Dementia incidence trend in England and Wales, 2002-19, and projection for dementia burden to 2040: analysis of data from the English Longitudinal Study of Ageing

Towards the automatic detection of activities of daily living using eye-movement and accelerometer data with neural networks

Early diagnosis of neurodegenerative diseases, such as Alzheimer's disease, improves treatment and care outcomes for patients. Early signs of cognitive decline can be detected using functional scales, which are written records completed by a clinician or carer, detailing a patient's capability to perform routine activities of daily living. For example, tasks requiring planning, such as meal preparation, are some of the earliest affected by early mild cognitive impairment. In this article, we describe work towards the development of a system to automatically discriminate and objectively quantify activities of daily living. We train a selection of neural networks to discriminate a novel list of 14 activities, specially selected to overlap with those measured by existing functional scales. Our dataset consists of eight hours of development data captured from four individuals wearing the Continuous Ambulatory Vestibular Assessment (CAVA) device, which was originally developed to aid the diagnosis of vertigo. Using frequency domain recognition features derived from eye-movement and accelerometer data, we compare several classification approaches, including three bespoke neural networks, and two established network architectures commonly applied to time-series classification problems. In 10-fold cross-validation experiments, a peak mean accuracy of 64.1% is obtained. The highest accuracy across all folds is 75.3%, produced by networks comprising Gated Recurrent Units. The addition of eye-movement data is shown to improve discrimination compared to using accelerometer data alone, by close to 9%. Classification accuracy is shown to degrade if the system is trained such that test subjects are excluded from the training data, with the small size of the dataset given as a likely explanation. Our findings demonstrate that the addition of eye-movement data can significantly improve the discrimination of daily activities, and that neural networks are well suited to this task.

Prosocial Intentions and Subsequent Cognitive Health: A Prospective Cohort Study

OBJECTIVES

Prosociality, defined as positive other-regarding intentions and behaviors, is a modifiable factor demonstrated to be associated with better mental, physical, and cognitive health in older adults. Prior studies have largely focused on individual prosocial behaviors, especially volunteering. This study examines whether prosocial intentions are associated with maintaining cognitive health over time.

METHODS

Data are from 7,844 adults aged 50 or older in the English Longitudinal Study of Ageing. A 9-item prosocial intentions scale was derived from self-reported items assessing altruism and collectivism. Cognitive health was assessed via biennial completion of tasks related to executive function and verbal memory and incident dementia diagnosis over 11 years. Linear mixed-effects models examined relationships between prosocial intentions and changes in executive function and verbal memory. Cox proportional hazards models assessed risk of developing dementia. A broad array of demographic, socioeconomic, and health-related covariates were also considered.

RESULTS

Results from mixed-effects analyses suggest higher prosocial intentions are associated with better cognitive health maintenance after controlling for sociodemographics and baseline health characteristics including depressive symptoms. Participants with high versus low prosocial intentions had 24% slower decline in verbal memory and 55% slower decline in executive function. Similarly, higher prosocial intentions were associated with a 35% reduced hazard of dementia during this same period in fully adjusted models.

DISCUSSION

These results suggest aspects of prosociality beyond formal volunteering facilitate maintaining cognitive health among older adults and may provide novel targets for future interventions to enhance healthy aging.

Reevaluating the Role of Education in Cognitive Decline and Brain Aging: Insights from Large-Scale Longitudinal Cohorts across 33 Countries

Why education is linked to higher cognitive function in aging is fiercely debated. Leading theories propose that education reduces brain decline in aging, enhances tolerance to brain pathology, or that it does not affect cognitive decline but rather reflects higher early-life cognitive function. To test these theories, we analyzed 407.356 episodic memory scores from 170.795 participants > 50 years, alongside 15.157 brain MRIs from 6.472 participants across 33 Western countries. More education was associated with better memory, larger intracranial volume and slightly larger volume of memory-sensitive brain regions. However, education did not protect against age-related decline or weakened effects of brain decline on cognition. The most parsimonious explanation for the results is that the associations reflect factors present early in life, including propensity of individuals with certain traits to pursue more education. While education has numerous benefits, the notion that it provides protection against cognitive or brain decline is not supported.

Forecasting stroke and stroke-driven dementia in a rapidly ageing population: a model-based analysis of alternative projection scenarios for Ireland

OBJECTIVE

Understanding future population needs is key for informing stroke service planning. This study aims to evaluate scenarios for future trends in stroke age-specific incidence and case fatality, and estimate their impact on projected stroke and poststroke dementia prevalence in Ireland.

DESIGN

This is an epidemiological modelling study based on a probabilistic Markov model. We extrapolated trends in age-specific stroke incidence and case fatality from 1990 to 2019 and applied these to 2016 to 2046. We defined trend scenarios based on stability and low and high decline, broadly based on the lower and upper bounds of evidence for trends to date. We also examined nonlinear trends involving decelerating decline over time and varying trends by age.

SETTING/PARTICIPANTS

The study is conducted on the Irish population aged 40-89 years in the period 2022-2046. We used multiple data sources, including systematic review and observational evidence.

INTERVENTIONS

Not applicable.

