## Dementia Storm (Counts et al.)

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### Scope and epidemiological projections
- Dementia contributed 33.1 million disability-adjusted life years in 2019.
- If the burden continues to grow at the same rate as in the past decade, dementia will contribute:
  - 55.1 million in 2030
  - 81.1 million in 2040
  - 115.8 million in 2050
- The global burden of dementia will more than triple over the next 30 years and will become the fifth greatest contributor to global disability among people ages 55 and up.
- Prevalence pattern: symptoms of Alzheimer’s disease and related dementias are relatively rare in people younger than 50, but prevalence practically doubles every five years thereafter.
- Geographic shift in burden (2019–2050 projections):
  - Lower-middle-income countries will account for nearly 30 percent of the growth in dementia-related disability-adjusted life years.
  - Upper-middle-income countries will account for 12 percent growth during 2019–2050.
  - The share in advanced economies will decrease by 30 percent.
  - By 2050, poorer countries are projected to contribute more to the global disease burden of dementia than wealthier ones.

### Economic and societal burden — summary of forecasts
- All selected studies forecast substantial increases in the societal and economic burden of dementia in coming decades; many project the burden will more than double between 2020 and 2050, with one study forecasting a nine-fold increase.
- Key study forecasts (all costs adjusted to 2020 US$ and reported as total costs and per capita costs where given):
  - Cimler and others (2019) — European Union; costs include direct medical, long-term care, informal care (opportunity cost):
    - Total Costs Forecast (2020 US$, billions):
      - 2015: 281
      - 2030: 510
      - 2040: 636
      - 2050: 766
      - 2060: 862
      - 2070: 906
      - 2080: 933
    - Per Capita Forecast Costs (2020 US$):
      - 2015: 553
      - 2030: 988
      - 2040: 1,239
      - 2050: 1,511
      - 2060: 1,735
      - 2070: 1,857
      - 2080: 1,935
  - Jia and others (2018) — Alzheimer’s disease & Dementia; China/Global; costs include direct medical, direct nonmedical, indirect costs:
    - AD Costs China (Total, 2020 US$, billions):
      - 2015: 183
      - 2020: 272
      - 2030: 554
      - 2040: 1,092
      - 2050: 2,064
    - Dementia Costs Global (Total, 2020 US$, billions):
      - 2015: 1,046
      - 2020: 1,452
      - 2030: 2,774
      - 2040: 5,274
      - 2050: 9,959
    - AD Costs China (Per capita, 2020 US$):
      - 2015: 571
      - 2020: 820
      - 2030: 1,585
      - 2040: 2,979
      - 2050: 5,439
    - Dementia Costs Global (Per capita, 2020 US$):
      - 2015: 3,259
      - 2020: 4,388
      - 2030: 7,933
      - 2040: 14,388
      - 2050: 26,247
  - Sado and others (2018) — Dementia; Japan; costs include direct medical, formal long-term-care, informal care (mixed replacement cost and opportunity cost):
    - Total Costs Forecast (2020 US$, billions):
      - 2015: 144
      - 2020: 168
      - 2030: 206
      - 2040: 221
      - 2050: 219
    - Per Capita Forecast Costs (2020 US$):
      - 2015: 1,129
      - 2020: 1,325
      - 2030: 1,704
      - 2040: 1,947
      - 2050: 2,071
  - Wimo and others (2017) — Dementia; Global; costs include direct medical, direct social care, informal care (opportunity cost):
    - Total Costs Forecast (2020 US$, billions):
      - 2015: 893
      - 2030: 2,180
    - Per Capita Forecast Costs (2020 US$):
      - 2015: 2,784
      - 2030: 6,246
  - Hurd and others (2013) — Dementia; United States; costs include care purchased in marketplace and informal costs (replacement cost or forgone wages):
    - Replacement Cost (Total, 2020 US$, billions):
      - 2010: 385
      - 2020: 456
      - 2030: 646
      - 2040: 914
    - Forgone Wages (Total, 2020 US$, billions):
      - 2010: 318
      - 2020: 377
      - 2030: 534
      - 2040: 757
    - Replacement Cost (Per Capita, 2020 US$):
      - 2010: 1,244
      - 2020: 1,377
      - 2030: 1,847
      - 2040: 2,493
    - Forgone Wages (Per Capita, 2020 US$):
      - 2010: 1,029
      - 2020: 1,140
      - 2030: 1,528
      - 2040: 2,066
- Caveat: Because of differences in discount rates and methods, not all forecasts are directly comparable.
- The studies generally included direct medical costs and many included informal caregiving costs; some included nonmedical costs such as transportation to appointments.
- Important omissions: none of the studies examined effects on productive activities outside the market (for example, uncompensated childcare older adults provide) or accounted for the extent to which individuals value averting dementia; the actual social and economic burden is likely larger than these studies predict.

