The Alzheimer Society of Ireland Pre-Budget Submission 2017

The Alzheimer Society of Ireland Pre-Budget Submission 2017

The Ask: Invest 67million towards home care supports for people with dementia Executive Summary The Alzheimer Society of Ireland calls on Government to invest 67million towards home care supports for people with dementia - 36million for packages of care and support for those in the early to mid-stages and 31million for enhanced packages for those with more complex care needs. This investment will support people to stay at home, which is stated Government policy and the preferred choice of people with dementia. It also goes some way in achieving the key principles of the National Dementia Strategy, that of personhood and citizenship. We need to shift thinking in how we provide home care; financing it as an integral aspect of long-term care, not only as a solution to the hospital crisis. While financing of long-term residential care has increased, investment in home care has gone down. Combined with greater transparency and entitlement to long-term residential care we are effectively channelling people into institutions. Standardised processes of assessment for home care, certainty of entitlement and centralised ring-fenced funding must be allocated on an annual basis to enable people to remain at home. People with dementia require a continuum of flexible innovative care, individual needs-led approaches, appropriate to changing and complex needs arising from the condition. This means providing lower levels of care and support in the earlier stages and high levels of care as the condition progresses. The outcomes of investing in home care services and supports will: 1. Meet the demand for care at home, allowing for greater flexibility to appropriately meet need and reverse cuts to home care services. 2. Reduce unnecessary hospital admissions and shorten length of hospital stay for people with dementia. 3. Avoid inappropriate, unnecessary or premature admission into long-term residential care. 4. Reduce carer stress and support family carers. 2

Introduction People with dementia have the right to help to attain and maintain maximum independence, physical, mental, social and vocational ability and the full inclusion and participation in all aspects of life. (The Alzheimer Society of Ireland and Irish Dementia Working Group, 2016 1 ) The 2014 published National Dementia Strategy 2 (NDS) provides guidance on how to approach home care provision for people with dementia as it seeks to progress the dual and overarching principles of personhood and citizenship by enabling people with dementia to maintain their identity, resilience and dignity and by recognising that they remain valued, independent citizens who, along with their carers, have the right to be fully included as active citizens in society. A key component to achieving this is supporting people to live at home for as long as possible; as is the preferred choice of people with dementia 3. Fundamentally home care should not be tied to getting people out of hospitals but framed as an integral aspect of the provision of long term care in its own right; as a preventative measure keeping people well in the community and out of acute and long-term care services in the first place. Through the NDS implementation programme 22 million was allocated for the delivery of intensive home care packages for people with dementia. These packages, operating in eight pilot sites were linked to delayed discharge, implemented initially to solve problems in the acute hospital system. The provision of home care therefore requires a paradigm shift, investing in home care for its own sake, not linked to our hospital system. The NDS funding for the delivery of home care for people with dementia is coming to an end shortly and while the evaluation of this programme will be useful for future planning and care delivery there is a proven need for current home care support services to be enhanced with sufficient funding to allow for flexibility, taking an individual needs-led approach. This submission will outline how continuous cuts to home help and home care packages are effectively channeling people to long-term care; causing the institutionalisation of people with dementia. This is not only expensive, it is inappropriate. Where services do exist they are not responsive or flexible enough to meet the often complex and very individualised care and support needs of people living with dementia (Donnelly et al, 2016 4 ). In addition, living with dementia means there is a longer care continuum, requiring low levels of social care and support in the earlier stages and requiring high levels of care in the latter stages. 3

