U.S. GOVERNMENT PRINTING OFFICE

WASHINGTON : 

For sale by the Superintendent of Documents, U.S. Government Printing Office

Internet: bookstore.gpo.gov Phone: toll free (866) 512–1800; DC area (202) 512–1800

Fax: (202) 512–2104 Mail: Stop IDCC, Washington, DC 20402–0001

67–052PDF 2011

GLOBAL STRATEGIES TO COMBAT THE

DEVASTATING HEALTH AND ECONOMIC IMPACTS

OF ALZHEIMER’S DISEASE

HEARING

BEFORE THE

SUBCOMMITTEE ON AFRICA, GLOBAL HEALTH, 

AND HUMAN RIGHTS

OF THE

COMMITTEE ON FOREIGN AFFAIRS 

HOUSE OF REPRESENTATIVES

ONE HUNDRED TWELFTH CONGRESS

FIRST SESSION

JUNE 23, 2011

Serial No. 112–96

Printed for the use of the Committee on Foreign Affairs

(

Available via the World Wide Web: http://www.foreignaffairs.house.gov/

(II)

COMMITTEE ON FOREIGN AFFAIRS 

ILEANA ROS-LEHTINEN, Florida, Chairman 

CHRISTOPHER H. SMITH, New Jersey 

DAN BURTON, Indiana 

ELTON GALLEGLY, California 

DANA ROHRABACHER, California 

DONALD A. MANZULLO, Illinois 

EDWARD R. ROYCE, California 

STEVE CHABOT, Ohio 

RON PAUL, Texas 

MIKE PENCE, Indiana 

JOE WILSON, South Carolina 

CONNIE MACK, Florida 

JEFF FORTENBERRY, Nebraska 

MICHAEL T. MCCAUL, Texas 

TED POE, Texas 

GUS M. BILIRAKIS, Florida 

JEAN SCHMIDT, Ohio 

BILL JOHNSON, Ohio 

DAVID RIVERA, Florida 

MIKE KELLY, Pennsylvania 

TIM GRIFFIN, Arkansas 

TOM MARINO, Pennsylvania 

JEFF DUNCAN, South Carolina 

ANN MARIE BUERKLE, New York 

RENEE ELLMERS, North Carolina 

VACANT 

HOWARD L. BERMAN, California 

GARY L. ACKERMAN, New York 

ENI F.H. FALEOMAVAEGA, American 

Samoa 

DONALD M. PAYNE, New Jersey 

BRAD SHERMAN, California 

ELIOT L. ENGEL, New York 

GREGORY W. MEEKS, New York 

RUSS CARNAHAN, Missouri 

ALBIO SIRES, New Jersey 

GERALD E. CONNOLLY, Virginia 

THEODORE E. DEUTCH, Florida 

DENNIS CARDOZA, California 

BEN CHANDLER, Kentucky 

BRIAN HIGGINS, New York 

ALLYSON SCHWARTZ, Pennsylvania 

CHRISTOPHER S. MURPHY, Connecticut 

FREDERICA WILSON, Florida 

KAREN BASS, California 

WILLIAM KEATING, Massachusetts 

DAVID CICILLINE, Rhode Island 

YLEEM D.S. POBLETE, Staff Director 

RICHARD J. KESSLER, Democratic Staff Director 

SUBCOMMITTEE ON AFRICA, GLOBAL HEALTH, AND HUMAN RIGHTS

CHRISTOPHER H. SMITH, New Jersey, Chairman 

JEFF FORTENBERRY, Nebraska 

TIM GRIFFIN, Arkansas 

TOM MARINO, Pennsylvania 

ANN MARIE BUERKLE, New York 

DONALD M. PAYNE, New Jersey 

KAREN BASS, California 

RUSS CARNAHAN, Missouri 

(III)

C O N T E N T S 

Page

WITNESSES 

Richard Hodes, M.D., director, National Institute on Aging, National Institutes of Health ...................................................................................................... 7

Daisy Acosta, M.D., chair of the executive board, Alzheimer’s Disease International ................................................................................................................. 23

Mr. Eric Hall, president and chief executive officer, Alzheimer’s Foundation 

of America ............................................................................................................. 28

Bill Thies, Ph.D., chief medical and scientific officer, Alzheimer’s Association . 33

Mr. George Vradenburg, founder, USAgainstAlzheimer’s .................................... 40

Giovanni Frisoni, M.D. (via teleconference), deputy scientific director, IRCCS–

FBF Alzheimer’s Center ...................................................................................... 46

Jeffrey Cummings, M.D., director, Cleveland Clinic Lou Ruvo Center for 

Brain Health ......................................................................................................... 50

Hugh Hendrie, M.D., professor, Indiana University ............................................. 57

LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING 

Richard Hodes, M.D.: Prepared statement ............................................................ 10

Daisy Acosta, M.D.: Prepared statement ............................................................... 26

Mr. Eric Hall: Prepared statement ........................................................................ 30

Bill Thies, Ph.D.: Prepared statement ................................................................... 35

Mr. George Vradenburg: Prepared statement ....................................................... 42

Giovanni Frisoni, M.D.: Prepared statement ........................................................ 48

Jeffrey Cummings, M.D.: Prepared statement ...................................................... 53

Hugh Hendrie, M.D.: Prepared statement ............................................................ 61

APPENDIX 

Hearing notice .......................................................................................................... 76

Hearing minutes ...................................................................................................... 77

The Honorable Russ Carnahan, a Representative in Congress from the State 

of Missouri: Prepared statement ......................................................................... 78

The Honorable Christopher H. Smith, a Representative in Congress from 

the State of New Jersey, and chairman, Subcommittee on Africa, Global 

Health, and Human Rights: Material submitted for the record ...................... 79

(1)

GLOBAL STRATEGIES TO COMBAT THE DEVASTATING HEALTH AND ECONOMIC IMPACTS OF ALZHEIMER’S DISEASE 

THURSDAY, JUNE 23, 2011

HOUSE OF REPRESENTATIVES,

SUBCOMMITTEE ON AFRICA, GLOBAL HEALTH,

AND HUMAN RIGHTS

COMMITTEE ON FOREIGN AFFAIRS, 

Washington, DC. 

The subcommittee met, pursuant to notice, at 2:10 p.m., in room 

2200, Rayburn House Office Building, Hon. Christopher H. Smith 

(chairman of the subcommittee) presiding. 

Mr. SMITH. The subcommittee will come to order. I want to apologize for the lateness in starting. We are just completing a vote. But 

I do thank you all for being here and for joining us at this first ever 

congressional hearing examining the global strategies to combat 

the devastating health and economic impacts of Alzheimer’s disease. This is the first in what will be a series of hearings. And 

hopefully over the course of the next 11⁄2 years, this will be an opportunity to really refocus congressional efforts on the fact that this 

is not just a domestic problem, but also an international one that 

needs additional congressional engagement. 

Alzheimer’s disease is the most common form of dementia, and 

it is a degenerative, irreversible, and terminal disease. Alzheimer’s 

disease is most prevalent in people over 65 years of age, but earlyonset Alzheimer’s can occur at a much younger age, as we all 

know, even decades earlier. Alzheimer’s progressively destroys remembering, thinking and reasoning skills, and eventually even the 

ability to carry out the simplest of tasks. 

While the cause and progression of Alzheimer’s disease are not 

well understood, research indicates that the disease is associated 

with plaques and tangles in the brain that begin to develop 10 to 

20 years before any problems are evident. As plaques and tangles 

form, neurons lose their ability to function, and eventually die. As 

more neurons expire, affected brain regions begin to contract. In 

the final stages of Alzheimer’s, there is widespread damage and tissue shortage. 

Current treatments provide modest symptomatic benefits, but 

there are no therapies available that can halt or even delay the 

progress of the disease. The effects and duration of the disease vary 

from patient to patient, but it is invariably fatal. 

According to the Alzheimer’s Disease International there were 

some 35.6 million people living with Alzheimer’s and other demenVerDate 0ct 09 2002 14:27 Feb 16, 2012 Jkt 000000 PO 00000 Frm 00005 Fmt 6633 Sfmt 6633 F:\WORK\AGH\062311\67052 HFA PsN: SHIRL
2

tias in 2010, and the number of people living with dementia is expected to nearly double every 20 years to 65.7 million in 2030, to 

115.4 million in 2050. However, the increase is greater for low and 

middle income countries, as some 57 percent of all people with dementia are currently living in low and middle income countries. 

And that will rise to 63.4 percent in 2030, and a whopping 70 percent in 2050. 

Here in the United States, up to 5.4 million people have Alzheimer’s disease, and the number is expected to increase to up to 

16 million by 2050 unless something is done to reverse the trajectory. The elderly population as a whole is growing, but the oldest 

elderly are the fastest growing age bracket. 

According to Alzheimer’s Disease International, the total world- wide estimated cost of dementia is $604 billion, with 89 percent of 

the costs occurring in high income countries and about 70 percent 

of those costs occurring in just two regions, Western Europe and 

North America. In low and middle income countries, the costs of informal care, in other words unpaid care provided by families and 

others, accounts for some 64 percent of all care, while in high income countries the informal care accounts for 40 percent of the 

costs. 

Even in countries that have high health care expenditures and 

that provide government-funded support for long-term care, a vast 

amount of that care occurs informally within families. Not only will 

the increase in the population with Alzheimer’s and other dementias result in skyrocketing costs of health care, but changing family 

dynamics will further exacerbate the economic stress on families, 

societies, and governments. 

As an example, on Monday of this week I chaired a hearing of 

the Commission on Security and Cooperation in Europe, also 

known as the U.S. Helsinki Commission, on the implications of demographic trends in the OSCE region, and we looked at some other 

parts of the world as well. Dr. Richard Jackson, Director of Global 

Aging Initiative at the Center for Strategic and International Studies, testified in that hearing that in certain European countries by 

2020 the extended family will essentially be nonexistent. Half of 

young adults don’t have any brothers or sisters or uncles or aunts 

or cousins. Another projection during the same hearing was that 

Japan could potentially experience an explosion of Alzheimer’s 

prevalence of up to 1 in 25 as a result of the aging of the population, coupled with some 40 percent of the Japanese being childless. So the number of caregivers available will rapidly decline in 

Japan and elsewhere. 

When we look more closely at projected demographics for some 

countries, the pool of family caregivers is shrinking as the number 

of individuals with Alzheimer’s is correspondingly exploding, which 

will significantly shift the costs of care away from unpaid, informal 

care to institutional and direct medical care. 

Poor recognition, under-diagnosis, and lack of public awareness 

are all causes of significant problems for afflicted individuals and 

their caregivers, especially in low and middle income countries. 

