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Malta

National Dementia Strategies (diagnosis, treatment and research)

Background information about the National Dementia Strategy

Status and historical development of the National Dementia Strategy

The development of a National Dementia Strategy started with the setting up of the Malta Dementia Strategy Group in May 2009 (please see below). This resulted in a report comprising ten recommendations following consultation with healthcare experts and various stakeholders organised by the Malta Dementia Strategy Group. Stakeholders came from five groups, namely education, professional bodies, long-term care service providers, acute and intermediate service providers and the community. The community consisted of the Maltese Dementia Society, the general public, representatives from the Catholic Church and local council representatives. Following the consultation with stakeholders, the general public were invited to provide further feedback by means of a widely publicised questionnaire which could be filled in anonymously and was available on Internet or by post. 613 completed questionnaires were received and analysed. For details of the findings, please see Scerri (2012).

The Malta Dementia Strategy Plan is in its final stages of completion and its publication falls within the remit of the Malta Ministry of Health, the Elderly and Community Care. It is intended to include measures aimed at improving the quality of life of individuals with dementia, their caregivers and relatives. These measures are expected to be implemented between the years 2012 and 2020.

Involvement of the Alzheimer association (and/or people with dementia)

The Malta Dementia Society has been involved from the very begining. Members of the Malta Dementia Society Management Committee formed the core of the Malta Dementia Strategy Group of experts entrusted to devise a series of recommendations that would provide a comprehensive strategic framework that would lay the ground for the final plan. Indeed, the General Secretary of the Malta Dementia Society acted as Chairperson for the Strategy Group. The document containing the recommendations as well as ways with which these could be achieved was presented to the central health authorities in January of 2010.

Diagnosis, treatment and research

Issues relating to diagnosis

Timely diagnosis in the planned National Dementia Strategy

In Malta, the majority of individuals with dementia are not diagnosed early on in the disease process. This is mainly because there is not enough awareness of the early symptoms that characterise the condition both among the general public as well as healthcare professionals. Most of these individuals are cared at home leading to significant caregiver burnout (Innes et al., 2011). The inaccurate notion that dementia symptoms are part of normal ageing is still prelevant and this leads to a delay in seeking medical advice. The Dementia Plan envisages the need for timely diagnosis and support. This can be achieved by increasing awareness about the condition at all levels, drawing up a referral pathway and adequate protocols for diagnosis, increasing the number of dementia specialists and providing support to patients and caregivers following diagnosis.

The Dementia Society of Malta advocates that every individual with suspected dementia should have the opportunity of timely diagnosis through the utilisation of specialised services such as those offered by the Memory Clinic and upon diagnosis to have a long-term care plan drawn up.

Which healthcare professionals are responsible for diagnosing dementia

All medical professionals in Malta have the authority to diagnose dementia. Dementia can therefore be diagnosed by a GP or a specialist. However, GPs’ consultation times, in most cases, are brief and usually do not exceed ten minutes. GPs’ times are not fixed by appointment and depend on GPs’ discretion. Specialists usually have longer appointment times but charge significantly higher fees compared to GPs.

The duration of each appointment is not fixed but is solely at GPs’ discretion.

Currently there are no incentives that improve timely diagnosis.

Type and degree of training of GPs in dementia

GPs do not receive a great deal of training on dementia during their medical studies (i.e. more than 10 hours during their undergraduate training).

Currently, professional undergraduate training on dementia does not exceed ten hours in total during the 5-year medical course. In the past, it used to be much less. Specialised training programmes in family medicine include a 2-month part-time post in geriatrics where GP trainees have the opportunity to experience ageing and dementia on a ‘hands-on’ basis. Training mostly focuses on the medical model.

There is no obligation for continuing education. However, seminars and talks on subjects of interest are organised by local associations of family doctors usually in collaboration with the pharmaceutical industry. Attendance at these gatherings is usually rewarded by CPD (continuing professional development) points. Dedicated websites are also available (http://mcfd.org.mt, http://www.thesynapse.net).

Required tests to diagnose dementia

There are no official guidelines yet concerning tests which must be used in order to diagnose dementia and/or Alzheimer’s disease. Diagnostic tools are therefore at the GP’s discretion although the MMSE is perhaps the most popular. The National Plan envisages the setting up and adoption of a protocol for diagnosis to be used in governmental-run healthcare settings.  

