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Regional patterns - Mediterranean countries

Cost of dementia

by Paul-Ariel Kenigsberg, Fondation Médéric-Alzheimer

In Greece and Turkey, access to diagnosis and care for people with dementia appears to be hampered by cultural barriers. In Turkey, a population-based study of people without dementia, aged 70 years and older, living in an urban area of Istanbul, showed that the concept of dementia was not generally considered as a medical problem by the elderly Turkish population, regardless of age and education (1). Another Turkish study showed that the impact of informal care is very high. (2).

Greece moved toward a national healthcare system only in the 1980s . In rural populations, healthcare was served to a large extent by physicians without formal training in general practice and a low level of knowledge in relation to Alzheimer’s disease in 2001. People with frontotemporal lobar degeneration are diagnosed later in the disease in Greece and Turkey rather than in the United States, presumably because their behavioural symptoms are not easily detected by the medical system in these countries, underscoring the need to create culturally appropriate indices of the behavioural symptoms (3). Psychiatrists of the Aristotle University of Thessaloniki have challenged the appropriateness of neuropsychologic assessment with existing instruments to Greek psychogeriatric patients, as validation studies in Greece revealed certain difficulties both for the Mini-Mental State Examination (MMSE) and the Cambridge Cognitive Evaluation for the Elderly, probably due to cultural differences, functional illiteracy of the Greek elderly, restricted access to news over past decades, coexistence of mood disorders and low levels of cooperation with the examiner (4).

In Italy, organisational factors, such as scanner availability and waiting list, play a relevant role in the prescription of imaging examinations in patients with cognitive impairment, with a rather low perceived added value for diagnosis of Alzheimer’s disease among Alzheimer’s centers of Northern Italy in 2003 (5). The total cost of brain disorders in Italy has been estimated to be 40.8 billion € in 2008 (3% of the gross national product), of which 8.6 billion € for dementia (21% of the total)(6) In 1997, the first Italian study on primary data estimated annual non-medical costs per person with Alzheimer’s disease to be 13,388,000 LIT/year (6,914 € of 2008), and informal unpaid care to be 72,877,000 LIT (37,637 € of 2008)(7).

In Spain, specific cultural contexts in Hispanic culture, with the importance of family key values, have been shown to influence dementia caregiving in relation with burden and depressive symptoms (8). Most people with dementia in Spain live at home with their families, women being the major contributors to informal care (9). Current change in the family structure are transforming the care of people with dementia through new cohabitation arrangements and rotation practices between family members, a mechanism related to the rejection of long-term care institutions (10). Willingness to pay of the general population for alternative policies directed to people with Alzheimer’s disease has been estimated to be 4 €/hour per person for home care, 0.43 €/hour for day centers and 0.42 €/hour for medium or long stay centres (11).

Direct health care costs of Alzheimer’s disease represented 2.4% of the total public health expenditure in the Canary Islands in 2006. Across all severity levels, total annual cost was estimated to be 10 billion € for Alzheimer’s disease patients older than 65 years in Spain. The average annual cost per person with Alzheimer’s disease was 28,198 €. The most important categories of costs were for informal care and drugs. Costs increased with cognitive impairment with an average annual cost of 14,956 € for mild, 25,562 € for moderate and 41,669 € for severe stages (12, 13). An economic modelling study estimated in 2006 that community-based people with Alzheimer’s disease under standard care were spending 6 months in a non-dependent state and incurred average total costs of 24,700 € per person over 2 years (14). In a population setting, costs of vascular dementia in people 65 years old and above have been estimated to be 11,039 € per person per semester, compared to 8,086 € per semester for Alzheimer’s disease (15).

About 34% of people with Alzheimer’s disease were treated by specific drugs in 2004 in Spain. Overall consumption of these drugs has increased from 0.026 to 3.235 defined daily dose per 1,000 inhabitants per day (DHD) between 1996 and 2004. Overall costs of the DHD dispensed in 2004 reached about 6 million €. As total treatment cost increased ninety-fold in current €, daily treatment cost decreased about 30% during this period (16).


