The rising prevalence of dementia is a global emergency
痴呆症患病率上升是个全球性的紧急情况

被遗忘的问题 The forgotten problem-书迷号 shumihao.com

OF ALL THE troubles facing the world, the rising prevalence of dementia might seem among the less pressing. The reason behind it—longer lifespans—is to be cheered; it does not advance at the speed of a viral infection but with the ponderous inevitability of demographic change; and its full effects will not be felt until far into the future. But the reality is very different. Dementia is already a global emergency. Even now, more people live with it than can be looked after humanely. No cure is in the offing. And no society has devised a sustainable way to provide and pay for the care that people with it will need.
全世界面临的所有麻烦中,痴呆症患病率上升看起来似乎属于不太紧迫的那类。其背后的原因——人们更长寿了——本身值得庆贺,而且它的扩展并不似病毒感染那般迅速,而是与迟缓而不可避免的人口结构变化同步。另外,它的全面影响要到很久以后才能感受得到。但现实却非常不同。痴呆症已经成为全球性的紧急情况。即便是现在也已经有患者得不到人道的照顾。眼下并没有治愈的方法,也没有哪个社会想出了一种可持续的方式来提供和支付患者所需的护理。

“Dementia” is an umbrella term for a range of conditions, with a variety of causes, of which the most common is Alzheimer’s disease, accounting for 60-80% of cases. It usually starts with forgetfulness and a mild loss of cognitive functioning. But as it advances, people lose the ability to look after themselves. Many require round-the-clock care long before they die. It does not just affect the elderly, but they are much more likely to have it—and life expectancy globally has climbed from not much more than 30 a century ago to over 70 now, and over 80 in rich countries. By some estimates, 1.7% of 65- to 69-year-olds have dementia and the risk of developing it doubles every five years after that. At present, about 50m people around the world have the condition, a number expected to rise to 82m by 2030 and 150m by 2050. Most of the new cases are in the developing world, where populations are rising and ageing.
“痴呆症”是个涵盖一系列疾病的总称,致病原因也多种多样,其中最常见的是阿尔茨海默病,在所有病例中占到60%到80%。痴呆症通常始于健忘和认知功能轻度丧失。但随着病情的发展,患者会失去自理能力。许多人在去世前很久就需要全天候的护理。它并不仅仅影响老年人,但他们更有可能患上此症——而全球预期寿命已经从一个世纪前的30出头攀升到现在的70多岁,在富裕国家更是超过了80岁。据估计,65岁至69岁的人中有1.7%患有痴呆症,此后每五年罹患该病的风险增加一倍。目前全球约有5000万人患病,预计到2030年将升至8200万,到2050年升至1.5亿。大多数新增病例出现在人口正在增长并老龄化的发展中国家。

The problems these numbers will bring everywhere have already been felt in countries where people are older, and especially acutely during lockdowns—witness the difficulty of looking after people with dementia in their own homes, and the large numbers in overstretched care homes who receive little individual attention. As families shrink, single children and grandchildren will struggle to cope with their old folk. Already, dementia care has had a knock-on effect on general health care. Before the pandemic as many as a quarter of beds in British hospitals were occupied by people with dementia. There was nowhere else for them to go.
这些数字将给全世界带来的难题现在就已在老龄化更严重的国家显现出来,在封城期间被强烈地感知——看看在家里照顾痴呆症患者有多难吧,还有那些不堪负荷的护理院中有大批患者得不到个体化照顾。随着家庭规模的缩小,独生子女和孙辈将很难照护他们的长辈。痴呆症护理已经对一般医疗系统造成了连锁效应。在新冠疫情发生前,英国医院多达四分之一的床位被痴呆症患者占据。他们也没有别的地方可去。

Not all the news is bad. Recent research has shown that behaviour such as smoking less, exercising more and losing weight in middle age has reduced the risk of dementia among old people in some Western countries in the past 30 years. And America’s Food and Drug Administration has promised to decide by March 2021 whether to license a drug said to be the first to stem cognitive decline in Alzheimer’s patients. But the risk of dementia still seems to be rising in much of the world and any new therapy in the foreseeable future is likely to benefit only some patients partially.
倒也不是只有坏消息。近期有研究表明,过去30年,部分西方国家的老年人通过在中年时少吸烟、多锻炼和减肥等行为降低了患痴呆症的风险。另外,美国食品和药物管理局承诺在2021年3月之前对一款药物做出审批决定,据说这是第一款可阻止阿尔茨海默病患者认知能力下降的药物。但是在世界的大部分地区,患痴呆症的风险似乎仍在上升,而且在可预见的未来出现的任何新疗法很可能只会让一些患者部分受益。

