Sociodemographic and Economic Aspects
Dementia is a superordinant category of illness that includes all conditions causing loss of cognitive abilities in an individual who was previously intellectually normal (or was functioning at a higher level) and that are not accounted for by an acute illness causing delirium (Geldmacher & Whitehouse, 1996). Dementia is a slowly progressive, currently incurable, long-lasting disease (Whitehouse, 1997) that ranks very high in the global burden of diseases. In 1994, the incidence of dementia was the ninth most frequent among all disorders (959,000 cases per year) in the United States, and its prevalence ranked eighth (7,082,000 cases; Murray & Lopez, 1997). In most industrialized countries the prevalence of Alzheimer’s Disease (AD), the most common dementing disorder, varies between 6% and 8% of persons older than 65. In every decade after the sixth, the number of patients suffering from AD approximately doubles (Katchaturian & Radebaugh, 1998), with an estimated 30% of the population older than 85 years of age affected by it (Ritchie & Kildea, 1995). AD and other degenera-
tive dementias have a drastic impact on the lives of patients and on family members who serve as caregivers for these patients (Cayton, 1993; Coon & Edgerly, 1999). Moreover, dementia induces enormous health care costs, which will increase more rapidly in an aging society (Meerding, Bonneux, Polder, Koopmanschap, & van der Maas, 1998). In the United States, the annual direct costs of treating AD were estimated to be $21 billion in 1991 (Ernst & Hay, 1994) and $29.8 billion in 1998 (Menzin, Lang, Friedman, Neumann, & Cummings, 1999). In the Netherlands in 1994, dementia ranked third in total health care costs (5.6% with 7.4% for women and 2.9% for men), first in the 65-84 age group (9.5%), and first in the over 85 age group (22.2%; Meerding et al., 1998). In the early stages of the disease, major costs stem from the loss of patient’s and caregiver’s productivity and from family out-of-pocket expenses (Schumock, 1998). In the advanced stages of the disease, costs are mainly linked to long-term and institutional care (Menzin et al., 1999). Until now, escalating health care costs were for care and not for cure (Meerding et al., 1998) of an increasing number of affected people (Katchaturian & Radebaugh, 1998). The expected impact of new drug developments may result in not only an improvement of the patient’s cognitive functioning and quality of life but also a reduction in the time spent by caregivers, a delay in nursing home placement, and a reduction of indirect costs (Schumock, 1998). But the current goal is to obtain rapidly a 5-year delay in the onset of the disease, which could reduce the number of patients by 50% (Katchaturian & Radebaugh, 1998). For these reasons, the economic evaluation of AD and related dementia will play an increasingly influential role in clinical and resource allocations in the coming years. Physicians and other health care professionals should familiarize themselves with techniques of cost-effectiveness analysis (Neumann, Herrmann, Berenhaum, & Weinstein, 1997), and this is the aim of this chapter.