Global Research for

Global Action

Centre for Global Mental HealthKing’s College London1066drg@iop.kcl.ac.uk

Prof. Martin Prince

Where do older people live?

In 1950, just over half of the world’s older population lived in less developed regions

By 2050, the proportion will be 80%

Discourses around global ageing

“Ageing is a development issue. Healthy older persons are a resource for their families, their communities and the economy” (WHO Brasilia Declaration on Ageing, 1996)

“Global aging is the dominant threat to global economic stability - without sweeping changes to age-related public spending, sovereign debt will soon become unsustainable” (Standard and Poor’s – Global Aging 2010: an irreversible truth)

Ageing and public health What is different about old age?

Degenerative disorders – stroke, dementia Complex comorbidities Disability and needs for care Fragile income security and social protection

Why do older people matter? Account for the majority of disease burden and cost

(health and societal) Underserved

Major Challenges? Access to effective, age-appropriate healthcare Diminishing/ meeting long-term care needs

10/66 DRG research agenda

• Pilot studies (1999-2002)– Development and validation of culture and education-fair

dementia diagnosis– Preliminary data on care arrangements

• Population surveys – baseline phase (2003-2009)– Prevalence of dementia and other chronic diseases– Impact: disability, dependency, economic cost– Access to services– Nested RCT of ‘Helping carers to care’ caregiver intervention

• Incidence phase (2008-2010)– Incidence (dementia, stroke, mortality)– Risk factors– Course and outcome of dementia/ Mild Cognitive Impairment

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Methods/ reviewsValidationDementia descriptiveDementia aetiologyBPSD - clinical CaregivingOther chronic diseasesMortalityHealth care/ policyIntervention

10/66 DRG Publications by topic

www.alz.co.uk/1066

Prevalence and ‘numbers’

Developed/ developing country differences

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5

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25

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60- 70- 80- 90Age

% p

reva

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e EURODEMIbadan, NigeriaBallabgarh, India

Prevalence studies worldwide - 2004

Prevalence of 10/66 and DSM IV Dementia

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5

10

15

20

%

DSMIV

DSMIV

1066

Rodriguez et al for 10/66, Lancet 2008

So is it 8-10% or <1%?

Cross-cultural development, calibration and validation (Prince et al Lancet 2003)

In Cuba, better validity than DSM-IV against local clinician diagnosis (Prince et al, BMC Public Health 2008)

Strong predictive validity in Chennai, India after three year follow-up (Jotheeswaran et al, ADAD 2010)

10/66 algorithm validity

Needs for care at baseline and follow-up – 10/66 Dementia cases

0%10%20%30%40%50%60%70%80%90%

100%

%

much caresome careno care

Incidence phase (n=13,000)

• Sites– Cuba, DR, Venezuela,

Mexico, Peru, China• Outcomes

– Dementia, Stroke, Dependence, Mortality

• Aetiology• Cardiovascular risk (BP/

smoking/ fasting glucose/ cholesterol)

• Diet (anaemia, B12, folate, subclinical hypothyrodism, albumin, anthropometry)

• Developmental factors• APOE and other genetic

factors

Comparing incidence according to 10/66 and DSM-IV criteria

01020304050Incidence/ 1000 PYR

Cuba DR

Venez

uela

Peru (u

rb)

Peru (r

ur)

Mexico

(urb

)

Mexico

(rur)

China (urb

)

China (rur)

DSMIV

DSMIV

1066

Directly standardised incidence rates (age-specific person years - EURODEM incidence pooled analysis)

Site 10/66 Dementiaincidence/ 1000 pyr

Cuba 21.9 (19.0-25.1)Dominican Republic 24.1 (20.3-28.5)

Peru, urban 20.1 (15.3-25.9)Peru, rural 22.8 (16.5-30.8)Venezuela 40.1 (35.0-45.8)Mexico, urban 21.3 (16.1-27.7)

Mexico, rural 50.7 (41.7-61.0)China, urban 31.2 (25.8-37.1)China, rural 37.5 (31.5-44.1)

DSM-III-R incidence/ 1000 pyr

EURODEM 18.4

Mortality among people with dementia, by site

Site Mortality rate (per 1000 person years)

Age and sex adjusted mortality hazard ratiosNo

dementiaDementia cases

Cuba 44.8 195.4 3.20 (2.61-3.92)Dominican Republic 54.5 148.3 2.22 (1.75-2.81)Peru, urban 18.7 139.3 5.69 (3.33-9.73)Peru, rural 28.9 59.5 1.74 (0.68-4.44)Venezuela 24.3 98.4 2.27 (1.42-3.62)Mexico, urban 31.6 114.4 2.70 (1.56-4.67)Mexico, rural 36.6 89.7 1.56 (0.94-2.59)China, urban 40.7 168.1 3.02 (2.13-4.28)China, rural 57.0 216.1 3.59 (2.47-5.21)India, urban 62.5 171.6 2.33 (1.48-3.67)

Pooled meta-analysed effect

2.77 (2.47-3.10)

