The Global Impact of Dementia

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%

Alarmist (?) discourses over global ageing

“Global leaders see a higher cost for social services, possible labor shortages, and higher costs for pensions, and health care as probable outcomes” (AARP, 2004)

“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)

An alternative view

“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)

We celebrate rising life expectancy as one of humanity’s major achievements….. this demographic transformation challenges all our societies to promote increased opportunities for older persons to realize their potential to participate fully in all aspects of life. (Madrid International Plan of Action on Ageing, 2002)

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

• Cognitive test• Clinical interview• Socio-demographic and risk factor

interview• Physical/ neurological examination• Fasting blood test• Informant interview

– 10/66 dementia– DSM IV Dementia– DSM IV/ ICD10 mental

disorder– Chronic disease Dx– Hypertension, diabetes,

metabolic syndrome

The 10/66 protocol

www.alz.co.uk/1066

Prevalence and ‘numbers’

Prevalence studies worldwide - 2004

Prevalence of 10/66 and DSM IV Dementia

0

5

10

15

20

%

DSMIV

DSMIV

1066

Rodriguez et al for 10/66, Lancet 2008

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

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

Incidence of 10/66 dementia, by age and country

0

10

20

30

40

50

60

70

80

90

65-69 70-74 75-79 80+

Age group (years)

Inci

de

nce

/ 1

00

0 p

ers

on

ye

ars

Cuba

DR

Peru

China

Venezuela

Mexico

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

Site DSM-IV dementiaincidence/ 1000 pyr

10/66 Dementiaincidence/ 1000 pyr

Cuba 9.3 21.9

Dominican Republic 8.7 24.1

Peru, urban 7.5 20.1

Peru, rural 7.6 22.8

Venezuela 9.2 40.1

Mexico, urban 7.8 21.3

Mexico, rural 11.0 50.7

China, urban 17.7 31.2

China, rural 15.6 37.5

EURODEM DSM-III-R dementia

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)

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

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

Prof Martin Prince

Institute of Psychiatry

King’s College London, UK

Numbers of prevalence studies by year of data collection

high incom e country

middle or low income country

Study location

198

0

198

2

198

4

198

6

198

8

199

0

199

2

199

4

199

6

199

8

200

0

200

2

200

4

200

6

Year of data collection

0

4

8

12

Nu

mb

er o

f st

ud

ies

Prevalence of dementia, by region

0

1

2

3

4

5

6

7

8

9S

tan

da

rdis

ed

pre

vale

nce

(%

)

New estimates, compared with ADI/ Lancet

0102030405060708090

100110120130

2000 2010 2020 2030 2040 2050

24.442.7

82.0

millions

90.2

48.0

26.4

115.4

Increase in numbers of people with dementia, by development status

ADI World Alzheimer Report 2009, Eds Prince & Jackson

The relative impact of different health conditions, across 10/66 centres, on disability

Health condition/ impairment Meta-analysed relative risk for association with dependency

Mean population attributable fraction (SD)

1. Dementia 1.9 (1.8-2.0) 25.1%

. Hypertension 1.0 (1.0-1.10) 14.4%

2. Stroke 1.4 (1.3-1.5) 11.4%

3. Limb paralysis/ weakness 1.8 (1.7-1.9) 10.5%

4. Arthritis 1.3 (1.3-1.4) 9.9%

5. Depression 1.4 (1.3-1.5) 8.3%

6. Eye problems 1.1 (1.1-1.2) 6.8%

7. Gastrointestinal problems 1.1 (1.1-1.2) 6.5%

8.Diabetes 1.1 (1.1-1.2) 4.1%

9. COPD 1.0 (1.0-1.1) 3.3%

10. Hearing problems 1.1 (1.0-1.2) 2.2%

Ischaemic heart disease 1.0 (0.9-1.2) 0.8%

Skin diseases 1.1 (0.9-1.3) 0.1%

Sousa et al for 10/66, Lancet, 2009

• 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

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

Dementia UK Results

Where are the people with dementia?

25900

81619

656807098671446

212456

94739

45737

0

50000

100000

150000

200000

250000

65-74 75-84 85-89 90+

Nu

mb

er

of

peo

ple

Residential care

Community

424k in the community (64%)244k in care homes (36%)Proportion in care homes rises with age

Care homes

Community27% 28% 41% 61%

Per capita cost, by World Bank income group

Distribution of costs by sector

Dependence and social protection for older people

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 benefits

4. Incentivise family care

5. Provide basic information, training and support for caregivers in the community

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

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)

• No domiciliary assessment/ care• Clinic based service• No continuing care• ‘Out of pocket’ expenses

Prince et al, World Psychiatry, 2007

The WHO Mental Health Global Action Plan

• Seven priority areas – depression, psychosis, epilepsy, dementia, child and adolescent disorders, alcohol use, suicide

• Development of evidence-based practice guidelines for non-specialists in LAMIC

• Implementation

• Evaluation

• Increasing the coverage of evidence-based community interventions in low and middle income countries

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 2010

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– Clinical care– Social policy– Prevention

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

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

Aquiles Salas, Mariella Guerra, Raul Arizaga. 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 Stewart

www.alz.co.uk/10661066drg@iop.kcl.ac.uk

My thanks to