IPA Bulletin
Around the World

A Comparative Study of Some Aspects of Dementia Services in Korea and the United Kingdom

BY DR. AJIT SHAH (United Kingdom); DR. NALINI ELANCHENNY  (United Kingdom); AND DR. GUK-HEE SUH (Korea)

Introduction 
The proportion of the elderly in the general population in developed and developing countries is increasing. A particular rise in those over 80 years has been forecast in developed countries like the United Kingdom (UK) and developing countries like Korea. The prevalence of dementia doubles every 5.1 years increase in age, after the age of 60. This implies that there will be an increase in the absolute number of dementia sufferers in both the UK and Korea. There have been very few comparative studies of psychogeriatric services across different countries (Reifler, 1997; Shah and Abelskov, 2003; Bramesfeld, 2003). One study was simply a descriptive comparison of the author’s personal views on psychogeriatric services in the UK, Ireland and United States (Reifler, 1997). Another study was a mailed survey of psychogeriatric services of the IPA membership (Shah and Abelskov, 2003). This study had a poor response rate and there were only 20 respondents from 10 different countries; only one developing country was represented. It was not possible to draw any firm conclusions from it. Another study, using published literature and an interview with an expert in geriatric psychiatry, compared various aspects of service provision for depression in six European countries (Bramesfeld, 2003). A recent comparative cross-national study of behavioral and psychological signs and symptoms of dementia (BPSD) between Korea and the UK (Shah et al., 2003) allowed a comparison between  these two countries for some aspects of services for dementia.

Method
The detailed methodology has been described elsewhere (Shah et al., 2003) and only the relevant components are described here. 

1. Sample A consecutive series of referrals with a diagnosis of dementia to a psychogeriatric service in the UK and Korea were studied. Any referred patients fulfilling the broad DSM-IV diagnosis of dementia were included. The psychogeriatric service in the UK was based in a west London hospital serving a well-defined geographical catchment area population of 10,000 elderly (those over the age of 65 years). This UK service was comprised of a well-established, community-oriented, multi-disciplinary team with an emphasis on assessments in the patients’ homes. The team had access to a range of health resources including community follow-up, outpatient clinics, day hospitals, and acute admission, rehabilitation, respite and long-term inpatient beds. It also had access to a range of social service resources including home care, home help, meals on wheels, day centers, and residential and nursing homes. The availability of health service resources is free at the point of delivery in the UK, although social services help is subject to “means testing.” 

The Korean psychogeriatric service was located in a dementia clinic of the Hangang Sacred Heart Hospital in Seoul. This service received referrals from sources nationwide (including general practitioners, general psychiatrists, social workers, patients and relatives) and was hospital-based with junior and senior psychiatrists, nurses and a social worker. Although the Korean service had access to nursing homes, their availability was limited. Also, unlike the UK, not every Korean is registered with a general practitioner. In Korea payment is required on a “fee for service” basis. 

2. Data collection Detailed information on the source of referral, reasons for referral given by the referrer, medication being received at the time of the referral and demographic factors was collected on a structured and standardized pro forma (available from the authors). For the BPSD aspect of the study, all subjects were rated on the BEHAVE-AD, the Cornell Depression Scale and the Mini Mental State Examination (Shah et al., 2003). The English versions of these scales were used in the UK and appropriately translated versions were used in Korea. 

Results 
Results pertaining to BPSD are being published elsewhere (Shah et al., 2003) and only data pertinent to delivery of service will be described here. 

1. Sample.
In Korea, a total of 122 consecutive referrals were included with no subjects being excluded. In the UK, a total of 105 consecutive referrals were considered for study, but only 80 (79%) subjects were included. The reasons for exclusion of 25 subjects are provided in the BPSD report (Shah et al., 2003). 

2. The demographic and clinical characteristics of both samples. 
The median age for the Korean and the UK sample was 78 (52-102 years) and 82 (67-95 years) respectively. The proportion of men in the Korean and the UK sample was 21% and 43% respectively. Half of the Korean subjects were married and half were widowed; in the UK sample, 30% were married, 43% were widowed and 19% were single. The median (range) number of people living in the Korean household was two (1-8) compared to two (1-6) in the UK household. All Korean subjects lived in their own home compared to only 71% of UK subjects. The remainder of UK subjects lived in sheltered facilities where subjects have their own flat with access to a warden either on the telephone or in person (13%), and residential or nursing homes (10%).

 As described in our report on BPSD (Shah et al., 2003), Koreans were younger (P=0.006), had more women (P<0.0001), were more likely to be married (P=0.01), less likely to be single (P<0.0001), more likely to live in their own homes (P<0.0001) and have a greater number of people in the household (P<0.0001). The proportion of patients with Alzheimer’s disease, vascular dementia, and other dementias in the UK sample was 45%, 43% and 13% respectively; corresponding figures for the Korean sample were 76%, 24% and 0.

Korean subjects were more likely to have Alzheimer’s disease (P<0.0001) and the UK subjects were more likely to have vascular dementia (P=0.0079). The MMSE score was significantly lower in the Korean sample (P<0.0001). The total BEHAVE-AD score (P<0.0001) was significantly higher in the Korean sample. The Cornell scale scores were not significantly different between the two countries.