• Launched World Alzheimer Day, September 21st, New York, 2009– Prevalence– Numbers– Impact– Action

Prof Martin PrinceInstitute of PsychiatryKing’s College London, UK

Prevalence of dementia, by region

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1

2

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6

7

8

9S

tand

ardi

sed

prev

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ce (%

)

Increase in numbers of people with dementia, by development status

ADI World Alzheimer Report 2009, Eds Prince & Jackson

Promoting lifelong physical health – opportunities for prevention

• Early life– Education (?nutrition, growth,

neurodevelopment)• Mid to late-life

– Cardiovascular disease and its risk factors, mental stimulation, physical activity, depression

• Late-life– ? Undernutrition (micronutrient deficiency and

anaemia)

PRs* for association between skull circumference (largest vs. smallest quarters) and 10/66 dementia

* Controlling for age, gender, education and family history of dementia

theta.1 101

Combined

CubaDRPeru UPeru RVenezuelaMexico UMexico RChina UChina RIndia UIndia R

0.75 (0.63-0.89)

Sociodemographic and socioeconomic/ cognitive reserve risk factors for incident 10/66 dementia

Risk factor RR* 95% CI HeterogeneityHiggins I2

Base model (mutually adjusted)Age 1.67 1.56-1.79 49 (0-76)Sex (m vs f) 0.72 0.61-0.84 25 (0-64)Education (per level) 0.89 0.81-0.97 50 (0-77)Lower occupation attainment (per level)

1.04 0.95-1.13 0 (0-65)

More assets (per asset)

0.93 0.88-1.00 63 (24-82)

Extensions to base model (adjusted for base model but not each other)Literacy 0.68 0.55-0.84 53 (1-78)Animal naming (per word)

0.93 0.91-0.94 61 (19-81)

Luria (Fist-Edge-Palm) – higher score worse performance

1.28 1.18-1.38 76 (54-88)

* Hazard ratio from proportional hazards competing risk regression

An index of the quality of public healthcare – detection and control of hypertension

Detection Control Detected and controlled

GoodPeru (rural) 97% 93% 90%Peru (urban) 93% 78% 73%Puerto Rico 91% 65% 58%ModerateMexico (urban) 80% 55% 44%Venezuela 83% 50% 42%DR 82% 48% 39%Mexico (rural) 73% 52% 38%China (urban) 79% 45% 36%PoorS Africa 82% 32% 24%Cuba 70% 34% 24%India (rural) 43% 43% 18%India (urban) 44% 37% 16%China (rural) 51% 5% 3%

Prince et al, Journal of Hypertension, 2011

Undernutrition – associations with mortality, incident dependence and dementia

Pooled RR(95% CI)

Heterogeneity(95% CI)

Incident dementia 1

1.22(0.91-1.61)

0%(0-68)

Incident dependence 1

1.11(1.08-1.14)

18%(0-60)

Mortality 2 1.81(1.54-2.13)

68% (39-84)

Mortality among people with dementia 3

1.60(1.27-2.02)

44%(0-76)

1 – controlling for age, sex and education

2 – controlling for age, sex, education, depression, dementia, stroke and number of physical impairments

3 – controlling for age, sex, education and dementia severity

Numbers of prevalence studies by year of data collection

high incom e countrymiddle or low income country

Study location

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

Year of data collection

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Num

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dies

• World Alzheimer Day, September 21st, London, 2010– Global Societal Economic

cost– $604bn– 1% of GDP– Equivalent to world’s 18th

largest economy– Larger than the annual

turnover of Walmart

Anders WimoKarolinska Institute, SwedenMartin PrinceKing’s College London, UK

Relative impact of different health conditions, across 10/66 centres, on disability and dependence

Health condition/ impairment Mean population attributable fraction(Dependence)

Mean population attributable fraction(Disability)

1. Dementia 36.0% 25.1%2. Limb paralysis/ weakness 11.9% 10.5%3. Stroke 8.7% 11.4%4. Depression 6.5% 8.3%5. Visual impairment 5.4% 6.8%6. Arthritis 2.6% 9.9%

Sousa et al, Lancet, 2009; BMC Geriatrics 2010

Prioritisation – research into chronic diseases

0 5 10 15

% contribution to years lived with disability

100000

200000

300000

400000

500000

600000

700000

rese

arch

pub

licat

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in la

st 1

0 ye

ars

DementiaStroke

Arthritis

Mental disorders

Heart disease

Cancer

0 10 20 30

% contribution to years of life lost

100000

200000

300000

400000

500000

600000

700000

publ

icat

ions

in la

st 1

0 ye

ars

DeafnessStrokeDementia

ArthritisDiabetes

Blindness

Mental disorders

Heart disease

Cancer

How do we prioritise chronic diseases in high income countries?

