Tsai PH, Chen SP, Lin KN, Wang PN, Wang HC, Liu CY, Hong CJ, Liu HC. Survival of ethnic Chinese with Alzheimer's disease: a 5-year longitudinal study in Taiwan. J Geriatr Psychiatry Neurol. 2007 Sep;20(3):172-7.

Survival time and mortality risk factors in patients with Alzheimer's disease (AD) have been documented in Western countries, but comparable information on the ethnic Chinese is scarce. We consecutively recruited 159 AD patients and 145 control subjects from the Memory Clinic of Taipei Veterans General Hospital. After admission to the study, each subject received clinical, neuropsychological, and psychiatric evaluation and apolipoprotein E genotyping. Survival status was followed for 5 years. Forty-six AD patients (28.9%) and 3 control subjects (2.1%) died during the 5-year follow-up period. The mean survival time for AD patients was 4.48 years (SD = 0.1 years) after the time of enrollment. Among individuals with AD, those with severe disease, older patients, and those experiencing hallucinations were at greater risk for increased mortality. As expected, AD shortened life expectancy in these patients. The factors found to correlate with a shorter life span may suggest effective health care strategies for AD patients.

Chiang CJ, Yip PK, Wu SC, Lu CS, Liou CW, Liu HC, Liu CK, Chu CH, Hwang CS, Sung SF, Hsu YD, Chen CC, Liu SI, Yan SH, Fong CS, Chang SF, You SL, Chen CJ. Midlife risk factors for subtypes of dementia: a nested case-control study in Taiwan. Am J Geriatr Psychiatry. 2007 Sep;15(9):762-71.

OBJECTIVE: To identify the midlife risk factors for subtypes of dementia newly developed later in life. METHODS: A nested case-control study was conducted on 157 demented cases and 628 comparison cases selected from 40,636 men and women who were enrolled from 1982 to 1992. Four comparison cases were frequency-matched on age, time at enrollment (within 6 months), gender, and residential township. Midlife risk factors included vascular risk factors (body mass index [BMI], total cholesterol, total triglycerides, blood glucose, cerebrovascular accident [CVA] history, diabetes mellitus history, and hypertension history), cigarette smoking, and alcohol consumption. Dementia assessments were ascertained through the computerized data linkage from National Health Insurance Database from 2000 to 2002 and clinically confirmed by neurologists or psychiatrists. Conditional logistic regression analysis was used to estimate the matched odds ratio (OR) and its 95% confidence intervals (CI) for each risk factor. RESULTS: A J-shaped relationship was observed between BMI (kg/m(2)) and dementia. The multivariate-adjusted ORs (95% CI) of developing dementia were 1.84 (1.02-3.33), 1.87 (1.08-3.23) and 2.44 (1.39-4.28), respectively, for BMIs of <20.5, 23.0-25.4, >or=25.5 compared with a BMI of 20.5-22.9 as the referent group (OR = 1.0). Similar findings were observed for Alzheimer disease (AD) and vascular dementia (VaD). The association between obesity (BMI >or=25.5) and both AD and VaD was statistically significant among cigarette smokers but not among nonsmokers. Additionally, history of CVA was a significant risk factor for VaD, but not for AD. CONCLUSION: Being underweight, being overweight, and a cerebrovascular accident in midlife may increase the risk of dementia in late life.

Chiu NT, Lee BF, Hsiao S, Pai MC. Educational level influences regional cerebral blood flow in patients with Alzheimer's disease. J Nucl Med. 2004 Nov;45(11):1860-3.

We tested the hypothesis that educational level influences regional cerebral blood flow (rCBF) in Alzheimer's disease (AD) patients. METHODS: The severity of AD was measured with the Cognitive Ability Screening Instrument (age and education adjusted). rCBF was assessed using (99m)Tc-hexamethylpropyleneamine oxime brain SPECT; differences in rCBF between groups with different educational levels were determined using statistical parametric mapping (SPM). RESULTS: In matched low-education (< or =6 y; n = 29) and high-education (>6 y; n = 29) groups, SPM revealed 2 statistically significant clusters of voxels with higher rCBF in the high-education group: one in the left lateral inferior, middle, and superior temporal gyrus; another in the left medial temporal area to the left inferior frontal gyrus. CONCLUSION: We provide biologic evidence that education may lead to relatively higher rCBF in specific areas in AD patients, which may explain the effects of education on clinical manifestations of AD.

Lin RT, Lai CL, Tai CT, Liu CK, Yen YY, Howng SL. Prevalence and subtypes of dementia in southern Taiwan: impact of age, sex, education, and urbanization. J Neurol Sci. 1998 Sep 18;160(1):67-75.

