Dementia and chronic diseases - a global view

Centre for Global Mental HealthKing’s College London1066drg@iop.kcl.ac.uk

Martin Prince

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+

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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?

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Prevalence of 10/66 and DSM IV Dementia

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Rodriguez et al for 10/66, Lancet 2008

So is it 8-10% or <1%?

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 lived with disability, not mortality

• 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 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

• 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

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

28.0% 44.4%

Disability pension

2.7% 0.0%

Food insecurity 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

The WHO Mental 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

• Increasing the coverage of evidence-based community interventions in low and middle income countries

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

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

A more integrated approach?

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