PRIMARY AND SECONDARY OUTCOME MEASURES

We projected the incidence and prevalence of stroke (International Classification of Disease (ICD) codes I60-I61, I63-I64), poststroke dementia (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) criteria) and poststroke disability (modified Rankin Scale 3-5).

RESULTS

The stable scenario indicated a projected 85 834 stroke survivors in 2046 (95% uncertainty interval (UI)=82 366-89 655), an increase of 45.7% from 2022. Assuming a high incidence decline and low case-fatality decline indicated a 5.4% increase in prevalence. Intermediate scenarios based on lower rates of decline, or decline rates slowing over time, implied an increase between 25.8% and 40.3%. Results did not differ substantially when we varied trends by age.In the stable scenario, we projected 16 978 poststroke dementia prevalent cases in 2046 (95% UI 14 958-19 157), an increase of 58.9% from 2022. In the high decline scenario, the increase would be 24.5%, with intermediate scenarios implying an increase between 41.3% and 56.3%.

CONCLUSIONS

Future stroke healthcare needs will vary substantially depending on epidemiological trends. There is an urgent need to both invest in prevention strategies and plan for likely increases in future stroke care needs.

Reevaluating the Role of Education in Cognitive Decline and Brain Aging: Insights from Large-Scale Longitudinal Cohorts across 33 Countries

Why education is linked to higher cognitive function in aging is fiercely debated. Leading theories propose that education reduces brain decline in aging, enhances tolerance to brain pathology, or that it does not affect cognitive decline but rather reflects higher early-life cognitive function. To test these theories, we analyzed 407.356 episodic memory scores from 170.795 participants >50 years, alongside 15.157 brain MRIs from 6.472 participants across 33 Western countries. More education was associated with better memory, larger intracranial volume and slightly larger volume of memory-sensitive brain regions. However, education did not protect against age-related decline or weakened effects of brain decline on cognition. The most parsimonious explanation for the results is that the associations reflect factors present early in life, including propensity of individuals with certain traits to pursue more education. While education has numerous benefits, the notion that it provides protection against cognitive or brain decline is not supported.

Dementia diagnosis rates and the impact of ethnicity, rurality and deprivation

OBJECTIVES

NHS England publishes monthly national and regional estimated dementia diagnosis rates (DDR) to assess the healthcare system's effectiveness in identifying dementia cases. Previous research indicates that sociodemographic factors, such as ethnic minority status, socioeconomic deprivation, and rurality, influence both healthcare quality and dementia risk. This study aimed to examine the association between these sociodemographic factors and DDR, and to estimate an ethnicity-adjusted DDR using available ethnic group data.

METHOD

We analysed NHS Digital Primary Care Dementia Data electronic health records for July 2023. We used a linear regression model to determine the association between DDR and ethnicity, deprivation, and rurality factors using local authority region level data. We also adjusted the DDR at the level of sub-integrated care boards based on previously published odds ratios of dementia diagnosis by ethnic group.

RESULTS

Regression modelling revealed that areas with higher proportions of minority ethnic groups and greater rurality had lower DDRs. Conversely, higher levels of deprivation were linked to higher DDRs. After adjusting for different odds ratios for dementia in minority ethnic groups, the national DDR decreased by 1%, with regional diagnosis rates dropping by up to 5.4%.

CONCLUSION

Higher regional proportional ethnic minority population and greater rurality were associated with a lower DDR which might reflect poorer access to diagnostic services. Higher deprivation levels were associated with a higher DDR which might reflect higher rates of dementia in more deprived populations. We discuss measures to improve the accuracy and utility of the DDR, with a specific focus on ethnicity.

The SLaM Brain Health Clinic: remote biomarker enhanced memory clinic for people with mild cognitive impairment within a National Health Service mental health trust

BACKGROUND

The novel South London and Maudsley Brain Health Clinic (SLaM BHC) leverages advances in remote consultations and biomarkers to provide a timely, cost-efficient and accurate diagnosis in mild cognitive impairment (MCI).

AIMS

To describe the organisation, patient cohort and acceptability of the remote diagnostic and interventional procedures.

METHOD

We describe the recruitment, consultation set-up, the clinical and biomarker programme, and the two online group interventions for cognitive wellbeing and lifestyle change. We evaluate the acceptability of the remote consultations, lumbar puncture, saliva genotyping, and remote cognitive and functional assessments.

RESULTS

We present the results of the first 68 (mean age 73, 55% female, 43% minoritised ethnicity) of 146 people who enrolled for full remote clinical, cognitive, genetic, cerebrospinal fluid and neuroimaging phenotyping. A total of 86% were very satisfied/satisfied with the remote service. In all, 67% consented to lumbar puncture, and 95% of those were very satisfied, all having no significant complications. A total of 93% found taking saliva genotyping very easy/easy, and 93% found the cognitive assessments instructions clear. In all, 98% were satisfied with the Cognitive Wellbeing Group, and 90% of goals were achieved in the Lifestyle Intervention Group.

