Dementia is growing at an alarming rate throughout the world, especially in Asia. For a snapshot of how medical leaders in Singapore are working to tackle the issue, Roche Diagram magazine gets the perspective of a doctor who is on the front lines of treating the disease, and a nonprofit Chief Executive Officer (CEO) who is advocating on behalf of those who suffer from it.
Thirty years ago, dementia was not talked about much in Singapore. That was partly because the city’s elderly population was much smaller back then. It was also due to widespread stigmatisation of the disease – even among those whose family members were suffering from it.
‘Dementia’ is an umbrella term that comprises a wide range of cognitive conditions related to general mental decline. Alzheimer’s disease is perhaps the most well-known due to its prevalence, accounting for 50-60% of all dementia cases.¹ Other types of dementia include vascular dementia, frontotemporal dementia, and dementia due to Parkinson’s disease.
Mr Jason Foo, CEO of the Alzheimer’s Disease Association of Singapore (ADA), recalls how, in the late 1980s, “elderly people were found wandering the streets” in Singapore. “The authorities picked them up because they were lost and obviously had dementia,” he said. When returning them to their homes, police were shocked to find that their own families had abandoned them. The demands of caring for them had become too much to bear.
In response to this problem, a group of doctors banded together to form ADA, a local member of the worldwide Alzheimer’s Disease International (ADI), in 1990. Mr Foo, an accountant at that time, was brought aboard as a volunteer to be treasurer of ADA. In 2012, he became its CEO, a full time position which he has held ever since.
ADA has made significant progress under Mr Foo’s leadership, helping to reduce the stigma attached to people who suffer from dementia while providing much-needed support and resources to their caregivers. Still, the organisation has a lot more to do going forward. According to the Well-being of the Singapore Elderly (WiSE) study led by the Institute of Mental Health in 2015, nearly 82,000 Singapore residents had dementia in 2018 and that number is expected to surpass 100,000 soon.2
The increase in dementia cases is a global phenomenon that can be credited to an otherwise positive trend: people are living longer. According to ADI, the number of people with dementia worldwide is currently estimated at more than 50 million. That number is expected to reach 75 million in 2030, and 131.5 million in 2050. The fastest growth is taking place in China, India, and their South Asian neighbours.3
“As people live longer, the risk becomes higher,” Mr Foo said. According to the UK-based Alzheimer’s Society, people who reach 80 years of age have a one in six chance of developing dementia.4 The average life expectancy in Singapore is roughly 82 years. If life expectancy continues to rise, the diagnosis and treatment of dementia will become one of the country’s most daunting healthcare undertakings of the 21st century.
A passionate pioneer
You might say Dr Chan Kin Ming was ahead of his time.
In 1989, he joined a small group of doctors to launch the first department of geriatric medicine in Singapore. In 1991, he started the Alexandra Geriatric Centre at Alexandra Hospital, the first of its kind. It also housed the Geriatric Day Hospital, another first in Singapore that shifts care from the hospital into the community. He says a “sense of mission” led him to a field that is often passed over in favour of more glamorous specialties. Today, Dr Chan is widely respected for his expertise in geriatric medicine. Increasingly, that includes dementia.
According to Dr Chan, older patients often grow concerned about dementia when they experience memory problems. While it is true that age is a major risk factor for dementia – above the age of 65, one’s risk of developing Alzheimer’s disease or vascular dementia doubles roughly every five years5 – Dr Chan cautions patients against self-diagnosing based on “senior moments”. “Sometimes memory loss is a result of age-associated memory impairment, not dementia,” he said.
“Diagnosing dementia is a complex process involving a number of steps. It typically starts with a series of cognitive tests, including the Montreal Cognitive Assessment and the Folstein Mini Mental State Examination, which measures judgement, planning, problem-solving, reasoning, and memory. If the patient is found to be cognitively impaired, blood tests are performed to find out whether the patient is suffering from an illness or a vitamin deficiency, such as an electrolyte imbalance from kidney disease, thyroid disorder or Vitamin B12 deficiency, that could affect memory function,” said Dr Chan.
