Abstract
The purpose of this study is to analyze the economic burden of persons with Alzheimer’s disease (AD) and Parkinson’s disease (PD) in Europe. On the basis of available data about the number of persons with dementia, their prevalence, and treatment and care costs, a mean cost burden is estimated for the year of 2030 and for the year of 2050 in Europe. The method of retrospective analysis of available sources was used; furthermore, analysis of database data such as WHO and Eurostat, which provide information about the number of older people and people with dementia; and specification of direct and indirect medical and nonmedical costs of patients with AD and PD from current studies was also used. The findings of this study confirm that the number of patients affected with AD and PD, as well as annual costs of the treatment and care of these patients, in the selected European countries are rapidly growing. The cost burden of both AD and PD in the selected European countries rises year by year, and by 2050, the cost burden of both diseases in fact will be almost two times higher in comparison with the year of 2010. In 2050, the overall mean cost burden is estimated to reach 357 billion Euros. The European Union calls for a joint initiative in the development of a uniformed strategic plan in the fight against dementia.
INTRODUCTION
At present the number of older people is growing, particularly in the developed countries such as those in the European Union (EU) [1, 2]. In 2060, the number of people in the EU countries is estimated to reach 517 million and one third of these people will be aged 65+ [3]. Nowadays these older people form 17% of the whole EU population, and by 2060, the percentage of the elderly population is estimated to reach 30%. This demographic trend causes significant problems such as occurrence of aging diseases, out of which the most common is dementia. Currently, about 47.5 million (14%) people are being affected by this form of disease all over the world. Annually, this number is growing by 7.7 million in new cases. It is estimated that by 2050, the number of demented people in the world will triple and reach 135.5 million (41%) [4].
Dementia comprises different kinds of diseases that arise due to damage of neurons in the brain [4]. Dysfunction or death of these neurons affects a person’s memory, cognition, and behavior [5]. In the worst cases, people are unable to walk or swallow. The most frequent types of dementia are as follows: Alzheimer’s disease (AD), vascular dementia, dementia with Lewy bodies, mixed dementia, Parkinson’s disease (PD) dementia, and frontotemporal lobar degeneration.
The death rates of people suffering from these diseases worldwide are illustrated in Figs. 1 and 2. The red spots represent AD rank between 53.77–5.73. The highest death rates are found in Finland (53.77), USA (45.58), and Canada (35.50), which are then followed by 11 other European countries (Fig. 1).
There is a similar situation in case of PD. However, the death rate is different. The red spots are the areas with the highest incidence, which is between 4.66 and 3.0. The highest death rate is again in Finland (4.66), while USA ranks fourth (4.51) and most of the following ten countries are European countries (Fig. 2).
Alzheimer’s and Parkinson’s diseases
Both diseases are aging diseases of neurodegenerative character, and they develop certain common symptoms over the course of the disease such as speech impairments [7, 8] or depression, however, a lot of features are different. Table 1 summarizes the key dissimilarities between AD and PD, particularly in the early stages [9, 10].
As far as pharmacological treatment, both diseases cannot be cured; only their symptoms can be partially treated. In case of AD, there are about 81 drugs, however, so far only four of these drugs have been clinically approved (Table 2, Fig. 3). They can be divided into two classes [11, 12]: anticholinesterases for the treatment of mild and moderate AD (donepezil, rivastigmine, galantamine); and the other anti-dementia drugs such as the NMDA receptor antagonist, memantine, which is used for the treatment of moderate to severe AD.
In comparison with AD, PD has several clinically approved drugs for its treatment. Two basic groups of drugs (anticholinergic agents and dopaminergic agents) used in the treatment of PD, including their subgroups and individual agents are illustrated in Table 3 and Fig. 4.
In addition, deep brain stimulation (DBS) can be used, but only with those patients whose symptoms cannot be treated with the drugs mentioned above [15]. DBS is a surgical procedure that is used to treat the debilitating motor symptoms of PD, such as tremor, rigidity, stiffness, or walking problems. DBS uses a surgically implanted, battery-operated medical device called an implantable pulse generator, which is similar to a heart pacemaker and has the size of a stopwatch. This device delivers electrical stimulation to specific areas in the brain that control movement, thus blocking the abnormal nerve signals that cause PD symptoms [16]. Furthermore, in the course of PD progression, patients have to take other drugs, which focus on non-motor symptoms of PD such as cognitive impairments. These are caused by a lack of other neurons in the brain and contain other chemicals than dopamine, especially acetylcholine, which is also typical of AD. However, the treatment is quite lengthy and thus expensive, particularly as far as the administration of these drugs, which also represent the direct costs, is concerned.
