Epidemiological Study of Mild Cognitive Impairment and Dementia in Taiwan Yu Sun MD. PhD April 19, 2013
Epidemiology of dementia worldwide 35.6 million people with dementia worldwide in 2010 nearly double every 20 years 65.7 million in 2030 115.4 million in 2050 New cases worldwide: 7.7 million /year 1 case/4 seconds http://www.alz.co.uk/research/statistics
Epidemiology of dementia The prevalence doubles with every fiveyear increment at age after 65 http://www.alz.co.uk/research/statistics
Prevalence of dementia
Past reports of dementia prevalence in the elderly in Taiwan 林宗義台灣 rural/urban 1946 0.6% 林宗義台灣 rural/urban 1961 0.7% 林信男恆春 rural 1982 2.7% 劉秀枝台灣 (rural/urban 1988 (2.0%) 葉炳強台北 rural/urban) 1991 (1.9% 劉秀枝金門 rural 1993 2.5% 劉景寬高雄 urban 1992 4.4% 林瑞泰南台灣 (rural/urban) 1993 (3.7% 李朝雄宜蘭 rural 1994 4.2% 劉景寬高屏 urban 1994 3.8% 1988-1994 428/12677 = 3.38% 應用心理研究 2000 劉秀枝主編
Background and Purpose No nationwide epidemiological study of dementia in Taiwan in the past 20 years To survey the prevalence of mild cognitive impairment, very mild dementia, and all dementia To evaluate the associated factors of dementia
Methods Computerized random sampling on the census data of all the 19 counties or cities in Taiwan Door-to-door survey using structured questionnaire Time: January 2011 to December 2012 Demographic data, socioeconomic status, life style, co-morbidities and mental tests Mental function screening tools Mini-Mental Status Examination (MMSE) Clinical Dementia Rating (CDR)
sample visit % 宜蘭縣 242 122 50.41% 台北市 1,316 1,499 113.91% 台中市 905 1,630 180.11% 台東縣 123 37 30.08% 台南市 867 1,657 191.12% 花蓮縣 171 82 47.95% 南投縣 286 20 6.99% 屏東縣 443 166 37.47% 苗栗縣 301 74 24.58% 桃園縣 650 332 51.08% 高雄市 1,122 915 81.55% 基隆市 172 14 8.14% 雲林縣 433 400 92.38% 新北市 1,247 697 55.89% 新竹市 156 12 7.69% 新竹縣 232 4 1.72% 嘉義市 121 149 123.14% 嘉義縣 343 431 125.66% 彰化縣 631 96 15.21% total 9,761 8,337 85.41% 台北市,113.91% 新北市,55.89% 桃園,51.08% 新竹市,7.69% 新竹縣,1.72% 苗栗縣,24.58% 台中,180.11% 彰化,15.21% 南投,6.99% 雲林,92.38% 嘉義市,123.14% 嘉義縣,125.66% 台南,191.12% 高雄,81.55% 屏東,37.47% 花蓮,47.95% 台東,30.08% 基隆市,8.14% 宜蘭縣,50.41%
Results 28,600 aged 65 yrs screened 8337 with complete interview Mean age: 76.25 ± 6.76 yrs Female: 4330 (52%)
Demographic data of study participants (n=8337) Categorical variables, n, % n % Women 4330 51.94 Age group 65- <75 y/o 3829 45.93 75-<85 y/o 3438 41.24 85 y/o 1070 12.83 Body Mass Index (BMI) <=18 222 3.06 18<BMI 24 3759 51.88 24<BMI 30 2912 40.19 >30 352 4.86 Education Illiterate 2582 30.97 Literate or primary school 3729 44.73 Junior or senior high school 1398 16.77 College or University 627 7.52 Marriage, married and live with spouse 5231 62.74 Life style and habit Vegetarian 461 5.53 Tea 2358 28.28 Coffee 1088 13.05 Betel nut 396 4.75 Drinking 1043 12.51 Smoking 1605 19.25 Taking nap 4594 55.10 Regular exercise 3375 40.48 Active social network 1159 13.90 Categorical variables, n, % n % Comorbidities Hypertension 4248 50.95 Diabetes mellitus 6542 78.47 Cerebrovascular disease 573 6.87 Hyperlipidemia 1392 16.70 Lung disease 456 5.47 Liver disease 381 4.57 Gastritis or peptic ulcer 1342 16.10 Cities Taipei 1499 17.98 New Taipei 697 8.36 Taichung 1630 19.55 Tainan 1657 19.88 Kaohsiung 915 10.98 Others 1939 23.26 Areas North 2754 33.03 Central 2146 25.74 South 3318 39.80 East 119 1.43