CONCLUSIONS

The SLaM BHC provides a highly acceptable and safe clinical model for remote assessments and lumbar punctures in a representative, ethnically diverse population. This allows early and accurate diagnosis of Alzheimer's disease, differentiation from other MCI causes and targets modifiable risk factors. This is crucial for future disease modification, ensuring equitable access to research, and provides precise, timely and cost-efficient diagnoses in UK mental health services.

Implementing and sustaining dementia care coordinators across integrated care systems: a realist evaluation

BACKGROUND

Globally, dementia care is under strain. Rising rates across ageing populations, coupled with overstretched health and care systems, mean that people living with dementia and their carers are missing out on crucial support. Addressing dementia care is a key priority for the UK government. This has led to a period of care transformation, including the implementation of new dementia support services across integrated care systems (ICS). However, little is known about how these new services work. This evaluation identifies how a dementia care coordinator service, implemented in the largest ICS in England, works for people living with dementia, their carers and the workforce.

METHODS

A realist evaluation using mixed methods was carried out between 2022 and 2024. This involved a repeat survey with dementia care coordinators, carried out a year apart, alongside 57 interviews with coordinators, service managers, healthcare practitioners, people living with dementia and their carers. A realist logic of analysis was applied across all data sets.

RESULTS

Three broad concepts were identified including (1) workforce design and organisational culture, (2) meeting the needs of people living with dementia and their carers and (3) connecting to services and integrating care. A total of 23 context-mechanism-outcome configurations (CMOCs) across these concepts highlighted that whilst tensions exist between the service and wider system, dementia care coordinators ultimately act as bridge builders, connecting people to much-needed support. However, services like this could become a victim of their own success due to increasing caseloads and the risk of staff burnout.

CONCLUSIONS

The dementia care coordinator service is capable of supporting people who are pre- and post-dementia diagnosis despite the care system being under strain. This is a direct result of the bridge building work of the dementia care coordinators. Our findings support evidence-based recommendations for those wanting to implement and sustain a system-wide service and provide evidence for policy makers to consider increased funding for this service nationwide.

Asthma and cognitive dysfunction in older adults: the mediating role of systemic immune-inflammation index

Asthma and cognitive dysfunction represent significant public health challenges. Our study aimed to investigate the relationship between asthma and cognitive dysfunction in adults aged ≥ 60 years, and explore the role of systemic immune inflammation index (SII) in asthma - cognitive dysfunction link. The retrospective cross-sectional study included 2,579 participants aged ≥ 60 years from the 2011-2014 National Health and Nutrition Examination Survey (NHANES) cycles. Asthma diagnosis was confirmed using the MCQ010 questionnaire, cognitive function assessed through the Digit Symbol Substitution Test (DSST). SII was calculated using the formula: (platelet count × neutrophil count)/lymphocyte count. Controlling for demographic variables including sex, age, race and/ethnicity, poverty-to-income ratio (PIR) and education level, a negative association was found between asthma and DSST scores (β = -1.75, 95% CI: -3.38, -0.120, P = 0.037). This association persisted even after further adjustments for body mass index (BMI) and diabetes (β = -1.72, 95% CI: -3.38, -0.057, P = 0.043). Moreover, subgroup analysis showed no significant association of sex, age, race/ethnicity, BMI or diabetes with the relationship between asthma and cognitive function. Mediation analysis indicated SII was a mediator of asthma-induced cognitive impairment, a notable Average Causal Mediated Effect (ACME) (P = 0.004) between SII and cognitive dysfunction. Our investigation indicated that elderly asthma (aged ≥ 60 years) was predisposed to cognitive dysfunction, independent of sex, age, race/ethnicity, BMI and diabetes. Furthermore, mediation analysis suggested that asthma might contribute to cognitive dysfunction through the involvement of SII.

Projecting Long-Term Care Costs Among Older Adults With ADL Disabilities and Cognitive Impairment in China

BACKGROUND

Mounting evidence suggests that cognitive impairment is strongly associated with disability in activities of daily living (ADL disability) and long-term care (LTC) costs. However, studies forecasting future LTC costs often overlook these relationships. Consequently, this study aims to more accurately project future LTC costs in China over the next 20 years by considering the intertwined association between disability and cognitive impairment on future LTC costs.

METHODS

Data were from 10 959 adults ≥65 years from the 2005-2018 waves of the Chinese Longitudinal Healthy Longevity Surveys. We used the Markov model to project the population of China and track the transition of older adults in the next 20 years between 4 disability-cognition states. We employed a 2-part model to estimate LTC costs (direct and indirect LTC costs) per capita.

RESULTS

The proportion of disabled older adults with cognitive impairment was projected to increase from 1.4% in 2021 to 3.4% in 2040, while that of those without cognitive impairment was projected to decrease from 4.7% in 2021 to 4.5% in 2040. The direct and indirect LTC costs were projected to increase from 0.3% and 0.2% of gross domestic product (GDP) in 2021 to 1.4% and 0.7% in 2040 for disabled persons without cognitive impairment and from 0.1% and 0.1% of GDP in 2021 to 1.3% and 1.3% in 2040 for those with cognitive impairment, respectively.

CONCLUSIONS

Policy-makers could include the assessment of cognition in the LTC needs assessment and allocate more compensation to LTC insurance participants with cognitive impairment.

