Dementia

Dementia: A public health priority
> CHAPTER 4 > DEMENTIA HEALTH AND SOCIAL CARE SYSTEMS AND WORKFORCE
Income Group Psychiatrists Other medical
doctors
Nurses Psychologists Social workers Occupational
therapists
Other health
workers
Low 0.05 0.06 0.42 0.02 0.01 0.00 0.12
Lower-Middle 0.54 0.21 2.93 0.14 0.13 0.01 1.33
Upper-Middle 2.03 0.87 9.72 1.47 0.76 0.23 13.07
High 8.59 1.49 29.15 3.79 2.16 1.51 15.59
World 1.27 0.33 4.95 0.33 0.24 0.06 2.93
Table 4.1 Median rate of human resources per 100 000 population working in the mental health sector by World Bank income group (147)
BOX 4.1
MAIA (Maisons pour l’Autonomie et Intégration des malades
Alzheimer) in France
MAIAs are a key component of the French Alzheimer Plan
aiming to provide better reception, orientation and care for
persons with dementia. The MAIA model aims to reduce uncertainty
for families who do not know who to contact and who
would otherwise have to negotiate a maze of separate and
poorly coordinated systems.
The MAIA solves this problem by creating a process of integration
through a network of partners in the field of care, assistance
and support in the local settings, such as hospitals,
general practitioners, day care centres, Alzheimer’s disease
centres, council services, social services, home workers, volunteers,
dementia associations etc. The goal is to offer a onestop
shop, irrespective of the organization through which the
person first enters the system. The response must also be as
comprehensive as possible. The MAIA system does not replace
the existing system but provides the structure for improved
coordination. The MAIA provides services in response to the
needs expressed by the persons concerned, rather than the
resources that happen to be in place.
Fifteen trials have demonstrated that MAIA works at subdepartment
level. The trials show that local coordination is necessary
to achieve a first level of integration and to allow case managers
(for complex cases) to act effectively. Scaling up has begun
and, by 2014, 500 MAIA will provide full coverage of France.
Source: Reference 125.
The role of primary care
It is widely accepted that the initial identification of likely cases of
dementia is an important function of primary care. Many suggest
that formal diagnosis should be done by specialists, as explicitly
stated in France’s Alzheimer Plan (125), and is implicit in the United
Kingdom’s policy (121), in that determining eligibility for, and initiation
of, anti-dementia drug prescriptions should be carried out only
by specialists in the field. Because primary care has an important
role to play, it would be challenging to decrease the treatment gap
even in well-resourced high-income countries without effective
coordination between primary care and specialist services.
In LMIC, primary care and non-specialists have a much bigger role
to play in diagnosing and managing dementia because of insufficient
numbers of specialists (Figure 4.1). Furthermore, outreach in
the community and regular home visits are important for identifying
older persons with early-stage dementia. WHO has identified
dementia as one of the priority conditions to be addressed in its
Mental Health Gap Action Programme (mhGAP), particularly in
LMIC (181). Within this programme, evidence-based guidelines have
been developed for the management of dementia by non-specialists
with a view to scaling up treatment and reducing the treatment
gap (9) (Box 4.2).
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