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.

BACKGROUND: Dementia incidence declined in many high-income countries in the 2000s, but evidence on the post-2010 trend is scarce. We aimed to analyse the temporal trend in England and Wales between 2002 and 2019, considering bias and non-linearity. METHODS: Population-based panel data representing adults aged 50 years and older from the English Longitudinal Study of Ageing were linked to the mortality register across wave 1 (2002-03) to wave 9 (2018-19) (90 073 person observations). Standard criteria based on cognitive and functional impairment were used to ascertain incident dementia. Crude incidence rates were determined in seven overlapping initially dementia-free subcohorts each followed up for 4 years (ie, 2002-06, 2004-08, 2006-10, 2008-12, 2010-14, 2012-16, and 2014-18). We examined the temporal trend of dementia incidence according to age, sex, and educational attainment. We estimated the trend of dementia incidence adjusted by age and sex with Cox proportional hazards and multistate models. Restricted cubic splines allowed for potential non-linearity in the time trend. A Markov model was used to project future dementia burden considering the estimated incidence trend. FINDINGS: Incidence rate standardised by age and sex declined from 2002 to 2010 (from 10·7 to 8·6 per 1000 person-years), then increased from 2010 to 2019 (from 8·6 to 11·3 per 1000 person-years). Adjusting for age and sex, and accounting for missing dementia cases due to death, estimated dementia incidence declined by 28·8% from 2002 to 2008 (incidence rate ratio 0·71, 95% CI 0·58-0·88), and increased by 25·2% from 2008 to 2016 (1·25, 1·03-1·54). The group with lower educational attainment had a smaller decline in dementia incidence from 2002 to 2008 and a greater increase after 2008. If the upward incidence trend continued, there would be 1·7 million (1·62-1·75) dementia cases in England and Wales by 2040, 70% more than previously forecast. INTERPRETATION: Dementia incidence might no longer be declining in England and Wales. If the upward trend since 2008 continues, along with population ageing, the burden on health and social care will be large. FUNDING: UK Economic and Social Research Council.

Growing old in China in socioeconomic and epidemiological context: systematic review of social care policy for older people.

BACKGROUND: From 2020 to 2050, China's population aged ≥65 years old is estimated to more than double from 172 million (12·0%) to 366 million (26·0%). Some 10 million have Alzheimer's disease and related dementias, to approach 40 million by 2050. Critically, the population is ageing fast while China is still a middle-income country. METHODS: Using official and population-level statistics, we summarise China's demographic and epidemiological trends relevant to ageing and health from 1970 to present, before examining key determinants of China's improving population health in a socioecological framework. We then explore how China is responding to the care needs of its older population by carrying out a systematic review to answer the question: 'what are the key policy challenges to China achieving an equitable nationwide long-term care system for older people?'. Databases were screened for records published between 1st June 2020 and 1st June 2022 in Mandarin Chinese or English, reflecting our focus on evidence published since introduction of China's second long-term care insurance pilot phase in 2020. RESULTS: Rapid economic development and improved access to education has led to widescale internal migration. Changing fertility policies and household structures also pose considerable challenges to the traditional family care model. To deal with increasing need, China has piloted 49 alternative long-term care insurance systems. Our findings from 42 studies (n = 16 in Mandarin) highlight significant challenges in the provision of quality and quantity of care which suits the preference of users, varying eligibility for long-term care insurance and an inequitable distribution of cost burden. Key recommendations include increasing salaries to attract and retain staff, introduction of mandatory financial contributions from employees and a unified standard of disability with regular assessment. Strengthening support for family caregivers and improving smart old age care capacity can also support preferences to age at home. CONCLUSIONS: China has yet to establish a sustainable funding mechanism, standardised eligibility criteria and a high-quality service delivery system. Its long-term care insurance pilot studies provide useful lessons for other middle-income countries facing similar challenges in terms of meeting the long-term care needs of their rapidly growing older populations.

What will the cardiovascular disease slowdown cost? Modelling the impact of CVD trends on dementia, disability, and economic costs in England and Wales from 2020-2029.