Graph 1: Cost of dementia care in Ireland (Cahill et al, 2012) 5 In addition, State spending on dementia to date has been low and inadequate, with the majority of the cost borne by family carers (see Graph 1). It is therefore incumbent on current decision-makers to support people through financing both enhanced home care packages for those in the latter stages of the condition and lower levels of home care support services for those in the early to midstages. All home care must be flexible, meeting individual needs, moving away from a time-to-task approach. At times people may require social supports rather than personal care, such as support around domestic tasks, nutrition, medication management, the provision of in-home respite hours and support around social activity and engagement. All of which should be self-directed, with the person with dementia at the centre of care planning and delivery. Setting targets As a starting point the Alzheimer Society of Ireland (ASI) recommends meeting the needs of 10% of the population of people with dementia who live in the community; this equates to 2,000 people 1. For those in the later stages of dementia, compared to other long-term care users, people with dementia need more personal care, more hours of care, and more supervision, all of which is associated with greater caregiver strain, and higher costs of care (Alzheimer Disease International, 2013 6 ). The ASI therefore calls for investment into enhanced home care packages for people with dementia, at a cost of the average long-term residential care bed e.g. 915 2. Evidence suggests 30% of people with dementia living in the community require high levels of care, on the cusp of entering long-term residential care. We therefore recommend these packages are delivered to 600 people. Allowing for increases in costs (up to 1,000 per week), this equates to a cost-neutral investment of 31 million per annum. We also need to look to preventative home care approaches. There is strong evidence (O Shea and Monaghan, 2015) 7 that innovative, low level, flexible strategies to support people with dementia at home, particularly those in the early to mid-stages of dementia can be hugely successful in keeping people living well in their community. We therefore call on the Government to invest in home care supports for people in the earlier stages of dementia, equating to 500 per week (just under half of the average cost of long-term care bed per week) reaching 1,400 people. This equates to an investment, with longer-term savings, in home care supports of 36million. 1 55,000 people live with dementia. 63% of the total number (55,000) of people with dementia live in the community, which equates to 19,800 people. 10% of this is 1,980 people. 2 Taken from HSE official statistics - http://www.hse.ie/eng/services/list/4/olderpeople/nhss/cost.pdf 4

This 67million is a low level per annum investment, equating to just 6.7% of the total amount spent on longterm residential care last year ( 993million). It is a start in meeting the growing demand for home care and will help to realise stated Government policy to support people to live at home 3. This investment will require innovation in how it is implemented, with specificity for people living with dementia, bringing added value to the health and social care system and allowing for greater flexibility and continuity to meet individual need. The remainder of this submission provides the rationale for this investment. We outline how an integrated system, with standardised needs assessment, centralised and ring-fenced funding for home care, facilitating earlier intervention is the best use of resources. It supports quality of life and if delivered appropriately, can enable people with dementia rather than disempower them. The outcomes of investing in home care services and supports will: 1. Meet the demand for care at home, allow for greater flexibility to appropriately meet need and reverse cuts to home care services. 2. Reduce unnecessary hospital admissions and shorten length of hospital stay for people with dementia. 3. Avoid inappropriate, unnecessary or premature admission into long-term residential care. 4. Reduce carer stress and support family carers. 1. Meet the demand for care at home, allow for greater flexibility and reverse cuts to home care services What will this achieve? Further develop a cost-effective alternative to long-term care. Meet the growing demand for home care. Allow for greater flexibility and continuity, meeting need more appropriately. Improve Ireland s position in meeting international standards in the provision of home care. There is growing consensus that home or community based care can be a cost-effective alternative to long-term residential care for some older people (Review of the Nursing Home Support Scheme, 2015 8 ; OECD, 2005 9 ). 3 Care for the Aged Report, 1968, Years Ahead report, 1988; National Positive Ageing Strategy, 2015; National Dementia Strategy, 2014; Future Health; Strategic Framework for Reform of the Health Service 2012-2015. 5

