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Global Research for
Global Action
Centre for Global Mental HealthKing’s College [email protected]
Prof. Martin Prince
• 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/[email protected]
My thanks to
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
www.alz.co.uk/1066
Developed/ developing country differences
0
5
10
15
20
25
30
35
60- 70- 80- 90Age
% p
reva
len
ce
EURODEMIbadan, NigeriaBallabgarh, India
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%?
• Launched World Alzheimer Day, September 21st, New York, 2009– Prevalence– Numbers– Impact– Action
Prof Martin Prince
Institute of Psychiatry
King’s College London, UK
Prevalence of dementia, by region
0
1
2
3
4
5
6
7
8
9S
tan
da
rdis
ed
pre
vale
nce
(%
)
Increase in numbers of people with dementia, by development status
ADI World Alzheimer Report 2009, Eds Prince & Jackson
WHO Report, 2012– Prevalence– Numbers– New incidence
data– Cost– Policy
“I call upon all stakeholders to make health and social care systems informed and responsive to this impending threat”
Dr. Margaret Chan, Director General, WHO
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
0
10
20
30
40
50Inc
ide
nc
e/ 1
00
0 P
YR
CubaDR
Venez
uela
Peru (u
rb)
Peru (r
ur)
Mex
ico (u
rb)
Mex
ico (r
ur)
China
(urb
)
China
(rur)
DSMIV
DSMIV
1066
Prince et al, Lancet 2012
Asia47%
Africa7%
North America11%
Latin America5%
Europe30%
Global Distribution of Incident Dementia (7.7 million new cases per year)
WHO Report 2012 – Dementia a Public Health Priority
One new case every 4 seconds!
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)
Can prevention help to reduce the burden of dementia?
Exposure Meta-analysed RR - association with AD
Population attributable risk fraction (PARF%)
Diabetes 1.39 (1.17-1.66) 2.4%
Midlife hypertension 1.61 (1.16-2.24) 5.1%
Midlife obesity 1.60 (1.34-1.92) 2.0%
Physical inactivity 1.82 (1.19-2.78) 12.7%
Smoking 1.59 (1.15-2.20) 13.9%
Depression 1.90 (1.55-2.33) 10.6%
Low education 1.59 (1.35-1.86) 19.1%
COMBINED TOTAL 50.7%
(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
Treatment and care
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
• 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 is the leading contributor to disability and dependence (10/66 studies)
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
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
%
DirectmedicalDirectsocialInformalcare
Worldwide distribution of costs by sector
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%
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
More carrot, less stick….
1. Universal non-means tested ‘social’ pensions
2. Access to disability benefits for people with dementia
3. Caregiver benefits
4. Provide services for people with dementia and their carers 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
Albanese et al, BMC Health Services Res 2011
Medical help-seeking by people with dementia and their carers
0
10
20
30
40
50
60
70
%
Carer noted MI
BPSD
SMI
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
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– Social policy – long-term care– Prevention– Continuous monitoring on key indicators