BACKGROUND: There is uncertainty around the health impact and economic costs of the recent slowing of the historical decline in cardiovascular disease (CVD) incidence and the future impact on dementia and disability. METHODS: Previously validated IMPACT Better Ageing Markov model for England and Wales, integrating English Longitudinal Study of Ageing (ELSA) data for 17,906 ELSA participants followed from 1998 to 2012, linked to NHS Hospital Episode Statistics. Counterfactual design comparing two scenarios: Scenario 1. CVD Plateau-age-specific CVD incidence remains at 2011 levels, thus continuing recent trends. Scenario 2. CVD Fall-age-specific CVD incidence goes on declining, following longer-term trends. The main outcome measures were age-related healthcare costs, social care costs, opportunity costs of informal care, and quality adjusted life years (valued at £60,000 per QALY). FINDINGS: The total 10 year cumulative incremental net monetary cost associated with a persistent plateauing of CVD would be approximately £54 billion (95% uncertainty interval £14.3-£96.2 billion), made up of some £13 billion (£8.8-£16.7 billion) healthcare costs, £1.5 billion (-£0.9-£4.0 billion) social care costs, £8 billion (£3.4-£12.8 billion) informal care and £32 billion (£0.3-£67.6 billion) value of lost QALYs. INTERPRETATION: After previous, dramatic falls, CVD incidence has recently plateaued. That slowdown could substantially increase health and social care costs over the next ten years. Healthcare costs are likely to increase more than social care costs in absolute terms, but social care costs will increase more in relative terms. Given the links between COVID-19 and cardiovascular health, effective cardiovascular prevention policies need to be revitalised urgently.

Dementia and disadvantage in the USA and England: population-based comparative study.

OBJECTIVES: To compare dementia prevalence and how it varies by socioeconomic status (SES) across the USA and England. DESIGN: Population-based comparative study. SETTING: Non-Hispanic whites aged over 70 population in the USA and England. PARTICIPANTS: Data from the Health and Retirement Study and the English Longitudinal Study of Ageing, which are harmonised, nationally representative panel studies. The sample includes 5330 and 3147 individuals in the USA and England, respectively. MAIN OUTCOME MEASURES: Between country differences in age-gender standardised dementia prevalence, across the SES gradient. Dementia prevalence was estimated in each country using an algorithm based on an identical battery of demographic, cognitive and functional measures. RESULTS: Dementia prevalence is higher among the disadvantaged in both countries, with the USA being more unequal according to four measures of SES. Overall prevalence was lower in England at 9.7% (95% CI 8.9% to 10.6%) than the USA at 11.2% (95% CI 10.6% to 11.8%), a difference of 1.4 percentage points (pp) (p=0.0055). Most of the between country difference is driven by the bottom of the SES distribution. In the lowest income decile individuals in the USA had 7.3 pp (p<0.0001) higher prevalence than in England. Once past health factors and education were controlled for, most of the within country inequalities disappeared; however, the cross-country difference in prevalence for those in lowest income decile remained disproportionately high. CONCLUSIONS: There is inequality in dementia prevalence according to income, wealth and education in both the USA and England. England has lower dementia prevalence and a less steep SES gradient. Most of the cross-country difference is concentrated in the lowest SES group, which provides evidence that disadvantage in the USA is a disproportionately high risk factor for dementia.

Effects of clonidine on progressive ratio schedule performance in Fmr1 knockout mice.

RATIONALE: Fragile X syndrome (FXS), the most prevalent genetic form of intellectual disability, is characterized by intellectual impairment, impaired sociability, aggression, self-injury, hyperactivity, and attention deficits. A consequence of the hyperactivity and attention deficits is that individuals with FXS are frequently diagnosed with attention deficit hyperactivity disorder (ADHD) and treated with medications approved for ADHD (e.g., the α2-agonist clonidine). The pharmacotherapy of FXS is often accompanied with behavioral therapies that rely on positive reinforcement and other operant principles. Despite the commonplace mixture of drug and behavioral therapy, little attention has been paid to the observation that clonidine or other psychotropic drugs may alter operant processes. OBJECTIVES: In the present progressive ratio study, we used a knockout mouse model to test the effects of the fragile X genotype, the α2-agonist clonidine, and the fragile X genotype and clonidine together on operant processes in a positive reinforcement task. RESULTS: We found that clonidine decreased the progressive ratio breakpoint, increased the length of post-reinforcement pauses, and slowed the run rate. None of these effects varied by genotype. The effect on breakpoint suggests that clonidine alters motivation, but analysis using mathematical principles of reinforcement (MPR) did not rule out motor parameters as a contributor. CONCLUSIONS: Our findings show that clonidine alters operant behavior and serve as a caution for combining clonidine with behavioral therapies that rely on positive reinforcement. Further research using different murine behaviors (e.g., touchscreen tasks) or different animal models (e.g., knockout rats) is needed to explore the interaction between pharmaco- and behavioral therapy.