European analysis of average costs in dementia care found that residential long-term care costs 4,491 per month compared to 2,491 4 for aggregate costs from home care (Wübker et al, 2014 10 ). With population ageing, the demand for home care will increase. This requires financing to ensure that a package of flexible care, with contributions from a number of sources, is available to people with dementia. Early findings 5 from the ASI and the Health Research Board funded project De-Stress shows that the behavioural and psychological symptoms of dementia are the most challenging for family carers, much more so than those related to functional disability. However, evidence shows that formal services are not responding appropriately, focusing on providing personal care (Donnelly et al, 2016 11 ). This highlights the lack of dementia focused care at home. Setting targets for the provision of care is extremely important in terms of financing and service planning. The HSE 12 utilising OECD s recommended figures set targets of providing long-term care to between 10% and 20% of people aged 65 years and over. They assume, using the figure of 4.85% requiring residential care (both long stay and short stay care), that approximately 10-11% of people aged 65 years and over require some form of home care. As a starting point we recommend a similar target of 10% for the provision of home care for people with dementia. This target will grow year-on-year as the number of people with dementia increases. The HSE are spending less now on home support services than they did in 2008, despite the increase in number of people aged 85 and over and those living with complex conditions such as dementia (Donnelly et al, 2016 13 ). Donnelly et al s (2016) review of home care policy shows worrying cuts to home care services. State spending on home care services has decreased despite increases in the older population. In total, home help hours have decreased by 2.3 million hours between 2009 and 2014, as shown in table 1 below: Table 1: Decreases in the provision of home help number of hours provided 2008 and 2014 Service 2008 2014 Home Help 12.6 million hours 10.3 million hours Source: HSE Annual Report and Financial Statements 2008 and 2014 4 This figure does not include the cost attributed to care provided by family carers. 5 Contact ASI for further information of these preliminary findings. See also Donnelly et al (2015) Depression and Anxiety in Spousal Dementia Caregivers in Ireland. Presentation given at Care Alliance Family Carer Research Conference, Dublin 2015. 6

This is despite significant increases since 2008 in the population aged 65 years and over, with steep rises in the oldest age group, those aged 85 years and over. The number of clients receiving home help services has also decreased, as shown in Table 2: Table 2: Decreases in the provision of home help service clients receiving this service 2011 and 2015 Year 2011 2015 % of older population receiving home help hours 10.1% 8% Number of clients receiving home help hours 54,000 48,390 Source: HSE (2016: 95) Planning for Health 14 Comparing the figures on home care spend in 2015, as outlined by the former Minister for Health 15 in July 2015, to official HSE figures on home care spend in 2009, shows that there has been an 11 million cut in home care services between 2009 and 2015. Table 3: Decreases in the spend on home help and home care packages 2009 and 2015 Service 2009 2015 Home Help 211 million 185 million Home Care Packages 120 million 135 million Total 331 million 320 million Source: 2009 figures from HSE, 2011 16 As a result, Ireland is slipping below international standards for the proportion of the population aged 65 and older receiving home help as recommended by the OECD (HSE, 2016 17 ), thus indicating a high level of unmet need. The current system prioritises people within the acute hospital system. Recent research evidence (Donnelly et al, 2016 18 ) shows that quicker access to long-term care (both residential and community) exists for older people in the acute system. Unlike access to community care, long-term residential care in Ireland is underpinned by legislation; the Nursing Home Support Scheme (NHSS) Act (2009). As a result, the process for assessment, access and funding is much more transparent. Each year ring-fenced centralised funding is allocated to the Scheme and people ordinarily resident in the State have an entitlement to access this care. This is not the case for community services. A central component of increasing funding for home care will be to centralise this, with its own distinct budget which is clearly stated at the start of each budgetary year. 7

