Current status of professional memory clinics, inpatient services, and health professionals in China

Abstract

INTRODUCTION

This study aims to explore the current status of dementia‐specific diagnosis and treatment in China.

METHODS

This national survey was conducted in mainland China from September 2022 to February 2023, with strong support from the Cognitive Disorders Group of the Chinese Society of Neurology, Chinese Medical Association.

RESULTS

Among 2721 hospitals surveyed, 244 (8.97%) have dementia‐specific clinics (DSCs) and 166 (6.10%) have dementia‐specific inpatient departments (DSIDs). Almost all hospitals have brain structural imaging capabilities and basic hematological examinations, but dementia‐specific medical staff (DSMS) equipped for DSCs or DSIDs are rare. The proportion of patients with cognitive impairment receiving care through a DSCs or DSIDs is low, and most patients present with advanced (moderate to severe) disease.

CONCLUSION

The survey shows that the proportion of DSCs and DSIDs is low, and the regional distribution varies significantly. Trained DSMS and specialized facilities for the diagnosis and treatment of dementia are inadequate.

Highlights

• This study was a multi‐center national research to comprehensively investigate the distribution and features of dementia‐specific clinics and inpatient departments in mainland China, given that the limited literature was available regarding the dementia‐specific centers.

• The study points to significant regional differences in the distribution of cognitive‐specific clinics and inpatient departments in mainland China. More centers in Eastern Regions compared to Western Regions, a greater presence in provincial capitals as opposed to other cities, and a predominance of tertiary hospitals over non‐tertiary ones. The aim is to provide data support for advancements in medical research within this field.

• Domestic dementia patients have inadequate access to specialized medical resources and expert assistance, which significantly contrasts with the growing number of dementia cases in China.

1. INTRODUCTION

Dementia is a major public health concern in aging populations. A Chinese national cross‐sectional study estimates that approximately 15.07 million individuals aged 60 years and over in China have been diagnosed with dementia. ¹ Currently, the diagnosis and treatment of dementia here are not ideal, and many problems remain, including (1) limited public awareness and low numbers of outpatients. More than half of individuals who are ultimately diagnosed with dementia do not seek medical service because of lack of awareness about dementia, financial difficulties, or stigma. ² (2) The diagnostic rate for dementia is low. Diagnosis of dementia is medically challenging, and in most cases requires more than one doctor's office visits and multiple diagnoses. A national report ³ showed that only 36.79% of cases of Alzheimer's disease (AD) are diagnosed at the first visit. (3) Medical resources and specialists are lacking. An incomplete statistic shows there are only about 2000 dementia specialists in China. ¹

Dementia‐specific physicians diagnose and coordinate the treatment of dementia, and dementia‐specific clinics (DSCs) and dementia‐specific inpatient departments (DSIDs) are the centers of treatment for dementia. The distribution of these centers and their efficacy in diagnosis and treatment of dementia determine the direction and scope of China's national policy and action. However, there is no inventory of the current state of DSCs and DSIDs in China, and the survey of dementia‐specific medical staffs is relatively superficial and not conducive to the formulation of health policy.

In order to implement the relevant requirements of The Healthy China Action (2019–2030) and actively respond to the World Health Organization's Global Action Plan for Public Health Response to Dementia 2017–2025, we conducted a cross‐sectional national survey to reveal the current state of DSCs and DSIDs in China. According to Dr. Jia's report, ⁴ almost all DSCs and DSIDs are set up in tertiary hospitals in China. Thus, the aimed participants are all tertiary hospitals (n = 3275, according to the 2022, China Health Statistics Yearbook published in 2023) in Mainland China. Finally, 2721 (83.08%) tertiary hospitals in 31 provinces/municipalities/autonomous regions cooperated in completing the survey from September 2022 to February 2023, with the strong support of the Cognitive Disorders Group of the Chinese Society of Neurology, Chinese Medical Association. This project was designed to collect basic evidence about the current state of dementia‐specific diagnosis and treatment in China and to provide a uniform reference for the government to further promote and formulate health policy.

The main findings of the survey:

RESEARCH IN CONTEXT

1. Systematic review: We searched PubMed and the China National Knowledge Infrastructure database for articles published up to December 31, 2022, using the terms “cognitive impairment”, “dementia”, “memory clinics”, “medical services”, “multicenter”, and “China”. We screened papers by reviewing abstracts to identify full‐text reports that were relevant to the study aims and found no more than 10 studies focused on dementia‐specific clinics or inpatient departments in China. These studies pointed out that the lack of dementia‐specific clinics in China is insufficient to meet the current situation of dementia patients in China, but these studies were not nationwide surveys, and the data need to be updated.

2. Interpretation: To our knowledge, we provided the latest, national‐wide, most comprehensive survey to date including 2721 Chinese tertiary hospitals in 31 provinces/municipalities/autonomous regions largest employer in China from September 2022 to February 2023. We found that the current situation of dementia diagnosis and treatment in mainland China still cannot meet the needs of patients with cognitive impairment in China, and there is a lot of room for improvement. These findings provide professional reference data for the government to further promote or formulate new medical and health policies.