Toughening Cellulose: Compatibilizing Polybutadiene and Cellulose Triacetate Blends.

We report the synthesis of an ABA triblock copolymer of the structure CTA-b-PB-b-CTA (CTA = cellulose triacetate and PB = polybutadiene) and its ability to compatibilize immiscible CTA/PB polymer blends. CTA-b-PB-b-CTA was synthesized via ring-opening metathesis polymerization of cyclooctadiene (COD) in the presence of CTA containing a single olefin on the reducing end. The ABA triblock copolymer was incorporated into CTA/PB blends, resulting in films that were clear, tough, and creaseable, and increases in modulus, elongation at break, and toughness were observed with addition of as little as 1 wt % compatibilizer. Scanning electron microscopy revealed well-defined PB phases in the CTA matrix that decreased in domain size as more compatibilizer was added. This work may enhance the application scope of CTA and other cellulose-derived renewable polymers.

Who Receives Medicaid in Old Age? Rules and Reality.

Medicaid is a government programme that also provides health insurance to the elderly who have few assets and either low income or catastrophic health care expenses. We ask how the Medicaid rules map into the reality of Medicaid recipiency, and we ask what other observable characteristics are important to determine who ends up on Medicaid. The data show that both singles and couples with high retirement income can end up on Medicaid at very advanced ages. We find that, conditioning on a large number of observable characteristics, including those that directly relate to Medicaid eligibility criteria, single women are more likely to end up on Medicaid - so are non-white people, but, surprisingly, their higher recipiency is concentrated in the higher income percentiles. We also find that people with low incomes who have a high-school diploma or higher degree are much less likely to end up receiving Medicaid than their less-educated counterparts. All of these effects are large and depend on retirement income in a very non-linear way.

The role of temporal intervals on reinforcer accumulation.

Animals accumulate reinforcers when they forgo the opportunity to consume available food in favor of acquiring additional food for later consumption. Laboratory research has shown that reinforcer accumulation is facilitated when an interval (either spatial or temporal) separates earning from consuming reinforcers. However, there has been no systematic investigation on the interval separating consuming reinforcers from earning additional reinforcers. This oversight is problematic because this second interval is an integral part of much of the previous research on reinforcer accumulation. The purpose of the current study was to determine the independent contributions of these two temporal intervals on reinforcer accumulation in rats. Each left lever press earned a single food pellet; delivery of the accumulated pellet(s) occurred upon a right lever press. Conditions varied based on the presence of either an intertrial interval (ITI) that separated pellet delivery from the further opportunity to accumulate more pellets, or a delay-to-reinforcement that separated the right lever press from the delivery of the accumulated pellet(s). Delay and ITI values of 0, 5, 10 and 20 s were investigated. The delay-to-reinforcement conditions produced greater accumulation relative to the ITI conditions, despite accumulation increasing the density of reinforcement more substantially in the ITI conditions. This finding suggests that the temporal separation between reinforcer accumulation and subsequent delivery and consumption was a more critical variable in controlling reinforcer accumulation.

End-Of-Life Medical Spending In Last Twelve Months Of Life Is Lower Than Previously Reported.

Although end-of-life medical spending is often viewed as a major component of aggregate medical expenditure, accurate measures of this type of medical spending are scarce. We used detailed health care data for the period 2009-11 from Denmark, England, France, Germany, Japan, the Netherlands, Taiwan, the United States, and the Canadian province of Quebec to measure the composition and magnitude of medical spending in the three years before death. In all nine countries, medical spending at the end of life was high relative to spending at other ages. Spending during the last twelve months of life made up a modest share of aggregate spending, ranging from 8.5 percent in the United States to 11.2 percent in Taiwan, but spending in the last three calendar years of life reached 24.5 percent in Taiwan. This suggests that high aggregate medical spending is due not to last-ditch efforts to save lives but to spending on people with chronic conditions, which are associated with shorter life expectancies.

The Accuracy of Economic Measurement in the Health and Retirement Study.

We assess the quality of the HRS's measures of out-of-pocket medical spending and health insurance premia, both in the "core interviews" and in the "exit interview" data. We provide detailed evidence on the quality of the HRS insurance premia data, and we compare the HRS exit data to exit data in the MCBS. We document how changes in survey questions, including the introduction of "unfolding brackets," affect the HRS measures. We document what we believe are errors in the HRS imputations and provide some suggestions for improving the accuracy of some imputed variables. Overall, we find the HRS data to be of high quality. However, we believe that many interesting variables in the HRS are under-utilized because users must perform imputations themselves.

