Macao Dementia Policy: Challenges and prospects (innovative practice)

Background

Dementia is a significant chronic condition that mostly affects older people, with 50 million people worldwide living with dementia in 2018, a figure expected to triple to 152 million by 2050, as more people live longer (Alzheimer’s Disease International, 2018). Macao is a Special Administrative Region of China with a population of 653,100. Older people aged 65 years and above accounted for 10.5% of the total population, and life expectancy at birth was 83.4 years in 2017 (Macao Statistics and Census Bureau, 2018). Age is the major risk factor for dementia and it is expected that the number of people with dementia will increase rapidly. According to one international report, there were about 4000 people with dementia in Macao, with a prevalence of 4.98% (Alzheimer’s Disease International, 2014).

Challenges facing Macao with its ageing population and traditional culture

In Chinese culture, the experiences of most families with an older person living with dementia include sensitivity and stigma. The families typically keep the problem to themselves; to talk about such issues outside the family is regarded as a betrayal of trust. Both the older persons with dementia and their caregivers would tend to ignore the symptoms and avoid talking to other people. As a result, early diagnosis and management are uncommon, leading to a worse prognosis and poorer quality of life (Baghirathan et al., 2018). Previous data demonstrated that the diagnosis rate of dementia in Macao was 37.5% in 2015 (Macao Health Bureau, 2017), which was lower than the expected diagnosis rate of 50% by World Health Organization (WHO, 2017).

Taking care of the older persons is strongly advocated in Confucian philosophy and traditional Chinese culture. However, in reality, younger generations are tending to develop an outlook that is more self-centered. As a consequence, older persons may not be able to get the respect and care that they are supposed to deserve from the younger generations (Yip, Chi, & Chiu, 2002). Furthermore, a local study indicated that the fragmented medical services and social care and a lack of awareness of dementia among health professionals in Macao raised challenges for older people with dementia and their caregivers (Zeng, 2016).

Within response to the above-mentioned challenges, the Secretary for Social Affairs and Culture Dr Alexis Tam Chon Weng developed the Macao Dementia Policy in 2016. The Macao Government announced the Macao Dementia Policy in World Alzheimer’s Month 2016, and at the same time established the Dementia Working Group and Dementia Medical Center. This landmark policy in Macao was recognized by Alzheimer’s Disease International (2016) as the 27th globally. Macao Dementia Policy, aligned with WHO Global Action Plan on the Public Health Response to Dementia 2017–2025, aims at promoting dementia friendly communities and establishing a dementia service network in Macao.

The Government of Macao Special Administrative Region, China, directed by this policy, is striving to: (1) work with non-governmental organizations (NGOs) to provide citywide public education to increase public awareness and understanding of dementia; (2) streamline cognitive assessment and referral process; and (3) strengthen integrated medical services and social care. The objectives are to provide a seamless network to achieve early prevention, early detection, early diagnosis, early treatment, and early support for people with dementia and their caregivers. In order to achieve these objectives, the following were established: the Dementia Working Group, a cognitive assessment network in Health Centers, the Dementia Medical Center, and the Dementia Support Center of Macao Government (Figure 1).

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Figure 1.

Conceptual framework of Macao Dementia Policy.

Prospects on implementation of Macao Dementia Policy

The Dementia Working Group was set up to raise public awareness and understanding of dementia. More than 100 NGOs in the region have signed a charter to join the Alliance to Build Dementia Friendly Macao. A series of activities were held by Macao Government and the Alliance to promote healthy lifestyle, reduce the risk of dementia, detect dementia at an earlier stage, and raise public awareness and understanding of dementia. “Dementia International Forum: Building a dementia friendly Macao” was held jointly by Macao Health Bureau, Social Welfare Bureau, and Macau Alzheimer’s Disease Association in 2017 and 2018, respectively. These concise and effective community engagement initiatives have been given high credit by Alzheimer’s Disease International (2019) to be scaled up in more regions and countries.

To achieve early diagnosis, the cognitive assessment network extended to all eight Health Centers throughout Macao and to some private health settings. Nearly 100 medical staff members from Health Bureau and community were trained to competently perform cognitive assessment. An outcome of improved assessment was that the number of confirmed cases of dementia increased from 1603 in 2016, to 1900 in 2017 and 2290 in 2018. The diagnosis rate of dementia also increased from 37.5% in 2015, 42.1% in 2016, 46.0% in 2017, to 51.5% in 2018 (Macao Health Bureau, 2018), achieving the Global Target 4 proposed by WHO (2017) Global Action Plan on the Public Health Response to Dementia 2017–2025.

The Dementia Medical Center works with social care facilities to provide a seamless integrated medical service and social care for people with dementia and their caregivers. The waiting time for consultation at Dementia Medical Center was greatly reduced from more than six months to less than one month because of streamlined referral process. The Dementia Support Center offers comprehensive post-diagnosis services, including counseling, health education, training, and support to people with dementia and their families. Furthermore, Macao Social Welfare Bureau provides a wide variety of services and support for people with dementia and their caregivers, such as home care, day care, respite care, and institutional care. Changes were made in many social care facilities to meet the needs of people with dementia.

In addressing the requirements for information systems for dementia service, Macao Health Bureau set up a web page to disseminate the information about dementia services and care. An electronic system was created to share information among all eight Health Centers and Dementia Medical Center. Macao Health Bureau also developed Dementia Registry to collect data systematically.

In conclusion, these initiatives manifest that the Macao Government has taken great strides in creating a dementia friendly community, as well as improvements in waiting times, diagnosis rates, and treatment through a seamless network of dementia support services, which has been highly praised by Alzheimer's Disease International in 2019 as a positive model.