Dementia care in Hong Kong Professor Kwok Chi Yui Timothy Department of Medicine & Therapeutics (Geriatrics) Prince of Wales Hospital The Chinese University.

Dementia care Dementia care in Hong Kongin Hong Kong

Professor Kwok Chi Yui TimothyProfessor Kwok Chi Yui TimothyDepartment of Medicine & Therapeutics (Geriatrics)Department of Medicine & Therapeutics (Geriatrics)

Prince of Wales HospitalPrince of Wales HospitalThe Chinese University of Hong KongThe Chinese University of Hong Kong

Director of Jockey Club Centre for Positive Ageing Director of Jockey Club Centre for Positive Ageing

ContentContent

Dementia and its estimated care costs in Dementia and its estimated care costs in Hong KongHong Kong

Dementia servicesDementia services Risk factors of nursing home placementRisk factors of nursing home placement Survey of subvented day careSurvey of subvented day care Dementia specific day care Dementia specific day care Family caregiver training Family caregiver training

No. and proportion of people aged 65+ in Hong Kong, 1986-2036

0

500

1000

1500

2000

2500

1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 2022 2024 2026 2028 2030 2032 2034 2036

Year 年份

Num

ber

人口

數目

('00

0)

0%

5%

10%

15%

20%

25%

30%

Prop

ortio

n in

pop

ulat

ion

佔總

人口

比例

Number 人口數目

Proportion 佔總人口比例

Sources: (1) Website of the Census and Statistics Department, Hong Kong. (2) Hong Kong Population Projections 2007-2036.

Prevalence of Dementia in Prevalence of Dementia in community dwelling older community dwelling older

people in HKpeople in HK

Centre for Health Protection (2006). Aware (Newsletter). Volume 3, Issue 12

Estimated number of people aged 60+ with Estimated number of people aged 60+ with

dementia in Hong Kongdementia in Hong Kong

0.11

0.28

0.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

2010 2036Year 年份

Num

ber

(mil

lion

)患

者數

目 （

百萬

） ↑2.6 times 2.6 倍

0.22.0

9.9

0.6

5.2

25.9

0

5

10

15

20

25

Hospitalisation (lowerbound)

Residential care Informal caregiver

Cos

t (H

K$

bill

ion

)成

本 （

十億

港元

）

2010

2036

Costs of Care for Dementia Costs of Care for Dementia in HKin HK

Cadenza project

Early StageEarly Stage

Loss of advanced ADLLoss of advanced ADL InsightInsight Anxiety, DepressionAnxiety, Depression Social relationship Social relationship

problemsproblems Drug/ lifestyle non-Drug/ lifestyle non-

adherenceadherence Nutritional problemsNutritional problems Financial managementFinancial management Home safetyHome safety

Moderate StageModerate Stage Loss of Basic Loss of Basic

ADLADL Home safetyHome safety Caregiver Caregiver

supportsupport Behavioral Behavioral

problemsproblems DepressionDepression PsychosisPsychosis Loss of insightLoss of insight

Late StageLate Stage

• FallsFalls• Physical dependencyPhysical dependency• SomnolenceSomnolence• Poor Feeding Poor Feeding • Psychiatric problemsPsychiatric problems• End of life issuesEnd of life issues

Dementia Care Services in Dementia Care Services in Hong KongHong Kong

Social Social Social CentreSocial Centre Day CareDay Care

SubventedSubvented Self financed (dementia specific)Self financed (dementia specific)

Enhanced or Integrated Home Care (NGO)Enhanced or Integrated Home Care (NGO) Caregiver training (DH, NGO)Caregiver training (DH, NGO) Old ageOld age Home Home (Subvented, Private) (Subvented, Private)

Long term careLong term care Respite careRespite care

Dementia Care ServicesDementia Care Services

MedicalMedical Geriatric/Geriatric/Neurology/Neurology/Psychogeriatric Psychogeriatric

clinics in public hospitalsclinics in public hospitals Memory clinicsMemory clinics Private doctorsPrivate doctors