Estimating the incidence of dementia in New Zealand: a cohort study applying capture-recapture modelling to routinely collected linked health datasets

Background

Issues of under-diagnosis and under-coding of dementia in routinely collected health data limit their utility for estimating dementia prevalence and incidence in Aotearoa New Zealand (NZ). Capture-recapture techniques can be used to estimate the number of dementia cases missing from health datasets by modelling the relationships and interactions between linked data sources. The aim of this study was to apply this technique to routinely collected and linked health datasets and more accurately estimate the incidence of dementia in NZ.

Methods

All incident cases of dementia in the NZ 60+ population were identified in three linked national health data sets-interRAI, Public hospital discharges, and Pharmacy. Capture-recapture analysis fitted eight loglinear models to the data, with the best fitting model used to estimate the number of cases missing from all three datasets, and thereby estimate the 'true' incidence of dementia. Incidence rates were calculated by 5-year age bands, sex and ethnicity.

Findings

Modelled estimates indicate 36% of incident cases are not present in any of the datasets. Modelled incidence rates in the 60+ age group were 19.2 (95% CI 17.3-22.0)/1000py, with an incident rate ratio of 1.9 (95% CI 1.9-2.0) per 5-year age band. There was no difference in incidence rates between males and females. Incidence rates in Asian (p < 0.001) but not Māori (p = 0.974) or Pacific peoples (p = 0.110) were significantly lower compared to Europeans, even after inclusion of missing cases.

Interpretation

This is the first study to provide estimates of age 60+ dementia incidence in NZ and for the four main ethnic groups and suggests over a third of incident dementia cases are undiagnosed. This highlights the need for better access to dementia assessment and diagnosis so that appropriate supports and interventions can be put in place to improve outcomes for people living with dementia and their families.

Funding

Nil.

Obesity and survival in advanced non-small cell lung cancer patients treated with chemotherapy, immunotherapy, or chemoimmunotherapy: a multicenter cohort study

BACKGROUND

The association of body mass index (BMI) with survival outcomes in patients with advanced non-small cell lung cancer (NSCLC) treated with first-line chemotherapy, immunotherapy, or chemoimmunotherapy is controversial. We aimed to investigate these associations, including associations in male and female patients specifically, in a multicenter cohort study.

METHODS

We retrospectively analyzed data from seven cohorts comprising 7021 advanced non-small cell lung cancer patients who received chemotherapy (three cohorts), immunotherapy (two cohorts), and chemoimmunotherapy (two cohorts) from five data sources, including a de-identified nationwide (US-based) NSCLC clinico-genomic database and two randomized, double-blind, phase 3 clinical trials. BMI was categorized as underweight, normal weight, overweight, or obese. Underweight patients were excluded because of their small proportion. The primary endpoints were the associations between BMI and progression-free survival (PFS) and overall survival (OS) stratified by treatment type and sex, which were assessed using Kaplan-Meier methods and adjusted Cox modeling. Meta-analyses were performed to combine the adjusted hazard ratios.

RESULTS

In the pooled analysis, obesity was significantly associated with improved OS in patients receiving chemotherapy (hazard ratios [HR] = 0.84, 95% confidence interval (CI) 0.76-0.93), but there was no association with PFS (HR = 0.91, 95% CI 0.82-1.02). The association of BMI with OS for patients receiving chemotherapy differed by sex, with an inverse association in men (HR = 0.74, 95% CI 0.64-0.84), but no association observed in women (HR = 0.96, 95% CI 0.81-1.13, Pinteraction = 0.018). No impact of BMI on OS or PFS was detected in patients receiving immunotherapy or chemoimmunotherapy. Obese patients had the lowest level of tumor mutational burden, similar level of programmed death-ligand 1 expression and ESTIMATE scores.

CONCLUSIONS

Obesity may be associated with an increased overall survival among male patients treated with chemotherapy, whereas not associated with the outcomes in patients treated with immunotherapy or chemoimmunotherapy.

Risk of Dementia in Parkinson's Disease: A Systematic Review and Meta-Analysis

Estimates of the risk of dementia in Parkinson's disease (PDD) vary widely. We aimed to review the incidence of PDD and in a meta-analysis estimate the pooled annual incidence and relative risk of PDD while also exploring factors that may contribute to heterogeneity between studies. Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed and MEDLINE and EMBASE were searched for articles reporting the number of cases of dementia in a population, followed longitudinally, with a minimum of 100 dementia-free Parkinson's disease (PD) patients at baseline. Meta-analyses and meta-regressions were used to estimate the pooled incidence rate of PDD and the relative risk of PDD versus healthy controls (HC). A total of 32 studies were identified, 25 reporting the incidence of PDD and 10 reporting the relative risk of PDD versus HC. The pooled incidence rate of PDD was 4.45 (95% confidence interval [CI], 3.91-4.99) per 100 person-years at risk, equating to a 4.5% annual risk of dementia in a PD prevalent population. The relative risk of PDD was estimated to be 3.25 (95% CI, 2.62-4.03) times greater than HC. Factors contributing to study heterogeneity and disparities in the estimated risk of PDD include the age of patients, year of recruitment, and study location. Significant gaps remain with no studies identified in several geographical regions. Future studies should stratify by age and standardize reporting to reduce overall heterogeneity. © 2024 The Author(s). Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Benefits of population-level interventions for dementia risk factors: an economic modelling study for England

BACKGROUND

Individual-level interventions for dementia risk factors could reduce costs associated with dementia and some are cost-effective. We aimed to estimate the cost-effectiveness of population-level interventions for tackling dementia risk factors.

