The Looming Alzheimer’s Epidemic: Population Aging and its Effects on Society and

the Economy

Jane A. Driver, MD, MPHDivision of Aging, Brigham and Women’s Hospital

VA Boston Healthcare SystemAssistant Professor of Medicine, Harvard Medical School

Catholic University of America April 24, 2013

The Looming Alzheimer’s Epidemic: Population Aging and its Effects on Society and the Economy

Jane A. Driver, MD, MPHGeriatric Research Education and Clinical Center,

VA Boston Healthcare SystemDivision of Aging, Brigham and Women’s Hospital

Assistant Professor, Harvard Medical School

A Passage to India

“Each human soul is worth more than the entire material universe.” -Thomas Aquinas.

What is Dementia?

• Chronic progressive disease of the brain– Global deterioration in intellect, including

memory, learning, orientation, language, comprehension, judgment and comportment

• Most common causes– Alzheimer’s Disease– Vascular dementia

Stages of Alzheimer’s Disease• Stage 1: No impairment• Stage 2: Very mild cognitive decline • Stage 3: Mild cognitive decline (MCI)• Stage 4: Moderate decline (Early AD- IADLs)• Stage 5: Moderately severe (Moderate AD- ADLs)• Stage 6: Severe decline (complete dependence)• Stage 7: Very severe decline (nonverbal)

Grace

• http://www.youtube.com/watch?v=7wbYEK7O14E

Types of Care for People with Dementia

• Informal care– Unpaid care provided by family and others

• Social care– Community care professionals, nursing home

• Medical care– Outpatient visits, medications, hospitalizations

Voxel-wise comparison to amyloid negative group

Treatment Trials- 2012

• Bapinezumab- negative trials• Solanezumab

– 2 large phase III trials were negative– When results were combined, cognitive decline

was slowed by 34% in those with the mildest symptoms

– First evidence that a drug targeting B-amyloid might be useful for prevention

AD Prevention Trials Starting in 2013

Trial Name Patient Population Drug Being TestedA4 Trial- AD Cooperative Study

1000 patients aged 70-85 with positive florbetapir scans

SolanezumabB-secretase inhibitor

Alzheimer’s Prevention Initiative (API)

Presenilin mutation carriers in ColumbiaApoE4 homozygotes 60-80 years old

Crenezumab

Dominantly Inherited Alzheimer’s Network (DIAN)

Asymptomatic gene carriersYoung

GantenerumabSolanezumabB-secretase inhibitor

Epidemiology of Dementia in the US

• 5.4 million Americans have AD; will triple by 2050• 65 and older: 1 in 8; 85 and older: 1 in 2• 2/3 of people with dementia are women• Average life expectancy after AD diagnosis: 8y• Annual cost of dementia care in 2011: 183 billion• Estimated annual cost by 2050: 1.1 trillion• Medicare spending on dementia will increase by

600% by 2050

Alzheimer’s Disease Facts and Figures, 2011. www.alz.org

Mortality Rates for Common Diseases in the United States

Source: Alzheimer’s AssociationFacts and Figures 2011 Report

Global Economic Impact of Dementia

• 0.5% of the world’s population has dementia• Total worldwide estimated costs $604 billion

in 2010– 70% of costs occur in Western Europe and North

America– 1% of the world’s gross domestic product

• By 2030 costs projected to increase by 85%

World Alzheimer’s Report 2010: The Global Economic Impact of Dementia

World Alzheimer’s Report 2010: The Global Economic Impact of Dementia

World Alzheimer’s Report 2010: The Global Economic Impact of Dementia

Future Projections

• Currently only 6% of people with dementia in low or middle income countries live in NHs

• Set to expand rapidly due to– Increase in wages as countries develop– Rapid societal aging– Demographic and social changes that reduce

availability of informal caregivers– Per-person costs of dementia care will increase

Alzheimer’s Disease International, 2009. www.alz.co.uk

Speed of Population AgingNumber of years for % of population aged 65 and over to rise from 7% to 14%