A Patient Presenting with Tuberculous Encephalopathy and Human Immunodeficiency Virus Infection.

BACKGROUND: In the USA, Mycobacterium tuberculosis infection is more likely to be found in foreign-born individuals, and those co-infected with human immunodeficiency virus (HIV) are more likely to have tuberculous meningitis. The literature is lacking in details about the clinical workup of patients presenting with tuberculous meningitis with encephalopathic features who are co-infected with HIV. This report demonstrates a clinical approach to diagnosis and management of tuberculous meningitis. CASE REPORT: A 33-year-old Ecuadorean man presented with altered consciousness and constitutional symptoms. During the workup he was found to have tuberculous meningitis with encephalopathic features and concurrent HIV infection. Early evidence for tuberculosis meningitis included lymphocytic pleocytosis and a positive interferon gamma release assay. A confirmatory diagnosis of systemic infection was made based on lymph node biopsy. Imaging studies of the neck showed scrofula and adenopathy, and brain imaging showed infarctions, exudates, and communicating hydrocephalus. Treatment was started for tuberculous meningitis, while anti-retroviral therapy for HIV was started 5 days later in combination with prednisone, given the risk of immune reconstitution inflammatory syndrome (IRIS). CONCLUSIONS: A clinical picture consistent with tuberculous meningitis includes constitutional symptoms, foreign birth, lymphocytic pleocytosis, specific radiographic findings, and immunodeficiency. Workup for tuberculous meningitis should include MRI, HIV screening, and cerebral spinal fluid analysis. It is essential to treat co-infection with HIV and to assess for IRIS.

Medicaid Insurance in Old Age.

The old age provisions of the Medicaid program were designed to insure retirees against medical expenses. We estimate a structural model of savings and medical spending and use it to compute the distribution of lifetime Medicaid transfers and Medicaid valuations across currently single retirees. Compensating variation calculations indicate that current retirees value Medicaid insurance at more than its actuarial cost, but that most would value an expansion of the current Medicaid program at less than its cost. These findings suggest that for current single retirees, the Medicaid program may be of the approximately right size.

Medical Spending of the US Elderly.

We use data from the Medicare Current Beneficiary Survey (MCBS) to document the medical spending of Americans aged 65 and older. We find that medical expenses more than double between ages 70 and 90 and that they are very concentrated: the top 10 per cent of all spenders are responsible for 52 per cent of medical spending in a given year. In addition, those currently experiencing either very low or very high medical expenses are likely to find themselves in the same position in the future. We also find that the poor consume more medical goods and services than the rich and have a much larger share of their expenses covered by the government. Overall, the government pays for over 65 per cent of the elderly's medical expenses. Despite this, the expenses that remain after government transfers are even more concentrated among a small group of people. Thus, government health insurance, while potentially very valuable, is far from complete. Finally, while medical expenses before death can be large, on average they constitute only a small fraction of total spending, both in the aggregate and over the life cycle. Hence, medical expenses before death do not appear to be an important driver of the high and increasing medical spending found in the US.

Simple tone discriminations are disrupted following experimental frontal traumatic brain injury in rats.

PRIMARY OBJECTIVE: To assess cognitive deficits in a rat model of brain injury. RESEARCH DESIGN: Cognitive deficits are some of the most pervasive and enduring symptoms of frontal traumatic brain injury (TBI) in human patients. In animal models, the assessment of cognitive deficits from TBI has primarily been limited to tests of spatial learning. Recently, simple discrimination performance has been shown to be sensitive to frontal brain damage. The current study provides a detailed characterization of deficits in a two-choice tone discrimination following a bilateral frontal controlled cortical impact injury. METHODS AND PROCEDURES: Rats were trained on a two-tone discrimination task in a standard operant chamber, then either a frontal brain injury was delivered or sham procedures performed. Following recovery, they were re-tested on the discrimination task and then tested on a reversal of the discrimination. MAIN OUTCOMES AND RESULTS: Frontal injury caused substantial deficits in responding and discrimination accuracy as well as an increase in side bias. CONCLUSIONS: Based on the outcomes seen in this study, discrimination and other operant tasks may provide a sensitive tool to assess the effect of therapeutic agents on cognitive deficits in animal models, which could lead to improved characterization of deficits and yield an improved assessment tool to aid in drug discovery.