In those developing countries, it is often incorrectly assumed that 

dementia, such as Alzheimer’s, is a normal part of aging and that 

nothing can be done to address it. Because of lack of recognition 

3

of the nature of the problem, there is a lack of pressure on government bodies to respond to the crisis. As a result, there is a lack 

of effort to devote resources toward finding a cure to help those 

with Alzheimer’s by providing assistance or seeking a diagnosis 

and caring for those potentially afflicted. 

International cooperation and collaboration to find solutions for 

Alzheimer’s is not new, as clearly demonstrated by the fact that the 

Alzheimer’s Disease International began in 1984, 27 years ago, 

with four members, and has grown now through the years to over 

75 members. Similarly, I look forward to receiving testimony outlining past, present, and future international research collaborations. 

However, we do seem to be at a precipice now of making great 

strides on several different fronts. First, there is the greater recognition, including in low and middle income countries, of the need 

to address Alzheimer’s as a major public health crisis. I agree with 

you, those who will testify, that we need to pressure international 

institutions responsible for health issues to recognize dementia as 

a global health problem. That is why Congressman Markey and I, 

and we do cochair the Alzheimer’s Caucus here in the House, and 

we have done so for over a decade, we have coordinated a letter 

signed by 28 Members of Congress to the U.N. General Assembly 

President Deiss to include Alzheimer’s disease in the September 

U.N. Summit on Noncommunicable Diseases. Involvement of international organizations such as the United Nations and WHO are 

necessary to make substantial inroads toward raising awareness of 

dementia and beginning to address it in national health care policies and action plans. I plan on sending today’s hearing record to 

all relevant U.N. officials, PAHO officials, and officials in the EU, 

and especially to heads of country delegations at the United Nations. 

Second, there is a significant momentum toward broader sharing 

and an increasing number of proposals for major intergovernmental 

research projects that will take advantage of emerging research opportunities and new computing platforms and communications 

technologies. Also, in response to two of our witnesses, Eric Hall 

and George Vradenburg, who made recommendations in their testimony for a government-sponsored international conference, I will 

soon introduce legislation to convene in the first quarter of calendar year 2012, or at a date thought to be more appropriate, an 

international conference to include at a minimum countries that 

have or are in the process of developing national Alzheimer’s plans. 

Third, it is significant that the NIH funded the first intensive 

caregiver support intervention proven to be effective, through rigorous testing, in an ethnically diverse population, and that they are 

beginning to export the program. I do look forward to Dr. Hodes’ 

testimony on this and other outstanding initiatives that he is leading at the NIA. 

Finally, since 2005, several countries have developed national 

Alzheimer’s plans or strategies, which have already begun to accelerate changes in health care systems. I was honored to have introduced with Congressman Markey legislation to create a national 

strategic Alzheimer’s plan for the United States. The National Alzheimer’s Project Act, or S. 3036, which was passed first by the SenVerDate 0ct 09 2002 14:27 Feb 16, 2012 Jkt 000000 PO 00000 Frm 00007 Fmt 6633 Sfmt 6633 F:\WORK\AGH\062311\67052 HFA PsN: SHIRL
4

ate and then by the House and signed in December by the President—or in January I should say, January 4th; it was a large, huge 

legislative victory for the cause of Alzheimer’s here in the United 

States. The National Alzheimer’s Project Act, NAPA, is designed to 

help turn the tide by creating a national strategic plan to address 

the rapidly growing crisis of Alzheimer’s disease. NAPA provides 

for the coordination of all Alzheimer’s disease efforts across the 

Federal Government. It also establishes an advisory council on Alzheimer’s research, care, and services that would allow participation 

by patient advocates, health care providers, researchers, and State 

health departments in the evaluation of Federal Alzheimer’s plans 

and the formulation of a strategic plan to reduce costs and improve 

health services. Recognizing the importance of international collaboration, the law requires coordination with international bodies 

to make the United States Government a committed partner in the 

global fight against Alzheimer’s. 

Like many of you, I will be following closely the implementation 

of NAPA. And if Dr. Hodes would like to share any information on 

HHS activities on implementing NAPA, we would certainly appreciate any insights he could provide. 

While the national Alzheimer’s strategic plan is being developed, 

Congressman Markey and I have also introduced additional legislation designed to bolster programs for Alzheimer’s research and diagnosis. 

In May, we introduced the Alzheimer’s Breakthrough Act, H.R. 

1897, designed to accelerate treatments that prevent, cure, hopefully, or slow the progression of Alzheimer’s disease and reduce the 

financial burden of Alzheimer’s on federally funded programs and 

families. The Director of NIH will develop a strategic research 

plan, including budget estimates, for Alzheimer’s disease, focused 

on targeting scientific opportunities and priorities, developing public-private partnerships, and improving coordination of Alzheimer’s 

disease research across 27 institutes and centers at the NIH. 

Instead of prescribing a funding level for Alzheimer’s research at 

NIH, as we attempted to do in previous bills, which sadly did not 

pass, this bill requires the experts at NIH to tell Congress and the 

administration what Alzheimer’s research is needed to develop 

treatment breakthroughs and what level of funding is needed to accomplish that goal. 

In addition, I have joined Congressman Markey in introducing 

H.R. 1386, the Health Outcomes, Planning and Education for Alzheimer’s Act, or HOPE, which will provide Medicare coverage for 

a comprehensive diagnosis of Alzheimer’s disease and help improve 

care and reduce costs by providing information and resources to 

newly diagnosed patients and their families. 

I am very pleased to now yield to my good friend and colleague 

Mr. Payne, fellow New Jerseyan, for any comments he might have. 

Mr. PAYNE. Thank you very much. And let me commend my colleague, Chairman Smith, for calling this very important hearing: 

Global Strategies to Combat the Devastating Health and Economic 

Impact of Alzheimer’s Disease. You, Mr. Chairman, along with 

Congressman Markey, Congresswoman Waters, and others, have 

been important drivers on this issue of Alzheimer’s and other forms 

of dementia. 

5

I would also like to thank our witnesses. I look forward to hearing each of you and your testimonies on how Congress can best 

tackle Alzheimer’s globally, specifically in Africa and developing 

nations that lack infrastructure to provide basic needs or are engaged in conflicts that displace large portions of their population 

and whose health care centers are overwhelmed with those suffering from HIV/AIDS, malaria, tuberculosis, and neglected tropical 

diseases. 

Alzheimer’s disease, or AD, is the most common form of dementia. Symptoms include difficulty with speech, memory loss, depression or anxiety, and a decrease in mental ability. The disease often 

begins to show signs after the age of 65, and its likelihood of onset 

and severity increases as one ages. There is no cure, and symptoms 

are irreversible. 

According to Alzheimer’s Disease International’s 2009 World Alzheimer’s Report in 2010, there were an estimated 35.6 million people suffering from dementia. This same report cites that 58 percent 

of these people lived in low and middle income countries. It is projected that in 2050 the total number of those with dementia will 

be close to 110 million, with 71 percent in those low and middle 

income countries. 

This growth, however, is likely to be less dramatic in sub-Saharan Africa, where life expectancy is below that of the usual age of 

onset. There may be additional reasons for a lower prevalence of 

dementia in developing countries outside of lower life expectancy. 

Part of this may simply be diagnosis. There is no set approach or 

test to diagnose Alzheimer’s, as we all know, nor can the disease 

be labeled conclusively until postmortem. Given that mild dementia 

can be subtle and a strain on health care centers in these countries 

due to diseases such as HIV and others, as I mentioned, it is often 

severe. It is reasonable to assume that in many of these countries 

this is being overlooked, and therefore, as we would know, underreported. 

I am interested to hear the panel’s thoughts on these issues, as 

well as the potential causes of Alzheimer’s. It is thought by many 

that genetics play a role. However, environmental factors may also 

contribute. In New Jersey, we have had a tremendous increase in 

Alzheimer’s, in a State that has had environmental problems 

throughout the years, and we feel that that may be one of the possible causes. However, there is no conclusive evidence to that fact. 

These include high blood pressure, cholesterol, illiteracy, lower education levels, and stress. 

I am also interested in learning how these factors are being 

taken into consideration when both diagnosing and treating Alzheimer’s. Additionally, I would like to know how these factors are 

taken into account when looking at Alzheimer’s from a global perspective. 

Though a cure does not yet exist, both drugs and nondrug treatments are available for sufferers here in the United States and 

other developed countries. I hope to learn from our witnesses today 

about the best practices in combating Alzheimer’s and how these 

practices can be applied to developing nations. 

I also hope to hear how those with Alzheimer’s and other forms 

of dementia are being treated in conflict zones. Disabled people are 

6

often faced with increased challenges when displaced due to violence, and I am interested in learning about specific challenges Alzheimer’s sufferers face in these crisis situations. 

Again, I look forward to the testimony of our witnesses, and I 

yield back the remainder of my time. 

Mr. SMITH. Thank you, Don. I would like to now yield to a good 

friend and colleague, Ed Markey, who is the cochair of the Alzheimer’s Caucus, and has been a true leader in that issue for a 

long, long time. 

Mr. MARKEY. Thank you, Mr. Chairman, very much. You and I 

created the Alzheimer’s Task Force 13 years ago, and I think we 

are really making progress on the issue. But at the same time, 5.4 

million Americans now have Alzheimer’s, 15 million baby boomers 

will have Alzheimer’s. If we don’t find a cure for Alzheimer’s, that 

one disease will equal and exceed the entire defense budget of the 

United States in Medicare and Medicaid payments for those families. Last year it was $132 billion in Medicare and Medicaid that 

went just to Alzheimer’s. 

So the numbers are absolutely staggering. Within a generation, 

there will be more people over the age of 60 than under the age 

of 15. So, you know, we are in a race against time here in terms 

of our ability—that is across the whole planet. And so this isn’t just 

a national, but an international issue because you can multiply the 

consequences, you know, for America across the whole rest of the 

population of the world, and it is imperative for us to have action 

plan that does work because failure is not an option here. We, like 

the Apollo astronauts coming back, we have to fabricate some way 

of finding the clues that will make it possible for us to make it possible for children to have to look to the history books to find that 

there ever was such a disease as Alzheimer’s. 

But it is something that I think has to be bipartisan. And your 

leadership and Congressman Payne’s leadership helps to demonstrate that. And thank you for inviting me here today. Thank 

you, Doctor, for all of your incredible work on this issue. 

Mr. SMITH. Mr. Markey, thank you very much for your leadership over all these years. In a place where bipartisanship seems to 

be diminished, there are some issues where that is simply not the 

case, and this is one of those. It has been great to work with you 

those 13 years on this issue, and may it continue. 

Mr. MARKEY. Thank you. 