The purpose of this study is to analyze the economic burden of persons with AD and PD in Europe. On the basis of available data regarding the number of persons with dementia, their prevalence, and treatment and care costs, a mean cost burden is estimated for the year of 2030 and for the year of 2050 in Europe. The prediction for these two years has been chosen in order to compare this burden with the estimates of the World Alzheimer Report and to evaluate it and see whether this later prediction expects higher burden or not.
The treatment and reduction of the symptoms and drugs described above are part of the studies on costs of persons with AD and PD. Since there is no uniform strategy for monitoring the economic burden of these diseases in European countries, the content of these studies include different types of surveys, which serve as a basis for determining the economic burden for European countries. This is specified in theMethods.
METHODS
The methods applied in this study include a retrospective analysis of available sources; analysis of database data such as WHO and Eurostat, which provide information about the number of older people and people with dementia; and specification of direct and indirect medical and nonmedical costs of patients with AD and PD [17, 18].
Attention is focused on costs in Europe, where the issue of aging of the population and rising number of people with dementia is the most topical and where the systems of healthcare financing are more or less the same. On the basis of different research studies on this topic, the following countries were selected: Czech Republic, France, Germany, Italy, Sweden, and United Kingdom. The basic form of the healthcare system is the same in all European countries. The countries listed above were selected with respect to the topicality, availability, and comparability of the data provided in the reviewed studies.
For the definition of total costs of AD in Europe, four research studies from four different countries were selected: UK [19], Czech Republic [20], France [21], and Germany [22]. Their monitored cost units are mutually comparable. In the Czech study [20], the direct medical costs were monitored. They included costs of outpatient examination, hospitalization, institutionalization, pharmacological and non-pharmacological treatment, emergency service, home nursing service, rehabilitation, and laboratory tests. Furthermore, other direct costs such as transport, modification of home environment, and overheads and, finally, indirect costs were also calculated. They were depicted as lower job productivity of patients and caregivers. In the French study [21], the costs were divided into direct costs of formal medical care (medical care, outpatient examination, drugs) and non-medical care (home care, respite care). In addition, the indirect costs measuring productivity loss were calculated. The German study [22] divided the costs into formal medical care (inpatient care, outpatient care, drugs, rehabilitation, medical equipment, non-medical services, home nursing care) and informal care (mean time which caregivers spent with their clients).
The British study [19] also monitored both direct and indirect costs. The direct costs included medical costs of institutionalization, outpatient care, hospital stays, drugs, social care in community centers, community health services, social care, respite care, and costs of accommodation for patients. The indirect costs involved the time which caregivers spent with their patients.
The calculation of PD costs included the studies from the following countries: Czech Republic, Italy, Germany, and Sweden. The costs in the Czech Republic [23] covered direct and indirect costs, where direct costs are: inpatient care, outpatient care, ancillary therapy, drugs, special home equipment, and formal care. The Italian study [24] included almost the same: inpatient care, outpatient care, drugs, special home equipment, and formal and informal care. In addition, the indirect costs were again monitored. In the Swedish study [26], the direct costs consisted of medical and nonmedical units, and the indirect costs were calculated as lost productivity. In the German study [25], the direct and indirect costs were assessed in 145 patients. The direct medical costs involved rehabilitation, hospitalization, outpatient treatment, ancillary treatment and ambulatory diagnostic procedures, and drugs. The non-medical direct costs included transportation, special equipment, social/home-help services, and sickness benefit. The indirect costs for lost productivity were also calculated.
RESULTS
Development of the estimated economic burden of the treatment and care about the persons with AD and PD
The calculation of the estimated values of the economic burden in Europe in the form of direct costs is based on the estimated number of population affected by dementia and prevalence of incidence of this disease. The exact estimates of the prevalence of dementia depend on the definition and specific threshold used [27]. The syndrome affects approximately 5–8% of individuals at the age 65+, 15–20% of individuals at the age 75+, and 25–50% of individuals at the age 85+. AD is the most common dementia, accounting for 50–75% of the total, with a greater proportion in the higher age ranges [28]. The estimated numbers of people with dementia in Europe are described in Table 4, based on the data of the Alzheimer’s Society [29].
Furthermore, the WHO [31] and the Alzheimer’s Society [29] determined the proportional incidence of individual types of dementia (Fig. 5).
The proportion of people suffering from AD is, according to WHO [31], 62% and from PD 5% [31]. These data with the estimated numbers of people affected with dementia serve as the basis for the calculation of the economic burden. Table 5 specifies the numbers of people with AD and PD for the year of 2010, and outlines estimates for the year of 2030 and for the year of 2050.
Possible costs of people with AD and PD are illustrated in Table 6. The costs can be estimated only roughly on the basis of different types of research studies. There is no common system for the monitoring of costs. In many cases, individual studies differ in their monitored variables. Most often, these items are divided into direct and indirect costs, both of medical and non-medical character. The key is the lost opportunity costs, prices in individual countries, and, most importantly, the lost wages of the patient and his/her caregiver, which forms the essential unit of indirect costs. Further calculations are based on the studies conducted in the selected European countries that provide comparable data. They contain both direct and indirect medical costs. Units of individual studies were recalculated into the costs per patient per year in Euros.
