Dementia and chronic
diseases - a global view
Martin Prince
Centre for Global Mental Health
King’s College London
[email protected]
Global population ageing –
where do older people live?
The world’s population is
ageing. People are living
longer, and fertility is declining
This process is occurring
more rapidly in developing
countries
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)
Some important questions

What is different about old age?





Degenerative disorders – stroke, dementia
Not one condition but several (comorbidity)
Disability, and needs for long-term care
Fragile economic 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
Attention to dependence and long-term care
What are the chronic diseases, and why do
they matter?

Heart disease, stroke, cancer, diabetes, mental
disorder, dementia, blindness, deafness
Tend to impact later in life, although some evidence
for increased mortality at younger ages in low and
middle income countries
Incurable conditions, requiring long-term
management
‘Lifestyle’ risk factors – smoking, underactivity, diet,
obesity
Associated with considerable mortality and
disability
Already the leading cause of death in all world
regions apart from sub-Saharan Africa
A global epidemic








Population ageing
The ‘health transition’ – globalisation of risk behaviours
Leading contributors to global burden of disease
among people aged 60+
160
140
120
100
LIC
80
MIC
60
HIC
40
20
Ca
rd
io
va
sc
ul
a
Ca r
nc
Se er
Ch
ns
r
Ne on ory
ic
ur
re
op
sy sp
ch .
ia
t
In ric
fe
ct
Re ion
sp
.
Di inf.
ge
st
Di ive
ab
et
es
M
us
cu Inju
lo
r
sk y
el
et
al
0
Millions of Disability Adjusted Life Years (DALYs) by cause and region
What is dementia?

A syndrome, not a single disorder



Characterised by progressive cognitive impairment
(memory, language, thinking, judgment)
Many underlying causes – Alzheimer’s disease, vascular
dementia, Dementia with Lewy bodies, Frontal Temporal
dementia
A condition of later life



Around 5% of cases have onset before the age of 60
Prevalence doubles with every five year increase in age
Low levels of awareness and help-seeking



A ‘normal part of ageing’
‘Nothing can be done’
Stigma and shame
A large ‘treatment gap’



Half to two-thirds not diagnosed in high income countries
90% + not diagnosed in low and middle income countries
Developed/ developing country
differences?
35
% prevalence
30
EURODEM
Ibadan, Nigeria
Ballabgarh, India
25
20
15
10
5
0
Age
60-
70-
80-
90
R
ic
o
ub
a
C DR
ar
Pe ac
ru as
Pe (urb
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ex (r
ic ur
M o( )
ex ur
ic b)
C o(
hi ru
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(
C
hi urb
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In (ru
di
a r)
In (ur
di b)
a
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S ur)
Af
ric
a
C
to
Pu
er
Prevalence of 10/66 and DSM IV Dementia
20
15
% 10
DSMIV
5
1066
0
DSMIV
So is it 8-10% or <1%?
Rodriguez et al for 10/66, Lancet 2008
A global epidemic
36 million now
66 million by 2030
115 million by 2050
One new case every 4 seconds
The impact of dementia
• Mainly through years
disability, not mortality
lived
with
• Among
older
people,
dementia
contributes much more than other
chronic diseases to
– Disability (Sousa et al, Lancet, 2009)
– Needs for care (Sousa et al, BMC Geriatrics, 2010)
– Carer strain (Honyashiki M, Int Psychogeriatrics 2011)
• Economic cost……..
The chronic disease global health agenda
IN
• Focus on prevention of
‘premature’ mortality
• Prioritisation of CVD, cancer,
diabetes
• Anti-smoking measures, salt
reduction, diet, activity
OUT
• Ageing?
• Consequences of failed
prevention?
• Management of chronic
conditions in late-life?
• Disability and long-term care?
Why might this be short-sighted – Economic
cost of dementia (Dementia UK report)
Economic cost of dementia
683,000 people with dementia
1.7 million by 2050
8%
15%
Total costs
£17 billion
41%
Costs per person
Average
£25,472
36%
Mild dementia
(community)
Moderate dementia
(Community)
£14,540
£20,355
People in care homes £31,263
Health service
Community care
Informal care
Care homes
• 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
Long term care, 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
Disability
pension
Food insecurity
28.0%
44.4%
2.7%
0.0%
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. Promote independence, prevent and manage
dependence
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
WHO
• The
Increasing
theMental
coverage of
evidence-based
community
interventions in
low and middle
income countries
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
Packages of care for dementia – not
rocket science!
• Casefinding
• Brief diagnostic
screening assessment
• Making the diagnosis
well – information and
support
• Attention to physical
health
• Carer interventions
• Commitment to
continuing care
Prince et al, PLOS Medicine 2010
A more integrated approach?
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
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
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Dementia and chronic diseases a global view (Martin Prince)