3. Future directions: Dementia is a major public health concern in older adults. Currently, the diagnosis and treatment of dementia is not optimistic, and there are still many problems. Our national survey found that the distribution of dementia‐specific clinics and inpatient departments was uneven and didn't adequately meet the needs of dementia patients. Therefore, it is crucial to further expand the construction of dementia‐specific clinics and inpatient departments, especially to expand support for the Western Region. In addition, we should actively train dementia‐specific medical staff to conduct scientific diagnosis and treatment, which is conducive to the early identification and management of dementia, which is very important to delay the progression of the disease and reduce the burden on families and society.

The proportion of DSCs and DSIDs is low, and the regional distribution varies significantly. Among 2721 hospitals in mainland China, 244 (8.97%) have DSCs and 166 (6.10%) have DSIDs (Figure 1). There are more DSCs or DSIDs in the Eastern region than in the Western Region (Figure 2), in provincial capital cities than in other cities, and in tertiary Garde‐A hospitals than in those not tertiary Garde‐A hospitals. This figure is far from adequate compared to other countries. South Korea has set up 256 local dementia centers in various regions since 2017, responsible for risk reduction, early diagnosis, and raising public awareness. ⁵

FIGURE 1.

The distribution of DSCs and DSIDs in participated hospitals. This figure showed the number of DSCs (green) and DSIDs (blue) in the 2721 tertiary hospitals we surveyed. There were 79 tertiary hospitals only setting up DSCs, one tertiary hospital only setting up DSIDs, and 165 tertiary hospitals setting up both DSCs and DSIDs. DSCs, dementia‐specific clinics; DSIDs, dementia‐specific inpatient departments

FIGURE 2.

The distribution of DSCs (left) and inpatient departments (right) in Mainland China. According to geographic region, we use red to represent the Eastern Region, blue to represent the Central Region, and green to represent the Western Region. At the bottom of the figure, the measurement value represents the proportion (%), and all colors from light to dark indicate the proportion from low to high. Left part: In Eastern Chinese Mainland, Beijing has the highest proportion (26.40%) of dementia‐specific clinics, followed by Zhejiang province (22.45%), Shanghai (18.31%), and Tianjin (14.81%). In the Central Chinese Mainland, Henan Province has the highest proportion (15.13%) of dementia‐specific clinics, followed by Jiangxi province (11.84%), Shanxi province (11.59%), and Jilin province (7.58%). The proportion of dementia‐specific clinics in Western Chinese Mainland is the highest in The Ningxia Hui Autonomous Region (21.05%), followed by Chongqing (10.87%), Sichuan province (10.84%), and Yunnan province (8.77%). Right part: Zhejiang province has the highest proportion of DSIDs in Eastern Chinese Mainland (15.31%), followed by Tianjin (14.81%), Guangdong province (9.36%), and Beijing (8.00%). The proportion of DSIDs in Central Chinese Mainland is the highest in Henan province (15.13%), followed by Jiangxi province (11.84%), Shanxi province (8.70%) and Anhui province (5.10%). The proportion of DSIDs in Western Chinese Mainland is the highest in The Ningxia Hui Autonomous Region (15.79%), followed by Chongqing (10.87%), Sichuan province (9.64%), and Yunnan province (5.26%). DSCs, dementia‐specific clinics; DSIDs, dementia‐specific inpatient departments

Facilities for dementia diagnosis and treatment are inadequate. Brain structural imaging and basic hematological examinations are available in all hospitals. There are 1160 (41.16%) hospitals (including 566 in the Eastern Chinese Mainland, 386 in the Central Chinese Mainland and 208 in the Western Chinese Mainland) have the capacity to measure Aβ/tau in biofluids (CSF and plasma). Among the hospitals with DSCs or DSIDs (n = 245), 225 (91.84%) are also equipped with separate neuropsychological assessment rooms and 184 (75.10%) can provide cerebrospinal fluid assessment for pathological biomarkers. Only 86 (35.10%) hospitals have fluorodeoxyglucose‐positron emission tomography (FDG‐PET) capability, and fewer than 15.0% can perform Aβ PET (n = 33, 13.47%) or tau PET (n = 26, 10.61%) scans for pathological protein deposition. Biomarker detection plays a very important role in the diagnosis of cognitive impairment. Meanwhile, with the birth of etiological treatment for AD (such as lecanemab, donanemab, and other anti‐amyloid drugs), the clinical dependence on biomarkers is increasing, which requires more and more hospitals to equip with biomarker detection equipment or method.