Issues related to medical treatment

Medical treatment in the planned National Dementia Strategy

In the recent past, Malta was one of two countries in the European Union that did not provide any sort of financial assistance for AD medication. Indeed, this was one of the ten recommendations that were included in the document drawn up by the Malta Dementia Strategy Group and presented to the authorities in January 2010. Such recommendation is also included in the final Plan. Although the latter has not yet been published, the central health authorities felt that such situation needed to be rectified. As a result, in March of 2012, dementia was included in Schedule V of the Malta Social Security Act which lists a number of chronic conditions to which free medication should be available by the goverment health services (https://ehealth.gov.mt/download.aspx?id=6853)

The National Plan recommends that free entitlement to AD medication only occurs following diagnosis by specialists in governmental-run healthcare settings. GPs would still be able to prescribe them but it would be an out-of-pocket expense for patients. This was done to ensure that diagnosis is conducted by specialists rather than GPs who, in most cases, do not have the necessary training in diagnosing dementia

The availability of medicines in general

The government supplies medicines free of charge to all in-patients in government hospitals and for three days following discharge. Otherwise they are supplied on a means tested basis. There are two schedules under the Social Security Act Cap. 318 to grant free medicines:

Schedule II (referred to as the Pink Card), entitles households with low total income (means tested) to medicines listed in the Government Formulary, subject to completion of certain requirements (e.g. hospital consultant's signature in the case of certain medicines). A Pink Card can also be issued for people with tuberculosis, leprosy or poliomyelitis and their after effects. People with diabetes can also benefit from this schedule.

Schedule V (referred to as the Yellow Card), entitles people with diseases listed under the fifth schedule of the Social Security Act for free medicines for that condition irrespective of financial position. These include many chronic diseases such as malignancy, chronic cardiovascular and respiratory disease, collagen disease, endocrine diseases, schizophrenia and others. The list has recently (February 2012) been updated and includes dementia .

For more information on medicines entitlement in Malta refer to: https://ehealth.gov.mt/HealthPortal/strategy_policy/pharm_pol_mon/med_entitle_unit/schedule_v.aspx

The availability of Alzheimer treatments

All four AD drugs are available in Malta and can be purchased through out-of-pocket payments. Dementia has recently been included in the Schedule V list and AD drugs should be available free of charge after being included in the national formulary. However, a drug protocol would have to be drawn up first which stipulates which patients are entitled to the drugs, based on the level of cognitive impairment, the type of dementia etc. Consequently, inclusion in the Schedule V does not necessarily mean that the drugs are provided for free immediately.

Free treatment is expected to continue following approval by the specialist. The latter will also be responsible for discontinuation of treatment.

Conditions surrounding the prescription and reimbursement of AD drugs

Prescriptions can be made both by specialists and family doctors. Assessment and diagnostic tools vary but most healthcare professionals make use of the MMSE. MMSE limits have not yet been determined but should be indicated in the planned drug protocol.

An MRI scan is not obligatory although most individuals suspecting dementia and attending the Memory Clinic are usually prescribed imaging, depending on the situation.

There are no restrictions on the prescription of AD drugs to people who live alone or are in residential care.  

Prescription and reimbursement

Donepezil

Rivastigmine

Galantamine

Memantine

Available

Yes

Yes

Yes

Yes

Reimbursed (expected to be free in the near future)

(No)

(No)

(No)

(No)

Initial drug reimbursed if prescribed by

No restrictions on prescription but not

refunded

No restrictions on prescription but not refunded

No restrictions on prescription but not refunded

No restrictions on prescription but not refunded

Continuing treatment reimbursed if prescribed

No restrictions on prescription but not

refunded

No restrictions on prescription but not refunded

No restrictions on prescription but not refunded

No restrictions on prescription but not refunded

Required examinations

 

MMSE is the preferred tool

MMSE is the preferred tool

MMSE is the preferred tool

MMSE is the preferred tool

MMSE limits.

 

Not yet

determined

Not yet

determined

Not yet

determined

Not yet

determined

Issues relating to research

Dementia research in Malta is mostly conducted on a personal level. Researchers in this particular field of study are few and financial resources limited. Most of the published research comes form the University of Malta, the only tertiary education establishment in the Maltese islands. There is international collaboration in several areas of dementia research spanning molecular and cellular aspects of the disease process as well as its impact on the Maltese society. The forthcoming Dementia Plan envisages the need for training and research in dementia also in view of the fact that the number of elderly individuals is expected to rise significantly in the coming years.

Malta is not involved in the EU Joint Programme – Neurodegenerative Disease Research (JPND) but is a Collaborator in the Joint Action “Alzheimer Cooperative Valuation in Europe (ALCOVE)”.

References

Innes A, Abela S and Scerri C. (2011). The organisation of dementia care by families in Malta: The experiences of family caregivers.Dementia10(2): 165-184.

Scerri C. (2012). Challenges of developing a dementia strategy: the case of Malta. In: A. Innes, F. Kelly and L. McCabe,Key issues in Evolving Dementia Care: International Theory-based Policy and Practice. London: Jessica Kingsley, pp. 150-172. ISBN 978-0-470-19510-9.

Acknowledgements

Charles Scerri, General Secretary of the Malta Dementia Society and Senior Lecturer at the Faculty of Medicine & Surgery, University of Malta.

 

 
 

Last Updated: Tuesday 14 May 2013

 

 
  • Acknowledgements

    The above information was published in the 2012 Dementia in Europe Yearbook as part of Alzheimer Europe's 2012 Work Plan which received funding from the European Union in the framework of the Health Programme. Alzheimer Europe gratefully acknowledges the support it has received from the Alzheimer Europe Foundation for the preparation and publication of its 2012 Yearbook.
  • European Union
 
 

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