Global Research
for
Global Action
Prof. Martin Prince
Centre for Global Mental Health
King’s College London
1066drg@iop.kcl.ac.uk
My thanks to
• 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
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
35
% prevalence
30
EURODEM
Ibadan, Nigeria
Ballabgarh, India
25
20
15
10
5
0
Age
60-
70-
80-
90
Prevalence and ‘numbers’
Prevalence studies worldwide - 2004
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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
• Launched World
Alzheimer Day,
September 21st, New
York, 2009
–
–
–
–
Prevalence
Numbers
Impact
Action
Prof Martin Prince
Institute of Psychiatry
King’s College London, UK
7
6
5
4
3
2
Standardised prevalence (%)
Prevalence of dementia, by region
9
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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
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”
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
40
30
20
DSMIV
10
1066
DSMIV
(u
rb
Pe
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ru
M
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ur
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Incidence/ 1000 PYR
50
Prince et al, Lancet 2012
Global Distribution of Incident Dementia
(7.7 million new cases per year)
Africa
7%
Europe
30%
North America
11%
Latin America
5%
One new case
every 4 seconds!
Asia
47%
WHO Report 2012 – Dementia a Public Health Priority
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
Population
RR - association attributable
with AD
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
(Barnes and Yaffe
2011)
50.7%
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 Wimo
Karolinska Institute, Sweden
Martin Prince
King’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
Worldwide distribution of costs by sector
LI
C
IC
LM
UM
IC
Direct
medical
Direct
social
Informal
care
HI
C
%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Dementia UK Results
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
Dementia UK Results
Where are the people with dementia?
250000
212456
Number of people
200000
424k in the community (64%)
244k in care homes (36%)
Proportion in care homes rises
with age
150000
Care
homes
Residential
care
27%
28%
41%
61%
94739
100000
81619
71446
65680
70986
45737
50000
25900
0
65-74
75-84
85-89
90+
Community
Community
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
Albanese et al, BMC Health Services Res 2011
Prince et al, World Psychiatry, 2007
Medical help-seeking by people with dementia and
their carers
70
60
50
%
Carer noted MI
BPSD
40
SMI
30
20
10
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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
Horizontal vs. vertical approachers
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
– Scalable models of evidence-based clinical care to
close the treatment gap
– Social policy – long-term care
– Prevention
– Continuous monitoring on key indicators