A comparison of dementia care and policy in five Asian regions: A literature review
Article information
Abstract
Purpose
This review was comprised of an integrative analysis of the literature on the current state of dementia and related issues in Hong Kong, Japan, South Korea, Taiwan, and Thailand.
Methods
Published reports and policy documents from MEDLINE, CINAHL, PubMed, and each government’s database were used in this review.
Results
All five Asian regions are projected to become super-aged societies within 12 years, and the number of people with dementia has increased in these regions. All five regions have established dementia policies, which include improving dementia awareness, risk reduction, early diagnosis, and support programs for caregivers. However, there is a lack of information systems for sharing dementia data and research funding for dementia.
Conclusion
It is necessary to establish a dementia committee for Asian regions to actively address the challenges posed by the upcoming super-aged societies and to complement the insufficient research. This review provides future directions for dealing with diverse dementia-related issues and can serve as the basis for forming an Asian dementia committee.
INTRODUCTION
Dementia is a pressing global health issue that affects individuals, families, societies, and nations in terms of health care systems, national economies, and overall global health. The World Alzheimer report predicts that the annual number of new dementia cases in Europe and the United States will decrease to 2.5 million and 1.7 million, respectively, while in Asia, it will increase to 4.9 million [1]. As the number of people with dementia grows worldwide, especially in Asia, issues related to dementia and its care have become global health and social concerns, in addition to domestic issues.
Each country has its own specific strategies and policies for preventing and managing dementia. Since the World Health Organization (WHO) has established a Global Action Plan for the Public Health Response to Dementia, focusing on areas such as public awareness, prevention, early diagnosis, quality care and service provision, caregiver support, workforce planning, effective training, and research on diseases and evidence-based care, it is essential to ensure that each country’s policies on dementia prevention and management align with these standards. In the G7 countries (Canada, Germany, Italy, the UK, the US, France, and Japan), dementia policies are being adapted to the WHO’s Global Action Plan on the Public Health Response to Dementia, with ongoing evaluations [2]. However, dementia policies in Asian countries have not yet received the same level of consideration [3,4]. Additionally, Hong Kong, Japan, South Korea, Taiwan, and Thailand have aging populations and are projected to become the top six regions in Asia with an aging society by 2035 [5]. While there are similarities among these Asian regions, social and cultural differences may offer complementary insights to other regions. Therefore, this study aims to explore and compare the current state of dementia and its related issues in terms of dementia care and health/nursing policy in Hong Kong, Japan, South Korea, Taiwan, and Thailand and derive future directions for dealing with diverse dementia-related issues.
METHODS
Ethical statements: This study was exempted from approval by the Institutional Review Board as it is a review of the literature using previously published studies.
To examine and compare information on dementia care and policy in Asian regions, nursing scholars specializing in gerontological studies were contacted. Scholars from seven regions, including Hong Kong, Japan, Taiwan, Thailand, Australia, Singapore, and South Korea, were approached initially. Eventually, five nursing scholars with over 10 years of nursing experience and research experience with older adults participated in the study. They were provided questionnaires addressing 1) the epidemiology and characteristics of dementia, 2) diagnostic criteria or screening strategies for dementia, 3) health policies related to dementia, and 4) directions for nursing care for older adults with dementia. Instead of a systematic literature search, five scholars selected and reviewed literature that well reflected the current status and policies of dementia in each country. The authors used published reports and policy documents from databases such as MEDLINE, CINAHL, PubMed, and each government’s database to answer the questionnaires.
RESULTS
The dementia care and health policy of Hong Kong, Japan, South Korea, Taiwan, and Thailand are as follows (Table 1).
Characteristics of Dementia and Related Policies in Five Countries
1. Dementia Care and Health Policy in Hong Kong
1) Epidemiological Evidence and Characteristics of Dementia
In 2022, the population of people aged 65 and older in Hong Kong was 1,520,000, accounting for 20.5% of the total population [6]. It is estimated that around 20% to 30% of individuals over 80 years old experience some form of dementia [7]. Dementia is the seventh leading cause of death in Hong Kong, comprising 3% of registered deaths in 2022, following diseases such as malignant neoplasms and pneumonia [7]. Alzheimer’s disease is the most common type of dementia in Hong Kong, accounting for almost 65% of cases, followed by vascular dementia, which makes up approximately 30% of cases [8]. Factors contributing to the risk of developing dementia in people in Hong Kong include being female, having a lower level of education, impaired physical function [8], advancing age, cerebrovascular factors [9], social isolation, long-term exposure to air pollution [10], and existing cognitive impairment [11].