Problems for UsersProblems for Users

Patchy servicesPatchy services Limited access to information about Limited access to information about

servicesservices Long waiting timeLong waiting time Limited private market - limited economic Limited private market - limited economic

resourcesresources

Old age homes in Hong Old age homes in Hong KongKong

60,000 beds60,000 beds 25% are in subvented homes run by NGO25% are in subvented homes run by NGO The remaining mostly for profit private homeThe remaining mostly for profit private home

ss Small number of self financed homesSmall number of self financed homes by by

NGONGO 90% of private home residents are on social se90% of private home residents are on social se

curity (max. US$ 750 per month)curity (max. US$ 750 per month) Waiting time for subvented homes – 4 to 5 yrsWaiting time for subvented homes – 4 to 5 yrs

Survey of attitudes Survey of attitudes towards OAHtowards OAH

People aged 65 yrs or more and their People aged 65 yrs or more and their family caregivers were recruited from family caregivers were recruited from geriatric OPD, social and day care centres geriatric OPD, social and day care centres in 2007-8in 2007-8

Structured questionnaire interview by RAStructured questionnaire interview by RA Subjects categorized into cognitive Subjects categorized into cognitive

impaired (by AMT <6/10 or diagnosed impaired (by AMT <6/10 or diagnosed dementia) or notdementia) or not

Response rate 80%Response rate 80%

Funded by the Hong Kong Jockey Club “CADENZA” project

Characteristics of cognitively Characteristics of cognitively impaired subjects and family impaired subjects and family

caregiverscaregiversElder (N=230)Elder (N=230) Family Family

(N=351)(N=351)

Age (yrs)Age (yrs) 80.380.3 52.752.7

MaleMale 133 (28%)133 (28%) 59 (26%)59 (26%)

MarriedMarried 94 (41%)94 (41%) NANA

Lived aloneLived alone 12 (5%)12 (5%) NANA

No schoolingNo schooling 148 (65%)148 (65%) 18 (5%)18 (5%)

Primary Primary educationeducation

55 (24%)55 (24%) 62 (18%)62 (18%)

Secondary or Secondary or moremore

26 (11%)26 (11%) 271 (72%)271 (72%)

Characteristics of cognitively Characteristics of cognitively impaired subjects and family impaired subjects and family

caregiverscaregiversElderElder FamilyFamily

Domestic Domestic helperhelper

80 (35%)80 (35%) 135 (39%)135 (39%)

Part time Part time helperhelper

11 (5%)11 (5%) 26 (7%)26 (7%)

MildMild dementiadementia

53%53% 41%41%

Use of social servicesUse of social services

Demented Demented (N=351)(N=351)

Non-Non-demented demented (N=354)(N=354)

Social centreSocial centre 42%42% 41%41%

Day careDay care 46%46% 31%31%

Meal on Meal on wheelwheel

12%12% 10%10%

Home helpHome help 7%7% 10%10%

RespiteRespite 4%4% 1%1%

Any of aboveAny of above 72%72% 66%66%

Preference for OAHPreference for OAH

ElderElder FamilyFamily

Cognitively Cognitively normalnormal

23.3%23.3% 27.8%27.8%

Cognitively Cognitively impaired impaired (mild)(mild)

11.8%11.8% 44.2%*44.2%*

Cognitively Cognitively impaired impaired (severe)(severe)

NANA 68.5%68.5%

Disagreement on OAH Disagreement on OAH preferencepreference

Cognitively Cognitively impairedimpaired

Cognitively Cognitively normalnormal

Number of Number of dyaddyad

187187 288288

DisagreementDisagreement 37.4%*37.4%* 20.5%*20.5%*

P <0.001

Predictors of preference for Predictors of preference for OAH in the cognitively OAH in the cognitively

impairedimpaired Stepwise logistic regressionStepwise logistic regression Elder – Use of community services Elder – Use of community services

