Preparing Singapore for Dementia

ADJOURNMENT MOTION

The Deputy Leader of the House (Mr Zaqy Mohamad): Mr Speaker, Sir, I beg to move, "That Parliament do now adjourn."

Question proposed.

Preparing Singapore for Dementia

3.16 pm

Ms Poh Li San (Sembawang): Mr Speaker, Sir, September was World Alzheimer's Month. It is a timely reminder to consider how we can better prepare Singapore to be a dementia-friendly society.

Singapore is ageing rapidly. In time to come, there will be more senior citizens and they will live longer, too. Currently, around one in six Singaporeans is aged 65 and older, with an average lifespan of 83.5 years. By 2030, around one in four citizens will be aged 65 and above.

The downside is that with more older people, there will also be more people afflicted with dementia. Amongst the seniors, one in 10 persons above age 60 has been diagnosed with dementia. The incidence rate will increase to one out of two for those above age 85.

At present, there are approximately 92,000 persons diagnosed with dementia and this number is projected to increase by 65% to 152,000 in the next eight years.

These staggering statistics represent a wake-up call. Is Singapore ready to cope with more people living with dementia? More importantly, can Singapore be a more dementia-friendly society as this disease becomes more prevalent in our rapidly-ageing society?

Dementia is a terminal illness because people living with dementia, or PLWDs in short, will not recover. Their condition will only deteriorate over time. In the advanced stage, most PLWDs would require extensive caregiving needs. Caregiving for PLWDs is challenging and may require 24/7 attention.

Very often, family members will have to give up their work and some may even suffer from burnout. There will be also implications for the caregivers' own financial security in old age and the productivity of our labour force will also take a hit. The economic impact to the families and society at large cannot be underestimated.

On this note, I would like to ask the Ministry if a comprehensive study on the social and economic impact of dementia on Singapore can be commissioned.

My mother is also a PLWD. Caregiving has, indeed, been very challenging. Fortunately, my family members have been able to rally together to support one another and we are fortunate to have access to help and support.

However, for many Singaporeans, they may have great difficulty coping with caregiving for a loved one afflicted with dementia. In fact, I have met several residents who are struggling to cope with caregiving. They shared that due to lack of social interaction during the pandemic, their loved ones who are afflicted with dementia have shown significant cognitive decline and deterioration of their motor skills.

In recent years, there have been concerted efforts to increase awareness and provide community support services to help families with PLWDs. I sincerely appreciate the efforts made by the Government and various community groups, voluntary welfare organisations (VWOs) and volunteers to assist PLWDs and their families.

Nonetheless, we are racing against time as there is a fast-closing window to get ready before the dementia emergency hits us. I urge the Government to expedite the implementation of dementia-focused policies and the building of more dementia-friendly infrastructure and community programmes.

As details regarding future measures for dementia was not quite covered in the recent Healthier SG White Paper, I would like to share my ideas in this Adjournment Motion. They are in three broad categories. I will start with building capacity which takes the longest lead time; then mitigation against challenges associated with dementia; and finally, prevention.

Many of the suggestions and feedback are collated from community partners whom I work with. I would like to thank Dementia Singapore, Agency for Integrated Care, National Volunteer and Philanthropy Centre, AWWA Singapore, Dementia and Co, and the Tsao Foundation, amongst others, for the impactful work that has been done to help PLWDs and their families.

I would also like to take this opportunity to express my appreciation and gratitude to the staff, volunteers and families who had shared their thoughts and suggestions with me. I hope to carry their voices in this House so that, as a society, Singapore can be better prepared for dementia.

Capacity projection for dementia care is a challenging task because the needs of PLWDs are wide-ranging and complex. There are different types of dementia and the health conditions for PLWDs at different stages of dementia can vary across a wide spectrum.

There is no one-size-fits-all solution. A range of care facilities are needed to provide comprehensive care for PLWDs and to support their caregivers. Capacity building can be broadly discussed in two categories, namely, medical facilities and expertise, as well as community facilities and programmes.

Over the years, the Government has been building up its capacity in the provision of primary care. By 2030, there will be 32 polyclinics island wide. I look forward to mental health and memory clinics being available in all polyclinics so that PLWDs can access these facilities quite conveniently.

I urge the Ministry to consider including dementia detection as an option for seniors undergoing regular health screening.