2) Diagnostic Criteria or Screening Strategies for Dementia
A diagnosis of dementia typically requires consideration of multiple factors. These may include the patient’s medical history, findings from a physical examination, cognitive screening, diagnostic investigations such as blood tests and neuroimaging, and review of medications contributing to cognitive impairment. Following diagnosis, individuals with dementia may receive care from a range of healthcare professionals, including primary care providers, allied health professionals, and medical specialists [12].
3) Health Policy Related to Dementia
In addition, support groups for caregivers and people with dementia exist in Hong Kong. The Alzheimer’s Disease Association supports people with dementia and their families by offering counseling services, support groups, and educational programs to help them cope with the challenges of caring for someone with dementia [13]. The Hong Kong Alzheimer’s Disease Association also provides various services, including social activities, home visits, and caregiver training programs to support people with dementia and their caregivers [14]. The Hong Kong Jockey Club Charities Trust also provides funding for various dementia-related initiatives, including developing a dementia-friendly community, public education campaigns, and caregiver training programs [15].
4) Further Directions of Nursing Care for Older Adults With Dementia
Despite efforts by the government, hospitals, and communities to support people with dementia and caregivers, there are limitations in the services provided, and the needs of people with dementia and caregivers are not fully met. Effective staff training is necessary to deliver high-quality care to people with dementia [13]. Early diagnosis of dementia is also crucial, as many patients with mild dementia go undetected in primary care settings. Therefore, cognitive assessments should be integrated into routine health assessments [14].
In addition to medical treatment, psychological support, counseling, and social support are essential to improving the quality of life for people with dementia and their caregivers. Referral to available support services should also be provided [11,15]. Palliative services are not well developed in Hong Kong, so promoting these services will be necessary to help patients and caregivers make decisions [11].
2. Dementia Care and Health Policy in Japan
1) Epidemiological Evidence and Characteristics of Dementia
In Japan, the population aged 65 years and above was 36.2 million in 2020, with an aging rate of 29.0% [16]. In the same year, there were 6 million people with dementia, which accounts for one in six older people aged 65 years and above [17]. In a national survey of eight municipalities, 67.6% of people with dementia had Alzheimer’s disease, and 19.5% had cerebrovascular dementia [18]. Risk factors for dementia in Japan include interference with activities of daily living, decreased motivation and participation in social activities, lifestyle-related diseases, cancer, history of head injury, hearing loss, and chronic pain [19].
2) Diagnostic Criteria or Screening Strategies for Dementia
In Japan, the diagnosis of dementia is guided by the Japan Society of Neurology’s systematized dementia treatment guidelines, which are based on international treatment guidelines [20]. To support this, the country has established about 450 specialized medical institutions known as the “Center for Dementia-Related Diseases.” These centers provide continuous medical and care systems for the rapid differential diagnosis of dementia, follow-up after diagnosis, response during symptom exacerbation, and prevention of behavioral and psychological symptoms of dementia, physical complications, and delirium.
3) Health Policy Related to Dementia
In 2019, the Ministry of Health, Labor and Welfare enacted the National Dementia Strategy, which aims to promote “living in harmony with dementia” and “prevention” [21]. Each local government has formulated a dementia care pathway as a support system from the onset of the disease to diagnosis and beyond and promotes the diagnosis of dementia, linking it to public nursing care insurance. This is centered around the Community Comprehensive Support Center, a familiar consultation organization established in each junior high school district.
4) Further Directions of Nursing Care for Older Adults With Dementia
It is necessary to accumulate evidence of care to establish response methods after an early diagnosis, as has been done in the past. Additionally, since many people with dementia live alone, some elderly individuals take care of even older people, and some people with dementia take care of other people with dementia, there is an increasing need to develop methods to approach such socially vulnerable groups. Research recommendations and initiatives like information and communication technology can help address these social issues.