Prevalence of elderly people with abnormal cognitive function (n=8337) Dementia defined by MMSE and CDR n % CDR scoring 0 5975 71.67 0.5 1948 23.37 1 226 2.71 2 94 1.13 3 94 1.13 MMSE Normal, MMSE 25 4495 53.92 Abnormal, MMSE <25 3842 46.08 MMSE with cutpoint adjusted by education Normal 6129 73.52 Abnormal 2208 26.48 Education adjusted MMSE Normal MMSE defined as 25 in literacy or educated 14 in illiteracy
Criteria for all-cause dementia -- Recommendations from the National Institute on Aging-Alzheimer s Association (NIAAA) The cognitive or behavioral impairment 2 of the following domains: a. Impaired ability to acquire and remember new information b. Impaired reasoning and handling of complex tasks, poor judgment c. Impaired visuospatial abilities d. Impaired language functions e. Changes in personality, behavior, or comportment McKhann GM, et al. Alzheimer s & Dementia 2011
Algorithm for Classification N= 8337 scdr=0 scdr=0.5 scdr 1 Normal MMSE MMSE > 24 in literate MMSE >13 in illiterate Abnormal MMSE Dementia N=414 Normal N=5975 Exclude scdr M and O and JPS=0 scdr M or O or JPS at least one 0.5 Others all = 0 scdr M or O or JPS only one 0.5 Others at least one > 0 scdr M or O or JPS at least two 0.5 Others at least one > 0 M: memory O: orientation JPS: judgment and problem solving CA: community affairs HH: home hobbies PC: personal care Unclassified N=347 MCI N=1337 VMD N=264 MCI: mild cognitive impairment; VMD: very mild dementia
Prevalence of dementia in elderly people ( 65 yrs / 70 yrs) with abnormal cognitive function Dementia defined by MMSE and CDR 65 yrs (n=8337) 70 yrs (n=6856) n % n % Cognitive function defined by CDR and MMSE Normal with CDR=0 5975 71.67 4713 68.74 Abnormal with CDR=0.5 1948 23.37 1751 25.53 Mild cognitive impairment (MCI) 1337 16.04 1192 17.38 Normal MMSE 873 10.47 766 11.17 Abnormal MMSE 464 5.5 427 6.21 Unclassified 347 4.16 317 4.62 Very mild dementia 264 3.17 242 3.53 Dementia with CDR 1 414 4.97 392 5.72
Prevalence of MCI and dementia in different age groups (n=8337) Age (yrs) MCI Very mild dementia Dementia with CDR>=1 n % n % n % 65- <70 (n= 1481) 145 9.79 22 1.49 22 1.49 70- <75 (n=2348) 310 13.20 35 1.49 32 1.36 75- <80 (n=1964) 345 17.57 59 3.00 73 3.72 80- <85 (n=1474) 300 20.35 62 4.21 109 7.39 85- <90 (n=759) 173 22.79 53 6.98 105 13.83 90 (n= 311) 64 20.58 33 10.61 73 23.47 Gender subgroup Male n % n % n % 65- <70 (n= 675) 50 7.41 11 1.63 10 1.48 70- <75 (n=1081) 108 9.99 9 0.83 10 0.93 75- <80 (n=940) 135 14.36 19 2.02 29 3.09 80- <85 (n=746) 137 18.36 24 3.22 43 5.76 85- <90 (n=419) 88 21.00 23 5.49 45 10.74 90 (n= 146) 30 20.55 7 4.79 29 19.86 Female n % n % n % 65- <70 (n= 806) 95 11.79 11 1.36 12 1.49 70- <75 (n=1267) 202 15.94 26 2.05 22 1.74 75- <80 (n=1024) 210 20.51 40 3.91 44 4.30 80- <85 (n=728) 163 22.39 38 5.22 66 9.07 85- <90 (n=340) 85 25.00 30 8.82 60 17.65 90 (n= 165) 34 20.61 26 15.76 44 26.67
