Dementia Storm on the Horizon
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- Authors: NATHANIEL COUNTS
- Published: December 2, 2021
Scope and clinical features
- Dementia refers to a group of conditions (Alzheimer’s dementia, vascular dementia, Lewy body dementia, and frontotemporal dementia) that:
- Have different underlying pathologies but share important features.
- Are progressive, ultimately fatal, irreversible, and lack treatments.
- Are relatively rare in people younger than 50; prevalence practically doubles every five years thereafter.
- Disability-adjusted life years (DALYs) are used as a common measure of disease burden, capturing impacts on functioning and life expectancy.
Burden projections and distribution
- Current ranking and projected growth:
- Dementia is currently the sixth greatest contributor to disability burdens globally among people ages 55 and up.
- 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, projected DALYs are:
- 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 it will become the fifth greatest contributor to global disability in this age group (Bloom and others 2021).
- Geographic and income-shift dynamics:
- The center of gravity for the global disease burden of dementia is shifting from advanced economies to low- and middle-income countries.
- Lower-middle-income countries will account for nearly 30 percent of the growth in dementia-related disability-adjusted life years from 2019 to 50.
- 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 (Bloom and others, 2021).
Economic and societal burden
- Forecasting evidence:
- Five representative studies were selected to illustrate predicted economic/societal burden; all forecast substantial increases in coming decades.
- Many studies find the burden will more than double between 2020 and 2050; one study forecasts a nine-fold increase.
- Cost components and limitations:
- All studies examined direct medical costs (outpatient, inpatient, long-term care); some included nonmedical costs (for example., transportation).
- Many studies attempted to include costs associated with informal caregiving.
- These studies do not account for effects on productive activities outside the market (for example., uncompensated childcare provided by older adults) or the extent to which individuals value averting dementia; the actual social and economic burden is likely larger than studies predict.
- Macroeconomic effects:
- Rising dementia burden will deplete the labor force and reduce productivity as individuals take on informal caregiving roles.
- Dementia care consumption of resources will reduce capital supply available for other investment.
- These effects will worsen global economic equity as the burden shifts to lower- and middle-income countries.
Research, clinical trials, and funding gaps
- Comparative underinvestment:
- 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.
- If dementia received investments comparable to cancer, it would likely initiate a cascade of treatment breakthroughs.
- Clinical trial performance and R&D challenges:
- 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 (PhRMA 2018).
- This equates to a 2.7 percent success rate.
- The success rate of drug development programs overall (those eventually leading to FDA approval) has been pegged at 13.8 percent (Wong and others 2019).
- The disease process for dementia remains not well understood; hundreds of candidate therapies effective in animal models often fail to 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 recruiting participants.
- Care delivery and financing barriers:
- Multiple randomized, controlled trials demonstrate benefits of interdisciplinary, team-based care for caregivers and patients, but such approaches are under-implemented.
- Fee-for-service health care payment models may undervalue team-based care and hamper wider implementation.
Lessons from COVID-19 and policy recommendations
- Framing:
- Dementia is characterized as a high-probability and low-visibility crisis, unlike COVID-19’s low-probability and high-visibility pandemics.
- COVID-19 demonstrated the global community’s ability to rapidly tackle complex research challenges with sufficient investment.
- Health system and care delivery actions:
- Prioritize support for interdisciplinary team-based care for patients and families living with dementia, especially in high- and middle-income countries.
- Scale disease management programs that implement standardized approaches to delivering and coordinating care for people with particular chronic diseases.
- Pursue innovative financing mechanisms (for example, value-based or outcomes-based contracting) to scale team-based care.
- R&D and financing actions (advanced economies to lead):
- Increase spending on dementia in three areas:
- Direct funding (especially basic research).
- Stronger incentives for private investment in R&D.
- Support for patient access to R&D outcomes, including absorption of patient costs—particularly in low- and middle-income countries.
- Build a global R&D ecosystem that can develop clinical trial infrastructure and repositories of biological samples (biobanks).
- Encourage investment in many simultaneous drug development projects to diversify risk across projects.
- Establish a megafund with a government guarantee on principal investments to raise necessary capital; investments could work like bond financing: investors get their original investment back plus interest from proceeds of successful drug developments (Fagnan and others 2013).
- Support may extend to development of health care infrastructure in low- and middle-income countries.
- Equity considerations:
- Informal caretaking is intensive and often performed by family members, disproportionately women, impeding progress toward labor force equity.
- Many risk factors for dementia are associated with systemic disadvantages (including air pollution and lack of access to education or nutritious foods), concentrating the economic burden among those already most financially challenged.
- Rich-country efforts to link, scale, and invest can help poorer countries realize their productive capacity.
Conclusion and call to action
- Why it matters:
- Dementia is becoming an overwhelming societal burden with enormous health, social, and economic implications, especially as populations age worldwide.
- What to do:
- Massive investments in care, prevention, and R&D are needed now.
- Advanced economies should lead these investments, incentivize private investment, and prioritize access for poorer economies.
- Rationale:
- Such actions are both humanitarian and economically sensible.
Source: Dementia Storm on the Horizon, F&D Magazine, NATHANIEL COUNTS, December 2021.
Content in this bundle
- عاصفة الخَرَف تلوح في الأفق
- Dementia Storm
- Tormenta de demencia en el horizonte ● Finanzas y Desarrollo ● Diciembre de 2021
- Counts
- 認知症の嵐
- ТУЧИ ДЕМЕНЦИИ
- 痴呆症风暴即将来袭 ● 《金融与发展》● 2021年12月号