1. Dementia and chronic diseases - a global view Centre for Global Mental Health King’s College London 1066drg@iop.kcl.ac.uk Martin Prince

2. 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%

3. 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)

4. Some important questions §What is different about old age? l Degenerative disorders – stroke, dementia l Not one condition but several (comorbidity) l Disability, and needs for long-term care l Fragile economic and social protection §Why do older people matter? l Account for the majority of disease burden and cost (health and societal) l Underserved §Major Challenges? l Access to effective, age-appropriate healthcare l Attention to dependence and long-term care

5. 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 l Population ageing l The ‘health transition’ – globalisation of risk behaviours

6. Leading contributors to global burden of disease among people aged 60+ Millions of Disability Adjusted Life Years (DALYs) by cause and region

7. What is dementia? §A syndrome, not a single disorder l Characterised by progressive cognitive impairment (memory, language, thinking, judgment) l Many underlying causes – Alzheimer’s disease, vascular dementia, Dementia with Lewy bodies, Frontal Temporal dementia §A condition of later life l Around 5% of cases have onset before the age of 60 l Prevalence doubles with every five year increase in age §Low levels of awareness and help-seeking l A ‘normal part of ageing’ l ‘Nothing can be done’ l Stigma and shame §A large ‘treatment gap’ l Half to two-thirds not diagnosed in high income countries l 90% + not diagnosed in low and middle income countries

8. Developed/ developing country differences?

9. Prevalence of 10/66 and DSM IV Dementia Rodriguez et al for 10/66, Lancet 2008 So is it 8-10% or <1%?

10. A global epidemic 36 million now 66 million by 2030 115 million by 2050 One new case every 4 seconds

11. 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……..

12. 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?

13. 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 Total costs £17 billion Costs per person Average£25,472 Mild dementia (community)£14,540 Moderate dementia (Community)£20,355 People in care homes£31,263

14. World Alzheimer Day, September 21 st, London, 2010 –Global Societal Economic cost –$604bn –1% of GDP –Equivalent to world’s 18 th largest economy –Larger than the annual turnover of Walmart Anders Wimo Karolinska Institute, Sweden Martin Prince King’s College London, UK

15. Long term care, and social protection for older people

16. 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

17. Social protection for people with dementia in India (10/66 DRG) Urban ChennaiRural Vellore Pension13.3%26.9% Money from family 28.0%44.4% Disability pension 2.7%0.0% Food insecurity28.0%17.6% No children available locally 9.3%7.5%

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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?

24. 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