Dementia prevalence increase with age Prevalence (%) 40 35 30 25 20 15 10 5 0 65-69 70-74 75-79 80-85 85-89 90+ Age VMD Dementia VMD+Dementia
Prevalence of dementia between Gender (Include very mild dementia) Prevalence (%) 45 40 35 30 25 20 15 10 5 0 65-69 70-74 75-79 80-85 85-89 90+ Age Men Women Total
Prevalence of MCI and dementia in different age groups (n=8337)
Prevalence of dementia growth from 1992 to 2012 in Taiwan Year Total population >=65 yrs Dementia VMD and dementia 1992 20,802,622 1,415,842 (6.81%) 47,855 (3.38%) 2012 23,315,822 2,600,152 (11.12%) 129,228 (4.97%) 211,652 (8.14%) Dementia population in 2012 Dementia population in 1992 =129288 / 47855 = 2.7 VMD: very mild dementia P opulation of elderly aged 65 yrs or more x 10 3 250 200 150 100 50 0 1992 2012 2012 D ementia D ementia VMD and D ementia Y ear
Dementia (include VMD) Comparison of dementia prevalence between countries (%) Age (yrs) USA (2007) Taiwan (2013) 70 13.90 9.25 71-79 5.00 4.62 90 37.4 34.08 Hong Kong (2007) Very mild dementia 70 3.57 8.5 Mild dementia 8.9 Mild to severe dementia 5.72 MCI 65 17.38 VMD: very mild dementia: CIND: cognitive impairment no dementia Singapore (2012) Mild CIND 60 7.2 Moderate to severe CIND 60 7.9 Neuroepideimiology 2007; Int Psychogeriatrics 2008; JNNP 2013
ADI consensus estimates for the prevalence of dementia (%) by WHO region and age group http://www.alz.co.uk/adi/pdf/prevalence.pdf December 2008
ADI consensus estimates for the prevalence of dementia (%) by WHO region and age group Taiwan 60-64 65-69 70-74 75-79 80-84 >=85 VMD 1.49 1.49 3 4.21 8.04 CDR>=1 1.49 1.36 3.72 7.39 16.64 Dementia 2.98 2.85 6.72 11.6 24.68
Comparison between normal participants and people with dementia using univariate analyses (include VMD, but not include MCI) Categorical variables, n, % Normal Dementia n % n % p Sex <0.0001 Women 2946 49.31 419 61.8 Men 3029 50.69 259 38.20 Age group <0.0001 65- <75 y/o 3172 53.09 111 16.37 75-<85 2341 39.18 303 44.69 >=85 462 7.73 264 38.94 Body Mass Index (BMI) 0.0002 <=18 141 2.64 26 4.83 18<BMI<=24 2749 51.54 306 56.88 24<BMI<=30 2187 41.00 176 32.71 >30 257 4.82 30 5.58 Education <0.0001 Illiterate 1486 24.87 325 47.94 Literate or primary school 2837 47.48 245 36.14 Junior or senior high school 1149 19.23 78 11.50 College or University 503 8.42 30 4.42 Marriage, married and live with spouse 3967 66.39 302 44.54 <0.0001