Early diagnostics and detection are critical to help patients slow down the progress of dementia. It is very important to catch this disease early because there is only a small window to intervene effectively through a beneficial combination of medication, exercise, brain stimulation and socialisation.

In terms of trained medical personnel, I also hope that MOH has been increasing the number of geriatricians and psychologists. I would like to know what is the projected ratio of geriatricians versus senior citizens by 2030. How will MOH build up this pipeline of medical specialists over the next eight years?

Ageing-in-place is the preferred way for PLWDs to live. Familiarity with the living environment will help them cope better as their memory fades. However, for families that are unable to provide caregiving or for PLWDs who do not have loved ones to care for them, admission into nursing homes then becomes inevitable.

In the community, the number of places in dementia day care centres, senior care centres and nursing homes have been increasing. However, I am concerned that the rate of increase may not keep up with the needs of the growing number of PLWDs.

I understand that the current waiting time for nursing homes is nine months to a year. While I am heartened to note that in the next 10 years, our nursing home bed capacity will go up by close to another 100% to more than 31,000 beds, I am worried if this is even enough, especially for elderly with issues like dementia.

I hope the Minister would share the progress on the infrastructure build-up plans and strategies to recruit staff and train them. Also, how will we ramp up our caregiver support and training? Would the Ministry elaborate on how these options will be financed, Government subsidies available and the estimated range that a family is expected to pay?

Other than nursing homes, having a range of care and accommodation options is key to support families who are struggling with family members with dementia. While some PLWDs may need 24/7 full-time care, some others will actually be able to manage a range of independent living with varying levels of support or supervision.

Hence, it is important to provide alternative models of care in the community for PLWDs, other than nursing homes and senior day care centres, such as the Wellness Kampung community facilities, where they can participate in social activities while their caregivers get some respite.

As our nation enters into an ageing demographic phase, it is crucial to review the design of our estates. Our estates will have to be more dementia-friendly. I would like to ask the Government to expedite the building of such community infrastructure, such as in new HDB estates and the Neighbourhood Renewal Programme, for existing estates to be dementia-friendly.

I would encourage fellow Members of Parliament and their Town Councils to consider adopting dementia-friendly designs for their repainting works. Distinctive colours and landmarks can be created to help PLWDs to better recognise their surroundings in case they lose their bearings and are unable to find their way home.

Another idea is to proliferate assisted living arrangements which allow seniors to remain independent and socially connected. This would also address the issue of many elderly living alone after their children get married and move out. One such example is Red Crown social enterprise, which arranges for several seniors to live together, provide companionship and help to take care of one another.

Some degree of Government involvement and grants can help to scale up this nascent industry and to ensure that operators meet minimum service standards.

VWOs play a key role to assist PLWDs and their caregivers. They have well-trained social workers and volunteers to engage PLWDs in social activities that will slow down their decline and calm their moods. They also assist caregivers with counselling services so that they can manage their stress better and deal with burnout.

Unfortunately, many families with PLWDs are not even aware of the services provided by these VWOs. Hence, the community network plays an important role to connect the VWOs with residents who may need assistance.

I would like to share that in Sembawang West constituency, we started a Dementia Caregivers Support Network to help residents access the services provided by the VWOs. The caregivers can also give each other mutual support and share their experiences and useful tips on caregiving.

However, many of such VWOs are only partially funded by the Government and will need to raise their own funds, competing with other VWOs for the charity dollar. After all, funds are required for these VWOs to scale up their services and do outreach so that more PLWDs and families can benefit.

I hope that MOH can review the funding model for such VWOs supporting dementia-friendly programmes so that they can focus their energies and resources on their programmes and services instead of on organising fund-raising activities.

Mr Speaker, the second thrust is to mitigate the challenges faced by PLWDs, especially for those in the early and moderate stages, for them to live more independently. To this end, a robust policy framework and adequate social infrastructure and services are essential for PLWDs to carry on with the basic functions to work, live and travel.

To protect the interests of PLWDs, we need to increase awareness of Lasting Power of Attorney (LPA), Advance Care Planning (ACP) and Advance Medical Directive (AMD). I urge the Ministry to consider increasing the visibility of LPAs, ACPs and AMDs at GPs, polyclinics as well as public and private hospitals.

