The Global Impact of Dementia

1. The Global Impact of Dementia Prof. Martin Prince, Centre for Global Mental Health King’s College London 1066drg@iop.kcl.ac.uk

2. 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%

3. 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)

4. 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)

5. 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

6. The 10/66 protocol • 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

7. www.alz.co.uk/1066

8. Prevalence and ‘numbers’

9. Prevalence studies worldwide - 2004

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

11. 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

12. Incidence of 10/66 dementia, by age and country

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

14. Mortality among people with dementia, by site

15. Sociodemographic and socioeconomic/ cognitive reserve risk factors for incident 10/66 dementia * Hazard ratio from proportional hazards competing risk regression

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

17. Numbersof prevalence studies by year of data collection

18. Prevalence of dementia, by region

19. New estimates, compared with ADI/ Lancet millions 115.4 90.2 82.0 48.0 26.4 42.7 24.4

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

21. The relative impact of different health conditions, across 10/66 centres, on disability Sousa et al for 10/66, Lancet, 2009

22. 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

23. 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

24. 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%

25. Per capita cost, by World Bank income group

26. Distribution of costs by sector

27. Dependence and social protection for older people

28. 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

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

30. More carrot, less stick…. • Universal non-means tested ‘social’ pensions • Access to disability benefits for people with dementia • Caregiver benefits • Incentivise family care • Provide basic information, training and support for caregivers in the community

31. 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

32. 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

33. The WHO Mental Health Global Action Plan • Increasing the coverage of evidence-based community interventions in low and middle income countries • 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

34. 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

35. 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

36. 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/1066 1066drg@iop.kcl.ac.uk My thanks to