(OR 1.7 per one service used)(OR 1.7 per one service used) Family caregiver – Caregiver Family caregiver – Caregiver

burden, elder related – functional burden, elder related – functional limitation, use of community servicelimitation, use of community service

One year follow-upOne year follow-up

Out of 797 subjects, 94% were Out of 797 subjects, 94% were successfully contacted by telephone; successfully contacted by telephone; 80 subjects (10.7%) had been 80 subjects (10.7%) had been admitted to OAHadmitted to OAH

48.8% of OAH admission to private 48.8% of OAH admission to private homeshomes

% OAH placement in demented % OAH placement in demented 17.3% versus 6.2% in non-demented, 17.3% versus 6.2% in non-demented, OR 3.2OR 3.2

Predictors of Predictors of institutionalization in institutionalization in

demented eldersdemented eldersOROR 95% CI95% CI

Male caregiverMale caregiver 2.192.19 1.03 -4.681.03 -4.68

Hospital stay ( past Hospital stay ( past 6mth)6mth)

2.342.34 1.17–4.691.17–4.69

Lived aloneLived alone 4.564.56 1.19 -17.511.19 -17.51

Functional statusFunctional status 0.930.93 0.88-0.990.88-0.99

Non-spouse Non-spouse caregivercaregiver

12.9612.96 1.07-157.031.07-157.03

Domestic/part time Domestic/part time helperhelper

0.300.30 0.13-0.690.13-0.69

Main findingsMain findings

One third of families looking after One third of families looking after demented people have full time domestic demented people have full time domestic helpers (foreign)helpers (foreign)

Day care and social centres are the most Day care and social centres are the most commonly used social service for dementiacommonly used social service for dementia

Many families of demented people want Many families of demented people want OAHOAH

More disagreement about OAH need More disagreement about OAH need between the elders and the family between the elders and the family caregivers if the elders are dementedcaregivers if the elders are demented

Main findingsMain findings

Use of domestic helper was effective Use of domestic helper was effective in preventing OAH placementin preventing OAH placement

Dementia family caregivers who had Dementia family caregivers who had used social services were more likely used social services were more likely to want OAH placement (? Not to want OAH placement (? Not coping well)coping well)

Survey on Subvented Day care Survey on Subvented Day care service service

for Dementia in Hong Kong for Dementia in Hong Kong

Background Background 59 day care centres in Hong 59 day care centres in Hong

Kong, with 3,200 active clients Kong, with 3,200 active clients

Provide nursing care, rehabilitatiProvide nursing care, rehabilitation, transporton, transport

1,100 on waiting list, average wa1,100 on waiting list, average waiting time 6.6 monthsiting time 6.6 months

Objectives of surveyObjectives of survey

Examine the proportion and characteristics of Examine the proportion and characteristics of dementia day care usersdementia day care users

Problems faced by staff in looking after the deProblems faced by staff in looking after the demented clients mented clients

MethodMethod

Questionnaire sent to person in charge of Questionnaire sent to person in charge of all 59 day care centres in April 2010all 59 day care centres in April 2010

Response rate 93%Response rate 93%

ResultResult

Among day care users, 44% had dementiaAmong day care users, 44% had dementia 48% of new cases had dementia48% of new cases had dementia Among dementia users, 74% were mobile Among dementia users, 74% were mobile

(independently or assisted)(independently or assisted)

照顧活動能力良好和失去活動能力的痴呆症個案時的困難程度Caregiving Difficulty for Mobile Dementia and Immobile

Dementia Clients

38%

11%

60%

45%

11%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

活動能力良好 Mobile 失去活動能力 Immobile

照顧

困難

Car

egiv

ing

Diff

icul

ty

非常困難Very difficult 比較困難Quite difficult 比較容易Quite easy

In mobile clients, aggressive behaviour or In mobile clients, aggressive behaviour or language (53%), wandering (21%), agitation language (53%), wandering (21%), agitation (15%) (15%)