In particular, the studies aimed at AD provide the data on costs according to the individual stages of this disease. However, most of the studies on PD do not include the costs according to these phases. Therefore, as demonstrated in Table 7, column 3, only mean values of both types of dementia have been selected for further calculation. Table 7 shows approximate values of costs of treatment and care (in millions) in the period 2010–2050. These values are means based on the studies described above. Therefore the range depends on the costs of individual countries. The highest costs are in the countries of Western Europe. This can be explained by higher wage costs of caregivers, higher price level, and higher lost wages (Table 7).
As Table 7 indicates, the cost burden of both AD and PD in the selected European countries rises year by year and by 2050 the cost burden of both diseases in fact will be almost two times higher in comparison with the year of 2010. In 2050, the overall mean cost burden is estimated to reach 357 billion Euros.
Wimo et al. [32] described the prognosis of dementia costs. This prognosis of costs is only based on a prevalence prognosis, based on UN’s demographic forecast, combined with Eurocode’s prevalence figures for Europe. The demographic forecast of costs will result in an increase in the whole Europe by about 43% between 2008 and 2030 to over 250 billion Euros [33].
Costs of dementia in 2010 and 2015 according to the World Alzheimer Report [30] were described as: Europe Central 14.2, Europe Eastern 14.3, and Europe Western 210.1 (billion Euros). Altogether, they totaled 238.6 billion Euros in 2010. For the year of 2015, they forecasted the total value for all of Europe at 301.2 billion Euros [30].
Our own calculations are not targeted at all dementias, but only on AD and PD. In comparison with the study by Wimo et al. [32], they indicate much higher burden than their study. The calculations of this study correspond to the World Alzheimer Report, which estimates a higher burden already for 2015 than Wimo et al. for the year of 2030. The costs for 2010 are, according to the World Alzheimer Report, 238.6 billion Euros. The results of this study show 191.2 billion Euros for AD and PD. Nevertheless, we set the range for the year of 2010 as between 66,922 and 325,572 billion Euros depending on the prices in individual European countries. The values are depicted in Table 7 and their big ranges indicate two main problems. Currently, there is no uniform strategic plan for all European countries (not even in the individual countries within their institutions) for monitoring the treatment and care costs of patients with AD and PD. This is also true for the selected types of costs. Therefore it is not possible to predict the economic and social burden for next years. However, more important is the issue that these approximate values point out the increasing burden, which will seriously affect medical and social systems.
DISCUSSION
The findings of this study show that aging diseases such as dementia, including AD and PD, bring serious social and economic issues. As Tables 6 and 7 demonstrate, both the number of patients affected with AD and PD, as well as annual costs of the treatment and care of these patients, in the selected European countries are rapidly growing. This is caused not only by recent demographic changes, but also by the fact that these dementias cannot be cured, and although both diseases eventually result in death, their progress can be slowed down by pharmacological and non-pharmacological approaches, which are quite costly. Although AD and PD differ in their symptoms, treatment, and care in certain aspects, Table 8 shows that the cost burden of both diseases should be nearly twofold in comparison with the year of 2010. Obviously, higher costs are in the countries of Western Europe where there are higher wage costs of caregivers, higher price levels, and higher lost wages.
The EU strives to enhance the process of the aging population by developing various regulations for the improvement of quality of life of this population group. For example, in 2009, a European Initiative for AD and other forms of dementia was approved. The main purpose of this initiative is to inform people about the threats of dementias and necessity to prevent it. In addition, in individual countries, research is being conducted in this field of dementia in order to enhance early diagnosis of this disease, its treatment, or financing of it. This initiative also calls for the joint fight against AD, respectively dementia, in all EU countries, in the form of developing national plans and strategies and establishing specialized centers, which would focus on this disease. The aim of these strategic plans should also be a collection of statistical data about different types of dementia in order to compare the economic burden across Europe. Table 8 shows the countries that have already developed such a strategic plan, the countries which are in the stage of its preparation, and the countries without this strategic plan.
Thus, the initiative’s effort is to involve as many states as possible in this fight in order to consequently effectively evaluate these plans and prepare a more efficient strategic plan afterwards. This plan can then help those countries who are in the stage of its preparation, as well as those that have not yet started to develop one.
Conclusions
The findings of this study confirm that the economic burden of aging diseases such as dementia represents a serious problem for medical and social systems in Europe. The prognosis just for AD and PD is 357 billion Euros for the year 2050. Thus, it is important to establish a uniform strategy in the fight against these diseases at both a national and international level.