Mr. SMITH. I would like to now introduce our first very distinguished witness, Dr. Richard Hodes, who has been director of the 

research program at the National Institute on Aging at the National Institutes of Health since 1993. Dr. Hodes has devoted his 

tenure to the development of a strong, diverse, and balanced research program. He focuses on the genetics and biology of aging, 

basic and clinical studies aimed at reducing disease and disability, 

including Alzheimer’s disease, and investigation on the behavioral 

and social aspects of aging. He is the author of many research papers, and is an active scientist in and contributor to the field of immunology. His full, very, very impressive resume will be made a 

part of the record. I would like to ask Dr. Hodes to proceed as he 

would like. 

7

STATEMENT OF RICHARD HODES, M.D., DIRECTOR, NATIONAL 

INSTITUTE ON AGING, NATIONAL INSTITUTES OF HEALTH 

Dr. HODES. Thank you, Congressman Smith, Congressman 

Payne, Congressman Markey, for the opportunity to be here and 

talk with you about international aspects of Alzheimer’s disease, in 

particular Alzheimer’s research. All of you have very effectively introduced the magnitude of the problem at an individual, personal, 

and social level, and the international nature of it. The projections 

for future increases in Alzheimer’s, moreover, are predicted to affect disproportionately the less developed parts of the world, again 

emphasizing the international aspects of what is yet to come. 

Overall, the science and pursuit of solutions to Alzheimer’s research is international. It is marked by some of the events that 

have been discussed already. International scientific colloquia, such 

as the International Conference on Alzheimer’s Disease, which will 

be held next month in France, typify the opportunities for scientists from around the world to share information in the goal of 

constructing the most efficient and effective plans for attacking the 

problems. 

In addition, also referred to after passage of NAPA, the National 

Alzheimer’s Project Act, there has been institution at DHHS of an 

interagency committee that is charged with coordinating efforts, including most notably, as read from that bill, efforts at an international level to consolidate and coordinate levels, and those are 

very much underway already. 

I would like to present in the next few minutes some of the examples in which the international approach has been particularly 

important in pursuit of Alzheimer’s research in three areas that I 

will typify, one of them being the area of basic research, the attempt to identify the underlying pathogenesis, the processes that 

lead to Alzheimer’s; second, the translation of this to early diagnosis, the ability to track disease and to facilitate the testing of 

interventions; and then finally, also alluded to, research aimed at 

addressing the great burden of caregivers, who currently constitute 

the major force for care of individuals with Alzheimer’s disease. 

Over the last years, we have instituted, for example, through 

NIH support a project called DIAN. It is a Dominantly Inherited 

Alzheimer’s Disease Network. As alluded to, Alzheimer’s is typically a disease of older individuals, but there is a relatively rare, 

though particularly tragic inherited form that can occur in individuals in their 30s and 40s and 50s. The disease is rare, but presents 

an unusual opportunity to study the features of Alzheimer’s disease 

with perceived clinical manifestations because it is so predictable 

in these individuals that sadly 100 percent assurance that over 

subsequent years they will develop Alzheimer’s. 

An initial collaboration between the United States, the United 

Kingdom, and Australia, soon to be joined by other nations, will 

look at the individuals from these families who are rare but exist 

in many parts of the world, to achieve a number of them to allow 

meaningful studies to better understand the processes that exist 

many years or even decades before Alzheimer’s disease, and in turn 

to address them before irreversible symptoms and damages occur. 

Also important has been the discovery of genetic risk factors for 

the more common form of adult onset, late onset Alzheimer’s disVerDate 0ct 09 2002 14:27 Feb 16, 2012 Jkt 000000 PO 00000 Frm 00011 Fmt 6633 Sfmt 6633 F:\WORK\AGH\062311\67052 HFA PsN: SHIRL
8

ease. Here, the techniques of GWAS, or genome-wide association 

studies, have been particularly important. And the international 

aspects here again I once more emphasize, because of the need to 

study large numbers of individuals, including individuals in diverse 

environmental contexts in order to understand the genetic risk factors, in the past years a number of new genes have been discovered 

through collaborations of investigators in the United States, Canada, and Europe. And just this year a new consortium worldwide 

will collect approximately 40,000 individuals with Alzheimer’s disease, allowing a still greater sensitivity in understanding the genetic factors that affect the disease, and in doing this to find targets for potential intervention. 

Another approach that has been critical is the identification of 

early changes in Alzheimer’s that allows not only for early diagnosis, but the means to track progression of disease. This is most 

important so we become more efficient in testing whether products 

are or are not effective. Currently, these trials generally mean 

treating several hundreds of individuals and waiting the years it 

takes to determine whether clinical course has been varied. New 

research looking at biomarkers that involve neuroimaging and spinal fluid chemistries have made enormous breakthroughs in past 

years. 

In particular, an initiative called ADNI, the Alzheimer’s Disease 

Neuroimaging Initiative, is really a remarkable precedent in which 

private sector, public sector, Federal, and not-for-profit and academic representatives have converged on a project which has made 

available now new means in the research setting for tracking disease through changes in structure and function years and even decades before the appearance of any symptomatology, and now promise to find the same predictive value in tests of cerebrospinal fluid. 

In order to increase the power and again the international scope 

of this, there have now been ADNI-like initiatives that are already 

in place in Europe, in Australia, and in Japan. There are additional 

efforts that are in progress now being established in China, in Taiwan and Korea, once again exemplifying the power that will come 

with coordinating efforts across nations to understand the factors 

which are in common and as well the factors which are independent and may vary from country to country. 

So specific examples in which comparison of effects in different 

countries is important and can be outlined as well. One, which you 

will hear about subsequently this afternoon from Hugh Hendrie, 

has been a remarkable study, the Ibadan-Indianapolis study, in 

which Nigerians living in Ibadan and those of Nigerian descent living in Indianapolis are compared for the factors which determine 

Alzheimer’s and other forms of dementia, again allowing a real and 

powerful opportunity to dissect genetic and environmental influences. 

Similarly, there are collaborations with Israel studying the way 

in which diabetes is a risk factor for development of Alzheimer’s 

disease; and recently, with assistance through U.S., institution of 

a study in China that is looking at the potential effects of exposure 

to trace elements on development of cognitive loss and dementia. 

Finally, I would turn to the emphasis that was placed here now, 

so long as we still have individuals suffering with Alzheimer’s and 

9

have to provide the best care we can to them and their care providers, NIH has also supported research aimed particularly at the 

well-being of care providers. The study REACH, Resources to Enhance Caregiver Health, has identified through clinical trials just 

as rigorous as those for drugs, interventions which are capable of 

decreasing the stress, depression, other health, adverse health outcomes in those individuals who are caring for patients with Alzheimer’s, and has also been effective in delaying the time of institutionalization so individuals with Alzheimer’s are able to spend 

more time at home with their families and loved ones. 

This study has been disseminated in the U.S. now very effectively through the Department of Veterans Affairs and the Administration on Aging, and we are looking similarly to extend this to 

an international level. Most recently, the very first of these efforts 

has been put into place in Hong Kong, where again in consultation 

U.S. studies of the outcomes of these clinical trials, we will have 

an opportunity to begin the process of international dissemination 

of these effective interventions. 

Just as has been described, the problem of Alzheimer’s is international, and will remain so, and for that very reason the research 

approach to it has to remain an international effort, and we at NIH 

and across the HHS are committed to this with many powerful beginnings and the prospect of much more to come. 

And I thank you for this opportunity to speak with you and look 

forward to addressing any questions you may have. 

[The prepared statement of Dr. Hodes follows:]

10


67052a-1.eps
11


67052a-2.eps
12


67052a-3.eps
13


67052a-4.eps
14


67052a-5.eps
15


67052a-6.eps
16

Mr. SMITH. Thank you very much, Dr. Hodes, for your testimony, 

and for the tremendous leadership you provide. Let me ask just a 

couple questions with regards to the sharing of data among scientists around the world. 

How robust is it? Is there a stovepipe mentality, or are scientists 

funded by your shop and others more than willing to share findings 

and to collaborate? 

Dr. HODES. Although there is always room for improvement, I 

think that there is an enormously positive attitude of data sharing 

in the area of Alzheimer’s research. To cite a couple examples or 

expand upon those that I mentioned, for example in the field of genetics, as we have studied the power that is needed to carry out 

genetic evaluations, we have quickly learned that the number of individuals studied by any one laboratory or even any one nation are 

often insufficient to make the discoveries that are needed. So some 

of the great discoveries the past years have come through voluntary participation, collaborations from investigators in many nations studying populations of these nations to accumulate the 

power needed for clinical trials and these clinical evaluations. 

The ADNI study, as I mentioned, is particularly informative because it stresses not only the willingness to collaborate, but sometimes the technical advances that are necessary in order to achieve 

collaboration. So what ADNI did in terms of its neuroimaging capacity was to establish the methodologies that allow individuals to 

be scanned by different machines, brain scans, in different parts of 

the country and in different parts of the world, and to make those 

compatible so that one could translate them into a common language, compare one subject or patient to another. With this enormous benefit, it is now possible to share the neuroimaging and 

other data from ADNI nationally and internationally. 

The international efforts that I mentioned are being taken with 

great care to harmonize so there will be a common language to 

allow translation. And I think with these technical issues addressed, we generally are finding very gratifying collaboration 

across nations. 

Mr. SMITH. Let me ask you, you mentioned the caregiver issue. 

I know that the veterans, because I used to be chairman of the Veterans’ Affairs Committee, we had a very important, I think, Alzheimer’s project, the REACH program: Resources for Enhancing 

Alzheimer’s Caregiver Health. Have you gleaned lessons from 

them? And what are you finding with regards to caregivers? And 

secondly, in planning, the United States doesn’t seem to be as poorly off as some countries in Europe. And again having just had this 

hearing, and without objection, I would like to make all four of the 

demographers’ testimonies from Monday’s hearing part of this 

hearing, because the impact of not having children and caregivers 

is going to be enormous both in terms of the patients themselves 

and on health care delivery systems worldwide. 

As I mentioned in my opening comments, it is catastrophic. It is 

a demographic winter that is just around the corner all over the 

world. And I mean one statistic that I found troubling in Russia, 

this was Nicholas Eberstadt provided this to our commission on 

Monday, for every 2 million births there are 3 million deaths in 

Russia. So I mean they are rapidly losing the ability to—plus an 

17

aging population—to have a caregiver available for an Alzheimer’s 

patient. Your thoughts on that? Do you collaborate, for example, 

with CMS or with HHS about projections of what costs really will 

be as the caregiver pool dries up even here in the United States 

and people then have to go into an institutionalized setting? 

