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 ofthe leading contributors to disease in older people. Dementia, most commonlycaused by Alzheimer's disease is characterised by a progressive loss ofintellectual abilities, typically leading to death five to seven years afterdiagnosis. Worldwide, dementia alone accounts for 11 percent of years livedwith disability. This is more than stroke (10 percent), cardiovascular disease(5 percent) and all forms of cancer (2 percent).

In developing countries, older people oftenlive in large family households where caregiving rolesand responsibilities may be shared. Nevertheless, family caregivers experience psychologicaland economic strain. Furthermore, traditional family structures are underthreat from changing attitudes towards older people, the education andemployment of women, migration, declining fertility, and HIV/AIDS, which has ‘orphaned’elderly parents and children. Without state provision, family support for olderpeople may fail.

Primary health care does not meet theneeds of the elderly mentally ill, who need a diagnosis, a comprehensivehome-based needs assessment, and longer term monitoring and care. Instead they tendto receive a clinic-based service orientated to the diagnosis of ‘treatable’physical conditions. In poorer countries, perhaps because of the inadequacy ofgovernment services, families of people with dementia are paradoxically morelikely to resort to expensive private medical services.

Governments have sought to bolster familycare through legislation or fiscal or social incentives. Instead, wider accessto pensions would increase self-reliance, and compensatory benefits forcaregivers and older people with mental disabilities would do much to redresstheir economic disadvantage.

Clinical interventions are available for anumber of conditions. For late-life depression, antidepressants andmultidisciplinary 'stepped care' have proved effective. For dementia, educationand 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 developedcountries, there is no reason that findings cannot be broadlyapplied.

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

• More training in the basic curriculum forprimary care staff, which will help move beyond a policy focus on simple curativeinterventions. Much can be done by extending therole of generic multi-purpose health workers who already work in thecommunity.
• Good quality residential care: important for those with littleor no family support. Developing effective systems of registration andinspection, training for care workers, and provision of medical servicesare equally important.
• Tackling the lack of awareness and understanding of dementia as a braindisease so families can seek help and receive support from health services. Alzheimer's disease associations,such as Alzheimer's Disease International, createa framework for positive engagement between clinicians, researchers,caregivers and people with dementia. They raise funds, disseminateinformation and act as advocates with governments, policy-makers and themedia.

The resourceimplications for chronic disease management are enormous. Developed countrieshave seen increasing proportions of their health budgets consumed in this way. Developingcountries will be profoundly affected. The only question is the extent to whichthey can manage change.