The Global Impact of Dementia
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Transcript of The Global Impact of Dementia
The Global Impact of Dementia
Centre for Global Mental HealthKing’s College [email protected]
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/[email protected]
My thanks to