Dr. HODES. There are a number of extremely important and good 

points made. The first of them, the question of how the Department 

of Veterans Affairs, and again I would add, the Administration on 

Aging, have been effective in translating the programs of research 

are a very important illustration of the way in which Federal agencies can collaborate. So the discovery, the demonstration in an experimental setting, a clinical trial that something is effective now 

needs to be followed up by these organizations, which in effect are 

doing demonstration projects, translating them into the real world. 

We work very closely, in fact our last meeting with the Department 

of Veterans Affairs was just last week, to monitor these outcomes. 

And as I mentioned, their translation internationally is beginning 

to occur as well. 

The demographics you described are indeed imposing and are a 

part of all our projections. So that even as we expressed optimism 

about a program such as REACH, which allows caregivers to take 

better care of those with Alzheimer’s, which is critically important 

in the present, as your remarks explain, we in the future may not 

have sufficient numbers of caregivers even with the best of circumstances to support, to care for those with Alzheimer’s, meaning 

that institutionalization may become an undesirable but only alternative, which all turns to emphasize yet once again the urgency of 

our finding a way to decrease the burden of Alzheimer’s, to prevent 

and treat it, because even the best of caregiving circumstances is 

going to be compromised by the very demographics that you described. 

Mr. SMITH. Let me ask you, is the 115 million Alzheimer’s patients by 2050, as provided by Alzheimer’s Disease International, 

is that order of magnitude what you think is accurate? 

Dr. HODES. I think it is very appropriate you asked about order 

of magnitude. And the answer is yes. You will see and hear and 

read many differences that have to do with projections based on 

different numbers of individuals currently affected. And that has to 

do with diagnostic criteria, with different predictions of birth rates, 

death rates, and longevity in populations. With so many unknowns 

there, it is unavoidable there is going to be a range of uncertainty 

in projections. But for order of magnitude, that seems to be precisely within the range of multiple proposals and projections. 

Mr. SMITH. A couple of final questions. In your opinion, are we 

on the verge of a chemical compound therapy intervention that 

might lead to at least arresting the progression of the disease? And 

can you make any kind of prediction that a cure might be found 

in the not too distant future? 

And secondly, George Vradenburg and Eric Hall both make a 

very strong appeal for an international meeting to share best practices. I would hope that it would be at the very highest of levels, 

presidents; secretaries or ministers of health, or Secretary of 

Health and Human Services in our case; and then an NGO inclusion, not just a side event, but something where they would really, 

18

the NGOs around the world, including here in the U.S., could really participate and be a part of it so that we could all share best 

practices. 

Eric Hall talks about the extraordinary work being done in 

Israel, for example, and how we might learn from that. You mentioned the Nigerian diaspora here and those in Nigeria, what we 

could learn from that. I mean, there are huge lessons learned. And 

if we were to push for this, which I am going to introduce a bill, 

or try to get some funding for it, I know my colleagues will all work 

collaboratively for that, off the top of your head do you think it 

would be a good time, 2012, as recommended by the Alzheimer’s 

Foundation, or could it be done sooner? 

Dr. HODES. So to the first question, of course I wish that I could 

estimate the time in which we will finally achieve the kind of effective interventions that we want. But what I can express for myself 

is the shared enthusiasm about scientists in the field for the undeniable and enormous pace of discovery. The amount we understand 

about the basic underlying processes, the degree to which we can 

now in individuals who are alive and either with or without symptoms, the underlying brain changes that are occurring enable an efficiency of clinical trials and tests on newly identified targets that 

is unprecedented. And so the pace of discovery will enhance. Just 

when that will converge on a final successful solution is certainly 

beyond my ability to predict. 

Your question about convening an international meeting, again 

I would emphasize that at the scientific level these meetings occur 

and need to occur, such as the ICAF that is coming up. What you 

are talking about, what has been proposed is a meeting at a larger 

level that goes beyond research to the application of research, the 

societal implications, the best practices. And here I can only express the great enthusiasm that we at NIH and others would have 

to make sure that we contribute to the evidence base and learn 

from such an exercise more about what the priorities need to be so 

that we can direct our research to best serve the process. So we 

would be certainly enthusiastic participants in such an activity. 

Mr. SMITH. And I think the political buy-in of having at the highest level Prime Ministers and Presidents, if that could be arranged, 

would make an enormous difference. You know, G–8, G–20 and the 

rest of the world. Thank you very much. And I do hope that is 

something that the administration could support very strongly as 

well, because it would take planning now to make that happen in 

the very near future. 

Mr. Payne. 

Mr. PAYNE. Thank you very much. Thank you for your testimony. 

As we know, we are in a new economic era here as we proceed 

to deal with the debt and the deficit, and as we are embarking on 

having a broader approach to the problem of Alzheimer’s here in 

the United States, but also abroad. I just wonder what, in your 

opinion, you know, have you seen as effective in the U.S. support 

of global dementia? And in your opinion, what steps could the U.S. 

Government take in order to improve our support of this global 

health issue? As I mentioned, we are sort of moving in the other 

direction, but this is such a devastating health issue, I just wonder 

if you have any advice that we might be able to use. 

19

Dr. HODES. Well, again I think from the perspective of an agency 

committed to research to identify best practices and means for 

intervention, it certainly is the translation of research findings as 

they currently exist, such as in areas of REACH that are likely to 

be effective. 

You touch upon another area where there has been a good bit of 

controversy of late, that is in terms of what we know about how 

to translate apparent risk factors for Alzheimer’s disease into recommendations for interventions that are likely to decrease the 

probability of developing Alzheimer’s. And there was a state of the 

science conference that was carried out by bringing in experts who 

reported about 1 year ago to NIH. They concluded, in language 

that really requires clarification, that there was no high quality 

evidence indicating that any intervention, for example, based on 

control of behavioral factors or blood pressure was proven to prevent Alzheimer’s disease development. This created I think an unfortunate perhaps over-interpretation of the fact that we don’t 

know what we can reasonably recommend. The clarity of evidence 

will continue to increase as we do more clinical research. 

But there is certainly strong associative evidence that suggests 

that people with high blood pressure, as you alluded to, with diabetes, people who don’t exercise, people who don’t have social 

connectivity are at higher risk for Alzheimer’s disease. And even as 

we continue to develop better research, the ability to support appropriate treatment of these cardiovascular risk factors and environmental factors is I think a very reasonable recommendation at 

this point in time. 

So disseminating that nationally and internationally I think is 

an appropriate use of the evidence base that we were able to generate and we continue to generate at the present state of knowledge. 

Mr. PAYNE. That sort of leads into another thought that I had 

that, as I mentioned in my testimony, that figures indicate that the 

majority of dementia cases are located in low to middle income 

countries throughout the world. Additionally, the World Health Organization estimates that currently 58 percent of the worldwide dementia is in moderate income countries. But of course the dilemma 

is the future, where it is estimated that 71 percent by 2050 will 

be in countries in that category. So I am just wondering what, in 

your opinion, do you think can be done in order to halt the growth 

of dementia cases? And additionally, what capacity building is 

being done in low and middle income countries so that they are 

better prepared to handle dementia cases, and much more of them 

as they will be coming in the coming years? Are they willing to listen? Do they feel it is an issue that, with all their other problems, 

that should be raised to a higher level? What has been, in your 

opinion, the response from countries in this category? 

Dr. HODES. I think one very important aspect of what you raise 

is the fact that as we have increasing proportions of individuals affected with dementia in less developed countries, we have to take 

great care to be sure that what we identify as causes and interventions that are effective for preventing or delaying Alzheimer’s are 

solutions that will be relevant to many parts of the world. And for 

example, the relative importance of risk factors such as hyperVerDate 0ct 09 2002 14:27 Feb 16, 2012 Jkt 000000 PO 00000 Frm 00023 Fmt 6633 Sfmt 6633 F:\WORK\AGH\062311\67052 HFA PsN: SHIRL
20

tension or diet versus genetics may well vary from one part of the 

world to another. Whether dementia caused by what we identify 

pathologically as Alzheimer’s disease versus that which has more 

important components of vascular disease is a critical determinant. 

I think you will hear more again from Dr. Hugh Hendrie as he 

talks, for example, about the informative comparison of Nigerians 

in Ibadan versus those of Nigerian descent in the U.S. is an example. We see changes in what the risk factors appear to be for these 

presumably genetically similar populations. And this itself is informative. But it suggests that to the future, as we develop effective interventions, we are going to have to pay attention to the likelihood that there will not be a single intervention that may be first 

shown to be effective in Bethesda or New Jersey or in Boston, and 

to assume that it will be universally applicable. 

So the research again has to continue internationally. Right now 

it is doing so in terms of risk factors. As we become better able to 

translate into interventions, we are going to have to similarly keep 

in mind that interventions are going to have to be tailored to the 

genetic, environmental, and socioeconomic conditions of the various 

nations of the world. 

Mr. PAYNE. Just finally, have we been able to determine whether 

there may be a correlation between diet or say weight factors, obesity? Have we seen any kind of correlation in your studies to those 

issues? 

Dr. HODES. Well, there is some very strong correlations between 

high blood pressure and risk of developing Alzheimer’s disease or 

dementia, between diabetes and the risk of developing Alzheimer’s 

disease or dementia. Now what is important is to move from those 

correlations to asking whether if we address blood pressure or control of diabetes we can make a difference in terms of cognitive function. And those very studies are currently underway. So that for 

example in the studies carried out with support from the Heart, 

Lung and Blood Institute or the Diabetes Institute, which are looking at various interventions to treat various levels of control of 

blood pressure or of blood sugar, NIA and other components of NIH 

have added to that measures of cognitive function and even of 

neuroimaging so we will learn in the format of a clinical trial 

whether we can establish evidence that indeed preventing high 

blood pressure or high blood sugar in addition to the very likely impact these are going to have on stroke, cardiovascular disease, and 

other complications of diabetes may also have a direct impact on 

cognitive function and risk of dementia. 

So your question directly, yes, there are strong correlations. Now 

even more important, testing to see if we intervene on those variables we can translate the correlation to find out whether it is 

causal and leads to a preventive intervention is the state that we 

are at currently. 

Mr. PAYNE. Thank you very much. I yield back. 

Mr. SMITH. Thank you very much, Mr. Payne. I just do have one 

final question. With regards to early-onset, are the risk factors the 

same, similar, or different? And what is the earliest onset that has 

been recorded thus far of Alzheimer’s? 

Dr. HODES. Well, in the category of dominantly inherited earlyonset Alzheimer’s disease, these cases around the world are caused 

21

by a number of mutations, but in one of only three genes. It is essentially 100 percent certain, tragically, that someone with this 

mutation will develop Alzheimer’s disease. The age ranges have 

been 50s, 40s, even 30s. They vary somewhat with the identity of 

the population and the genetic mutation. 