Insufficient dementia‐specific medical staff. Generally, only the most experienced physicians are permitted to attend DSCs. In the 166 hospitals with DSIDs, most of the dementia‐specific diagnosis and treatment is carried out by resident physicians (average 2.39 person/hospital) with a small number of associate chief and chief physicians (average 1.45 associate chief and 1.25 chief physicians/hospital) providing guidance and supervision. Certified neuropsychological assessors (including physicians and nurses) number 1.86/hospital on average, with few associate chief or chief physicians (average 0.77/hospital; 0.60/hospital). About half of DSIDs is equipped with cognitive rehabilitation therapists (97/166, 58.43%) and psychological counselors (84/166, 50.60%), and 66 (39.76%) DSIDs are equipped with nutritionists, and 56 (33.73%) DSIDs have dementia‐specific nursing staff. Our results support that the dementia‐specific medical staff in China is seriously insufficient, and more professional training programs are needed. In addition, these trainings should be carried out not only in tertiary hospitals, but also in primary hospitals, which is conducive to the early identification and management of dementia. Driven by The Healthy China Action (2019–2030), these works are being carried out steadily. However, Malaysia, ⁶ Canada, ⁷ Germany, ⁸ Scotland, ⁹ England ¹⁰ , ¹¹ and other regions have carried out primary training for dementia a few decades ago. We still have a long way to go.

Neuroradiologists and Neuropathologists also play an important role in the construction and work of DSCs and DSIDs; however, this survey did not involve the information of them. It is estimated that hospitals capable of completing FDG PET, Aβ PET, and/or tau PET will be equipped with one to two neuroradiologists (156 units without any PET CT equipment), and some hospitals with established neuroradiology disciplines will have more. Therefore, we infer that there are approximately 178 neuroradiologists in China, although it might not be appropriate. Unfortunately, we did not investigate the number of neuropathologists and have no way to know the number of members of all neuropathological academic organizations in China, nor could we infer the number based on the data collected. More in‐depth and systematic survey are needed in the future.

The consultation rate is low, and actual inpatient treatment capacity for individuals diagnosed with dementia is seriously insufficient. Totally, 2745 beds (average 16.54 beds/hospital) are available for dementia‐specific treatment, and 47,072 dementia patients (average 283.57 patients/hospital/year) were admitted to the 166 hospitals with DSIDs. Such treatment capacity cannot meet the needs of individuals with dementia in China. The 245 hospitals with DSCs and (or) DSIDs reported an annual total of 211,374 patient visits for cognitive impairment from September 2021 to September 2022, which is significantly lower than the estimated total number of dementia patients in China. ¹ Totally, fewer than 20% (37,053/211,374) of the patients who visited had mild cognitive impairment (MCI). And among all the dementia patients (Figure 3), AD remains the most common type of dementia, followed by vascular dementia (VaD) (22.92%, 39,958/174,321), other dementias (ODs) (11.22%, 19,563/174,321), frontotemporal lobar degeneration (FTLD) (4.11%, 7160/174,321), and dementia with Lewy bodies (DLB) (3.15%, 5490/174,321). Most cases had already advanced to the moderate to severe stage (Figure 4).

FIGURE 3.

The main subtypes of dementia in Mainland China. AD, Alzheimer's disease; DLB, dementia with Lewy bodies; FTLD, frontotemporal lobar degeneration; ODs, other dementias; VaD, vascular dementia

FIGURE 4.

Dementia severity of patients with cognitive impairment at consultation in Mainland China. CDR, Clinical Dementia Rating Scale

With the launch of lecanemab, a humanized immunoglobulin G1 (IgG1) monoclonal antibody that binds with high affinity to Aβ soluble protofibrils, ¹² a new chapter in the etiological treatment of AD has been opened in Mainland China. As of July 2024 (approximately 1 month after lecanemab launch), there were 960 eligible patients received treatment in 205 medical institutions [175 (85.37%) public institutions, 30 (14.63%) private institutions] nationwide. It follows that Chinese AD patients have a great interest in lecanemab and are willing to receive treatment. Despite the possibility of amyloid‐related imaging abnormalities (ARIA) after treatment, there are 252 experienced neurologists from 179 medical institutions are familiar with ARIA‐E (edema) and/or ARIA‐H (hemorrhage), and are capable of conducting or treating this. We believe that the vast population of MCI and mild dementia in China could potentially benefit from this treatment.

In conclusion, the current state of dementia diagnosis and treatment in China cannot meet the needs of individuals with cognitive impairment, and there is much room for improvement. These results provide a basis for the description of the current status of dementia diagnosis and treatment in China as well as a uniform reference for the further promotion and formulation of new medical and health policies by the government.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest. Author disclosures are available in the supporting information.

CONSENT STATEMENT

The Ethics committees of all centers approved all research activities in this multicenter study and waived informed consent because the data were pseudonymized from registers. The procedures were performed in accordance with the ethical standards of the Committee on Human Experimentation.

Supporting information

Supporting Information

Gan J, Xin J, Wang G, et al. Current status of professional memory clinics, inpatient services, and health professionals in China. Alzheimer's Dement. 2024;20:8198–8203. 10.1002/alz.14263