Comparison between normal participants and people with dementia using univariate analyses (include VMD, but not include MCI) Categorical variables, n, % Normal Dementia n % n % p Life style and habit Vegetarian 350 5.86 30 4.42 0.13 Tea 1923 32.18 95 14.01 <0.0001 Coffee 909 15.21 39 5.75 <0.0001 Betel nut 303 5.07 21 3.10 0.02 Drinking 802 13.42 56 8.26 0.0001 Red Wine 77 1.29 4 0.59 0.12 Smoking 1208 20.22 99 14.60 0.0005 Taking nap 3267 54.68 411 60.62 0.003 Regular exercise 2818 47.16 75 11.06 <0.0001 Active social network 989 16.55 33 4.87 <0.0001 Comorbidities Hypertension with treatmemt 2958 49.51 385 56.78 0.0003 Diabetes mellitus 1159 19.40 206 30.38 <0.0001 Cerebrovascular disease 227 3.8 140 20.65 <0.0001 Hyperlipidemia 1018 17.04 89 13.13 0.01 Lung disease 286 4.79 60 8.85 <0.0001 Liver disease 267 4.47 27 3.98 0.56 Gastritis or peptic ulcer 932 15.60 97 14.31 0.38
Associated factors for dementia (multiple logistic regression model, MCI not included) 95% confidence Adjusted ORs Variables interval p value Age 85 y/o or older 7.43 5.85-9.44 <0.0001 Female Gender 1.05 0.81-1.36 0.72 BMI 18 or less 1.36 0.81-2.29 0.25 Illiteracy 2.01 1.60-2.51 <0.0001 Marriage, married and live with spouse 0.68 0.55-0.85 0.0006 Life style and habit Vegetarian 0.78 0.47-1.28 0.32 Tea 0.41 0.30-0.55 <0.0001 Coffee 0.60 0.39-0.92 0.02 Drinking 0.98 0.66-1.45 0.92 Smoking 0.90 0.64-1.26 0.53 Regular exercise 0.17 0.12-0.22 <0.0001 Active social network 0.51 0.34-0.77 0.0013 Comorbidities Hypertension 1.12 0.91-1.39 0.29 Diabetes mellitus 1.81 1.43-2.30 <0.0001 Cerebrovascular disease 7.10 5.16-9.78 <0.0001 Hyperlipidemia 0.52 0.37-0.73 0.0001 Lung disease 1.81 1.20-2.73 0.005 Gastritis or peptic ulcer 0.96 0.70-1.32 0.82
Associated factors for abnormal cognitive function (MCI included) 95% confidence Adjusted ORs Variables interval p value Age 85 y/o or older 3.62 3.06-4.28 <0.0001 Female Gender 1.10 0.94-1.28 0.24 BMI 18 or less 1.20 0.86-1.68 0.28 Illiteracy 2.26 1.97-2.59 <0.0001 Marriage, married and live with spouse 0.79 0.69-0.90 0.0004 Life style and habit Vegetarian 0.79 0.59-1.05 0.11 Tea 0.62 0.53-0.72 <0.0001 Coffee 0.74 0.59-0.91 0.004 Drinking 1.08 0.87-1.35 0.47 Smoking 1.00 0.82-1.21 0.97 Regular exercise 0.48 0.42-0.55 <0.0001 Active social network 0.68 0.56-0.84 0.0002 Comorbidities Hypertension 1.08 0.95-1.23 0.24 Diabetes mellitus 1.38 1.19-1.60 <0.0001 Cerebrovascular disease 3.80 3.03-4.77 <0.0001 Hyperlipidemia 0.82 0.69-0.98 0.03 Lung disease 1.61 1.25-2.08 0.0002 Gastritis or peptic ulcer 1.18 1.00-1.40 0.05
Conclusions Dementia in the elderly ( 65 yrs): 8.14 % Very mild dementia: 3.17% Dementia with CDR 1: 4.97% MCI: 16.04% Diabetes mellitus, cerebrovascular and lung diseases might increase risk of MCI and dementia Maintenance of regular exercise and participating social activities seem to have benefit effects
Acknowledgments and Funding Grants from the Department of Health, Taiwan (DOH101E2012) We thank all the collaborators and staff of Taiwan Alzheimer s Disease Association (TADA) for their help in this study. Ming-Jang Chiu Huey-Jane Lee Shu-Chien Yang Ta-Fu Chen Ker-Neng Lin Chung-Chih Lin Pei-Ning Wang Li-Yu Tang
I TADA
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