In terms of identifying risk factors other than the gene, in those 

cases of course, since the gene is essentially determinant, there has 

been very little opportunity to ask whether that genetic predisposition or predestination, sadly, is influenced by other factors. So 

there isn’t so much known. 

Now, if we set aside those and ask about the cases of Alzheimer’s 

in which there is not a dominantly inherited mutation, but nonetheless are recurring not at the more common 80s or 70s, but occurring in the 60s or 50s, we are currently through population 

studies monitoring onset and prevalence of cognitive decline and 

even Alzheimer’s in populations that range in age from 50s through 

the 80s and 90s. For example, the Health and Retirement Study 

puts us in a position to better understand whether the risk factors 

vary with age. An important factor in studies currently in progress 

ought to be able to address this. 

Mr. PAYNE. Just one additional question also. The increase in the 

percentage or the number of people that are being diagnosed with 

Alzheimer’s, in your opinion do you think it is an increase that is 

happening or do you think that it has simply been underreported 

in the past and just called something else? 

Dr. HODES. I am not aware of any conclusive evidence that the 

risk of developing Alzheimer’s disease at a given age, other variables essentially being similar, has changed. There is room for this 

to occur. For example, if the epidemic we are seeing in obesity and 

associated diabetes were to continue, it is possible that due to an 

increase in diabetes and the associated risk in Alzheimer’s there 

might be such a change. But the short answer to your question, to 

date I think it is likely that the increase in what we are seeing is 

due to two principal factors, overwhelmingly the increase in the 

number of people who are reaching an age at which they are at 

higher risk, and in addition the greater awareness and diagnosis. 

Mr. SMITH. Finally, Dr. Hodes, could you give us a sense of how 

many laudable research proposals go unfunded because of inadequate funding? 

Dr. HODES. I can give you an answer which I think shows the 

magnitude of that category. Currently, the pay line, that is the percentile at which applications are being funded at NIA, and it is not 

so different across other components of NIH, this year for example 

for the bulk of grants is at the 11th percentile. I think there would 

be little disagreement, if any, that grants that receive percentile 

scores at least twice that level, into the 20s, are deemed by peer 

review to be outstanding. By that criterion, I would say that we 

could fund twice as much research as we are currently able to 

fund, and still be funding uniformly outstanding research, if that 

is responsive to the question. 

Mr. SMITH. That is very helpful. Thank you so much, Dr. Hodes. 

Thank you so much for your testimony. We look forward to working 

with you. Did you say if you would personally, or on behalf of the 

administration, be able to support an international conference? 

22

Dr. HODES. Of course I can’t speak for the administration. I can 

certainly say if there is such a conference, then I would be enthusiastic about there being a presence of agencies such as NIA and 

NIH to lend their perspective on evidence and to learn from such 

a conference about where research ought to be conducted. But beyond that——

Mr. SMITH. Clear it with OMB. Thank you very much, Dr. Hodes. 

I would like to now introduce our second panel. And without objection, I would like to make part of the record, as I indicated earlier, the four demographics experts who testified on Monday at the 

Commission on Security and Cooperation in Europe. And that is 

Dr. Nicholas Eberstadt, Dr. Jack Goldstone, Richard Jackson, and 

Steven Mosher. Without objection, it will be part of record. 

I would like to now introduce our second panel, beginning with 

Dr. Daisy Acosta, who is Alzheimer’s Disease International, chairman of ADI, which seeks to empower the 75 national Alzheimer’s 

associations around the world to promote and offer care and support for people with dementia and their caregivers, while maintaining a global focus. She is certified by the American Board of Psychiatry and Neurology, and Dr. Acosta specializes in geriatric psychiatry. She has a large clinical practice in the Dominican Republic, 

and is in charge of organizing and teaching at the university 

psychogeriatric unit in that country. Welcome, Dr. Acosta. 

We will then hear from Mr. Eric Hall, who is the President and 

founding CEO of the Alzheimer’s Foundation of America, and 

President and CEO of Alzheimer’s Foundation International, an 

outgrowth of AFA. Mr. Hall spearheaded the development of AFA 

to improve the quality of care for individuals with Alzheimer’s disease and related dementias and their families. During that goal, he 

has initiated major national initiatives related to early detection, 

training of health care professionals, and standards for dementia 

care settings. Mr. Hall has spoken at numerous conferences on Alzheimer’s disease and caregivers, and sits on leading advisory councils. 

We will then hear from Mr. Bill Thies, who is Chief Medical and 

Scientific Officer at the Alzheimer’s Association, which is dedicated 

to eliminating Alzheimer’s disease through the advancing of research, providing care and support for all affected by the disorder, 

and reducing the risk of dementia through the promotion of brain 

health. Mr. Thies oversees a research grants program at the Alzheimer’s Association. He launched Alzheimer’s & Dementia, the 

journal of the Alzheimer’s Association, and established the Research Roundtable, a consortium for industry, academia, and government, who meet regularly to explore topics of mutual interest 

in drug discovery and common barriers to progress. 

We will then hear from Mr. George Vradenburg, who is the 

founder of USAgainstAlzheimer’s, a national disease advocacy network, and chair of the Geoffrey Beene Foundation-Alzheimer’s Initiative on Early Diagnosis. Mr. Vradenburg also directs Leaders 

Engaged on Alzheimer’s Disease, a tri-sector coalition of Alzheimer’s-serving organizations. The USAgainstAlzheimer’s co-convenes with the Alzheimer’s Foundation of America. Mr. 

Vradenburg was drawn to Alzheimer’s advocacy through the death 

of his mother-in-law, Bea Lerner, from the disease. Prior to 2003, 

23

Mr. Vradenburg held several executive positions in large media 

companies. 

We will then hear from Dr. Giovanni Frisoni, who is currently 

with the Scientific Institute for Research and Care at Brescia, 

Italy, where he oversees research on Alzheimer’s and other neurological diseases. In addition, Dr. Frisoni is part of several international groups that are focused on Alzheimer’s research and treatment. His work is widely published in medical journals and books. 

In the past 6 years, Dr. Frisoni’s work has become more expansive, 

focusing on developing infrastructure for storing and processing 

brain imaging data to increasing the understanding of Alzheimer’s 

in Europe and in the United States. He will be joining us live from 

Italy in the order that I am announcing. 

We will then hear from Dr. Jeffrey Cummings, of the Cleveland 

Clinic Lou Ruvo Center for Brain Health. Dr. Jeffrey Cummings is 

director of that clinic for brain health in Las Vegas, Nevada, and 

Cleveland, Ohio. In addition to many articles and books, Dr. 

Cummings is the author of the Neuropsychiatric Inventory, which 

is the most commonly used tool for characterizing behavioral disturbances in dementia syndromes, and for measuring the effect of 

therapies on neuropsychiatric symptoms in Alzheimer’s disease. Dr. 

Cummings has served as president of the Behavioral Neurology Society and the American Neuropsychiatric Association. 

We will then hear from Dr. Hugh Hendrie, Professor of Psychiatry at Indiana University, where he directs the IU Center on 

Aging Research. Dr. Hendrie served as chairman of the Department of Psychiatry, a position he held for 25 years, until 2000. 

While in that position, Dr. Hendrie developed and directed a section focused on geriatric psychiatry. He served as the President of 

the American Association of Geriatric Psychiatry and The Geriatric 

Psychiatry Alliance. Dr. Hendrie is well known internationally for 

his research and published works on psychiatry. He is currently 

serving on the National Advisory Council on Aging. 

And that is it. Dr. Acosta, if you could begin, please. 

STATEMENT OF DAISY ACOSTA, M.D., CHAIR OF THE 

EXECUTIVE BOARD, ALZHEIMER’S DISEASE INTERNATIONAL 

Dr. ACOSTA. Thank you, Chairman Smith, Ranking Member 

Payne, for this opportunity to testify before you today. My name, 

as you said, is Daisy Acosta, and I come from the Dominican Republic. I am a caregiver, a doctor, and a researcher, and I am the 

chairperson of Alzheimer’s Disease International, the worldwide 

federation of Alzheimer’s associations around the world. Our 76-

member associations represent the people with dementia and their 

families in their countries. Alzheimer’s Disease International was 

founded here in this country in 1984, being the U.S. Alzheimer’s 

Association one of our founding members. Today, 27 years later, for 

the first time ADI has a chair from a developing country. So you 

can be sure that I am very proud of that. 

Alzheimer’s disease and other dementias, as you have been saying, is a global problem, and are the single most important health 

and social crisis of the 21st century. The impact of this disease 

today is massive, and will accelerate with the years to come. You 

have already said how many people live with dementia at this 

24

point, 37 million people. And this is going to increase due to global 

aging by more than 1 million per year, as you said before, to 115 

million by 2050. 

Alzheimer’s disease is devastating not only to the victims, but 

also to the families and to society at large, and there is something 

really that cannot be put in papers about the devastation of this 

illness. It is the human fiber of this illness. You really have to live 

with a person with dementia, with a family with dementia at least 

for 24 hours to understand the urgent need that we need to solve 

this problem. 

Alzheimer’s disease in developing countries, the burden of this 

disease falls completely on the families. And as you said before, 

again, these countries will see the largest increase in numbers in 

the next decades. So I want to stress again that this is a global 

problem, and that we have to find global solutions. The global cost of this illness, as you said, is $604 billion. This 

equals 1 percent of the global GDP. If Alzheimer’s disease were a 

country, it would be the 18th largest economy based on GDP. And 

it exceeds that annual turnover of any company in the world. And 

as you said, because I am glad to see that you really have all the 

facts with you and all the statistics with you, which is really great, 

but Alzheimer’s Disease International put together all this data in 

our two reports, the 2009 and 2010 reports, not just to sit in those 

reports. The aim to gather all this data was really to serve as a 

wakeup call for governments, leaders in the community, health 

care professionals, to really put this data into action. 

We have made great progress with many other diseases like cancer, HIV/AIDS, but we have done so because there has been a political commitment to act, and because of national planning and substantial investment in research and care options. And this is exactly what is needed to solve this problem. 

There is increasing awareness about Alzheimer’s disease and 

other dementias in the world. Several countries have launched a 

national plan or strategy, starting with Australia in 2005, and then 

France and South Korea in 2008. These plans have started creating 

significant changes in health care systems. More and earlier diagnoses are being made, better disease management, and increased 

research are key issues in this strategic planning. All of these governments are aware that investments made now will reduce future 

health-care costs. 

At our annual international conference in March 2011 in Toronto, we hosted for the first time a symposium looking at the results of these national plans. And we will do the same thing in 

2012. And I certainly hope to see the national plan for Alzheimer’s 

disease and other dementia in this great country being included in 

this symposium next year. 