11585

7369

6553

474545

2641

2727

25242323222120

FranceSweden

AustraliaUnited

CanadaHungary

PolandUnitedSpainJapan

AzerbaijanChina

SingaporeChile

JamaicaSri Lanka

TunisiaThailand

BrazilColombia

Source: US Census Bureau, 2000

Urgent Need for Action

• Government must make dementia a health care priority and develop a plan to provide and finance dementia care

• Need to re-design health care systems to deal with chronic, age-related diseases

• Increase funding for research and prevention– Currently about 10% of that spent on cancer research

• Adequate support for family caregivers and care of vulnerable elderly

Dementia Awareness

China Peru

Dominican Republic Sri Lanka

Margaret Sanger• "The most merciful thing

that a large family does to one of its infant members is to kill it." Women and the New Race

• "More children from the fit, less from the unfit -- that is the chief aim of birth control." Birth Control Review, May 1919,

Margaret Sanger (1879-1966)

Margaret Sanger

• Committed neo-Malthusian• Overpopulation is the world’s biggest problem• Contraception is the solution• People who are unfit should not procreate

– The poor, physically disabled, mentally disabled• “Quality not quantity”• New world order: birth control, population

control, eugenic control• Eugenic control + sexual libertinism

The Enemy: Female Fertility

“Possible drastic and Spartan methods may be forced upon society if it continues complacently to encourage the chance and chaotic breeding that has resulted from our stupidly cruel sentimentalism.”Forced sterilization legalized by the U.S. supreme court in 1927 in Buck v. Bell.

Margaret Sanger, The Eugenic Value of Birth Control Propaganda, Birth Control Review, October 1921.

Expenditure on Grant-Financed Development Activities of the United Nations System by Sector

0

5

10

15

20

25

Year

Per

cent

age

of T

otal

Population Energy IndustryTransport Communications Trade and DevelopmentScience and Technology Employment

Dark Days in India

• 1975-1977 Indira Gandhi suspended democracy for 21 months

• Her son Sanjay organized a nationwide compulsory sterilization campaign

• Mandated vasectomies or tubal ligations in families of 2 or more children

• Widespread fear and resistance• Thousands were forcibly sterilized

Continued Coercion

• Forced sterilization is now recognized as a crime against humanity

• In 2004, Uttar Pradesh’s population policy called for 930,000 sterilizations, paid for by $360m from USAid.

• Shift from force to coercion• Guns for sterilization

– Shotgun=2 sterilizations– Revolver=5 sterilizations

Randeep Ramesh, The Guardian, November 2004

Anti-U.S. mob attacks Hillary Clinton's convoy armed with eggs, paintballs and rocks in the Philippines. November 17, 2011

Human Population Growth

Population Growth 1775–2000

Japan’s Age Pyramid

Population Implosion

• A smaller younger population has to support a growing number of elderly people

• By 2035 even China will have a reversed age pyramid

• From 2000 to 2025, people above 65 will triple while those under 15 will increase by only 6%

China’s One Child Policy• Has prevented more

people than the US population

• Population will peak at 1.5 B at

• Within 15 years it will be short of 30 million brides

• The first country that will grow old before it grows rich

China

1980 1990 2000 Today90

95

100

105

110

115

120

GirlsBoys

• “No discussion of human capital can omit the influence of families on the knowledge, skills, values, and habits of their children and therefore on their present and future productivity.” -Becker (1992)

“The human development approach must tale full note of the robust role of the human capital, while at the same time retaining clarity about what the ends and means respectively are. What needs to be avoided is to see human beings as merely means of production and material prosperity.” -Sen (1998)

Human Capital Nobel Laureates

Food for Thought

• How will countries that get old before they get rich care for their oldest members?

• Can government or hired caregivers replace the informal care formerly provided by larger families?

• What are the long term effects of rapid declines in birth rates on society and the economy?

• When will US development policy catch up with reality?

Dementia: The Unsung Heroes

• 15 million Americans provide 17 billion hours of unpaid care for people with dementia yearly

• The economic value of this care is $202.6 billion• 80% of care at home is provided by family• 63% of caregivers have high levels of emotional

stress and 43% have high levels of physical stress• 1/3 of caregivers report symptoms of depression

Alzheimer’s Disease Facts and Figures, 2011. www.alz.org