### Economic mechanisms and equity impacts
- Dementia’s rising burden will:
  - Deplete the labor force.
  - Reduce productivity as individuals take on informal caregiving roles.
  - Reduce the capital supply available to invest elsewhere as dementia care consumes substantial resources.
- Informal caregiving is often provided by family members, with women typically bearing a disproportionate burden, which halts progress toward equity in the labor force.
- Risk factors for dementia are associated with systemic disadvantages (including air pollution and lack of access to education or nutritious foods), concentrating economic burden among those already in the most challenging financial situations and feeding cycles of poverty.
- As the burden shifts to lower- and middle-income countries, global economic equity concerns intensify.

### Research, development, and funding gaps
- Clinical trial and R&D shortcomings:
  - Dementia has one of the highest failure rates in clinical development.
  - An analysis of 150 trials completed between 1998 and 2017 for Alzheimer’s disease found 146 failures; only 4 were approved by the US Food and Drug Administration.
  - This equates to a 2.7 percent success rate for those Alzheimer’s trials.
  - The success rate of drug development programs overall (those eventually leading to FDA approval) has been pegged at 13.8 percent.
- Additional R&D challenges:
  - The disease process for dementia is still not well understood.
  - Hundreds of candidate therapies effective in animal models often do not translate to humans.
  - R&D is not well coordinated globally; data sharing has been limited.
  - Clinical trials for dementia are often prohibitively expensive because of difficulty in recruiting participants.
- Comparative funding inadequacy:
  - Cancers have more than 50 times as many interventional clinical trials registered on ClinicalTrials.gov as dementia, even though dementia contributes approximately eight times more to disability (context as presented in the article).
- Health system implementation gaps:
  - Multiple randomized controlled trials demonstrate benefits of interdisciplinary, team-based care for caregivers and patients, yet these approaches are under-implemented.
  - Fee-for-service payment models may undervalue team-based care, hampering wider implementation.

### Lessons from COVID-19 and strategic recommendations
- Framing: dementia is high-probability and low-visibility, unlike COVID-19 which was low-probability and high-visibility; COVID-19 demonstrates that rapid, well-resourced global responses to complex research challenges are feasible when the economic peril of inaction is clear.
- Recommended priority actions for advanced economies and global collaboration:
  - Ramp up spending on dementia, led by governments of advanced economies, which currently bear most economic and societal costs because of age structure.
  - Invest in three areas to boost dementia R&D:
    - Direct funding, especially for basic research.
    - Stronger incentives for private investment in R&D.
    - Support for patient access to the fruits of R&D, including absorption of patient costs—particularly in low- and middle-income countries.
  - Build a global R&D ecosystem that develops clinical trial infrastructure and repositories of biological samples (biobanks).
  - Encourage investment in many simultaneous drug development projects to diversify risk across projects.
  - Consider establishing a megafund with a government guarantee on principal investments; investments could operate like bond financing where investors get their original investment back plus interest from proceeds of successful drug developments.
  - Reconsider health care delivery for people with dementia: prioritize support for interdisciplinary team-based care, disease management programs, and innovative financing mechanisms (for example, value-based or outcome-based contracting) to scale care in many settings.
  - Link, scale, and invest from richer countries to help poorer countries realize full productive capacity and improve global economic equity.

### Conclusion — “What? So what? Now what?”
- What? Dementia is gradually becoming an overwhelming societal burden with rapidly rising health, social, and economic impacts.
- So what? The growing burden will metastasize as the world, especially poorer countries, experiences unprecedented population aging; this represents both a humanitarian crisis and an economic threat.
- Now what? Massive investments are needed in care, prevention, and R&D, led by advanced economies that incentivize private investment and prioritize poorer economies’ access to dividends; such action is both morally imperative and economically sensible.

*Article by Nathaniel Counts, Arindam Nandi, Benjamin Seligman, and Daniel Tortorice (Data for Decisions, LLC dementia research team).*

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_Source: https://www.imf.org/-/media/files/publications/fandd/article/2021/december/counts.pdf_