That is why governments should act now to lessen the social and economic harm from the growing prevalence of dementia. The first step is to recall the urgency with which many were promising to tackle the problem just a few years ago—in 2013, for example, when David Cameron, then Britain’s prime minister, used the rotating chairmanship of the G8 to convene a “dementia summit”, which promised to fund research with the goal of finding a “disease-modifying treatment” by 2025. Instead, funding for work on dementia has lagged far behind that for cancer or coronary heart disease. And as the pandemic hampers or prevents clinical trials and research, and sucks resources away from other areas, dementia risks again being left behind.
因此,政府现在应该行动起来,减轻痴呆症患病率上升带来的社会和经济损害。第一步就是要重新唤起几年前许多人承诺解决这个问题时曾有过的紧迫感——例如在2013年,时任英国首相的卡梅伦利用英国担任八国集团轮值主席国的机会召集了一次“痴呆症峰会”,会议承诺为痴呆症研究提供资助,以期在2025年前找到一种“疾病缓解疗法”。而事实却是,痴呆症研究获得的资助已经远远落后于癌症或冠心病。而且,由于疫情阻碍或阻止了临床试验和研究,并抽走了其他领域的资源,痴呆症有再次被抛在后面的风险。

Governments also need to think about long-term care for people with dementia. The question that is most often asked is how to pay for it. Japan’s compulsory long-term-care insurance scheme, requiring everyone aged 40-65 to pay a premium, seems attractive, as it avoids penalising the young. But it is not self-financing. The increasing burden there as elsewhere will fall on individuals and the taxpayer.
政府还需要思考痴呆症患者的长期护理问题。最常被问到的问题是该如何为此买单。日本实行强制性的长期护理保险计划,要求所有40到65岁的人支付保险费。这种做法似乎很有吸引力,因为它避免了将重担丢给年轻人。但该计划并不是自我融资的。和其他地方一样,日益加重的负担将落在个人和纳税人身上。

And an even more fundamental question than who pays for care is: who will do it? Undertaken with humanity and dignity, it is extremely labour-intensive. Technology can help lighten the load—using remote monitoring to let people stay at home and, perhaps in future, robots to perform some basic tasks. But looking after people with dementia requires people. The job is usually classified as low-skilled and is often poorly paid. In fact it demands huge reserves of patience, empathy and kindness. It should be better rewarded and more highly regarded even though that would add to the bill. In countries such as Japan and Britain, with acute shortages of care-workers, immigration will have to be made easier for those willing and able to do it.
比起由谁支付护理费用,一个更重大的问题是:谁来提供护理服务?护理要体现人道和尊严,是极其劳动密集型的工作。技术可帮助减轻负担:可以利用远程监控让人们待在家里;或许在未来,机器人可以执行一些基本任务。但照顾痴呆症患者还是需要人。这项工作一般都被归为低技能那一类,报酬通常也很低。事实上,它需要有极大的耐心、同理心和善意。这份工作应该得到更好的回报和更多的尊重,尽管这会增加支出。在日本和英国等护理人员严重短缺的国家,需要对那些愿意且有能力从事这项工作的人提高移民的便利度。

Lastly, evidence suggests that as many at 40% of cases of dementia can be delayed or averted by changing behaviour earlier in life. The trouble is that public-health campaigns have a patchy record and they do nothing for dementia’s most intractable pre-existing condition—old age. No cure, insufficient financing and a tricky public-health message: perhaps that is enough to make you throw up your hands in despair. Instead, however, it only underlines how the solutions to dementia, like the disease itself, will take decades to unfold. It is yet another reason to start working on them right away. ■
最后,有证据表明,多达40%的痴呆症病例可以通过在早年改变行为来延缓或避免。问题是过往的公共卫生宣传活动效果参差不齐,对于痴呆症最棘手的“既有病症”——老龄——也无补于事。无药可医、资金不足、公共卫生讯息传达难以收效,这一切也许足以让人绝望地举手投降。然而,这实际上只是突显出痴呆症的解决方案就像这种疾病本身一样,需要几十年的时间来发展。这是应该马上开始研究这些方案的另一个理由。