To determine the prevalence and subtypes of dementia in southern Taiwan, a two-phase study consisting of a phase I screening survey using the Mini-Mental Status Examination (MMSE) and a phase II diagnostic examination using the CERAD neuropsychological battery and the neurobehavioral examination was conducted. According to the household records, stratified random sampling by the degree of urbanization of the community was used, and 2915 inhabitants aged 65 and over participated in this study. The ICD-10NA criteria for dementia, NINCDS-ADRDA guidelines for Alzheimer's disease (AD), and NINDS-AIREN criteria for vascular dementia (VaD) were employed. Three hundred and ninety-eight persons who had MMSE scores below the cutoff values were recruited into the phase II study, of whom 108 had dementia. The prevalence rate (PR) of dementia was 3.7%, increasing from 1.3% in people 65-69 years old to 16.5% in people 85 years old and older. The age-standardized PR (ASPR) was 4.0%. AD (58 cases, 53.7%, PR=2.0%, ASPR=2.3%) was the most common cause of dementia, followed by VaD (25 cases, 23.1%, PR=0.9%, ASPR=0.9%), and mixed dementia (eight cases, 7.4%). After adjusting for age, sex and education using logistic regression analysis, aging was a significant risk factor for AD, VaD and total dementia. Female sex and illiteracy were significant risk factors for AD only. We concluded that the prevalence of dementia in Taiwan is lower than in the developed countries, which could be due to a relatively young elderly population and a high mortality from dementia in Taiwan. AD is the leading cause of dementia in Taiwan. Considering the high stroke prevalence, the relatively lower prevalence of VaD in Taiwan deserves further investigation.

Liu CK, Lai CL, Tai CT, Lin RT, Yen YY, Howng SL. Incidence and subtypes of dementia in southern Taiwan: impact of socio-demographic factors. Neurology. 1998 Jun;50(6):1572-9.

OBJECTIVE: To determine the incidence rate (IR) and subtypes of dementia in southern Taiwan. METHODS: From a cohort of 2,915 community inhabitants aged 65 years and over, 2,507 and 2,175 subjects participated in the first- and second-year follow-up surveys, respectively. A two-phase study used the Mini-Mental State Examination in phase I and the Consortium to Establish a Registry of Alzheimer's Disease (CERAD) neuropsychological battery and the neurobehavioral examination in phase II. We applied International Classification of Diseases (ICD)-10NA criteria for dementia, National Institute of Neurological and Communication Disorders and Stroke-Alzheimer's Disease and Related Disorders Association (NINCDS-ADRDA) guidelines for Alzheimer's disease (AD), and National Institute of Neurological Disorders and Stroke-Association Internationale pour la Recherche et l'Enseignement en Neurosciences (NINDS-AIREN) criteria for vascular dementia (VaD). RESULTS: The annual IR for total dementia was 1.28%, which increased with age from 0.77% for 65- to 74-year-olds to 6.19% for persons aged 85 years or older. AD (25 cases, 41.7%, IR=0.54%) was the most common cause of dementia, followed by VaD (19 cases, 31.7%, IR=0.41%) and mixed dementia (9 cases, 15.0%). After adjusting for sex, increasing age was significantly associated with total dementia and AD (p < 0.01). Illiteracy was associated with a marginally increased risk for total dementia (aRR=1.59, p < 0.1) as was being female for AD (aRR = 1.92, p < 0.1). The 2-year mortality rate was high among the demented (48% in total dementia, 38% in AD, and 60% in VaD). CONCLUSIONS: The age-specific incidence of dementia in Taiwan is approaching that of developed countries and the low prevalence of dementia (especially VaD) may be mainly due to the high mortality. Age was the major risk factor for total dementia and AD. Being female was probably a risk factor for AD, as was illiteracy for total dementia.

Liu CK, Lin RT, Chen YF, Tai CT, Yen YY, Howng SL. Prevalence of dementia in an urban area in Taiwan. J Formos Med Assoc. 1996 Oct;95(10):762-8.

This two-stage epidemiologic study was to investigate the prevalence and types of dementia among elderly people in the Saa-Min district of Kaohsiung City in Taiwan. In stage one, the Chinese Mini-Mental Status Examination (CMMSE) and Blessed Dementia Rating Scale were employed. In stage two, a comprehensive neurobehavioral examination and neuropsychologic tests were administered by neurologists and neuropsychologists. Dementia was defined by DSM-III-R criteria. The National Institute of Neurological and Communication Disorders and Stroke-Alzheimer's Disease and Related Disorders Association guidelines for Alzheimer's disease (AD) and the National Institute of Neurological Disorder and Stroke-Association international pour la Recherche et l'Enseignement en Neurosciences criteria for vascular dementia (VaD) were applied. A total of 1,016 randomly selected elderly people participated in phase one: 131 people with CMMSE below cutoff values participated in phase two, of whom 45 were confirmed to have a form of dementia. The prevalence of dementia in this sample was 4.4% (3.2% in men and 5.8% in women): 2.0% for those 65 to 74 years old, 8.3% for those 75 to 84 and 24.4% for those > or = 85 years old; 6.0% for those who were illiterate, 3.3% for those who attended grade-school; and 2.8% for those who finished junior-high-school. AD (22 cases, 48.9%) was the most common cause of dementia, followed by VaD (11 cases, 24.4%) and mixed dementia (MIX: 5 cases, 11.1%). Old age and being female were significant high risk factors for AD. Medical history indicated that stroke and hypertension were significant risk factors for VaD. A relatively high prevalence of dementia was observed in this study, probably because we assessed neurobehavior in great detail. Although AD was the leading cause of dementia in the present population sample. VaD and MIX also comprised an important proportion, reflecting the high prevalence of stroke in Taiwan. Older women had high risk for AD, not for VaD; and those with a history of stroke and hypertension had high risk for VaD, not for AD.

