Thank you for inviting me to speak on behalf of the Canadian Geriatrics Society.
When I was putting this together, I had to think long and hard about the focus I should take. I think the most important thing for the society is for us to bring forward the critical diseases that need to be included in any study of aging and any study of chronic disease.
The most important disease, from a geriatric perspective, is one that's often not considered a chronic disease. It's dementia. Dementia in many forms is considered the grandfather or the godfather of chronic disease. It's one that has the largest impact on health care and the largest impact on alternative level of care, and yet it's often marginalized. It's not found in our health care plans. I know that almost none of our regional health authorities in Ontario have included dementia care as part of their plans. It has a huge impact, but it seems to be peripheralized very often.
How common are Alzheimer's and related dementias? I would invite you to look at the Rising Tide: The Impact of Dementia on Canadian Society document at the Alzheimer Society of Canada website. It shows that we now have about half a million people in this country with dementia. That really underestimates the impact on Canadian society, because each of those persons with dementia has a caregiver or may have two or three caregivers, all of whom are at risk of anxiety disorders, depression, or caregiver burnout. So in fact if we look at how many people are impacted by dementia, it's probably one million to two million Canadians. The numbers are really huge, and there are about 100,000 new diagnoses every year, or one every five minutes.
It's highly prevalent. It's also very expensive. You can look at the cost breakdown. Right now it's costing us about $15 billion, and that's rising quickly. Once again, I would invite you to look at the Rising Tide report to see the methodology of that economic analysis, but the scale of the numbers is probably very correct.
So it's a prevalent disease, and it's an expensive disease. How does that make it any different from heart failure, from COPD, or from diabetes? There are two distinct differences with dementia. One is what we call the dementia domino effect. Many people can go along quite well managing their heart failure, their chronic lung disease, or their diabetes until they develop cognitive issues. Once dementia starts to be weaved into the mix, you start seeing loss of control of their heart failure, their COPD, or their diabetes. It spins out of control very quickly, they end up in hospital, they're stabilized, they're discharged, and they end up back in hospital. They go through a cycle with the health care professionals not really recognizing the underlying foundational problem that has caused destabilization. Many people have referred to having two or three chronic diseases at the same time. Certainly hospitals struggle with that. But once you mix dementia into the equation, hospitals really fall down and they really have great difficulty in managing dementia. That's been my clinical experience over 20 years and the clinical experience of dozens and dozens of geriatricians.
Does the data really support that? We do have a report from CIHI, the Canadian Institute for Health Information, and I've included two key pages from the CIHI report. If you want the full report, I do have some copies in French and English with me.
CIHI says that the main diagnosis driving alternate level of care, or ALC, rates in Canada is dementia. Diagnosed dementia is related to one-third, or 33%, of cases of ALC. I think that's a huge underestimate, because working in the hospital, many—if not most—cases of dementia are unrecognized. So if you really did a study and drilled down and asked how many people who are listed as requiring alternate level of care truly have dementia, I would not be surprised to see 50% or 60%. It's really the driving diagnosis for the destabilization of multiple chronic diseases and for our ALC crisis.
So any study of chronic diseases and aging that goes forward really, in our opinion, has to include dementia as a central component.
What opportunities are there? I'll throw out a few. I've talked to a few colleagues and we've discussed this at the Canadian Geriatrics Society. Certainly down the road we should look at models in other countries where they have dementia networks. We do have dementia networks in Canada; they're voluntary networks. People like me pay to be part of it. We support it with our own money. We should think about making those networks formalized and accountable to the Canadian public so they can organize dementia care and so they can link with other chronic diseases. As I said, it's that interplay between diseases.
Surprisingly, I presented to our department of endocrinology, and none of the diabetes specialists were aware that diabetes is a risk factor for dementia, and one of the first signs of dementia is inability to use your insulin. They didn't realize there was that interplay. And we've heard that before, that the specialties are not communicating, are not integrated. So any study of chronic disease really has to look at that integration of different chronic diseases.
As far as other things we can look at, national dementia strategies have been applied in other countries, and I'd certainly look at those models. Dementia should be included in any study that goes forward. That's message one.
I have a second message, and it has been brought forward already. We really have to take a long, hard look at community care. When you look at the cause of the hospital crises--the bed gridlock, the ALC crisis--the main cause is not what's happening in hospital. Hospitals and long-term-care institutions bear some of the responsibility, but we have a community care system that is not integrated and does not communicate. It is not strong enough to keep people out of the hospital, so it overflows into the acute care system. The acute care system, our most expensive site of care, becomes the default setting for all of these care issues, and it is not set up to deal with multiple chronic conditions or dementia. There are very few specialists in dementia working in the acute care system. If we want to fix the system and study chronic care, we have to look at how the system interacts with chronic disease.
Another issue is long-term care. There are problems in long-term care, but once again they are related to community care. Some studies out there indicate that 20% to 30% of people do not need to be in long-term care. I have some issue with the methodology of those studies. I have formal research training, and some of the methodology can be challenged. But when I talk to directors of long-term care they say that 20% to 25% of people probably don't need to be there any more. They had an illness that required prolonged recovery and they recovered and became better. They'd already sold their house and had nowhere to go, so the nursing home was their new home.
Other people enter long-term care or nursing homes because they cannot afford residences. Essentially, we're punishing low-income seniors by forcing them to go into long-term-care institutions prematurely, instead of finding alternate sites where they can live. In essence, for these people with chronic diseases who require care, we need subsidized residences rather than long-term care or nursing homes.
This does not just penalize low-income seniors; we are all paying the price. They are living in long-term-care beds or nursing home beds that are desperately required by acute care hospitals. This is one of the reasons we have a backup of patient flow going to long-term care, ALC crises, hospital bed gridlock, and emergency departments that are full. We have people in long-term care who do not need to be there. If as a society we gave them proper care, they would be in subsidized residences and we would not have to build as many nursing homes as people say we need. We need to build more, but not as many.
What can we do in the community? This is getting into your expertise, not mine. I'm a simple doctor--even worse, I'm a teaching doctor--but you guys can take it or leave it.