METHODS

In this economic modelling study, we included recommended population-based interventions from a previously published review article for which there was consistent and robust evidence of effectiveness in tackling a dementia risk factor (tobacco smoking, excess alcohol use, hypertension, obesity, air pollution, and head injury). We only included interventions if they had not been introduced in England or were in place but could be extended. The interventions studied were increases in tobacco pricing, minimum pricing for alcohol, raising alcohol price, salt reduction policies, sugar reduction policies, low emission zones, and compulsory helmet use for cycling by children (aged 5-18 years). We used published intervention effect sizes and relative risks for each risk factor and a Markov model to estimate progression to dementia in populations with and without the intervention, looking at lifetime risk, in the population of England.

FINDINGS

We estimated that reductions in excess alcohol use through minimum unit pricing would lead to cost-savings of £280 million and 4767 quality-adjusted life-years (QALYs) gained over an indefinite succession of age cohorts. Reformulation of food products to reduce salt would lead to cost-savings of £2·4 billion and 39 433 QALYs gained and reformulation to reduce sugar would lead to cost-savings of £1·046 billion and 17 985 QALYs gained. Reducing dementia risk from air pollution by introducing low emission zones in English cities with a population of 100 000 or more (that do not already impose restrictions) would lead to £260 million cost-savings and 5119 QALYs gained. Raising cigarette prices by 10% to reduce dementia risk from smoking would lead to 2277 QALYs gained and cost-savings of £157 million. Making bicycle helmets compulsory for children (aged 5-18 years) to reduce dementia risk from head injury would lead to cost-savings of £91 million and 1554 QALYs gained.

INTERPRETATION

Population-level interventions could help tackle life course dementia risk and save costs.

FUNDING

UK National Institute for Health and Care Research Three Schools dementia research programme.

Projection for dementia burden in China to 2050: a macro-simulation study by scenarios of dementia incidence trends

Background

It is unclear how temporal trends in dementia incidence, alongside fast-changing demography, will influence China's future dementia burden. We developed a Markov model that combines population trends in dementia, mortality, and dementia-related comorbidities, to forecast and decompose the burden of dementia in China to 2050.

Methods

Population-based Chinese ageing cohorts provided input data for a 10-health-state Markov macrosimulation model, IMPACT-China Ageing Model (CAM), to predict sex- and age-specific dementia prevalence among people aged 50+ by year to 2050. We assumed three potential future scenarios representing the range of likely dementia incidence trends: upward (+2.9%), flat (0%) or downward (-1.0%). Sensitivity analyses were conducted to examine uncertainty associated with trends in mortality rates and CVD incidence. The projected dementia burden was decomposed into population growth, population ageing, and changing dementia prevalence corresponding to the three incidence trend scenarios.

Findings

Under the upward trend scenario, the estimated number of people living with dementia is projected to rise to 66.3 million (95% uncertainty interval (UI) 64.7-68.0 million), accounting for 10.4% of the Chinese population aged 50+ by 2050. This large burden will be lower, 43.9 (95% UI 42.9-45.0) million and 37.5 (95% UI 36.5-38.4) million, if dementia incidence remains constant or decreases. Robustness of the projection is confirmed by sensitivity analyses. Decomposition of the change in projected dementia cases indicates dominate effects of increasing dementia prevalence and population ageing, and a relatively minor contribution from negative population growth.

Interpretation

Our findings highlight an impending surge in dementia cases in China in the forthcoming decades if the upward trend in dementia incidence continues. Public health interventions geared towards dementia prevention could play a pivotal role in alleviating this burgeoning disease issue.

Funding

National Science Foundation of China/UK Economic and Social Research Council.

Charting Alzheimer's Disease and Dementia: Epidemiological Insights, Risk Factors and Prevention Pathways

Alzheimer's disease (AD), the most common cause of dementia, is a complex and multifactorial condition without cure at present. The latest treatments, based on anti-amyloid monoclonal antibodies, have only a modest effect in reducing the progression of cognitive decline in AD, whereas the possibility of preventing AD has become a crucial area of research. In fact, recent studies have observed a decrease in dementia incidence in developed regions such as the US and Europe. However, these trends have not been mirrored in non-Western countries (Japan or China), and the contributing factors of this reduction remain unclear. The Lancet Commission has delineated a constrained classification of 12 risk factors across different life stages. Nevertheless, the scientific literature has pointed to over 200 factors-including sociodemographic, medical, psychological, and sociocultural conditions-related to the development of dementia/AD. This narrative review aims to synthesize the risk/protective factors of dementia/AD. Essentially, we found that risk/protective factors vary between individuals and populations, complicating the creation of a unified prevention strategy. Moreover, dementia/AD explanatory mechanisms involve a diverse array of genetic and environmental factors that interact from the early stages of life. In the future, studies across different population-based cohorts are essential to validate risk/protective factors of dementia. This evidence would help develop public health policies to decrease the incidence of dementia.