3. Dementia Care and Health Policy in South Korea
1) Epidemiological Evidence and Characteristics of Dementia
In South Korea, the number of individuals aged 65 years and above is 8,134,674 (15.7%) [22], and the country is expected to become a super-aged society by 2025 [23]. The number of people with dementia has increased by approximately 30%, from 285,773 in 2010 to 959,001 in 2019 [22]. The types of dementia include Alzheimer’s dementia (75.5%), vascular dementia (8.5%), and other types of dementia (15.8%) [22]. Women account for 70.7% of people with dementia, approximately 2.3 times higher than men, and the proportion of women steadily increases [24]. Most dementia patients are 80~89, accounting for approximately 40% of the total patients, followed by those aged 70~79, 60~69, 90~99, and 50~59 years [22].
2) Diagnostic Criteria or Screening Strategies for Dementia
For the diagnosis of dementia, the government provides cognitive function tests every 2 years to individuals aged 60 years and above [22]. The Cognitive Impairment Screening test is mainly used for screening, and the Seoul Neuropsychological Screening Battery (SNSB) was developed in South Korea as a diagnostic cognitive function test [22]. The SNSB evaluates five cognitive domains comprehensively: attention, language and related functions, visuospatial functions, memory, and frontal/executive functions [25].
3) Health Policy Related to Dementia
In 2008, the South Korean government declared “a war against dementia.” In 2012, the Dementia Management Act was enacted, and the Act established the National Institute of Dementia and 17 Metropolitan Dementia Centers [26]. The Korean National Institute of Dementia acts as a control tower for the National Dementia Management Project. Metropolitan Dementia Centers are key in managing people with dementia at each regional medical center [22]. The Dementia Relief Centers and the Dementia Counseling Call Center are also operating [26]. The head of each local government established the Dementia Relief Centers, which aim to stabilize the early stages of dementia, prevent symptoms from worsening, and provide emotional support for families of people with dementia through integration [26]. The Dementia Counseling Call Center provides 24-hour dementia counseling [22].
4) Further Directions of Nursing Care for Older Adults with Dementia
The South Korean Ministry of Health and Welfare announced the fourth government’s comprehensive dementia management plan, effective from 2021 to 2025 [27]. South Korea has established an infrastructure for dementia management according to the first to third plans. However, the infrastructure needs to be expanded to improve service accessibility through supply expansion. Additionally, the fourth plan should focus on customized case management and reducing the burden on caregivers.
4. Dementia Care and Health Policy in Taiwan
1) Epidemiological Evidence and Characteristics of Dementia
Taiwan has rapidly become one of the world’s fastest-aging countries, with the age group of 65 years or above accounting for 16.07% in 2020. It is projected to become a super-aged society by 2025 [28]. The prevalence of dementia has also increased significantly, reaching 8%, and is expected to double by 2040 [29]. Alzheimer’s is the most prevalent form of dementia in Taiwan, followed by vascular dementia [30]. Additionally, depression is an independent risk factor for subsequent vascular dementia. In the subgroup of depressed patients, older age, coronary artery disease, head trauma, and cardiovascular disease were identified as risk factors for vascular dementia [31].
2) Diagnostic Criteria or Screening Strategies for Dementia
Dementia is still underdiagnosed due to the public stigma associated with the disorder and patients and families underreporting symptoms. This stigma has been identified as a significant barrier to seeking a diagnostic evaluation and for caregivers to use community services and obtain support from family and friends [32]. In Taiwan, the Clinical Dementia Rating (CDR) is commonly used for both staging and diagnosis, as it is globally [33]. The Mini-Mental State Examination [34] is the most frequently used cognitive assessment. However, it has limitations, such as not thoroughly testing memory and executive functioning, having ceiling effects, being significantly influenced by education, and facing copyright issues [35]. The Cognitive Abilities Screening Instrument was also used, but it yielded particularly low scores for individuals who only speak Taiwanese, even after accounting for age and education [36]. Recently, a history-based clinical diagnostic system was developed for the Taiwanese population, as existing tools were not considered suitable. This system modified CDRs using Taiwanese patient data to better suit the local context [37].