People should be more aware of the role of social workers and professional donees registered with the Office of the Public Guardian and agencies, such as the Special Needs Trust Company, a non-profit agency which helps vulnerable people set up care plans using their insurance or assets.

To create more awareness, we need more talks and seminars at the community level as well as coverage on our free-to-air TV channels and Government social media on dementia and what to do in preparation. For instance, the media coverage on several high-profile cases related to vulnerable PLWDs being swindled by ill-intended relatives or friends had actually spurred people to set up LPAs and wills.

Beyond the Government and local communities, I would also like to suggest more involvement of the private sector. The public sector can collaborate with private entities to sponsor programmes within their companies and in the community to be dementia-friendly. Our transportation system, airport, malls and public building owners can incorporate features to make their spaces and customer interactions more dementia-friendly. For instance, SMRT is taking the lead to provide 98 of its train stations across Singapore with Go-To-Points by the end of 2022. These Go-To-Points will allow disoriented customers or commuters to calm down and wait in a comfortable space for their family members to bring them home safely.

Similarly, service providers, particularly banks, need to consider how they can better serve these customers while protecting their interests. It would be ideal if businesses can initiate these improvements. Notwithstanding, I hope the Government would consider expediting these changes with guidelines and, if necessary, legislation for specific sectors.

To promote inclusiveness, I would like to request more support for people with young onset dementia, or YOD. How can YODs remain employed for as long as possible? How can employers be incentivised to redesign job roles, offer micro jobs and shape a more dementia-friendly work environment? Also, how can employers be more understanding and supportive towards employed caregivers who are supporting loved ones at home with dementia?

I hope a more compassionate and inclusive workplace culture would develop over time, especially as retirement age is progressively extended to 70.

Mr Speaker, the age-old saying "prevention is better than cure" rings so true. In recent years, dementia has become more prevalent in Singapore. It leads me to wonder – does Singapore have a higher proportion of people with dementia, compared to other developed countries?

I am heartened to note the launch of the Lee Kong Chian School of Medicine Dementia Research Centre in April 2022. The centre will conduct research to understand more about this disease.

Evidence from various international studies shows that dementia can actually be prevented or delayed through the adoption of healthy lifestyle habits, including having regular physical activities, maintaining a balanced diet, not having excessive alcohol intake and not smoking. A recent study published in the International Journal of Epidemiology suggests that obesity may be associated with an increased risk for developing dementia.

While all of the above preventive actions are individual choices, the outcomes will have a profound impact on our families, our community and our nation. Thus, we must all make a greater concerted effort to help one another make good choices for our health and to persist in them.

In addition to the initiatives in Healthier SG, the Government should consider investing more resources into public education and campaigns and to redesign policies and systems to nudge our people to take greater responsibility for their own health and self-care. It will save individuals and the healthcare system a whole lot of money from medical bills and expenses in the future.

For example, our hawker centres and food courts are still serving mostly high carbs, meaty dishes with little vegetables. We will need to have more healthy choices for our national canteens and encourage people to consume more greens on top of less sugar, less salt and less oil.

It has also been found in a recent Harvard Medical School study that the lack of sleep in middle-age persons may increase dementia risk. Many of us, including my Parliamentary colleagues, sacrifice sleep to get more work done or to complete other tasks. One tell-tale sign of sleep deprivation is when Members occasionally nod off involuntarily in this Chamber. Let us set a good example and get at least six to eight hours of sleep daily.

Mr Speaker, dementia can happen to any one of us and our families will be adversely affected. As a nation, we need to recognise dementia is a fast-growing issue. In the next decade, a lot more work needs to be done to increase our capacity, to mitigate the challenges associated with dementia and to take preventive lifestyle changes.

While MOH expedites capacity building, we can all do our part to spread awareness about dementia, to improve our community facilities and programmes and also to take better care of ourselves while we are still young. Let us not burden our future generations with the challenges of caregiving.

Most importantly, let us work towards a more compassionate, caring and inclusive society to help people living with dementia live with meaning and dignity. [Applause.]

Mr Speaker: Ms Rahayu Mahzam.

3.35 pm

The Senior Parliamentary Secretary to the Minister for Health (Ms Rahayu Mahzam): Mr Speaker, I thank Ms Poh Li San for her suggestions to prepare Singapore for dementia. This is an important topic, given our ageing population and the rising number of persons with dementia.

