Woo, Lai Leng (2016) Cost of informal care of dementia in Singapore. PhD thesis, James Cook University.

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Abstract

Background: Informal costs of care including caregiver and foreign domestic workers (FDWs) time are important components of total cost of care for patients with dementia (PWD) and should be considered alongside formal costs such as medication and health service use. This study quantified the informal caregiver time and formal cost of medication and health service use for PWDs in Singapore and compare with those people without dementia (PWODs).

Methods: This study recruited 137 (with no dementia) and 51 patient- caregiver dyads with mild, moderate and severe dementia. The Resource Utilization in Dementia (RUD) instrument is used to quantify informal caregiver time and medication and health service use. The Barthel Index and the Subjective level of function are used to measure functional capabilities. The Chinese Mini Mental State Examination is used to measure the stage of dementia. The opportunity and replacement cost methods are used to calculate the wages forgone in terms of time for the caregivers of PWDs and PWODs.

Results: Comparisons of this study results for PWD and PWD are summarised below.

Age and Gender: The mean age of the caregiver for PWOD was older at 61.65 (SD = 12.45) compared to those PWD at 53.24 years (SD = 14.22). Females were the majority caregivers for PWDs and PWODs.

Relationship to patients: Spouses were the main caregiver for PWODs while children were the main caregivers for those PWDs. A few FDWs (1.96%) were the primary caregivers for PWDs but there was none for those PWODs.

Employment Status: A third (33.58%) of the caregivers for PWODs was gainfully employed while about half of the caregivers for PWDs were gainfully employed.

Living Accommodation: Majority of these PWODs (83.21%) stayed at home with their families and lived in their own homes (96.67%). But only slightly more than half of PWDs (54.90%) stayed with their families and less than half of them (47.06%) actually lived in their own homes.

Other caregivers: More than half of the caregivers (51.09%) were sole caregivers in taking care of PWODs while almost half (49.10%) of the primary caregivers had one other caregiver in helping them to take for PWDs.

Level of contribution by primary caregiver: Less than a third (28.47%) the primary caregiver spent 21-40% of their time in taking care of PWODs, while a third (33.33%) of the primary caregivers spent 1-20% of their time in caring for PWDs.

Presence of FDWs: A few primary caregivers employed FDWs (14.60%) in their households for PWODs. These FDWs were mainly to do housekeeping chores for these families. However, more than half of the households (58.82%) had employed FDWs for PWDs.

ADL, IADL and Supervision: The time spent by caregivers on ADL, IADL and supervision for PWODs were much lesser compared to those PWDs. This was mainly because these PWODs had lesser problems in their daily activities and hence also required less supervision compared to those with dementia.

Informal cost of care: The mean annual informal cost of care for PWODs was SG$ 5,477.03 while those PWDs was SG$ 44,530.55. Informal care costs were highest for patients with severe dementia, compared with patients with mild or moderate dementia. The mean annual informal cost of care was higher (M = SG$44,530.55, SD = 31,354.82) compared to the mean annual formal cost of care in Singapore (M = SG$25,654.11, SD = 10,016.48).

Conclusion: The study main findings were: 1) the mean annual cost of informal care for PWDs in Singapore was 1.7 times higher than cost of formal care; 2) the mean annual informal cost of care was 2.3 times higher than full time cost in Residential Care Facilities (RCFs); 3) the formal cost of care was highest for PWDs in RCFs, DCCs (Day Care Centres) and the direct medical cost (dementia); 4) informal cost of care for PWDs was the highest (63%), followed by direct social costs (33%) and direct medical cost (includes dementia and non-dementia medications (4%); 5) the annual costs of informal care for dementia care increased with disease severity; 6) for each higher value of CMMSE, the informal cost of care is reduced by SG$1,173.94; 7) there was no significant association between annual cost of informal care and functional abilities; 8) the mean annual informal cost of care in Singapore is comparable with those in developed countries like the United States, United Kingdom and Japan; 9) the informal cost of care for those with dementia did not vary much with or without the use of DCCs or DDCCs; 10) the costs for those who did not have FDWs was approximately more than double the costs for those with FDWs; 11) PWDs also suffered from an average of five other chronic health conditions; 12) the most common chronic conditions reported by these PWDs were hypertension, hyperlipidaemia, diabetes mellitus and ischemic heart disease; 13) the most commonly reported medications for patients with other chronic conditions included antipsychotics agents, antihypertensive agents and medications for dyslipidemia; 14) about three-fifths of PWDs had FDWs compared to less than a fifth of those PWODs; 15) the mean annual informal cost of care for PWODs was SG$ 5,477.03 while those PWDs was SG$ 44,530.55; and 16) the cost of a screening programmes in polyclinics for all PWDs was SG$64,800 (one-time) or estimated SG$518,400 to employ 18 nurses once a year or SG$547,200 if one extra nurse is employed.

The number of PWDs is rising rapidly worldwide due to higher life expectancy. Singapore is no exception with a rapidly ageing population and these ageing caregivers also have their own health care problems. There are currently about 40,000 people with dementia in Singapore (Alzheimer's Disease Association, Singapore, 2016), which is costing the government SG$2.81 billion annually. By 2030, that number is expected to rise to 92,000 (Alzheimer's Disease Association, Singapore, 2016). This will cost the government healthcare expenditure to escalate almost triple to SG$ 6.46 billion, of which SG$4.10 billion will be attributable to informal cost of care and SG$2.36 billion to formal cost of care for PWDs in Singapore.

In the long term, the informal cost of care in Singapore is likely to be shifted to the formal cost of full time RCFs when the cognition and function of the patients with dementia deteriorates further. Thus the cost will be transferred from caregivers to society. Transition from full HC or partial HC and DCCs or DDCCs into RCFs will only increase total costs of dementia care from a societal perspective. Ultimately, this is simply a zero sum game, where nobody benefits.

Further Research: Going forward, further research on a broadly defined framework to possibly include policies implementation into education and awareness campaigns, subsidy for dementia medications, more funding mechanisms for enrolment into DDCCs, DCCs, and RCFs, better integration of care management and services, expanding specialty services, more centralised screening and diagnostic facilities and memory clinics island-wide, improved training for health care professionals and caregivers and families, benefits and rewards scheme for informal caregivers and strengthening and expanding of the existing infrastructure for quality health care services for PWDs.

Item ID:	46126
Item Type:	Thesis (PhD)
Keywords:	aged; age-related health problems; Alzheimer’s; Asia Pacific Region; barriers; cost of care; day care centres; dementia; elderly care; elderly; foreign domestic carers; foreign domestic workers; home care; informal care; medical costs; medical expenses; Singapore
Date Deposited:	19 Oct 2016 02:13
FoR Codes:	17 PSYCHOLOGY AND COGNITIVE SCIENCES > 1701 Psychology > 170106 Health, Clinical and Counselling Psychology @ 100%
SEO Codes:	92 HEALTH > 9205 Specific Population Health (excl. Indigenous Health) > 920502 Health Related to Ageing @ 100%
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