Research spend (US NIH, 2008)

Healthcare spend (UK NHS)

Cancer $5.6bn £2.1bn

Cardiovascular disease

$2.0bn £4.3bn

Stroke $0.3bn £2.3bn

Dementia $0.4bn £1.4bn

Dementia UK Results

Economic cost of dementia

683,000 people with dementia1.7 million by 2050

Total costs £17 billion

Costs per person

Average £25,472

Mild dementia (community) £14,540Moderate dementia (Community) £20,355

People in care homes £31,263

8%

15%

36%

41%

Health serviceCommunity careInformal careCare homes

Distribution of costs by sector

Long term care and social protection for older people

Long-term care policy

WHO report (2002)• each community should determine

– the types and levels of assistance needed by older people and their carers

– the eligibility for and financing of long-term care support.

• In practice, governments– Do not provide or finance long-term care– Lack comprehensive policies and plans

Social protection legislation in India

“Old age has become a major social challenge and there is need to give more attention to care and protection of older persons. Many older persons . . . are now forced to spend their twilight years all alone and are exposed to emotional neglect and lack of physical and financial support”.Government of India (2007),

“With the joint family system withering away, the elderly are being abandoned. This has been done deliberately as they (the children) have a lot of resources which the old people do not have.” Social Justice Minister, Meira Kumar

Social protection for people with dementia in India (10/66 DRG)

Urban Chennai Rural Vellore

Pension 13.3% 26.9%

Money from family

28.0% 44.4%

Disability pension

2.7% 0.0%

Food insecurity 28.0% 17.6%

No children available locally

9.3% 7.5%

More carrot, less stick….

1. Universal non-means tested ‘social’ pensions

2. Access to disability benefits for people with dementia

3. Caregiver benefits4. Incentivise family care5. Provide basic information, training and

support for caregivers in the community

Intervention - the problem

• Dementia is a hidden problem (demand)

• Little awareness• Not medicalised• People do not seek help

• Health services do not meet the needs of older people (supply)

• Few specialists• Clinic based service - no

home assessment/ care• No continuing care• ‘Out of pocket’ expenses

Prince et al, World Psychiatry, 2007

Equity in delivery of healthcare - predictors of health service use in the last three months

Exposure Meta-analysed PR for association with service use

Age (per year) 0.99 (0.98-1.00)Male sex 0.93 (0.91-0.96)

Education 1.03 (1.01-1.05)Assets 1.08 (1.01-1.17)Health insurance 1.27 (1.16-1.38)In receipt of a pension 1.09 (1.04-1.14)

Physical illness/ impairments

1.37 (1.26-1.49)

ICD 10 depression 1.27 (1.07-1.38)Dementia 0.93 (0.90-0.97)

Albanese et al, BMC Health Services Research 2011

Prevalence of service use varied between 6% and 82% by siteHealth and demographic variables did not explain this variation? Out-of-pocket expenses at ecological (health system) level

Medical help-seeking by people with dementia and their carers

010203040506070

%

Carer noted MIBPSDSMI

Components of care e.g. …. Helping Carers to Care

• Use what there is– Extended role for existing

outreach services– Families

• ‘Low level’ interventions– 5 sessions in 8 weeks– Increase awareness and

understanding – Mobilise support

networks, improve family cohesion

– Basic management strategies in the home Dias et al PLOS One, Guerra et al

Rev Braz Psych; Gavrilova et al IJGP

Packages of care for dementia

• Casefinding• Brief diagnostic screening assessment• Making the diagnosis well – information

and support• Attention to physical comorbidity• Carer interventions (carer strain)• Cognitive stimulation• Non-pharmacological interventions for

behavioural and psychological symptoms

Prince et al, PLOS Medicine 2010Dua et al, PLOS Medicine 2011

VERTICAL (HEALTH CONDITIONS)• Dementia• Stroke• Parkinson’s disease• Depression• Arthritis and other limb

conditions• Anaemia

HORIZONTAL(IMPAIRMENTS)• Communication• Disorientation• Behaviour disturbance• Sleep disturbance• Immobility• Incontinence• Nutrition/ Hydration• Caregiver knowledge• Caregiver strain

Horizontal vs. vertical approachers

Conclusions• The world is facing a new epidemic of

unprecedented proportions• Its effects will be felt particularly in low and

middle income countries - currently least prepared to meet the challenge

• Societal costs will rise inexorably, driven by the increasing need for long term care

• Time for action– Scalable models of evidence-based clinical care to

close the treatment gap– Progressive fiscal and social policy – long-term care– Prevention– Continuous monitoring of key indicators

• Alzheimer’s Disease International• The 10/66 Dementia Research Group in 12

countries: – Juan Llibre Rodriguez, Daisy Acosta, Yueqin Huang,

Aquiles Salas, Ana Luisa Sosa, Mariella Guerra, Ivonne Jimenez, JD Williams, KS Jacob, Richard Uwakwe, Malan Heyns

• Our funders– The Wellcome Trust– US Alzheimer’s Association– World Health Organisation

• The London team– Cleusa Ferri, Renata Sousa, Emiliano Albanese, Michael

Dewey, Rob Stewartwww.alz.co.uk/10661066drg@iop.kcl.ac.uk

My thanks to