2. Reduce unnecessary hospital admissions and shorten length of stay for people with dementia in hospitals What will this achieve? Reduce the number of people with dementia entering acute care e.g. one in four people in acute care have dementia. Reduce the length of time people with dementia spend in hospital e.g. nearly twice as long compared to people aged over 65 and up to four times longer than the average stay. Reduce functional decline associated with hospitalisation for this population. Reduce risk of institutionalisation associated with hospitalisation for people with dementia. Reduce spending on dementia in acute care, estimated to be 21m. People with dementia are one of a core group who are caught in the delayed discharge cycle, with an estimated 25% of all patients in a typical general hospital having dementia (Cahill et al, 2012 19 ; Timmons et al, 2015 20 ). Worryingly 51% of delayed discharges between May 2013 and February 2015 were a result of delayed access to appropriate community supports (HSE, 2016 21 ). Targeted approaches to reduce the length of time people with dementia stay in hospital must be a priority. The average length of hospital stay for a person with dementia admitted and discharged to and from their home is 22 days (de Suin and O Shea, 2014 22 ). Compare this to the average length of stay for the general hospital population of 5.43 days and 12.3 days for someone aged over 65 (HSE, 2015 23 ). In addition, there is strong evidence that acute hospitals are inappropriate for people with dementia. The 2014 Irish National Audit of Dementia Care in Acute Hospitals literature review, for example, references research which found that: Hospitalisation is associated with functional decline for people with dementia (Hoogerduijin et al 2006). Hospital associated disability occurs in approximately one third of patients aged 70 years and over (Covinsky et al, 2011). People with dementia who enter the acute system are also at a higher risk of institutionalisation (Australian Institute of Health and Welfare, 2004). The current system is effectively causing people to progress into dementia at a faster rate. In Towards an Integrated Health Service or more of the Same Report (2008 24 ) by PA consulting, commissioned by the HSE, it 8

states that a fully integrated health system can deliver better service, better outcomes, and better value for taxpayers by shifting the delivery of appropriate care to day cases, increasing the volume and range of community based services and enabling acute hospitals to concentrate on providing specialist care. Budget 2017 offers an opportunity to go some-way towards achieving this; by providing low level supports to enhance people s independence at an earlier stage in the dementia journey and higher levels of both social and personal care at a later stage helping to avoid hospitalisation. 3. Avoid inappropriate, unnecessary or premature admission to long-term Residential Care What will this achieve? Meet people s preference to remain living at home for as long as possible. Support people to live well at home and avoid increased confusion and higher risk of mortality linked to admission to long-term care. Reduce the number (estimated to be 89%) of residents in long-term care who have dementia. Focus on early interventions which can reduce institutionalisation. Redress the balance long-term care funding is continuously increasing as home care is cut. Improve Ireland s standing in Europe in relation to the percentage of people in long-term care we have the second highest number of older people resident in long-term care and acute care in Europe. Former Minister of State, Kathleen Lynch acknowledged that Most people would prefer to live in their own homes and communities than reside in a nursing home (Review of the Nursing Home Support Scheme, 2015 25 ). This echoes the preferences of people with dementia (Alzheimer s Society, 2011 26 ). Yet the current system is channeling people into the acute and long-term care system. This is despite evidence which shows that transitioning to long-term residential care is a life changing event and can lead to increased confusion and risk of mortality (Mittelman, 2006 27 ). The HSE s figure of 37% of all long-stay beds being occupied by someone with dementia (HSE, 2014 28 ) is recognised as showing an under-diagnosis. For example, evidence from a sample of Dublin-based nursing homes found that 89% of residents had a cognitive impairment (Cahill et al, 2010 29 ). 9

Early intervention is critical to reduce the likelihood of nursing home placement, delaying and even preventing this 30. However, our financing model for long-term care has been to favour institutionalisation over community based care, as shown in Table 4 below, with increases in long-term care funding since 2009 of 84million. Compare this to the 11 million cut to home care in the same time period. Table 4: Funding of nursing home support scheme and number of recipients Year Funding ( m) People at Year End No. of saver cases Applications received 2009 909 Not available Not available 5,252 2010 979 Not available Not available 12,697 2011 963 21,548 Not available 9,323 2012 995 22,065 5,147 10,225 2013 974 23,007 3,690 10,406 2014 939 22,360 2,741 9,757 2015 993 23,960 Source: HSE (2015) Review of the Nursing Home Support Scheme In fact, 60% of the current budget for older person s care services supports long-term residential care (Review of the Nursing Home Support Scheme, 2015 31 ). When compared to other European countries, Ireland has the second highest proportion of people aged 65 and over resident in nursing homes and hospitals (Drennan et al, 2012, quoting Eurostat 2011 32 ). The 67million investment that the ASI seeks for home care services and supports is just 6.7% of the total budget spent on long-term residential care last year. 4. Reduce carer stress and support family carers What will this achieve? Provide a better infrastructure to support family carers in their caring roles. Redress the cost of care, where currently 48% of the cost of dementia care is borne by family carers. Reduce the impact of dementia caring which is found to have higher physical demands and longer care hours than other types of care. Help to reduce dementia family carers greater risk of psychological and physical health as a result of their caring role. Support people to provide care, important as carer burnout is the main reason for entry into longterm care. 10