Liu HC, Lin KN, Teng EL, Wang SJ, Fuh JL, Guo NW, Chou P, Hu HH, Chiang BN. Prevalence and subtypes of dementia in Taiwan: a community survey of 5297 individuals. J Am Geriatr Soc. 1995 Feb;43(2):144-9.

OBJECTIVE: To study the prevalence rate of dementia in Taiwan, the relative frequencies of its subtypes, and its associations with age, education, gender, and residence location. PARTICIPANTS: A total of 2753 men and 2544 women from four urban and four rural communities participated. Their age ranged from 41 to 88 years; 28% of them were at least 65 years old. Their education ranged from 0 to 20 years; 27% of them had less than 1 year of formal schooling. DESIGN: Phase I was a screening survey by trained nurses who administered a Chinese version of the Mini-Mental State Examination, the MMSE-T1, to all participants. Phase II involved the assessment for dementia by neurologists on the 1521 individuals who had scored less than 24 on the 30-point MMSE-T1. MAIN RESULTS: Thirty-one cases of dementia were identified by the DSM-III-R criteria, including 18 cases of Alzheimer's disease, 10 cases of vascular dementia, and three cases of other dementias. The prevalence rate in individuals aged 65 and over was 2.0%. Aging and illiteracy were associated with higher rates of dementia; gender and residence location made no difference. CONCLUSIONS: The prevalence rate of dementia was low in this Chinese population. Consistent with common findings from other parts of the world, a high rate of dementia was associated with older age and illiteracy, and Alzheimer's disease was the most frequent cause.

Fuh JL, Wang SJ. Cost-effectiveness analysis of donepezil for mild to moderate Alzheimer's disease in Taiwan. Int J Geriatr Psychiatry. 2008 Jan;23(1):73-8.

BACKGROUND: Donepezil is a drug used for treatment in patients with Alzheimer's disease (AD). Information regarding the cost-effectiveness of this medication was previously rare in Asia. We used techniques of decision analysis and economic evaluation in conjunction with available local epidemiological and clinical data on costs of mild to moderate AD to assess the cost-effectiveness of donepezil in Taiwan. METHODS: A four-state Markov model was built to simulate the disease progression of AD patients. Local transition probabilities and costs of different stages were from the studies published earlier. RESULTS: Over a 5-year span, donepezil treatment for mild or moderate AD patients is predicted to result in the gain of 0.505 QALYs when comparing to usual care, while at the same time reducing the cost by US$7,691. The incremental cost was US$3,647 from the payer perspective; thus, the incremental cost-effectiveness ratio was estimated to be US$7,226 when considering only the medical expenditures. CONCLUSIONS: Under some assumptions, donepezil treatment might be a cost saving strategy for mild to moderate AD patients in Taiwan from a societal perspective. It is inconclusive from the payer's part since we still lack a consensus for judging the cost-effectiveness of a new health care technology.

Chiu L, Shyu WC. Estimation of the family cost of private nursing home care versus home care for patients with dementia in Taiwan. Chang Gung Med J. 2001 Oct;24(10):608-14.

BACKGROUND: Although overall estimates of the cost of dementia in Taiwan have been published, the relative cost of home care versus nursing home care for these patients is unclear. This study estimated the costs of home care and nursing home care for families of patients with either Alzheimer's disease or vascular dementia in Taiwan. METHODS: Data from previous reports were used to estimate costs of home care and nursing home care for families of patients with dementia, as well as the prevalence of dementia in Taiwan. RESULTS: The cost of home care per patient per month was NT$85,256 for patients with Alzheimer's disease and NT$74,152 for patients with vascular dementia. Labor was the predominant factor (96%) in home care. When the cost of labor was deducted from the calculation, the family cost per patient per month was reduced to NT$4,059 for Alzheimer's disease and NT$2,956 for vascular dementia. For patients receiving nursing home care, costs per month per patient were estimated to be NT$28,972 for patients with Alzheimer's disease and NT$31,576 for those with vascular dementia. Nursing home fees were the major component of costs incurred by families (at least 78% of total family costs). For both Alzheimer's disease and vascular dementia, payment for nursing home services amounted to approximately one-third of the labor costs of home care. CONCLUSIONS: These results indicate that nursing home placement for dementia patients provides a labor cost-savings for families in Taiwan.