Risk and sex-specific trends of dementia and stroke in Italy Compared to European and high-income countries and the world: global implications

Abstract

Background

Understanding the increasing trends in Italy may inform new prevention strategies and better treatments. We investigated trends and risk factors of dementia, stroke, and ischemic heart disease (IHD) in Italy with the second-oldest population globally, compared to European and high-income countries and the world.

Methods

We analyzed the Global Burden of Disease Study (GBD) 2019 estimates on incidence and burden (i.e., disability and death combined) of the three conditions in both sexes. We also analyzed the burden attributable to 12 modifiable risk factors and their changes during 1990–2019.

Results

In 2019, Italy had 186,108 new dementias (123,885 women) and 94,074 new strokes (53,572 women). Women had 98% higher crude dementia and 24% higher crude stroke burdens than men. The average age-standardized new dementia rate was 114.7 per 100,000 women and 88.4 per 100,000 men, both higher than Western Europe, the European Union, high-income countries, and the world. During 1990–2019, this rate increased in both sexes (4%), despite a decline in stroke (− 45%) and IHD (− 17%) in Italy. Dementia burden attributable to tobacco decreased in both sexes (− 12.7%) during 1990–2019, while high blood glucose and high body mass index combined burden increased (25.4%). Stroke and IHD had similar trends.

Conclusions

While decreases in new strokes and IHDs are encouraging, new approaches to their joint prevention are required to reverse the rising dementia trends, especially among women. Life course approaches to promoting holistic brain health should be implemented at the community, national, and international levels before the growing trends become overwhelming.