MOH adopts a three-pronged approach to address dementia: first, strengthening prevention and early detection; second, building capacity of care services; and third, enhancing support for caregivers.

Beyond healthcare, I will also share how MOH has collaborated with different agencies, community groups and businesses to build more caring and dementia-inclusive communities.

Adopting a healthy lifestyle can reduce the risk of dementia. A 2020 report by the Lancet Commission estimated that 40% of dementia cases can be prevented or delayed by addressing 12 modifiable risk factors, including diabetes, obesity and hearing loss.

Through Healthier SG, we will empower our population to improve their health, such as through regular exercise and healthy eating. In addition, programmes like functional screening also allow us to identify seniors with hearing impairment and fit them with hearing aids. This enables seniors to maintain social engagement with others which helps to lower the risk of dementia.

Health Promotion Board (HPB) and Agency for Integrated Care (AIC) conduct campaigns and provide resources through portals like HealthHub and DementiaHub.SG to educate the public on common risk factors and signs of dementia. Through education, we hope to destigmatise dementia and encourage early help-seeking.

Early detection of dementia is important so that individuals receive timely treatment. Nevertheless, there is no clear evidence internationally that general dementia screening in persons without recognised signs or symptoms of cognitive impairment is an effective public health intervention. Hence, our current efforts in early detection continue to be targeted at those at risk.

Within the community, we have outreach teams known as CREST that proactively identify seniors at risk of dementia and refer them for assessment. As of December 2021, we have 68 CREST Teams. They have reached out to over 510,000 participants through outreach events and provided assistance to more than 32,000 persons.

Active ageing centres (AACs), polyclinics and trained general practitioners (GPs) also help to identify seniors with suspected dementia and refer them for assessment.

These cases will be referred to memory clinics in polyclinics and hospitals to confirm the diagnosis and cause of dementia. More than half of our polyclinics currently provide these services and we are in discussions to bring more polyclinics on board.

Various care services support persons at different stages of dementia.

The majority of dementia cases have mild to moderate needs and can be supported in the community. Dementia Day Care (DDC) services provide custodial care, cognitive stimulating activities and reminiscence therapy to improve or maintain the seniors' well-being. We have more than tripled the capacity of DDCs from 1,000 places in 2015 to 4,200 places in 2021.

We also have Community Intervention Teams (COMIT) that provide psychosocial interventions like counselling and case management. In FY2021, COMIT teams supported a total of 11,100 clients.

A small group of dementia cases may require inpatient care as their condition deteriorates. The majority of nursing homes can care for persons with dementia. From end-2015, we have added 4,000 nursing home beds to reach a total of over 16,000 beds in end-2020. Upcoming nursing homes developed by MOH are also built with dementia-friendly provisions like therapeutic gardens and closed-loop wandering paths.

The Member stated that the current wait time for a nursing home bed is nine months to a year. To clarify, the median wait time is currently around one month, although this may take longer for some seniors who have specialised care needs or specific preferences.

The Member asked about our pipeline of clinical manpower. Today, all doctors are trained to provide basic management of dementia conditions. Specialists like geriatricians and psychiatrists are equipped to manage more severe conditions associated with dementia. As at December 2021, there are 152 geriatricians and 277 psychiatrists registered with the Singapore Medical Council (SMC). This represents a 50% and 15% increase respectively from 2017. This translates to 2.8 geriatricians and 5.1 psychiatrists per 100,000 population.

There is no international consensus on the optimal ratio of geriatricians and psychiatrists to population.

MOH has also been increasing the number of residency training positions for geriatric medicine and psychiatrists. We will continue to review and adjust the pipeline of medical specialists to support ageing population needs.

We provide multiple layers of financial support to ensure that long-term care costs remain affordable.

Firstly, we provide means-tested subsidies of up to 80% for services like DDC.

Secondly, if dementia has impacted an individual's ability to perform activities of daily living, grants like Pioneer Generation Disability Assistance Scheme and CareShield Life insurance payouts would further help to defray the cost of care.

Lastly, MediFund will provide support for those who need further help.

As announced earlier this year, we will also enhance the Home Caregiving Grant to defray caregiving costs.

