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Part I

Why Canada needs a national strategy on dementia Add to ...

Canada currently has about 280,000 long-term-care beds, meaning about five per cent of seniors live in an institutional setting. The Alzheimer Society estimates that by 2038 there will be 690,000 long-term-care beds, a shortfall of at least 157,000 - unless there is adequate investment to provide care at home. "It doesn't make a lot of sense to have a lot more institutional care," Dr. Reichman says. "Warehousing is not the answer."

Almost two-thirds of patients now end up in institutions, for an average of three years - a span that a dementia strategy should strive to reduce substantially, most experts agree. They say that money spent on institutional care should go toward quality, not quantity.

Families also complain that policies at care facilities can be maddening. For example, they routinely expel patients who are violent or who don't follow a routine, even though both are common traits of people with dementia. These "hard to house" patients often end up occupying costly beds in acute-care hospitals.

Institutional care is also a financial burden for families, with the annual fee for a spartan, four-to-a-room nursing home about $20,000, even when heavily subsidized.

Dr. Reichman says small, home-like facilities offering special care to those in the advanced stages of Alzheimer should be the way of the future. Maison Carpe Diem, an innovative 15-bed home in Trois-Rivières, Que., is often cited as a model.

Solution three: Train specialists to find proper care for each patient

The gradual loss of memory and cognitive skills that characterizes dementia is frightening, for patients and their families alike. As the disease progresses, medical and social needs change regularly and keeping up is a challenge.

"Dementia is so complex that every patient needs a care manager," says David Harvey, government-relations officer with the Alzheimer Society of Canada. "But right now the typical case manager is a 78-year-old woman called 'the spouse' - and she's overwhelmed."

Mr. Harvey says someone diagnosed with dementia should be assigned a care manager, or system navigator, to co-ordinate both medical and social needs.

A personal approach may seem costly, but in cancer care, system navigators have proved cost-effective because they prevent waste and keep patients out of expensive hospital beds. Mr. Harvey stresses that this person wouldn't replace family members but let them provide care more effectively.

Because case managers can't be available around the clock, the Alzheimer Society is also calling for the creation of a dementia hotline. "Crises don't happen on a convenient 9-to-5 schedule," Mr. Harvey explains.

Solution four: Delay the decline with early diagnosis and prompt treatment

Most Canadians still view dementia as a normal part of aging. It is not, but this attitude means that many cases are diagnosed late and caregivers don't seek help until they are in crisis.

Early diagnosis is important because it allows treatment that can slow cognitive decline. While the drugs that currently exist to treat Alzheimer have a limited benefit, treating related conditions such as depression can greatly improve quality of life, and so too can changes in lifestyle (exercise, for example) and joining a support group.

There is no simple, single test for diagnosing Alzheimer's or other forms of dementia. But Sandra Black, research director of the neuroscience program at the Sunnybrook Research Institute in Toronto, says significant progress has been made in the detection of telltale signs of brain damage and loss of cognitive skills. In addition to the classic pen and pencil tests, there is a growing array of tests for biomarkers (such as proteins that point to underlying disease) as well as scans to detect amyloid plaques and tau tangles.

Dr. Black says there are also tests for certain genes, but no one advocates systematic screening because "it can be unethical to search for a disease when there is currently no treatment you can offer to control it."

On the other hand, because almost one-third of those over 65 develop some form of dementia, advocacy groups stress planning for the day that people can no longer express their wishes. A dementia strategy should promote the use of living wills and advanced care directives.

Solution five: Guarantee family caregivers the help they need

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