Evaluating a model of best practice in primary care led post-diagnostic dementia care: feasibility and acceptability findings from the PriDem study

OBJECTIVES

To evaluate the feasibility and acceptability of a primary care-based intervention for improving post-diagnostic dementia care and support (PriDem), and implementation study procedures.

DESIGN

A non-randomised, mixed methods, feasibility study.

SETTING

Seven general practices from four primary care networks (PCNs) in the Northeast and Southeast of England.

PARTICIPANTS

We aimed to recruit 80 people with dementia (PWD) and 66 carers INTERVENTION: Clinical Dementia Leads delivered a 12-month intervention in participating PCNs, to develop care systems, build staff capacity and capability, and deliver tailored care and support to PWD and carers.

OUTCOMES

Recruitment and retention rates were measured. A mixed methods process evaluation evaluated feasibility and acceptability of the intervention and study procedures. Using electronic care records, researchers extracted service use data and undertook a dementia care plan audit, preintervention and postintervention, assessing feasibility of measuring the primary implementation outcome: adoption of personalised care planning by participating general practices. Participants completed quality of life, and service use measures at baseline, 4 and 9 months.

RESULTS

60 PWD (75% of recruitment target) and 51 carers (77% of recruitment target) were recruited from seven general practices across four PCNs. Retention rate at 9 months was 70.0% of PWD and 76.5% of carers. The recruitment approach showed potential for including under-represented groups within dementia. Despite implementation challenges, the intervention was feasible and acceptable, and showed early signs of sustainability. Study procedures were feasible and accessible, although researcher capacity was crucial. Participants needed time and support to engage with the study. Care plan audit procedures were feasible and acceptable.

CONCLUSIONS

The PriDem model is an acceptable and feasible intervention. A definitive study is warranted to fully inform dementia care policy and personalised dementia care planning guidance. Successful strategies to support inclusion of PWD and their carers in future research were developed.

TRIAL REGISTRATION NUMBER

ISRCTN11677384.

Access to personalised dementia care planning in primary care: a mixed methods evaluation of the PriDem intervention

OBJECTIVES

Provision of personalised care planning is a national priority for people with dementia. Research suggests a lack of quality and consistency of care plans and reviews. The PriDem model of care was developed to deliver feasible and acceptable primary care-based postdiagnostic dementia care. We aimed to increase the adoption of personalised care planning for people with dementia, exploring implementation facilitators and barriers.

DESIGN

Mixed-method feasibility and implementation study.

SETTING

Seven general practices from four primary care networks (PCNs) in the Northeast and Southeast of England.

PARTICIPANTS

A medical records audit collected data on 179 community-dwelling people with dementia preintervention, and 215 during the intervention year. The qualitative study recruited 26 health and social care professionals, 14 people with dementia and 16 carers linked to participating practices.

INTERVENTION

Clinical dementia leads (CDL) delivered a 12-month, systems-level intervention in participating PCNs, to develop care systems, build staff capacity and capability, and deliver tailored care and support to people with dementia and their carers.

PRIMARY AND SECONDARY OUTCOME MEASURES

Adoption of personalised care planning was assessed through a preintervention and postintervention audit of medical records. Implementation barriers and facilitators were explored through semistructured qualitative interviews and non-participant observation, analysed using codebook thematic analysis informed by Normalisation Process Theory.

RESULTS

The proportion of personalised care plans increased from 37.4% (95% CI 30.3% to 44.5%) preintervention to 64.7% (95% CI 58.3% to 71.0%) in the intervention year. Qualitative findings suggest that the flexible nature of the PriDem intervention enabled staff to overcome contextual barriers through harnessing the skills of the wider multidisciplinary team, delivering increasingly holistic care to patients.

CONCLUSIONS

Meaningful personalised care planning can be achieved through a team-based approach. Although improved guidelines for care planning are required, commissioners should consider the benefits of a CDL-led approach.

TRIAL REGISTRATION NUMBER

ISRCTN11677384.

Changes in prevalence and incidence of dementia and risk factors for dementia: an analysis from cohort studies

BACKGROUND

Some cohort studies have reported a decline in dementia prevalence and incidence over time, although these findings have not been consistent across studies. We reviewed evidence on changes in dementia prevalence and incidence over time using published population-based cohort studies that had used consistent methods with each wave and aimed to quantify associated changes in risk factors over time using population attributable fractions (PAFs).

METHODS

We searched for systematic reviews of cohort studies examining changes in dementia prevalence or incidence over time. We searched PubMed for publications from database inception up to Jan 12, 2023, using the search terms "systematic review" AND "dementia" AND ("prevalence" OR "incidence"), with no language restrictions. We repeated this search on March 28, 2024. From eligible systematic reviews, we searched the references and selected peer-reviewed publications about cohort studies where dementia prevalence or incidence was measured in the same geographical location, at a minimum of two timepoints, and that reported age-standardised prevalence or incidence of dementia. Additionally, data had to be from population-based samples, in which participants' cognitive status was assessed and where validated criteria were used to diagnose dementia. We extracted summary-level data from each paper about dementia risk factors, contacting authors when such data were not available in the published paper, and calculated PAFs for each risk factor at all available timepoints. Where possible, we linked changes in dementia prevalence or incidence with changes in the prevalence of risk factors.