Social Services Agencies (SSAs) play a key role in providing long-term care services and support for caregivers. Besides direct funding for programmes and services, the Government also provides dollar-for-dollar matching grants for donations to SSAs through the Community Silver Trust.

Caregiving is an important responsibility. The Member asked about support for: (a) caregivers of newly-diagnosed individuals; (b) caregiver training; and (c) working caregivers. Let me address these questions.

Upon diagnosis, the caregiver may not fully understand the condition or know where to seek help. We have, therefore, started the CREST-Post Diagnostic Support (PDS) pilot to proactively reach out to families upon diagnosis, link them up with resources and equip caregivers with coping strategies. As of December 2021, there are two CREST-PDS teams and we plan to expand the number in 2023.

The Caregivers Training Grant (CTG) provides a $200 annual subsidy for attending courses, including on dementia care, where caregivers can learn to better manage their own stress and well-being. We will continue to review how to better support caregiver training.

For working caregivers, MOM has worked with the tripartite partners to encourage the adoption of flexible work arrangements (FWAs). Today, a vast majority of employees have access to FWAs. A new set of Tripartite Guidelines on FWAs will be further introduced by 2024 that will require employers to put in place a proper process to fairly consider and respond to employees' request for FWAs.

Caregivers can also tap on various community care options for their loved ones. These include DDCs and the Night Respite Care pilot for those experiencing sun-downing.

As the Member pointed out, persons with dementia face complex challenges, such as safety and mental capacity. We must take a whole-of-society approach to address these issues.

In 2016, AIC launched the Dementia-Friendly Singapore (DFSG) initiative to establish more dementia-friendly communities (DFCs).

Within a DFC, networks are created where residents, businesses and grassroots leaders are trained to look out for persons with dementia. Go-to-Points (GTPs) are also created to serve as "safe return" points for those who might be lost. The initiative was well-received and we have since established 15 DFCs across Singapore.

AIC will be launching a dementia campaign next month to rally more community and corporate partners to join us in making Singapore more dementia-friendly. We will expand our efforts to five sectors that regularly serve seniors, namely: transport, building, arts and leisure, banking and retail.

The Member highlighted our collaboration with SMRT. Besides transport, venues for the arts have also started catering programmes for persons with dementia. In 2016, Esplanade launched the "Sing Out Loud!" programme to help persons with dementia deepen engagements with their caregivers through singing. Last year, Esplanade also became the first arts venue to become a dementia Go-To-Point (GTP) and their staff also received basic training to assist visitors with dementia.

Creating a dementia-friendly physical environment is important for persons with dementia to move around safely and participate in social activities.

For instance, Nee Soon Town Council worked with stakeholders to paint HDB blocks with large block numbers and contrasting colours to help residents with wayfinding.

AIC is also working with Centre of Liveable Cities (CLC) and Singapore University of Technology and Design (SUTD) to study dementia-friendly neighbourhoods. The learnings gathered will be developed into a set of design guidelines to make the built environment safer and easier to navigate.

HDB will continue to explore incorporating such dementia-friendly features into new developments and in existing estates through upgrading programmes.

The Member also asked about micro-jobs for persons with dementia.

MOH and MOM will work with tripartite partners like Singapore National Employers Federation (SNEF) and NTUC to enhance the understanding of dementia at the workplace through educational materials and encourage employers to hire such persons where they are able to meet the operational needs of businesses.

Persons with dementia may find it increasingly difficult to make decisions independently. Seniors with mild dementia or even those who are well should plan ahead when they still have mental capacity, to give themselves and their loved ones peace of mind.

MOH, MSF and PSD are working to increase awareness and adoption of instruments, such as the Lasting Power of Attorney (LPA) and Advance Care Planning (ACP).

We launched the My Legacy portal in 2020 to raise awareness on planning ahead and serve as a one-stop portal for end-of-life related matters. It contains an LPA-ACP tool which allows users to make both documents at one go. This complements communications and engagement efforts, such as the annual ACP week campaign led by AIC, and involving our health and community care partners.

Planning for dementia is a continuous effort. We have made good progress and will continue to study further strategies to enhance dementia care. Let us work together to build a dementia-inclusive Singapore and support persons with dementia to lead purposeful and dignified lives.

Mr Speaker: Exactly on time.

Question put, and agreed to.

Resolved, "That Parliament do now adjourn."

Adjourned accordingly at 3.45 pm.