The vast majority of home-based care for people with dementia is provided by family members. Services such as day care, home help and particularly home care packages can clearly assist family carers to continue providing care, helping to avoid institutionalisation (Brodaty and Donkin, 2009 33 ). However, the availability of home care is uneven and inequitable (Donnelly et al, 2016 34 ). This has contributed to the strain that family carers experience while trying to cope with the demands of caregiving 35. Often it is when a crisis occurs that formal interventions are sought which is a reflection of our current reactive rather than proactive care system. Worryingly in Ireland, a higher level of care need is associated with increasing levels of family care and formal services do not respond where demand for care increases (Gillespie et al, 2014 36 ). This is despite the fact that dementia is associated with long care hours and physically demanding caregiving, with higher levels of burden experienced than other family carers (Brodady and Donkin, 2009 37 ). As a result, dementia carers are at increased risk of burden, stress, depression, and a variety of health complications. The following quote from a family carer shows how formal supports can support family carers to care for longer: Caring for mom has been a challenge. We are lucky in that we are a family of five who cope as best we can with the help of wonderful professional carers who assist during the day. It is because of this support network that we have been able to keep mom at home for so long, despite her current advanced state. But our lives are different now. We navigate our days according to a series of schedules and evenings off. We balance work, study and a social life with a care commitment. Mom can t be left alone for one minute and she can no longer do anything for herself from eating to washing. Katie, family carer The social and health care system relies heavily on family members to provide care, which means that burdensome aspects of care are extremely significant in terms of balancing the provision of care for people with dementia (Trépel, 2012 38 ). In fact one of the main reasons people with dementia enter long-term care is due to family carer burnout (Brodaty and Donkin, 2009 39 ). There has been a shift in the profile of Irish families and the availability of families to provide care has also changed. The funding for home care to support people to live at home has to be a priority and reflect this societal shift. Conclusion The ASI urges the Government to invest 67million in Budget 2017 in home care supports and services for people with dementia. This is a low level target and one that should be built-on year-on-year. It aims to meet 11

the needs of 10% of people currently living with dementia in the community at a fraction of the cost of longterm residential care and build on the recent investment made under the National Dementia Strategy. In addition, positive aspects of the Nursing Home Support Scheme should be adopted for home care such as the standardised process for assessment, certainty of entitlement and centralised, ring-fenced funding allocated on an annual basis. Investing in flexible, innovative models of home care for those in the earlier stages of dementia and enhanced packages of care for those requiring higher levels of care is the best use of resources. We need a paradigm shift away from prioritising acute care to providing a variety of responses to meet people s needs in their homes and communities. In this submission we have highlighted a cost effective alternative to acute and long-term care for people with dementia. An alternative that meets people s preferences and further enables the person as well as their family carer. We must meet dementia head-on, be innovative in our thinking on how to respond to the growing demand for health and social care in the person s home. By providing appropriate resources to allow for greater flexibility in the provision of home care services and social care supports we can begin to really make inroads in helping to maintain the identity, resilience and dignity of people with dementia, recognising that they remain valued, independent citizens who, along with their carers, have the right to be fully included as active citizens in society (NDS, 2014 40 ). 12