FINDINGS

We identified 1925 records in our initial search, of which five eligible systematic reviews were identified. Within these systematic reviews, we identified 71 potentially eligible primary papers, of which 27 were included in our analysis. 13 (48%) of 27 primary papers reported change in prevalence of dementia, ten (37%) reported change in incidence of dementia, and four (15%) reported change in both incidence and prevalence of dementia. Studies reporting change in dementia incidence over time in Europe (n=5) and the USA (n=5) consistently reported a declining incidence in dementia. One study from Japan reported an increase in dementia prevalence and incidence and a stable incidence was reported in one study from Nigeria. Overall, across studies, the PAFs for less education or smoking, or both, generally declined over time, whereas PAFs for obesity, hypertension, and diabetes generally increased. The decrease in PAFs for less education and smoking was associated with a decline in the incidence of dementia in the Framingham study (Framingham, MA, USA, 1997-2013), the only study with sufficient data to allow analysis.

INTERPRETATION

Our findings suggest that lifestyle interventions such as compulsory education and reducing rates of smoking through country-level policy changes could be associated with an observed reduction, and therefore future reduction, in the incidence of dementia. More studies are needed in low-income and middle-income countries, where the burden of dementia is highest, and continues to increase.

FUNDING

National Institute for Health and Care Research Three Schools' Dementia Research Programme.

Temporal trends in population attributable fractions of modifiable risk factors for dementia: a time-series study of the English Longitudinal Study of Ageing (2004-2019)

BACKGROUND

Interest in modifiable risk factors (MRFs) for dementia is high, given the personal, social, and economic impact of the disorder, especially in ageing societies such as the United Kingdom. Exploring the population attributable fraction (PAF) of dementia attributable to MRFs and how this may have changed over time remains unclear. Unravelling the temporal dynamics of MRFs is crucial for informing the development of evidence-based and effective public health policies. This investigation examined the temporal trajectories of MRFs for dementia in England.

METHODS

We used data from the English Longitudinal Study of Ageing, a panel study over eight waves collected between 2004 and 2019 (76,904 interviews in total). We calculated the PAFs for twelve MRFs (including six early- to mid-life factors and six late-life factors), as recommended by the Lancet Commission, and the individual weighted PAFs (IW-PAFs) for each risk factor. Temporal trends were analysed to understand the changes in the overall PAF and IW-PAF over the study period. Subgroup analyses were conducted by sex and socioeconomic status (SES).

RESULTS

The overall PAF for dementia MRFs changed from 46.73% in 2004/2005 to 36.79% in 2018/2019, though this trend was not statistically significant. During 2004-2019, hypertension, with an average IW-PAF of 8.21%, was the primary modifiable determinant of dementia, followed by obesity (6.16%), social isolation (5.61%), hearing loss (4.81%), depression (4.72%), low education (4.63%), physical inactivity (3.26%), diabetes mellitus (2.49%), smoking (2.0%), excessive alcohol consumption (1.16%), air pollution (0.42%), and traumatic brain injury (TBI) (0.26%). During 2004-2019, only IW-PAFs of low education, social isolation, and smoking showed significant decreasing trends, while IW-PAFs of other factors either did not change significantly or increased (including TBI, diabetes mellitus, and air pollution). Upon sex-specific disaggregation, a higher overall PAF for MRFs was found among women, predominantly associated with later-life risk factors, most notably social isolation, depression, and physical inactivity. Additionally, hearing loss, classified as an early- to mid-life factor, played a supplementary role in the identified sex disparity. A comparable discrepancy was evident upon PAF evaluation by SES, with lower income groups experiencing a higher dementia risk, largely tied to later-life factors such as social isolation, physical inactivity, depression, and smoking. Early- to mid-life factors, in particular, low education and obesity, were also observed to contribute to the SES-associated divergence in dementia risk. Temporal PAF and IW-PAF trends, stratified by sex and SES, revealed that MRF PAF gaps across sex or SES categories have persisted or increased.

CONCLUSIONS

In England, there was little change over time in the proportion of dementia attributable to known modifiable risk factors. The observed trends underscore the continuing relevance of these risk factors and the need for targeted public health strategies to address them.