The United States has shown global leadership in the past and 

was one of the first countries to create a dementia research budget 

in the 1990s. Having said that, as I understand, that budget has 

not followed the increase in number of people with dementia that 

has doubled in the last 20 years. And that budget has not been adjusted for inflation, as I understand. 

Your Congress has now taken an important step by passing the 

National Alzheimer’s Project Act. I congratulate the USA on this 

25

decision because it is a great opportunity to improve the ways that 

your health care system deals with dementia: Earlier diagnosis and 

intervention; giving more people access to medical and nonmedical 

treatment; and last, but not least, and I think it is extremely important, support for caregivers. 

This should be accompanied, of course, by increased budgets for 

research into the cause of the disease and possible prevention. 

If the USA takes these steps, it will encourage governments in 

other parts of the world, as well, to do so. And I am sure of that; 

at least, that will be so in my region where I live. 

ADI—and this is very important—and its members have empowered people with dementia to have a voice. I commend you to continue the productive work with the Alzheimer’s Association as a 

champion in advocacy and encouraging research efforts in your 

country. 

Finally, we need the help of the U.S. Government in an international issue. The United Nations are going to hold a high-level 

meeting on the 19th and 20th of September in New York City. It 

is a meeting about noncommunicable diseases. This summit currently does not include Alzheimer’s disease as one of the noncommunicable diseases—only cancer, diabetes, and heart and lung 

diseases—although these illnesses share the same risk factors and 

often coincide together. It would be great if a USA representative 

at the United Nations could raise this in the discussion on the outcome document that has already started. 

I think we really can win this fight against dementia, but only 

if governments get committed to do so. And we have no time to 

waste. The time to do it is now. It is time, really, for global action. 

Thank you very much. 

[The prepared statement of Dr. Acosta follows:]

26


67052d-1.eps
27


67052d-2.eps
28

Mr. SMITH. Dr. Acosta, thank you much for your testimony and 

your leadership. 

Mr. Hall? 

STATEMENT OF MR. ERIC HALL, PRESIDENT AND CHIEF EXECUTIVE OFFICER, ALZHEIMER’S FOUNDATION OF AMERICA 

Mr. HALL. Chairman Smith, Ranking Member Payne, thank you 

for convening this hearing and for inviting the Alzheimer’s Foundation of America to testify. I am Eric Hall, AFA’s founding president 

and CEO, and I am honored and privileged to be here today. 

My involvement in this cause is not simply a career endeavor, 

and it is more than simply my family history, as if that would not 

be enough, but it is a painful result of the many stories that I hear 

from struggling families across our country. I need to do something, 

we need to do something, and I beg you to make the most of the 

present opportunity and to make it happen now. 

The National Alzheimer’s Project Act passed by Congress last 

year was a groundbreaking first step toward the creation of a National Alzheimer’s Disease Plan in the United States. However, it 

is no secret that the U.S. is behind the curve of several other countries that already have national Alzheimer’s disease plans in place 

or in process. We have a lot of homework to do, but we can learn 

a lot from what has already been done overseas, both in planning 

and in political commitment. 

The next crucial step is an international meeting of countries 

with plans in place or in process in the first quarter of 2012. AFA 

would be honored to serve as an NGO supporting partner in such 

an effort and would be glad to work with ADI and others. AFA applauds ADI for its financial support of the 10/66 Dementia Research Group and its commitment to international collaboration. 

In AFA’s view, the international meeting would ideally consolidate how other countries have approached their plans and would 

produce a compendium with common threads. Such a meeting 

would help us develop our plan and help us to begin to develop a 

global approach to this pandemic. 

The meeting would also include a day or more of panel discussions on established policies, as well as innovative care programs 

abroad as well as those here in the United States, of which there 

are many. There is little doubt we can get there faster by reviewing 

what has already been done, what has been successful, and what 

to avoid. 

One example that the U.S. can learn from is the award-winning 

dementia care available in Israel through an organization called 

Melabev. Melabev is a founding member organization of the Alzheimer’s Foundation of Israel. And, together, they share a combined commitment to serve the Alzheimer’s population in that 

country. The Alzheimer’s Foundation of Israel is a not-for-profit organization that I established in January of this year through the 

Alzheimer’s Foundation International, which has been an outgrowth of the Alzheimer’s Foundation of America. 

Melabev has spent the last 30 years developing therapeutic activities that give people with dementia and Alzheimer’s disease a 

reason to get up in the morning. In addition to its day centers, 

Melabev also brings services and activities right into the family 

29

home. Each individual with dementia is given a geriatric assessment, and a range of health-care professionals are available for 

working with the individual and the family members under their 

roof. 

Not only does Melabev care for the person with dementia, but it 

also cares for the family caregivers. It provides palliative care for 

individuals in the end stages of the disease, as well as guidance on 

end-of-life issues for the whole family. In between regularly scheduled house calls, the members of this team are accessible by phone 

whenever needed. Melabev, quite simply, gives families a shoulder 

to lean on. 

Israel also has groundbreaking geriatric programs at Herzog 

Hospital in Jerusalem. Their motto is, ‘‘Restoring dignity to all.’’ 

Herzog Hospital is currently the only facility in Israel to combine 

neurological, behavioral, and social approaches in treating the full 

range of geriatric illnesses, including Alzheimer’s disease. Most 

uniquely, Herzog also has a specialized emergency room for behavioral and psychiatric issues. And all of its staff members, from physicians to social workers, are trained in geriatric approaches to 

care. 

Melabev and Herzog Hospital in Israel are just two quick examples of the many innovative programs available throughout the 

world. A congressional call for an international meeting is how we 

will learn more. And if we do things right, an international movement will follow. 

I would like to end with a quote from Peter Drucker, a writer 

who was awarded the Presidential Medal of Freedom in 2002. He 

said, ‘‘Unless commitment is made, there are only promises and 

hopes; but no plans.’’

AFA looks forward to working with members of the subcommittee to address the important issues raised in today’s hearing. And, of course, I would be honored to answer any questions 

you may have. 

[The prepared statement of Mr. Hall follows:]

30


67052b-1.eps
31


67052b-2.eps
32


67052b-3.eps
33

Mr. SMITH. Mr. Hall, thank you very much. And as you heard 

from my opening, I think we would be in one accord to try to push 

the very idea that you and others have espoused. I thank you so 

much for that. 

Mr. Thies? 

STATEMENT OF BILL THIES, PH.D., CHIEF MEDICAL AND 

SCIENTIFIC OFFICER, ALZHEIMER’S ASSOCIATION 

Mr. THIES. Chairman Smith, Ranking Member Payne, I appreciate your giving me the opportunity to speak to you today. My 

name is Bill Thies. I am the chief medical and scientific officer of 

the Alzheimer’s Association. 

I spent most of the time I sat in the back of the room crossing 

out parts of my presentation because other people were already giving that. 

And I think the numbers are really clear. This is an epidemic 

now. It is big. It is only going to get bigger. I think one of the 

things that we miss if we focus too much on the numbers is that 

this is a truly awful disease. It robs you of your memories and 

abilities, it robs you of your resources, and at the end it robs you 

of your dignity. 

There really is only one way out from under the burden of the 

Alzheimer’s epidemic, and that is by having new and better treatments to either slow the progression of the disease or actually prevent the disease from becoming symptomatic. Those sorts of efforts 

will, in fact, not only have to be done at a global level, but they 

also will benefit the whole world. 

I think that the Alzheimer’s Association has had an international 

science program for many years. Some of our particular activities 

have been mentioned. The Alzheimer’s Association International 

Conference on Alzheimer’s Disease that is coming up in Paris 

brings all of the researchers in Alzheimer’s from around the world. 

The international consortium, bringing the biggest sort of collections of genetics studies together, is one where the Alzheimer’s Association has been able to step in and fund at the last stage. 

I mean, basically, the Association is small by governmental 

standards, certainly. We do have the ability to convene, catalyze, 

and then promote the results of various studies. And we will continue to do that as frequently as we can. 

We do believe in collaboration with the scientists. Certainly, the 

Alzheimer’s Disease Neuroimaging Initiative (ADNI) study that 

has already been mentioned by Dr. Hodes has grown to be Worldwide ADNI, which is hosted by the Association. It is particularly 

important to have those studies grow in an orderly way so they 

really can be used complementary. 

We also have started projects like a European ADNI where we 

can invest a small amount of money. And you will hear from Dr. 

Frisoni later. And we particularly believe in trying to identify barriers to progress that actually we can have an impact with with our 

limited budget. So we do things like a cerebral spinal fluid standardization project in Europe and the United States, which is really 

designed to make measurements of CSF biomarkers really practical 

in a clinical sense. We look for those kinds of projects. 

34

And the future is clearly going to be determined by some legislation that has already been passed. National Alzheimer’s Project Act 

(NAPA), I would like to compliment the Members for having voted 

for that. But we not only have to pass NAPA, we actually have to 

implement it, and then we have to devote appropriate resources to 

that implementation. If we don’t do that, we simply will have a 

wasted exercise. 

And, finally, I would just like to conclude that I don’t think I 

have to tell those of you up at the panel that activities of the government are not always appreciated for the boons that they are. 

Some people will tend to disagree with you. But, in fact, efforts 

that increase the longevity and the quality of the life of the citizen 

is probably the finest public service that you can do. 

We just recently had the national conference of oncologists in 

Chicago, where they announced a variety of highly specific, terrifically effective new therapies for cancer. Heart disease, over the last 

50 years or so, has reduced the number of deaths from heart disease by 1 million a year—1 million people a year that don’t die 

from heart disease from new science. HIV/AIDS has gone from 

being a virtual immediate death sentence to now a chronic manageable disease. 

There is no secret for why that happens. We invest $6 billion a 

year for cancer, $4 billion a year for heart disease, and $2 billion 

a year for AIDS. We are at about $450 million for Alzheimer’s disease. Without increasing that significantly, we are going to see the 

peak of this epidemic and we are going to see the worst possibilities of it. 

And what I would challenge the panel to recognize is that this 

is a place where the United States is going to have to lead. It is 

going to have to lead the world, because the rest of the world is 

going to suffer from exactly the same disease without the resources 

to do anything about it. 

Thank you for your attention. 

[The prepared statement of Mr. Thies follows:]

35


67052c-1.eps
36


67052c-2.eps
37


67052c-3.eps
38


67052c-4.eps
39


67052c-5.eps
40

Mr. SMITH. Mr. Thies, thank you so much for your testimony and 

your extraordinary leadership, as well. 

Mr. Vradenburg? 