In immobile clients, aggressive behaviour or In immobile clients, aggressive behaviour or language (29%). Agitation (14%), eating problem language (29%). Agitation (14%), eating problem (13%), and fall risk (13%)(13%), and fall risk (13%)

Behavioural problems of dementia that Behavioural problems of dementia that staff found difficult to managestaff found difficult to manage

Manpower shortage (55%)Manpower shortage (55%) Lack of space (26%)Lack of space (26%) Environmental design (15%)Environmental design (15%)

Limiting factors in delivery of quality care to Limiting factors in delivery of quality care to mobile dementia clientsmobile dementia clients

Rationale for Dementia Rationale for Dementia specific day carespecific day care

Dementia friendly environmentDementia friendly environment Better trained staff to manage BPSDBetter trained staff to manage BPSD More cognitive stimulating activitiesMore cognitive stimulating activities Professional training for other Professional training for other

NGO’sNGO’s Self financing (No public funding) so Self financing (No public funding) so

farfar

Cognitive stimulation Cognitive stimulation activitiesactivities

Target cognitive and social functionTarget cognitive and social function Social element – group, family Social element – group, family

caregivercaregiver NOT practice on specific cognitive NOT practice on specific cognitive

modalitymodality Implicit learningImplicit learning Verbal skill - word association, object Verbal skill - word association, object

categorizationcategorization Reality orientationReality orientation

Randomized trial of cognitive Randomized trial of cognitive stimulating activities in stimulating activities in

demented peopledemented people Demented people in day centres or Demented people in day centres or

residential homes in Londonresidential homes in London MMSE 10-24MMSE 10-24 23 centres, cluster randomization23 centres, cluster randomization 14 sessions14 sessions

Reality orientation boardReality orientation board ReminiscenceReminiscence Multisensory stimulationMultisensory stimulation Implicit learningImplicit learning

Spector A 2010

SubjectsSubjects

CSTCST ControlControl

Age (yr)Age (yr) 85.785.7 84.784.7

Female:MaleFemale:Male 96:1996:19 62:2462:24

MMSEMMSE 14.214.2 14.814.8

ADAS CogADAS Cog 27.427.4 26.426.4

ResultResult

CSTCST ControlControl P valueP value

MemoryMemory 0.50.5 0.10.1 0.590.59

LanguageLanguage 0.5*0.5* -0.3-0.3 0.010.01

PraxisPraxis 0.20.2 00 0.320.32

Total Total 1.9*1.9* -0.3-0.3 0.010.01

QOL-ADQOL-AD 1.3*1.3* -0.8-0.8 0.010.01

Effect of Effect of CST CST was comparable to was comparable to Ch Cholinergic drug (D) on AD progressionolinergic drug (D) on AD progression

(MMSE)(MMSE)

CST+D CST+D (N= (N= 20)20)

D only D only (N=30)(N=30)

CST CST only only

(N=18)(N=18)

None None (N=18)(N=18)

BaselinBaselinee

23.023.0 21.221.2 19.419.4 19.419.4

Year Year OneOne

24.524.5 17.817.8 21.921.9 13.113.1

Year Year TwoTwo

21.621.6 13.913.9 20.120.1 8.68.6

Requena C 2006

Dementia Day/ Dementia Day/ Respite CareRespite Care

Dementia Day/ Dementia Day/ Respite CareRespite Care

ActivitiesActivities

Case managementCase management

One stop professional One stop professional

servicesservices

ActivitiesActivities

Case managementCase management

One stop professional One stop professional

servicesservices

Outcome of a cohort of 23 Outcome of a cohort of 23 new clients who stayed for 12 new clients who stayed for 12

months or moremonths or more BaselineBaseline Month 6Month 6 Month 12Month 12

Burden Burden

(max. 88)(max. 88)31.531.5 NANA 25.9*25.9*

MMSEMMSE 13.613.6 13.813.8 12.912.9

QOLQOL

(max. 100)(max. 100)75.575.5 69.769.7 72.372.3

CMAI CMAI

(max 203)(max 203)40.540.5 45.845.8 47.147.1

Family caregiver Family caregiver

Family Caregiver StressFamily Caregiver Stress

Most family caregivers of dementia Most family caregivers of dementia are stressedare stressed