3) Health Policy Related to Dementia
The Taiwanese government implemented a universal long-term care system in 2007, which includes the 10-year Long-term Care Plan 1.0 (2007~2016) and 2.0 (2017~2026), aimed at creating a comprehensive, integrated care system that promotes the dignity and independence of older people and the disabled in their communities [38]. In 2018, Taiwan established its national Dementia Prevention and Care Policy and Action Plan 2.0, focusing on building a dementia-friendly society. The Long-term Care Plan 2.0 expanded its services to include people with dementia over 50 years old. Its objectives included improving the capacity of long-term care for people with dementia, expanding resource networks for dementia care, strengthening case management and service mechanisms in the community, and establishing a training system for professionals in dementia care [38]. The policy “2025 Dementia Friendly Taiwan 777” aims to have over 70% of family caregivers of people with dementia receive support and training, over 70% of people with dementia receive appropriate services, and over 7% of the population acquire the appropriate knowledge of dementia and become dementia-friendly by 2025 [38].
4) Further Directions of Nursing Care for Older Adults With Dementia
Early diagnosis of dementia is crucial. However, stigma can hinder early diagnosis, making it difficult to identify the condition. Therefore, it is essential to raise public awareness about dementia, which requires education for various population groups. The stigma associated with dementia acts as a barrier to its early diagnosis, and as a result, the action plan includes an educational policy to eliminate this stigma [39]. In a study aimed at providing dementia awareness education to local communities, education on dementia awareness was provided in schools, including elementary schools [39].
5. Dementia Care and Health Policy in Thailand
1) Epidemiological Evidence and Characteristics of Dementia
In 2020, 11,627,130 people (17.57%) in the country were aged 60 years and above [40]. It is anticipated that, in 2033, Thailand will become a “super-aged society” when the proportion of the population aged 60 years or above reaches 28% [40]. In 2020, about 651,950 people with dementia in Thailand (191,295 male and 460,655 female), accounting for 1% of the total population [41]. A study in Thailand reported that the most common type of dementia was Alzheimer’s disease (50%), followed by vascular dementia (24%), dementia with Lewy bodies (6%), Parkinson’s disease dementia (6%), frontotemporal dementia (2.6%), progressive supranuclear palsy (2%) [42].
2) Diagnostic Criteria or Screening Strategies for Dementia
In Thailand, multiple cognitive function screening and assessment instruments are available, including the Thai versions of the Mini-Mental State Examination and Montreal Cognitive Assessment, and the Thai Mental State Examination [43]. However, a systematic review of dementia screening tests for older Thai individuals revealed that more than 70% of the tests were foreign. Only six dementia screening tests have been developed by Thai researchers: the Thai Mental State Examination, Chula Mental Test, Dementia Screening Test, Chula Clock-Drawing Scoring System, Dementia Assessment for Thai People at the Primary Level, and the Dementia Assessment for Thai People at the Secondary Level [43].
3) Health Policy Related to Dementia
The dementia service systems have established a protective framework for older adults. It is expected that if such a system is implemented across the country, it could minimize the risk of permanent damage and promote brain stimulation, leading to some improvement in cognitive function or, at the very least, the ability to slow down the deterioration process. In 2017, the Ministry of Public Health introduced “The Thailand Strategic Plan on Dementia (2017~2026),” which encompasses six critical strategies. These include Strategy 1 - the development and management of public policy mechanisms; Strategy 2 - raising awareness and understanding of prevention and mitigation of risks, including friendliness towards people with dementia; Strategy 3 - the development of an integrated comprehensive and accessible social service system suitable for the Thai context; Strategy 4 - enhancement of the capacity of families and caregivers, with participation from all sectors; Strategy 5 - development of data and information systems; and Strategy 6 - development of research and innovation that aligns with the Thai context and wisdom [41].