3. Referral characteristics
The source of the referral, reasons for referral and medication being prescribed at the time of the referral are illustrated in Table 1. UK subjects were more likely to be referred by their general practitioner (P<0.0001). Korean subjects were more likely to be referred by general psychiatrists (P=0.0008) and family members (P<0.0001). Korean subjects were more likely to be referred for advice on diagnosis (P<0.0001) and medication (P<0.0001) and less likely to be referred for advice on availability of services (P<0.0001) and social services (P<0.0001). There were no significant differences between the two countries for other reasons for referral listed in Table 1. In the Korean sample there was no relationship between the referral source and BEHAVEAD scores, Cornell Scale and MMSE scores. Such analyses were not possible in the UK sample as almost everyone was referred by their general practitioner. 

Discussion
This is one of the few comparative studies of some aspects of service delivery for dementia across countries, and the first between UK and Korea. The demographic differences between the two samples appear simply to reflect population demographic differences between the two countries. The less well-developed psychogeriatric services in Korea may explain the greater number of referrals from general psychiatrists, who may initially assess elderly patients with dementia and subsequently refer to the more specialist psychogeriatric service. Furthermore, there is a paucity of psychogeriatricians in Korea compared to the UK.

 The referral sources were different between the two countries and this is explained by differing models of service delivery. The specific UK service in this study had developed a model whereupon referrals were only accepted from other doctors including general practitioners, psychiatrists and hospital doctors. This is usually referred to as a “closed” model of referral. It has been argued that such a model allows general practitioners to filter referrals which may be more appropriate for other specialities (for example patients with delirium can be referred to geriatricians) or those they can deal with. Such a model is feasible if all elderly are registered with a general practitioner and have ready access to a general practitioner–as is the case in the UK. Thus, it is not surprising that the majority of referrals in the UK service were from general practitioners. The UK service was well developed with a community-oriented multidisciplinary team, an emphasis on assessments in the patient’s home, and access to a range of health and social service resources in the community and hospital. The Korean service had an “open” model of referral whereupon any professional. or even a lay person, could refer a patient to the service. This study clearly illustrates that Korean patients were referred by a variety of sources including general practitioners, psychiatrists, hospital doctors and family. An open referral model is further encouraged by the observation that not every Korean, in contrast to UK subjects, is registered with a general practitioner despite the fact that the entire Korean population is covered by the national insurance system. However, in Korea payment is required on a fee-for-service basis (every Korean is expected to pay part of the cost when receiving medical services provided by the national insurance system) whereas in the UK health services are free at the point of delivery. One advantage of the open referral system is that subjects who may not be referred by the general practitioner to a psychogeriatric service can have direct access to the psychogeriatric service; general practitioners may not refer the patient because they may not recognise dementia, erroneously believe nothing can be done and be unaware of the availability and role of psychogeriatric service. 

Most Koreans were referred for advice on diagnosis, management of BPSD and medication. There is a clear separation of treatment and social care in Korea, whereas in the UK there is movement towards integration of health and social care. Thus, it is not surprising that none of the Koreans were referred for advice on social service facilities. Furthermore, none of the Koreans were referred for day hospital admission because the Korean service lacked a day hospital. 

The Korean sample had lower MMSE scores and higher BPSD scores. There are several potential explanations for this discrepancy. First, Koreans may seek help at a more advanced stage of disease because a fee is charged for consultations, whereas this is not the case in the UK. Second, there is emphasis on early identification and management of dementia in the UK following implementation of the UK National Service Framework for Older People. This framework encourages the development of diagnostic and referral protocols for dementia between primary and secondary care, and the development of a single assessment process across different health and social care agencies. Third, the advent of cholinesterase inhibitors has resulted in a campaign across health, social service and voluntary sector for early detection of dementia in the UK. 

Differing models of service delivery, health seeking behavior of patients and carers, cultural factors, availability of primary and secondary care services, and the knowledge, expectations, and recognition of dementia among professionals in primary and secondary care may explain the differences in some aspects of service delivery between the two countries. However, caution should be exercised in generalizing the findings of this study to other psychogeriatric services as it was restricted to one UK and one Korean service.

Acknowledgements
We wish to thank all patients and their carers for participating in the study.

References
Bramesfeld A (2003) Service provision for elderly depressed persons and political and professional
awareness for this subject: a comparison of six European countries. International Journal of Geriatric Psychiatry, 18, 392-401.

Reifler B (1997) The practice of geriatric psychiatry in three countries: observations of an American in British Isles. International Journal of Geriatric Psychiatry, 12, 795-807.

Shah AK, Abelskov K (2003) Service Delivery Task Force questionnaire survey. Bulletin of the International Psychogeriatric Association. In Press.

Shah AK, Elanchenny N, Suh GK (2003) A comparative study of behavioural and psychological signs and symptoms of dementia in patients with dementia referred to psychogeriatric services in the UK and Korea. International Psychogeriatrics. In Press.

Reprinted from IPA Bulletin Volume 20 Number 4