Dementia facts and figures There are 54,793 41 people living with dementia in Ireland. Most live at home (63% 42 ). The vast majority 43 want to stay at home, in a familiar environment and linked to their local communities. For some the highest level of care will be required and long-term residential care is the right option. BUT for the majority access to appropriate levels of home care and support that provides protection, rehabilitation and support is essential. Our population is ageing (3.2% or 20,000 people annually). In line with this the number of people with dementia will rise to 68,216 44 in the next ten years. Demand for home care is rising. Having dementia increases demand for care due to changes in Activities of Daily Living (ADL) which deteriorate as dementia progresses (Trépel, 2011 45 ). Level of individual disability associated with dementia creates a need for personal care, social support and domestic assistance (O Shea et al, 2007 46 ). About the Alzheimer Society of Ireland The Alzheimer Society of Ireland is the leading dementia specific service provider in Ireland. We work across the country in the heart of local communities providing dementia specific services and supports and advocating for the rights and needs of all people living with dementia and their carers. Our vision is an Ireland where no one goes through dementia alone and where policies and services respond appropriately to the person with dementia and their carers, at the times they need support. A national non-profit organisation, The Alzheimer Society of Ireland is person centred, rights-based and grassroots led with the voice of the person with dementia and their carer at its core. The Alzheimer Society of Ireland also operates the Alzheimer National Helpline offering information and support to anyone affected by dementia at 1800 341 341. 13

References 1 Alzheimer Society of Ireland and the Irish Dementia Working Group (2016) Charter of Rights for People with Dementia. Dublin: Alzheimer Society of Ireland. 2 Department of Health (2014) The Irish National Dementia Strategy. Dublin. 3 Alzheimer s Society (2011) Support, Stay, Save Report. UK: Alzheimer s Society. 4 Donnelly, S. O Brien, M. Begley, E. and Brenna, J. (2016) Older People s Preference for Care: Policy but what about practice. University College Dublin/Age Action/Alzheimer Society of Ireland/Irish Association of Social Workers. 5 Cahill, S. O Shea, E. and Pierce, M. (2012) Creating Excellence in Dementia Care report. Trinity College Dublin/NUIGalway. 6 Alzheimer Disease International (2013) World Alzheimer Report: Journey of Caring; an analysis of long-term care for Dementia. 7 O Shea, E. and Monaghan, C. (2015) Genio Dementia Programme; Evaluation of Year Two. Galway: Irish Centre for Social Gerontology. 8 Department of Health (2012) Review of the Nursing Home Support Scheme. 9 OECD (2005) Ensuring Quality Long-term Care for Older People. 10 Wübker, A. et al. (2014) Costs of care for people with dementia just before and after nursing home placement: primary data from eight European countries. The European Journal of Health Economics 16(7). 11 Donnelly, S. O Brien, M. Begley, E. and Brenna, J. (2016) Older People s Preference for Care: Policy but what about practice. University College Dublin/Age Action/Alzheimer Society of Ireland/Irish Association of Social Workers. 12 HSE (2016) Planning for Health: Trends and Priorities to Inform Health Service Planning. 13 Donnelly, S. O Brien, M. Begley, E. and Brenna, J. (2016) Older People s Preference for Care: Policy but what about practice. University College Dublin/Age Action/Alzheimer Society of Ireland/Irish Association of Social Workers. 14 HSE (2016) Planning for Health: Trends and Priorities to Inform Health Service Planning. 15 Minister Varadkar speech in Dail Eirean. Available from: https://www.kildarestreet.com/debates/?id=2015-07-16a.848 16 HSE (2011) Comprehensive Review of Expenditure. 17 HSE (2016) Planning for Health: Trends and Priorities to Inform Health Service Planning. 18 Donnelly, S. O Brien, M. Begley, E. and Brenna, J. (2016) Older People s Preference for Care: Policy but what about practice. University College Dublin/Age Action/Alzheimer Society of Ireland/Irish Association of Social Workers. 19 Cahill, S. O Shea, E. and Pierce, M. (2012) Creating Excellence in Dementia Care report. Trinity College Dublin/NUIGalway. 20 Timmons, S. et al (2015) Dementia in older people admitted to hospital: a regional multi-hospital observational study of prevalence, associations and case recognition. Age and Ageing. September 28. 21 HSE (2016) Planning for Health: Trends and Priorities to Inform Health Service Planning. 22 de Suin, A. and O Shea, E. (2014) Report of the National Audit of Dementia Care in Acute Hospitals 2014. 14