STATEMENT OF MR. GEORGE VRADENBURG, FOUNDER, 

USAGAINSTALZHEIMER’S 

Mr. VRADENBURG. Thank you, Mr. Chairman, Ranking Member 

Payne, Mr. Marino, and Mr. Markey. My name is George 

Vradenburg. I founded USAgainstAlzheimer’s last year to try and 

commit this country to solving Alzheimer’s, addressing Alzheimer’s, 

by 2020. 

You, Mr. Chairman, have already responded to the three things 

that I was urging upon you in your opening comments, so I am 

going to take off in a different direction. 

You talked most eloquently and persuasively about the public 

health crisis that Alzheimer’s is and will be becoming. I would like 

to try and take some of what you have said and build on it, and 

say that this is not just a public health crisis; it is potentially a 

fiscal crisis and an economic crisis. 

And let me build on that by saying this: There are two major demographic changes—two major demographic changes affecting the 

world right now. 

Number one, we are living longer. For thousands of years, we 

used to live to age 30, you know, and then by 1900 it was age 50, 

now it is age 80. That trend isn’t going to stop. We are continuing 

to invest in the extension of life. We are continuing to do what we 

have been able to do in overcoming infectious diseases and, as Bill 

just pointed out, what we are doing to achieve better results in 

terms of heart and cancer, HIV/AIDS, and others. So we are going 

to extend life well into the 90s, into the 100s. My grandchildren, 

aging experts tell me, will live to 110 to 120. That is number one. 

That particular ability to extend human life has driven American 

economic growth and the growth of the developed world since 

World War II. We have increased our population, we have increased our labor participation, we have increased our workforce, 

and, in fact, we have driven economic growth. And economists will 

tell us that, because of that extension of life, we probably have doubled or tripled what the GDP would have been had we stayed at 

a life expectancy of 50 to 60 years old. That is one demographic 

change. So there is an economic impact to the extension of life. 

The second is the changing role of women in the world. In the 

developed nations, women are increasingly regarded as equals. 

They are increasingly entering the workforce as equals. And, as a 

consequence, they are having fewer children. And that means lower 

fertility rates, and that means that, not only in the developed world 

are we seeing aging and life extension, but we are seeing fewer 

people on the younger end of the scale. 

Now, what does that mean? In Europe, Western Europe, Russia, 

United States to a lesser extent, but in the Asian Rim countries, 

there are declining populations, fewer workers, and more people 

dependent upon public health systems for their support. That is 

producing fiscal stress on health systems around the world. And it 

is producing the risk that the developed world, particularly the 

Asian Rim and particularly Western Europe, are going to be declinVerDate 0ct 09 2002 14:27 Feb 16, 2012 Jkt 000000 PO 00000 Frm 00044 Fmt 6633 Sfmt 6633 F:\WORK\AGH\062311\67052 HFA PsN: SHIRL
41

ing in their relative economic growth and prosperity in the coming 

years. 

So how is Alzheimer’s relevant to all this? 

Number one, as we age physically, as we get to 90 or 100 years 

old—after 85, one in two has Alzheimer’s—we are going to see, increasingly, a physically able population but a cognitively disabled 

population. We are going to be in a situation where we are going 

to be able—some countries are going to be able to productively employ their older workforce through new technologies and techniques—a physically frail but still physically able population—but 

we cannot engage those people because of their cognitive disabilities. 

So we are going to see Alzheimer’s actually having an adverse effect on economic growth in some nations. And those nations that 

get it right and figure out how to support their aging populations, 

keeping them healthy and keeping them productive, are going to be 

winners in the 21st century. And those countries that do not figure 

out how to solve cognitive disability and how to address aging populations are going to be losers. 

And, secondly, on the fiscal stuff, Alzheimer’s is particularly costly. A 10-year duration of the disease. The cognitive disability basically means that people forget to take their meds for other purposes. So you are going to see complications of Alzheimer’s—Alzheimer’s is going to cause complications for diabetes and other diseases. And in the later stages of the disease, you will see greater 

institutionalization because of the total dependence of the victim. 

As a consequence, there are major fiscal impacts as a consequence, particularly, of Alzheimer’s. So it is economic growth 

issue, and it is a fiscal issue. So as we focus on what to do with 

our aging populations, we need to change our aging populations 

from people who are taking public benefits through our health-care 

systems, pension systems, and the like and turn them into productive taxpayers who are participants in the workforce. And that 

means keeping them healthy. That means not just physical health; 

that means cognitive health. 

And I would suggest, as you have written already, to the United 

Nations on the NCD conference, it is critical for the world to begin 

to recognize this not just as a health issue but as a fiscal issue. So, 

Mr. Chairman, as you were emphasizing the importance you attach 

to the potential of a government-led but NGO- and corporate-involved international conference among nations that have Alzheimer’s plans in place or in process, I would urge that the Treasury Department and the finance ministers be there as well as the 

health ministers. 

Because this is an issue that is confronting the developed world 

now. And, indeed, in the developing world, where this is going to 

become a bigger problem, like China, where their population will 

start shrinking in 20 years, this is going to have major shifts in 

the relative economic power, economic relationships, and, obviously, the fiscal stability of these sovereign budgets. 

So I thank you for the opportunity to be here today. And I applaud your leadership and that of Mr. Markey and the other members of the committee who are here on this subject. 

[The prepared statement of Mr. Vradenburg follows:]

42


67052e-1.eps
43


67052e-2.eps
44


67052e-3.eps
45


67052e-4.eps
46

Mr. SMITH. Mr. Vradenburg, thank you very much for your testimony. And your full statement and that of all of our distinguished 

panel—and this is truly a tremendous panel of experts. 

My hope is—and, again, as I said this, before I go to Dr. Frisoni, 

we will share this hearing record with policymakers throughout the 

entire world. I actually chair the Helsinki Commission, and we 

meet three times a year, at least. And heads of delegations, usually 

speakers—speaker of the Duma, for example—head of the Duma—

we will be handing this out, because there is a tsunami of disability 

that is predictable unless drastic action is taken. So, again, I thank 

you all. 

I will now go to Dr. Frisoni, who is coming in from Italy. 

Dr. Frisoni, please proceed. 

STATEMENT OF GIOVANNI FRISONI, M.D. (VIA TELECONFERENCE), DEPUTY SCIENTIFIC DIRECTOR, IRCCS–FBF ALZHEIMER’S CENTER 

Dr. FRISONI. Chairman Smith, Senator Markey, honorable Senators of the U.S. Congress, it is an honor to give this testimony to 

the U.S. Congress. 

The aim of my testimony is to stimulate greater coordination of 

large research efforts in the field of Alzheimer’s disease that will 

be undertaken in Europe and the U.S. In the coming years. As has 

been already underlined, much has been understood about how 

Alzheimer’s disease develops in the brain, thanks to research carried out in Europe, the U.S., and elsewhere in the past decades. 

We currently believe that Alzheimer’s develops due to the accumulation in the brain of at least two toxic proteins, amyloid and 

tau, that, with the variable contribution of the factors that have 

been mentioned, lead to progressive synaptic and neuronal damage. 

This has allowed us to design drugs that, administered sufficiently 

early in the 30-odd-year-long process, should delay or altogether arrest its progression. 

Enthusiasm on these achievements is reflected by a number of 

large research efforts with an innovative approach. While such efforts see active cooperation of scientists across the Atlantic, unfortunately these are not coordinated at the funding level. And I will 

give you the two most glaring examples, one in the U.S. and one 

in Europe. 

In the U.S., the Alzheimer’s Disease Neuroimaging Initiative, 

which has also already been mentioned by Dr. Hodes, the ADNI, 

is probably the largest ever single effort in Alzheimer’s, entailing 

150 million U.S. dollars for 10 years, coming from NIA and industry. ADNI aims to describe the natural history of the disease at the 

clinical and biological level with a number of highly sophisticated 

imaging and biochemical techniques. In all medical disciplines, 

ADNI has pioneered the paradigm of open access to research data, 

such that any scientist in the world can download an 

unprecedentedly wealthy database and do science on it. 

In Europe, 85 percent of the public research budget of European 

countries are fully controlled at a national level, and less than 1 

percent is reoriented to collaboration or coordination between countries through a number of community programs. This may change 

in the near future with the advent of joint programming funding 

47

schemes. These are led at the central level by the European Commission and aim to support and catalyze that 85 percent of research funded by national states by establishing closer and robust 

collaborations. The forerunner of all joint programs is the Joint 

Programming on Neurodegenerative Diseases, an effort just recently started and focusing mainly on Alzheimer’s disease. 

Remarkably, a European ADNI is currently active in Europe, 

thanks to close cooperation between U.S. and EU scientists, and 

the first JPND, Joint Programming on Neurodegenerative Diseases, is on a topic, standardization of biomarkers, where U.S. and 

EU scientists of the European Alzheimer’s Disease Consortium are 

working closely together, as Bill Thies was reminding everyone earlier on. 

The key role of the Alzheimer’s Association, to foster the transatlantic cooperation among scientists, should be here underlined 

and acknowledged. However, the funding of ADNI in the U.S. and 

JPND in Europe are not coordinated, such that scientists very 

closely aligned at the scientific level in the two areas of the world 

are completely detached when they run for grants. Transatlantic 

coordination might have the obvious positive fallout of maximizing 

the effectiveness and cost-effectiveness of research. 

Early initiatives, however, are being developed aiming to 

synergize research efforts across the Atlantic. A scientific infrastructure is under development, funded by the European Commission with overall 9 million euros, that will allow to bring the concept and benefits of cloud computing to imaging neuroscientists 

working on Alzheimer’s. The neuGRID electronic infrastructure 

will allow global scientists to exploit the enormous amount of scientific information conveyed by large public datasets such as the 

ADNIs. 

The Laboratory of NeuroImaging at the University of California 

at Los Angeles is full partner in the NeuGRID efforts. Works are 

under way, led by the Alzheimer’s Association, to develop the U.S. 

chapter of neuGRID, the Cloud Network of the Alzheimer’s Association, CNAA, where EU partners will be symmetrically represented. 

The neuGRID/CNAA example is just a drop in the vast sea of 

Alzheimer’s research. Funding bodies may wish to borrow this 

model of cooperation to inform the largest initiatives on Alzheimer’s in the EU and U.S. If this will happen and be effective, 

more funding bodies, from China, Japan, Australia, and elsewhere, 

may wish to join in. 

In conclusion, global research on Alzheimer’s is benefiting from 

enthusiasm of recent scientific discoveries and prospect of an effective cure. Decision makers in the U.S. and EU should capitalize on 

scientific enthusiasm by developing more effective funding strategies that will allow scientists to progress at greater speed. This will 

increasingly feed the fire of enthusiasm of scientists with the logs 

of knowledge and may ultimately lead to find an effective cure for 

this devastating disease. 

