Global Research for Global Action

1. Global Research for Global Action Prof. Martin Prince Centre for Global Mental Health King’s College London 1066drg@iop.kcl.ac.uk

2. 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 Stewart www.alz.co.uk/1066 1066drg@iop.kcl.ac.uk My thanks to

3. 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%

4. 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)

5. 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

6. 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

7. www.alz.co.uk/1066

8. Developed/ developing country differences

9. Prevalence and ‘numbers’

10. Prevalence studies worldwide - 2004

11. Prevalence of 10/66 and DSM IV Dementia So is it 8-10% or <1%? Rodriguez et al for 10/66, Lancet 2008

12. Launched World Alzheimer Day, September 21st, New York, 2009 • Prevalence • Numbers • Impact • Action Prof Martin Prince Institute of Psychiatry King’s College London, UK

13. Prevalence of dementia, by region

14. Increase in numbers of people with dementia, by development status ADI World Alzheimer Report 2009, Eds Prince & Jackson

15. WHO Report, 2012 • Prevalence • Numbers • New incidence data • Cost • Policy Dr. Margaret Chan, Director General, WHO “I call upon all stakeholders to make health and social care systems informed and responsive to this impending threat”

16. 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

17. Comparing incidence according to 10/66 and DSM-IV criteria Prince et al, Lancet 2012

18. Global Distribution of Incident Dementia (7.7 million new cases per year) One new case every 4 seconds! WHO Report 2012 – Dementia a Public Health Priority

19. Promoting lifelong physical health – opportunities for prevention • Early life • Nutrition, growth, neurodevelopment, education • Mid to late-life • Cardiovascular disease and CVD risk factors, occupation, mental stimulation, aerobic exercise, depression • Late-life • ? Undernutrition (micronutrient deficiency and anaemia)

20. Can prevention help to reduce the burden of dementia? (Barnes and Yaffe 2011) More realistically….. (WHO Report, 2012) 10% reduction in risk exposure – 250,000 fewer new cases (3.3% reduction) 25% reduction in risk exposure – 680,000 fewer new cases (8.8% reduction

21. Treatment and care

22. Current priorities….. • Based on • contribution to ‘premature’ mortality, not years lived with disability • potential for prevention • cancer, heart disease, diabetes • Research and clinical investment • UN NCD summit • The societal cost of dementia exceeds that of these three disorders combined

23. 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 Wimo Karolinska Institute, Sweden Martin Prince King’s College London, UK

24. Dementia is the leading contributor to disability and dependence (10/66 studies) Sousa et al, Lancet, 2009; BMC Geriatrics 2010

25. Worldwide distribution of costs by sector

26. Dementia UK Results Economic cost of dementia 683,000 people with dementia 1.7 million by 2050 Total costs £17 billion Costs per person Average £25,472 Mild dementia (community) £14,540 Moderate dementia (Community) £20,355 People in care homes £31,263

27. Dementia UK Results Where are the people with dementia? 424k in the community (64%) 244k in care homes (36%) Proportion in care homes rises with age Care homes Community 27% 28% 41% 61%

28. Long-term care – don’t panic – ACT! 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 • Are slow to develop comprehensive policies and plans • Seek to enforce family responsibilities

29. More carrot, less stick…. • Universal non-means tested ‘social’ pensions • Access to disability benefits for people with dementia • Caregiver benefits • Provide services for people with dementia and their carers in the community

30. 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 Albanese et al, BMC Health Services Res 2011 Prince et al, World Psychiatry, 2007

31. Medical help-seeking by people with dementia and their carers

32. 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 Dua et al, PLOS Medicine 2011

33. 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

34. 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 • Social policy – long-term care • Prevention • Continuous monitoring on key indicators