“If these secondary causes are ruled out, brain imaging tests – such as a computed tomography (CT) and a magnetic resonance imaging (MRI) scan –are conducted to determine the cause of the cognitive impairment. The MRI is particularly helpful, as it allows us to look directly at the hippocampus, the part of the brain associated with memory. The hippocampus is particularly sensitive to initial degeneration in patients with Alzheimer’s disease,” explained Dr Chan.
In recent years, diagnostics has evolved to include tests for cognitive biomarkers. It has been shown that an increase in beta amyloid in the brain and elevated tau proteins can predict the onset of Alzheimer’s disease.6,7 Beta amyloid load can be measured using an amyloid positron emission tomography (PET) scan of the brain.
Two separate laboratory tests can measure beta amyloid and tau protein in the cerebrospinal fluid (CSF).6,7 While measuring biomarkers with CSF immunoassays increase the certainty of an Alzheimer’s diagnosis, there remains a pressing need for further research into dementia diagnostics. “At this point,” Dr Chan said, “it is still very much a clinical diagnosis.”
A call for acceptance
Currently there is no specific treatment for dementia. Medicine may slow down the progression of dementia, but it cannot stop or reverse it. As the Asian population gets older, it seems fair to ask: is society prepared to deal with the problem?
“It depends on whether we have the resources to tackle it,” Dr Chan said. While institutional care, such as nursing homes and daycares, are available, they are not the first choice for caregivers who would prefer to keep their family member at home as much as possible.
That is where the efforts of Mr Foo and ADA come in. In 2016, ADA launched an innovative centre called Family of Wisdom, which provides both persons with dementia and caregivers a supportive place for activities such as stretching exercises, cooking, and more during the day. Not only does ‘Family of Wisdom’ help reduce the caregiving burden, but it also fosters a natural support system for caregivers. It has become an avenue for caregivers to learn care strategies from professionals, enjoy the support of other caregivers and get respite from the strenuous task of one-on-one caregiving.
As the number of people with dementia continues to grow, there will be a need for more innovative approaches. But first, Mr Foo said, Singapore will need to overcome some lingering negative attitudes toward the disease. “There is still a stigma,” he said. “Families don’t want to share openly when a relative has dementia.”
Mr Foo shares a story about an overseas conference where a person with dementia came on stage to share his story. “It was so impactful,” he said. “Only when we get rid of this stigma, people with dementia will be more willing to come out into the community to share their stories. That will help society in general to accept the disease and not judge those who unfortunately suffer from it.”
With that in mind, ADA recently opened a café that specifically employs people with dementia. “Some of our beneficiaries are in their 40s or 50s, and they are eager to still contribute to society. They don’t want to be cooped up in a daycare centre all day. However, it’s a challenge for them to find a job upon receiving their diagnosis. That’s why we are trying to create work for them. An example would be George – he doesn’t like to be in a daycare centre. But in the café, he is happy and he feels like he is contributing to society.”
While there is no cure for dementia, Mr Foo suggests there is a way to help persons with dementia have a better quality of life. By inviting them to tell their stories, and by including them in society, we can shed light on a disease that no longer belongs in the dark.
1Access Economics Pty Ltd. 2006. Dementia in the Asia Pacific region: The epidemic is here.
2Well-being of the Singapore Elderly (WiSE) study. 2017. Alzheimer’s Disease Association Singapore website.
3The Alzheimer’s Disease International. 2015. World Alzheimer’s report.
4Alzheimer’s Society UK. 2019. Risk factors you can’t change.
5Alzheimer’s Society UK. 2016. Risk factors on dementia fact sheet.
6Mattsson, N., Zetterberg, H., Hansson, O., et.al. 2009. JAMA 22, 302(4), 385-93.
7Hampel, H., Blennow, K. 2004. Dialogues Clin Neurosci,6(4), 379-390.