The Depression Anxiety Stress Scale 8: investigating its cutoff scores in relevance to loneliness and burnout among dementia family caregivers

The global trend of advanced aging comes at the cost of amplified onset of age-related diseases. Dementia is a common multifactorial age-related neurodegenerative disorder, which manifests with progressive declines in cognitive functioning and ability to perform activities of daily living. As polices discourage institutionalized care, family members act as primary caregivers and endure increased vulnerability to physical and mental health problems secondary to care-related changes in life routine and relationships. Targeting clinically significant distress at earlier stages through valid brief measures may promote caregivers' wellbeing and dementia care continuity/quality. This study aimed to determine the optimal cutoff score of the Depression Anxiety Stress Scale 8-items (DASS-8) in a convenience sample of 571 European caregivers (Mean age = 53 ± 12 years, Italian = 74.4%, Swiss = 25.6%) through three methods. K-means clustering classified the sample into high- and low-distress clusters based on DASS-8 score of 19. Receiver operator curve (ROC) analysis using 48 and 7 cutoffs of the Zarit Burden Interview (ZBI) and the Three-Item University of California, Los Angeles, Loneliness Scale-version 3 (UCLALS3), revealed two DASS-8 cutoffs (12.5 and 14.5, area under the curve (AUC) = 0.85 and 0.92, p values < .001, 95% CI 0.82-0.88 and 0.89 to 0.94, sensitivity = 0.81 and 0.78, specificity = 0.76 and 0.89, Youden index = 0.57 and 0.67, respectively). Decision modeling produced two DASS-8 cutoffs (9.5 and 14.5) for predicting low and high caregiving burden and loneliness, respectively. According to the median of all DASS-8 cutoffs (14.5) the prevalence of mental distress was 50.8%. Distress correlated with key mental problems such as burnout and loneliness-in path analysis, DASS-8 scores were predicted by the ZBI, UCLALS3, care dependency, and receiving help with care, especially among older, female, and spouse caregivers. Further diagnostic workup should follow to confirm psycho-pathogenicity among caregivers with DASS-8 scores above 14.5. Investigations of the DASS-8 in other countries/populations may confirm the validity of this cutoff score.

Incidence and Prevalence of Dementia: A 2015-2020 Population-Based Study in the Campania Region of Italy

OBJECTIVE

The aims of this study were to provide population-based estimates of prevalence and incidence of any dementia and Alzheimer's dementia (AD) in the Campania region (South Italy) and to validate towards a clinical registry.

METHODS

This was a population-based study, using routinely collected healthcare data of individuals living in the Campania region (South Italy) from 2015 to 2020. We included individuals aged ≥65 years alive at the prevalence day (January 1, 2021) who had at least one administrative record for dementia and/or AD from 2015 to 2020. Age-and sex-standardised prevalence rates were calculated using direct standardisation method (European population in 2020 as the reference population). To estimate the incidence, we tested three possible algorithms, which differed for the duration of the time interval between study baseline (January 1, 2015) and index date (first record for dementia and/or AD in administrative databases). We employed a clinical database for the validation of our algorithms towards neuropsychological test results.

RESULTS

Among individuals aged over 65 years, 80,392 had dementia, of which 35,748 had AD. The age- and sex-standardised prevalence rates per 1,000 individuals for any dementia and AD were 77.64 (95% confidence interval [CI] = 77.57; 77.68) and 34.05 (95% CI = 34.01; 34.09), respectively. There were 82.10 incident cases of any dementia per 100,000 per year (0.79 sensitivity and 0.62 specificity) and 59.89 incident cases of AD per 100,000 per year (0.80 sensitivity and 0.59 specificity). The capture-recapture method showed a very low number of undetected cases (1.7% for any dementia and 3.0% for AD). Our algorithms showed acceptable performance with the area under the curve ranging from 0.59 to 0.72 and a double likelihood ratio of correctly identifying individuals above and below mini-mental status examination (MMSE) standard cut-offs (24 and 26).

CONCLUSIONS

Prevalence and incidence of any dementia and AD in the Campania region (South Italy) from 2015 to 2020 are in line with previous estimates from other countries. Our algorithm, integrating administrative and clinical data, holds potential for assessing dementia's epidemiological burden, identifying risk factors, planning healthcare access, and developing prevention strategies.

Scaling-up an evidence-based intervention for family carers of people with dementia: Current and future costs and outcomes

OBJECTIVES

The STrAtegies for RelaTives (START) intervention is effective and cost-effective in supporting family carers of people with dementia. It is currently not available to all eligible carers in England. What would be the impacts on service costs and carer health-related quality of life if START was provided to all eligible carers in England, currently and in future?

METHODS

Effectiveness and cost-effectiveness data from a previously conducted randomised controlled trial were combined with current and future projections of numbers of people with newly diagnosed dementia to estimate overall and component costs and health-related quality of life outcomes between 2015 (base year for projections) and 2040.

RESULTS

Scaling-up START requires investments increasing annually but would lead to significant savings in health and social care costs. Family carers of people with dementia would experience improvements in mental health and quality of life, with clinical effects lasting at least 6 years. Scaling up the START intervention to eligible carers was estimated to cost £9.4 million in 2020, but these costs would lead to annual savings of £68 million, and total annual quality-adjusted life year (QALY) gains of 1247. Although the costs of START would increase to £19.8 million in 2040, savings would rise to £142.7 million and Quality adjusted life years gained to 1883.

CONCLUSIONS

Scaling-up START for family carers of people with dementia in England would improve the lives of family carers and reduce public sector costs. Family carers play a vital part in dementia care; evidence-based interventions that help them to maintain this role, such as START, should be available across the country.