they can manage change.

Martin Prince
Section of Epidemiology
Institute of Psychiatry,
De Crespigny Park
London SE5 8AF
UK
T +44 (0) 20 7848 0136
F +44 (0) 20 7277 0283
m.prince@iop.kcl.ac.uk
www.alz.co.uk/1066

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