4) Further Directions of Nursing Care for Older Adults With Dementia
Most Thai individuals with dementia are primarily cared for by family members, usually their adult children or a spouse, in their homes. However, some older people living in residential aged care facilities or nursing homes receive care from nursing home staff. Since dementia is not a common illness, there is no one-size-fits-all approach to managing cases. Therefore, it is essential to have community support mechanisms in place to help people with dementia and their caregivers achieve the best possible quality of life [44]. The Association of Dementia Caregivers advocates for public policies to improve dementia care and is currently promoting a “dementia-friendly community” for individuals with this condition [44]. In 2019, the public and private sectors established the model of comprehensive dementia care to create a seamless and integrated system of care and services for people with dementia. This concept was implemented in four pilot settings [44]. Additionally, the Ministry of Public Health plans to expand the model of dementia comprehensive care to 13 health regions throughout Thailand [44].
DISCUSSION
The review findings revealed that the number of older people and the prevalence of dementia are increasing in all five Asian regions, and policies on dementia are already being implemented in these regions. In Japan, one out of seven older people live with dementia. In South Korea, Taiwan, and Thailand, the percentages of people with dementia were 10.33%, 8%, and 1%, respectively. In Hong Kong, 20% to 30% of seniors aged 80 years or above are diagnosed with dementia. However, as each region provides different data types, limited comparisons can be drawn by contrasting the populations according to their age group. Any comparison may not be fully accurate. Nevertheless, since age is the most influential factor for dementia [45], we can assume that the rates will increase with age. Also, Alzheimer’s dementia is the most common type of dementia, accounting for 50% to 80% of dementia cases.
The WHO’s member states adopted the 2017~2025 Global Action Plan on the Public Health Response to Dementia in May 2017 [46]. The WHO recommends that all regions develop a dementia management plan to enhance the quality of life of people with dementia and their families, thereby reducing the burden on the community and countries [47]. Therefore, it would be appropriate to use the WHO’s Global Action Plan as a standard for comparing dementia systems in each region. Each of the five regions generally reflects the seven WHO action plans well. Still, we would like to compare each region’s current dementia management status according to the WHO action plans.
1. Dementia as a Public Health Priority
This proposed action aims to develop, strengthen, and implement national strategies, policies, or plans to support people with dementia and their caregivers. Fortunately, five regions have already implemented dementia plans under various names: the Comprehensive Dementia Management Plan in South Korea, the National Dementia Strategy in Japan, the Dementia Plan in Taiwan, and the Strategic Plan on Dementia in Thailand. Hong Kong does not currently have an independent dementia plan, but it does have policies related to dementia within its medical and social welfare policies.
2. Dementia Awareness and Friendliness
The second action plan proposes actions for member states to organize dementia awareness campaigns for the public. In Taiwan, stigma has been identified as one of the barriers to seeking diagnostic evaluation, community services, and support from family and friends [38]. Therefore, reducing stigma should be a priority in Taiwan’s efforts to increase awareness about dementia. Additionally, nursing education should address the stigma associated with dementia to ensure that future nurses have the right attitude toward dementia patients.
3. Dementia Risk Reduction
This action plan connects dementia with other health promotion initiatives, such as weight management, tobacco avoidance, and mentally stimulating activities. In Korea, cognitive tests for early detection have been provided to seniors aged 60 years or above. However, not only age but also vascular disease, obesity, and diabetes increase the risk of dementia. Therefore, policy changes are needed to classify individuals with these conditions as high-risk dementia groups and provide them with screening tests.
4. Dementia Diagnosis, Treatment, Care, and Support
This action plan includes the development of an efficient care pathway for people with dementia in the healthcare system. Sustainable care should be provided across the continuum of diagnosis and end-of-life [46]. In Japan, continuous services are provided through the Dementia Care Pathway, while in Korea, dementia screening tests and diagnoses are offered at the Dementia Relief Center. In Hong Kong, a multidisciplinary team of health professionals provides the service. In such situations, it is important to train nurses to effectively develop, implement, and evaluate dementia management pathways. Nurses should also collaborate with other healthcare professionals to establish guidelines for evaluating, diagnosing, and managing dementia and advocate for promoting sustainable patient treatment.
