Health inequalities in care for persons with dementia

Abstract

Health inequality is defined as any difference, disparity, or variation in all health-related aspects of individuals and groups. The World Health Organization regards ensuring equal access to promotion, prevention, diagnostics, and care for persons with dementia as a crucial goal in their global action plan for dementia. This thesis evaluated care for persons with dementia not only from a specific facet (cost of stroke rehabilitation and patient satisfaction), but also from an overall viewpoint (socioeconomic positions and immigration).

The overarching objective of this thesis was to explore the difference in care for persons with dementia in Sweden, in terms of costs of stroke rehabilitation, patient satisfaction with stroke care, socioeconomic positions and immigration.

Study 1 estimated inpatient stroke rehabilitation costs for persons with dementia, in comparison with persons without dementia. Our study showed that persons with dementia had significantly lower mean inpatient rehabilitation costs compared to their counterparts, with SEK 103,693/US$ 11,932 and SEK 130,057/US$ 14,966, respectively in the two groups. Persons with dementia had more comorbidities and poorer functioning, by comparison with non-dementia controls. The inpatient rehabilitation costs for persons with dementia were approximately 0.84 times the costs in persons without dementia. We also observed that stroke patients in the dementia group had significantly lower proportion of receiving inpatient stroke rehabilitation, compared to those in the non-dementia group.

Study 2 assessed whether persons with and without dementia were satisfied with stroke care and rehabilitation after suffering stroke. We discovered that persons with dementia, answering themselves, were less likely to be satisfied with acute stroke care, health care professionals’ attitude, communication with doctors, and stroke information that they had received, but not regarding inpatient or outpatient rehabilitation. When their caregivers helped to report, persons with dementia had significantly lower satisfaction with all items, compared to their nondementia controls. No significant association between proxy-reported satisfaction and dementia status was found, apart from satisfaction with outpatient rehabilitation as answered by the family.

Study 3 addressed the disparity in dementia diagnostics and anti-dementia medications among different socioeconomic positions. Our findings were that higher income persons with dementia were more likely to obtain the complete basic dementia diagnostic work-up, clock test, blood analysis, MMSE, CT-MRI, neuropsychological assessment, and occupational therapy assessment. Persons with dementia with higher education had a higher chance of acquiring these dementia examinations, apart from blood analysis and MMSE. Persons with dementia with higher education or income were more likely to be diagnosed at a memory clinic. There was no significant association between socioeconomic positions and the prescription of anti-dementia medications, except for the association between education and the use of memantine. This association showed that the highest educated persons with dementia had higher chance of receiving memantine.

Study 4 explored the association between the receipt of long-term care and socioeconomic positions of person with dementia. We found that higher educated persons with dementia were significantly more likely to acquire any kind of long-term care and home care, as well as had more monthly average number of home care hours, compared to lower educated persons with dementia. No significant association between income and the performance of any kind of longterm care or home care was found in this cohort. The receipt of institutional care was not significantly associated with either education or income. In the sub-group analysis, we observed that persons with dementia from lower socioeconomic positions and living alone were less likely to receive any kind of long-term care and home care. This association disappeared in persons with dementia living with another adult. Greater monthly average number of home care hours was found in cohabiting persons with dementia with higher income, but lower duration of home care hours was seen in individuals living alone.

Study 5 investigated how immigration status influenced the dementia diagnosis process and the use of anti-dementia medications. The main result of this study was that health inequalities in dementia diagnostics and the prescription of anti-dementia medications between Swedishborn and foreign-born persons with dementia were not obvious. Immigration was significantly associated with the receipt of complete basic dementia diagnostic work-up and the single diagnostic tests, the types of diagnostic unit and the prescription of anti-dementia medications. For instance, persons with dementia who were born in Asia, Africa and the other European countries had lower probability of receiving the complete basic dementia diagnostic work-up. However, most of these associations were not statistically significant anymore when adjusting for MMSE score.

To conclude, health inequalities in stroke care and rehabilitation were found, in which persons with dementia had lower inpatient stroke rehabilitation costs and lower satisfaction with stroke care, compared to persons without dementia. Socioeconomic inequalities in the dementia diagnostic process were shown by significantly lower likelihood of obtaining specific dementia diagnostic examinations, receiving a specified dementia diagnosis, and being diagnosed at a memory clinic in persons from lower socioeconomic positions. Meanwhile, socioeconomic inequalities in long-term care, as well as health inequalities in dementia diagnostic process and anti-dementia medications, were not profound regarding immigration in this study cohort.