23 Department of Health (2015) Review of the Nursing Home Support Scheme. 24 HSE (2008) Towards an integrated Care System or more of the Same; Background briefing. 25 HSE (2015) Review of the Nursing Home Support Scheme. 26 Alzheimer s Society (2011) Support, Stay, Save Report. UK: Alzheimer s Society. 27 As quoted in http://www.aihw.gov.au/workarea/downloadasset.aspx?id=6442465196. 28 HSE (2014) Long-stay Activity Statistics 2013. 29 Cahill, S. and Diaz-Ponce, A. (2010) The under-detection of cognitive impairment in nursing homes in the Dublin area: the need for on-going cognitive assessment. Age and Ageing, 39(1), 128-31. 30 http://www.aihw.gov.au/workarea/downloadasset.aspx?id=6442465196 31 Department of Health (2015) Review of Nursing Home Support Scheme. 32 32 Drennan, J., Lafferty, A., Treacy, M.P., Fealy, G., Phelan, A., Lyons, I. and Hall, P. (2012) Older People in Residential Care Settings: Results of a National Survey of Staff-Resident Interactions and Conflicts. Dublin: National Centre for the Protection of Older People and University College Dublin. 33 Brodaty, H. and Donkin, M. (2009) family Carers of People with Dementia. Dialogues in Clinical Neuroscience 11(2). 34 Donnelly, S. O Brien, M. Begley, E. and Brenna, J. (2016) Older People s Preference for Care: Policy but what about practice. University College Dublin/Age Action/Alzheimer Society of Ireland/Irish Association of Social Workers. 35 http://www.hindawi.com/journals/jar/2012/590724/ 36 Gillespie, P. et al., 2014. Longitudinal costs of caring for people with Alzheimer s disease. International Psychogeriatrics 27(5). 37 Brodaty, H. and Donkin, M. (2009) Family Carers of People with Dementia. Dialogues in Clinical Neuroscience 11(2). 38 Trepél, D. (2012) An Economic Perspective of Dementia Care in Ireland: Maximising Benefits and Maintaining Cost Efficiency. Dublin: Alzheimer Society of Ireland. 39 Brodaty, H. and Donkin, M. (2009) Family Carers of People with Dementia. Dialogues in Clinical Neuroscience 11(2). 40 Department of Health (2014) The Irish National Dementia Strategy. Dublin. 41 Pierce, M, Cahill, S. and O Shea, E. (2014) Prevalence and Projections of Dementia in Ireland, 2011-2046. Dublin: Trinity College Dublin/NUIGalway/Genio. 42 Cahill, S. O Shea, E. and Pierce, M. (2012) Creating Excellence in Dementia Care Report. Trinity College Dublin/NUIGalway. 43 Alzheimer s Society (2011) Support, Stay, Save Report. UK: Alzheimer s Society. 44 Pierce, M, Cahill, S. and O Shea, E. (2014) Prevalence and Projections of Dementia in Ireland, 2011-2046. Dublin: Trinity College Dublin/NUIG/Genio. 45 Trepél, D. (2011) Informal Cost of Dementia Care. The Economic and Social Review 42(4). 46 O Shea, E. (2007) Implementing Policy for Dementia Care in Ireland. Dublin: Alzheimer Society of Ireland. 15