Caring and communication skills Caring and communication skills often lackingoften lacking

At risk of depression, anxiety, poor At risk of depression, anxiety, poor sleep, hospitalization and mortalitysleep, hospitalization and mortality

Associated with elder abuse and Associated with elder abuse and BPSDBPSD

Predicts nursing home placementPredicts nursing home placement

InterventionsInterventions

Psycho-educationPsycho-education CounselingCounseling Family therapyFamily therapy Day care Day care

Counseling and support for Counseling and support for spouse caregiver of ADspouse caregiver of AD

2 x individual and 4x family 2 x individual and 4x family counseling sessions over four months counseling sessions over four months (family members selected by spouse (family members selected by spouse caregiver)caregiver)

ContentContent Counseling sessionsCounseling sessions

Management of behavioral problemsManagement of behavioral problems Communication among family membersCommunication among family members

Weekly support group after 4 month Weekly support group after 4 month follow-up follow-up

Ad hoc phone counseling for caregiver Ad hoc phone counseling for caregiver and family indefinitely and family indefinitely

Mittelman M S et al. Neurology 2006;67:1592-1599

©2006 by Lippincott Williams & Wilkins

Improvement in mood in the Improvement in mood in the long termlong term

Figure 2. Probability of nursing home placement (1 – survival probability) as estimated from a Cox proportional hazards model.

Mittelman M S et al. Neurology 2006;67:1592-1599

©2006 by Lippincott Williams & Wilkins

A randomized trial of Caregiver A randomized trial of Caregiver training in HKtraining in HK

Day care centre setting Day care centre setting Case manager visit/contact once in two Case manager visit/contact once in two

weeksweeks Family education/support group (one Family education/support group (one

two-hour session per week for 12 weeks)two-hour session per week for 12 weeks) 5 phases 5 phases

Orientation to dementia care (1)Orientation to dementia care (1) Educational workshop on dementia care (3)Educational workshop on dementia care (3) Family role and strength rebuilding (6)Family role and strength rebuilding (6) Community support resource (1)Community support resource (1) Review (1)Review (1) Chien WT Psychiatric services

2008

Subjects’ characteristicsSubjects’ characteristics

Family caregiverFamily caregiver Mean age 43.6 yrsMean age 43.6 yrs Caregiving 5.2 hours per dayCaregiving 5.2 hours per day

Demented eldersDemented elders Mean age 67.8 yrsMean age 67.8 yrs 80% early dementia80% early dementia All attended day careAll attended day care 55% received dementia drugs55% received dementia drugs 63% received antipsychotic drugs63% received antipsychotic drugs

ResultsResultsInterv. Interv. (N=44)(N=44)

Control Control (N=44)(N=44)

Month Month 00

Month Month 66

Month Month 00

Month Month 66

Burden Burden (max 96)(max 96)

68.168.1 56.7*56.7* 67.867.8 63.063.0

QOLQOL(max (max 144)144)

64.964.9 75.1*75.1* 67.167.1 69.869.8

MMSEMMSE 17.517.5 18.618.6 17.317.3 18.518.5

NPINPI 81.281.2 68.1*68.1* 83.883.8 84.884.8

Days/mtDays/mth h (institu(institution)tion)

13.213.2 11.1*11.1* 14.214.2 16.916.9

A 12-session psycho-educative A 12-session psycho-educative program by trained social workersprogram by trained social workers

One session once a week for 3 One session once a week for 3 months. months.