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  2. Zencir M, Kuzu N, Beser NG, Ergin A, Catak B, Sahiner T. Cost of Alzheimer's disease in a developing country setting. Int J Geriatr Psychiatry. 2005 Jul;20(7):616-22.
  3. Papatriantafyllou JD, Viskontas IV, Papageorgiou SG, Miller BL, Pavlic D, Bingol A, et al. Difficulties in Detecting Behavioral Symptoms of Frontotemporal Lobar Degeneration Across Cultures. Alzheimer Dis Assoc Disord. 2008 Aug 8.
  4. Fountoulakis KN, Kaprinis SG, Kaprinis GS. Special characteristics affecting the neuropsychologic assessment of the elderly in Greece. Am J Alzheimers Dis Other Demen. 2002 Sep-Oct;17(5):273-6.
  5. Riello R, Albini C, Galluzzi S, Pasqualetti P, Frisoni GB. Prescription practices of diagnostic imaging in dementia: a survey of 47 Alzheimer's Centres in Northern Italy. Int J Geriatr Psychiatry. 2003 Jul;18(7):577-85.
  6. Pugliatti M, Sobocki P, Beghi E, Pini S, Cassano GB, Altamura AC, et al. Cost of disorders of the brain in Italy. Neurol Sci. 2008 Apr;29(2):99-107.
  7. Cavallo MC, Fattore G. The economic and social burden of Alzheimer disease on families in the Lombardy region of Italy. Alzheimer Dis Assoc Disord. 1997;11(4):184-90.
  8. Losada A, Robinson Shurgot G, Knight BG, Marquez M, Montorio I, Izal M, et al. Cross-cultural study comparing the association of familism with burden and depressive symptoms in two samples of Hispanic dementia caregivers. Aging Ment Health. 2006 Jan;10(1):69-76.
  9. Castano-Ruiz V. Cuidados a las personas dependientes prestados por mujeres. Valoración económica. . Madrid: Ministerio de Igualdad. Instituto de la Mujer; 2008 .
  10. Rivera J, Bermejo F, Franco M, Morales-Gonzalez JM, Benito-Leon J. Understanding care of people with dementia in Spain: Cohabitation arrangements, rotation and rejection to long term care institution. Int J Geriatr Psychiatry. 2008 Jul 10.
  11. Negrin MA, Pinilla J, Leon CJ. Willingness to pay for alternative policies for patients with Alzheimer's Disease. Health Econ Policy Law. 2008 Jul;3(Pt 3):257-75.
  12. Jorgensen N, Cabanas M, Oliva J, Rejas J, Leon T. [The cost of informal care associated to incapacitating neurological disease having high prevalence in Spain]. Neurologia. 2008 Jan-Feb;23(1):29-39.
  13. Lopez-Bastida J, Serrano-Aguilar P, Perestelo-Perez L, Oliva-Moreno J. Social-economic costs and quality of life of Alzheimer disease in the Canary Islands, Spain. Neurology. 2006 Dec 26;67(12):2186-91.
  14. Antonanzas F, Rive B, Badenas JM, Gomez-Lus S, Guilhaume C. Cost-effectiveness of memantine in community-based Alzheimer's disease patients: An adaptation in Spain. Eur J Health Econ. 2006 Jun;7(2):137-44.
  15. Sicras A, Rejas J, Arco S, Flores E, Ortega G, Esparcia A, et al. Prevalence, resource utilization and costs of vascular dementia compared to Alzheimer's dementia in a population setting. Dement Geriatr Cogn Disord. 2005;19(5-6):305-15.
  16. Villar Fernandez I, Rabaneque Hernandez MJ, Armesto Gomez J, Garcia Arilla E, Izuel Rami M. [Use of specific drugs for Alzheimer's disease]. Neurologia. 2007 Jun;22(5):275-84.



Last Updated: Thursday 08 October 2009


  • Acknowledgements

    The EuroCoDe project received financial support from the European Commission. Neither the European Commission nor any person acting on its behalf is responsible for any use that might be made of the following information. Alzheimer Europe also gratefully acknowledges the support it received from Fondation Médéric Alzheimer for this project.
  • European Union
  • Fondation Médéric Alzheimer