Expert Panel

Expert Panel: highlights, taken measures in Italy, and lessons for global implications
Dementia disproportionately affects women [32]. Women live longer than men [33], though their longer years of life are not necessarily in good health [34]. The overall health of people in Italy has been improving over the last decades, with a reduction in mortality and disability separately or combined [35, 36]
Most caregivers are women (i.e., two-thirds of primary caregivers) contributing to a physical and psychological burden that can lead to caregivers' personal and economic burnout. A woman may have a full-time job, but be forced to work part-time or leave the workforce, with a loss of income and a corresponding contribution to the economy
Thoughtful consideration should be given to the adoption of cardiovascular risk management screening programs focusing on hypertension and other major risk factors among adults, similar to the UK NHS Health Check Program [37], to mitigate the potential long-term impact of well-established risk factors and risk conditions for stroke, ischemic heart disease, dementia, and other chronic diseases [38]. Successful initiatives adopted in other countries to improve prevention and quality of care in primary care, such as the Quality and Outcomes Framework in the UK [39], could apply in Italy and translate into a long-term reduction in dementia, ischemic heart disease, and stroke burden
The underlying principle is health in all policies which clearly shows that prevention should be an action that engages with a ONE health approach and all stakeholders [40]. Despite a national health system, Italy relies on regions to implement the plan requiring an organization able to provide equity of access to all citizens. In the World Health Organization (WHO) Health Equity Status Report [35], consideration of all the drivers of health equity is highlighted, namely the factors fundamental to creating more equitable societies, such as policy coherence, accountability, social participation, and empowerment [20]
Italy’s life expectancy has increased to 83 years and the birth rate decreased to 1.3 per woman. This creates an “opening scissor curve” of the growing number of older adults and fewer young people to support them. This calls for an urgent action plan to make the holistic brain health (cerebral, mental, and social) approach through the lifespan [31], so that small gains among all ages can translate into big gains in health, productivity, and well-being [3]. Dementia, ischemic heart disease, and stroke share treatable or modifiable risk factors [41]. Therefore, preventing one helps prevent the others. There is immense potential at the community level through a systematic, comprehensive, customized, cost-effective approach to joint prevention of the three conditions [28], demanding a focus on the message of integral (holistic) brain health [29]
Our findings should prompt a meticulously designed study of historical records in Italy and other regions and nations to determine whether the estimated trends are accurate to foresee implementing required prevention
Regional differences might explain some of the rising trends. For instance, the five southern provinces (i.e., Basilicata, Compania, Calabria, Apulia, and Molise) have the highest share of the overweight population, including children obesity, in Italy [42]. They also lack sufficient resources for the management of ischemic heart disease, stroke, and their metabolic risk factors. There are other efforts to boost prevention in Italy, such as the effort to implement the National Dementia Plan in Puglia (comprising four million inhabitants in Southeast Italy,a a relatively disadvantaged area compared to other regions)
In 2014, an Italian National Dementia Plan was approved for supporting people with dementia and their caregivers [43]. In 2021, the Italian government provided a €15 million budget for the National Dementia Plan during 2021–2023, while the annual costs of dementia are estimated at €15.6 billion per year, with 80% born by families of people with dementia [43]. The costs will continue to rise unless the growing tide of dementia is slowed by a lifelong brain health approach [31]
The Italian National Dementia Plan focused primarily on dementia care to support patients and their families, rather than on prevention. The economic crisis in Italy might explain part of the reported unfavorable dementia figures. Our findings suggest that the increasing trends in dementia burden in Italy are likely driven by unfavorable trends in major behavioral risk factors at the population level, such as unhealthy dietary habits and high body mass index, especially among low-socioeconomic subgroups [44]. These results call for urgent implementation of public health nationwide initiatives, promoting the adoption of healthy lifestyles at the population level, from childhood through adulthood
Italy plans to contribute to the achievement of Sustainable Development Goals (SDGs) and the European Union (EU) Green Deal with the National Plan for Prevention (NPP) 2020–2025 (available on the website of the Minister of Health, Italy) [45]. The Italian NPP 2020–2025 reinforces a vision that considers health as the result of a harmonious and sustainable development of human beings, nature, and the environment. Therefore, recognizing that human, animal, and ecosystem health are interconnected, promotes the application of a multidisciplinary, cross-sectoral, and coordinated approach to address potential or already existing risks originating from the environment–animal–ecosystem interface
The potential role of volunteer lay organizations is underestimated. ALICeb (Associazione per la Lotta all’Ictus Cerebraleie, in Italian) meaning Association for the Fight against Stroke is the Italian Federation of Regional Association made up of doctors, nurses, stroke survivors, and volunteers (https://www.aliceitalia.org/). It aims to improve the quality of life of people affected by stroke, their families, and people at risk. Since stroke doubles the risk of dementia [46], preventing stroke is one way of preventing some dementia. ALICe, for 10 years, screened over 10,000 patients and campaigned for awareness and prevention that were associated with a decrease in the number of patients hospitalized because of stroke [47]. This is an example of how volunteers and government organizations can work together
The Italian Ministry of Health and WHO Regional Office for Europe jointly launched the Italian Health Equity Status Report initiative (HESRi) [35], “Healthy Prosperous Lives for All in Italy,” to support decision-makers in Italy to create the conditions for every person to be able to flourish in health and life. The Italian HESRi is the generation of a new set of disaggregated indicators, derived specifically for the Italian HESRi analysis. This dataset brings together 1) indicators of the status and trends in inequities in health; 2) gaps and trends in the five essential conditions needed to live a healthy life; and 3) progress and trends in policy performance to reduce these inequities [35]
Until the Coronavirus disease (SARS-CoV-2; COVID-19) pandemic in 2020, life expectancy in Italy had been increasing, despite significant socioeconomic and regional inequities [35]. There is a clear social and educational gradient throughout most of the health indicators. Those with fewer years of education and less financial security, experience poorer health than those with more years of education and greater financial security. Italy entered the COVID-19 pandemic with multiple inequities (e.g., concerning the extent of non-communicable diseases, overweight and obesity, mental health issues such as depression, and risky health behaviors). Inequities in health were particularly apparent among women and young people, evaluated by education level, income quintile, and region
The potential impact of COVID-19 on cognition should be considered in future studies [48]
The WHO defines brain health as the state of brain functioning across cognitive, sensory, social-emotional, behavioral, and motor domains, allowing a person to realize their full potential over their life course, irrespective of the presence or absence of disorders [49]. Implementation needs to be at global, national, and community levels [28]. Moreover, brain health matters to all, and addressing the determinants of brain health through promotion and prevention can reduce the incidence of disorders that affect the central nervous system and should be practiced by all. Optimizing brain health improves mental and physical health and also creates positive social and economic impacts, all of which contribute to greater well-being and help advance society, irrespective of the presence or absence of disorders [49]. Healthier brains contribute to a healthier, happier society, and increased productivity in an increasingly digital and knowledge-based society [3]

1. ^aOne of the coauthors (GL) directs the team in Southeast Italy, advocating measures to modify lifestyle factors in the management of subjects with cognitive impairment being referred to the Center for Neurodegenerative Disease Research of the University of Bari
2. ^bOne of the coauthors (AN) cofounded ALICe and was vice president; she also founded the ALICe chapter in the Emilia-Romagna region and helped draft the stroke guidelines with the authorities. Emilia-Romagna is an administrative region of northern Italy with a population of 4.5 million. AN also founded two acute stroke units in community hospitals; the last earning the Gold Award of Angels of the European Stroke Organization