Each phone call lasts for around 30 Each phone call lasts for around 30 minutesminutes

Telephone delivered psycho-educative intervention Telephone delivered psycho-educative intervention

ContentContentNoNo ThemeTheme ContentContent

11 TT Identify problems and seeking helpIdentify problems and seeking help

22 TT Person center care in understanding the illness (Dementia)Person center care in understanding the illness (Dementia)

33 MM Communication skills with dementiaCommunication skills with dementia

44 MM Cognitive training and social activities’ planning Cognitive training and social activities’ planning (Daily schedule planning)(Daily schedule planning)

55 MM Understanding of BPSDUnderstanding of BPSD

66 MM Management of BPSD Management of BPSD

77 SS Emotional support (Grief and bereavement)Emotional support (Grief and bereavement)

88 SS Emotional support (Pressure release)Emotional support (Pressure release)

99 RR Environmental design and technological support Environmental design and technological support

1010 RR Introduction of community resource and utilizationIntroduction of community resource and utilization

1111 AA Financial Planning and ethical considerationFinancial Planning and ethical consideration

1212 AA Future planning (Long term care concern)Future planning (Long term care concern)

Subjects’ Characteristics (Caregivers)Subjects’ Characteristics (Caregivers)

CharacteristicCharacteristic Exp. Exp. (N=15)(N=15)

Con. Con. (N=15)(N=15)

< 60 years old < 60 years old 10 (67%) 10 (67%) 7 (47%) 7 (47%)

Children caregiverChildren caregiver 11 (73%) 11 (73%) 9 (60%) 9 (60%)

FemaleFemale 12 (80%)12 (80%) 11 (73.3%)11 (73.3%)

Primary education or Primary education or moremore

11 (73%) 11 (73%) 9 (60%) 9 (60%)

Not community servicesNot community services 12 (80%) 12 (80%) 11 (73.3%) 11 (73.3%)

Subjects’ Characteristics (Elders)Subjects’ Characteristics (Elders)CharacteristicCharacteristic Exp. (N=15)Exp. (N=15) Con. (N=15)Con. (N=15)

Aged 71-80 years oldAged 71-80 years old 12 (80%) 12 (80%) 7 (47%) 7 (47%)

FemaleFemale 11 (73%) 11 (73%) 10 (67%) 10 (67%)

Primary educational level Primary educational level or belowor below

14 (93%) 14 (93%) 15 (100%) 15 (100%)

Married Married 8 (53%) 8 (53%) 9 (60%) 9 (60%)

AMT scores are 4/10 or belowAMT scores are 4/10 or below 13 (87%) 13 (87%) 8 (53%) 8 (53%)

** In intervention group, ZBI score decreased significantly [ p =.002] In control group, ZBI score increased significantly [ p =.002]

Change of Zarit Burden IntervieChange of Zarit Burden Interview(ZBI)w(ZBI)

**

Change of Change of Revised Scale for Caregiving Self-Efficacy (RSCSE)

**

Change of Change of Cohen-Mansfield Agitation Inventory (CMAI)

*

ConclusionConclusion

Day care is the most commonly used service Day care is the most commonly used service by dementia family caregiversby dementia family caregivers

Half of subvented day care users are demented Half of subvented day care users are demented and staffs find it difficult to copeand staffs find it difficult to cope

Dementia specific day care has added benefitsDementia specific day care has added benefits Home care and social centre may be more Home care and social centre may be more

helpful to dementia clients if they provide helpful to dementia clients if they provide cognitive stimulation and case managementcognitive stimulation and case management

ConclusionConclusion

Family caregiver training is effective Family caregiver training is effective in reducing caregiver stress and in reducing caregiver stress and depression depression

The components includeThe components include Psycho-educationPsycho-education Management of BPSDManagement of BPSD Stress management techniquesStress management techniques Family supportFamily support

MediaMedia Face to face, Telephone, ?InternetFace to face, Telephone, ?Internet