5. Support for Dementia Caregivers
This action plan aims to develop evidence-based information and training programs for dementia caregivers, facilitate evidence-based resources to improve their knowledge and skills, and enhance their emotional skills. All five Asian countries have support programs for caregivers. However, G7 countries (e.g., Canada, Germany, Italy, the UK, the US, France, and Japan) provide caregivers with mental and psychological health counseling, and work-care-compatible policies, such as flexible work, have been enacted [47]. All five regions involved in this study must provide a comprehensive range of policies to support caregivers, in line with G7 countries, going beyond fragmentary support.
6. Information System for Dementia
The WHO recommends that dementia data be input into a shared platform to be analyzed and used to update dementia policies. However, information on each region’s information system for dementia was lacking among the five regions studied. In the United States, the Alzheimer’s Accountability Act was enacted to fund dementia research [48]. Similarly, South Korea established the Korea Dementia Research Center in 2020, which aims to analyze comprehensive pathological causes and mechanisms, develop predictive diagnostic technology, and develop treatments and prevention programs [49]. However, most non-government organizations monitoring dementia-related policies are established mainly in Western countries. These organizations continuously communicate and evaluate the status of dementia-related policies in member countries to recommend priorities through national committees [50]. Such committees should be established in Asian regions to allow respective governments to actively deal with the forthcoming super-aged society through up-to-date monitoring and data-sharing.
In conclusion, the discussion of this study has provided an in-depth analysis of the current state of dementia and its related issues in Hong Kong, Japan, South Korea, Taiwan, and Thailand, while identifying the areas that require further improvement. We have examined the progress made by each region in implementing dementia plans aligned with the WHO’s Global Action Plan and highlighted the challenges and opportunities in addressing stigma, early detection, care pathways, and caregiver support. Our findings emphasize the importance of regional collaboration and learning from each other’s experiences to enhance the effectiveness of dementia policies and strategies. As we move towards a super-aged society, it is crucial for these Asian regions to strengthen their commitment to addressing dementia-related issues and to adopt innovative solutions that will improve the quality of life for people with dementia and their caregivers.
CONCLUSION
This study explored and compared the current state of dementia and its related issues in Hong Kong, Japan, South Korea, Taiwan, and Thailand. The increasing prevalence of dementia in all five Asian regions and the implementation of policies on dementia highlights the need for comprehensive strategies and policies to address this issue. The WHO’s Global Action Plan on the Public Health Response to Dementia provides a framework for developing national strategies and policies to support people with dementia and their caregivers. While all five regions have implemented dementia plans, comparing their status according to the WHO action plans is necessary to assess their effectiveness. Addressing stigma associated with dementia, providing early detection and screening tests for high-risk groups, developing efficient care pathways for people with dementia in the healthcare system, and providing comprehensive support programs for caregivers are crucial steps towards reducing the burden of dementia on society. Additionally, establishing committees in Asian regions to monitor and evaluate the status of dementia-related policies is important to prepare for the forthcoming super-aged society through up-to-date monitoring and data-sharing.
The limitations of this study are as follows. First, the literature used was not systematically searched, and the literature needed by researchers in each country was selected. In addition, it is difficult to accurately compare the status or policies of dementia presented by each country because they are not uniform. Nevertheless, this study is meaningful in that it reviewed the status and systems of dementia in Asian countries that had not been previously presented to global standards. Based on the findings of this study, policymakers should prepare appropriate responses to this phenomenon, given that many Asian countries are rapidly aging.
Notes
Authors' contribution
Study conceptualization & methodolohy - YK and DJ; Data collection and analysis - YK, YH, LY, JJJL, SL, MY, HCS, and DJ; Drfting and critical revision of the manuscript - YK, YH, LY, JJJL, SL, MY, HCS, and DJ; Supervision - YK and DJ; All authors have read and agreed to the published version of the manuscript.
Conflict of interest
No existing or potential conflict of interest relevant to this article was reported.
Funding
National Research Foundation of Korea (NRF) grants funded by the Korea government, grant number 2020R1A2C1013713.
Data availability
Please contact the corresponding author for data availability.