And I thank you for your attention. 

[The prepared statement of Dr. Frisoni follows:]

48


67052f-1.eps
49


67052f-2.eps
50

Mr. SMITH. Dr. Frisoni, thank you so very much. I know it is 

very late there. I hope you can hang on a little bit longer for, perhaps, a question or two from the members or, perhaps, our panel, 

who might want to pose a question to you. 

Dr. Cummings? 

STATEMENT OF JEFFREY CUMMINGS, M.D., DIRECTOR, 

CLEVELAND CLINIC LOU RUVO CENTER FOR BRAIN HEALTH 

Dr. CUMMINGS. Thank you, Chairman Smith, Mr. Payne, Mr. 

Marino. It is a pleasure to be here, and I am grateful for your willingness to call attention to this tremendous problem that we face. 

We haven’t heard too much about Africa so far, so I am going to 

say a few things about Africa. And then I am going to tell you 

about a couple of experiments that we are doing at the Cleveland 

Clinic Lou Ruvo Center that we think could be exported and could 

be influential in terms of the way patients are cared for. 

So, as you have heard, Alzheimer’s disease is age-related, and I 

would like to make the point that the African continent is aging, 

just as every continent is. So there are 36 million people in the 

sub-Saharan African region that are over the age of 60. And that 

predicts a cognitive impairment number, population, of around 9 

million—Alzheimer’s disease, plus mild cognitive impairment of 

various sorts. Dr. Hendrie has done terrific work in Nigeria. There 

are recent reports from the Congo and from other republics that 

suggest that the numbers are becoming more comparable to Western numbers over time—that is, high. 

For every patient with Alzheimer’s disease, there are at least two 

caregivers. So if we say there are 9 million victims, then we have 

to say that there are at least 18 million caregivers on the African 

continent who are involved with Alzheimer’s disease. That is a tremendous number, a tremendous burden. 

The cost of Alzheimer’s disease, of course, is terrific. It is estimated at $172 billion annually in the United States now. Africa is 

spending $2.9 billion annually on its dementia population. And 

these economies are ill-suited to absorb very much more, in terms 

of care of elderly and demented individuals. So they are going to 

have trouble responding meaningfully to the burden, and the increasing burden, that this represents. 

Risk factors are very important. And I take Dr. Hodes’ admonishment that we don’t have the kind of data that we would like, and 

it is going to be hard to get. We understand, for example, that hypertension in mid-life contributes to dementia in late life. Well, 

that is a long-term experiment, right, for you to decide whether reducing hypertension in mid-life is going to have an effect 20 or 30 

years later. 

So we are not going to have the kind of data that we would like 

to have for intervention. And we are going to have to accept some 

of the correlative data that we have now, such as there is an association between Alzheimer’s disease and high blood pressure, with 

diabetes, with low educational level, and with head trauma. All of 

those things are overrepresented in Africa in the population, and 

they represent very substantial risk factors for cognitive impairment in the African population. 

51

Stroke is a risk factor for Alzheimer’s disease. There are twice 

as many strokes in African blacks compared to African whites. So 

stroke is playing a substantial role in Alzheimer’s disease in Africa. 

Nutritional status is compromised in much of sub-Saharan Africa. And we hear a lot about nutrition in children and nutrition in 

lactating women, but we hear very little about nutrition in the elderly, and yet it is a risk factor for Alzheimer’s disease and cognitive impairment. 

Stress is a risk factor for Alzheimer’s disease. So think of war 

and famine and refugee status and what that must do to the incidence and prevalence of cognitive impairment in the African population. 

Behavioral problems—and I am quoting here Dr. Acosta’s work 

and the tremendous work of the 10/66 Group—behavioral problems 

such as agitation and depression and sleep disturbances are common in Alzheimer’s disease. They have been shown to be present 

in 70 percent of dementia patients in developing countries—so, 

very high. 

Dementia has largely been under-prioritized, I think for financial 

and simple educational reasons, in Africa. The policies that could 

be supported would be: Increasing awareness; they would be social 

protection. Mr. Payne, you mentioned that when there is displacement of populations, the last protected are the elderly. So social 

protection programs would go a long way toward helping this. Access to good-quality, age-appropriate health care would be very important. And reducing disability could make a tremendous impact 

in the lives of these patients. 

Now, I will just tell you about two things we doing at the Cleveland Clinic that I think are important. 

One is our patients first philosophy. You have the choice of taking the science to the patient or taking the patient to the science. 

So we said, let’s put the patient in the middle, let’s make them the 

focus, let’s try to understand the experience they are having. So we 

took away waiting rooms, for example, because we don’t think a patient with mild disease should be in a waiting room with a patient 

with severe disease. So there are no waiting rooms in our clinics. 

We changed the geography so that there is a circle of flow of patients through the clinic and out, so that the only chance of one patient encountering another is in the elevator lobby. 

We give a patient a flower when they leave our clinic, because 

we are trying to make this an experience that, if they can remember it, they will remember it as a pleasant experience, and certainly the caregiver will remember it. 

We have built our caregiver programs around the experience of 

the patients. So we have dance programs, where patients and caregivers come together to dance. We have music programs. We have 

weekly ‘‘lunch and learn’’ programs. These are the things that we 

draw people into to help make their lives better. 

Finally, we said to ourselves, our interest is in clinical trials. I 

am basically a person committed to new therapeutics in Alzheimer’s disease. And we have way too few Alzheimer’s patients 

coming into clinical trials. A tiny minority of patients with Alzheimer’s disease are participating in trials, and yet trials are the 

only way to get new drugs approved for Alzheimer’s disease. 

52

So we said, let’s give the patient the message that they can help 

solve this problem; that doctors and scientists, without the help of 

the patient, cannot solve Alzheimer’s disease; that patients have to 

be part of the Alzheimer’s disease solution. So we empower them 

to be part of the solution for Alzheimer’s disease by participating 

in clinical trials. And we have some of the highest participation 

rates in the country for our patient population in clinical trials. 

Now, a final point about clinical trials and an experiment we are 

trying. By and large, clinical trials are conducted at individual sites 

throughout the country. And they recruit slowly; it is the slowest 

part of every drug-development program. And almost no drug-development program finishes on time. So we are literally slowing 

our ability to get to new drugs because we cannot conduct the clinical trials fast enough. 

In Cleveland Clinic, what we have decided to do is to make all 

of the sites of the Cleveland Clinic clinical trial sites. In Nevada, 

in Ohio, in Florida, everybody is participating in clinical trials. It 

is all controlled by one IRB, because regulatory hurdles are a major 

reason for slowing clinical trials. This is one of the barriers that 

can be solved. 

I will tell you a final point, which is that we recently reviewed 

the 269 Alzheimer’s trials being conducted in the world now. Only 

28 percent of them are being done in the United States. So trials 

have been exported outside of the country because we are not able 

to adequately recruit for them in the United States. 

We are very concerned about the quality of some of those trials 

conducted at international sites. We need to solve the problem of 

recruitment. We do not have a national Alzheimer’s disease clinical 

trials recruitment program. We need to solve that problem so that 

we can get more patients into trials in the United States. And we 

need better collaboration internationally, because most of the trials 

are being done outside of the United States. Our growth in getting 

new drugs for Alzheimer’s disease depends on international collaboration. 

I will stop there. Thank you very much for the opportunity to 

speak with you. 

[The prepared statement of Dr. Cummings follows:]

53


67052g-1.eps
54


67052g-2.eps
55


67052g-3.eps
56


67052g-4.eps
57

Mr. SMITH. Thank you very much, Dr. Cummings. 

Dr. Hendrie? 

STATEMENT OF HUGH HENDRIE, M.D., PROFESSOR, INDIANA 

UNIVERSITY 

Dr. HENDRIE. Chairman Smith, Ranking Member Payne, and 

other members of the subcommittee, I am just delighted to be here, 

to be invited to this really remarkable conference and understanding, again, all of these initiatives that, honest to goodness, 

Congressman, I wasn’t very well aware of, so maybe you need to 

do more education to your republic. And it is wonderful to hear. 

I also would like to thank everyone very much for the comments 

that people have made before over our study, the IndianapolisIbadan Dementia Project, which I have been principal investigator 

of originally, but I am not now the principal investigator, but still 

involved. And that is what I wanted to talk about today. I thought 

maybe my best contribution will be to try to bring you through 

some of the evolution of this particular project. It will show you 

how these comparative global studies can be very influential in 

identifying, potentially modifying risk factors, the surprises we 

sometimes come up with, and the challenges that you have to make 

them. 

Now, I did put with the testimony the outline of the project. Alas, 

when we went through all of the various iterations, it became very 

tiny and it required a great effort to read the little comments. So 

your staff member kindly put it on up on the screen. And if that 

is okay with Chairman Smith, I could go ahead and very quickly 

go over the findings. 

So, again, you have heard about all of this before. Comparing 

rates of illness between countries or communities can be very informative. You can compare risk factors then for the illness. And 

the benefits of the international studies developing in developed 

countries is it produces huge diversity. So you can look at much, 

much different environments than you can if you are just concentrating on one country. 

Our first venture actually was not in Africa but with the Cree, 

elderly Cree, in Manitoba, a place where I practiced before. But 

during the course of this study, we met a very remarkable man, 

and that was Professor Ben Osuntokun, who was from the University of Ibadan in Nigeria. And he came over to study with us for 

a year, in the process of this study. And the Indianapolis-Ibadan 

project is his idea. And I wish I could take credit for it, but it was 

his. 

And so, what he said was—now I can’t even read it on there. Oh, 

well, we tried our best. There are versions of it that are bigger on 

the table. 

But what he said was, he had information from his population 

in Nigeria, Yoruba, from autopsy studies he had done, that he 

didn’t think Alzheimer’s disease occurred in the Yoruba because of 

a lack of plaques and tangles in the brain and so on. 

So what he proposed was a kind of unique thing. He said, why 

don’t we do a classical migrant study? We will look at the Africans 

living in Ibadan, Nigeria, which is in West Africa, and we will look 

at the migrant population. That is where most of the African-AmerVerDate 0ct 09 2002 14:27 Feb 16, 2012 Jkt 000000 PO 00000 Frm 00061 Fmt 6633 Sfmt 6633 F:\WORK\AGH\062311\67052 HFA PsN: SHIRL
58

icans came from as part of the slave trade, of course, that came 

over from West Africa—not all were Yoruba—and were in the various communities. 

So we sat down and we wrote the Indianapolis-Ibadan project. 

We would look at large numbers of community-dwelling elderly 

people in Ibadan and large numbers of elderly African-Americans 

living in Indianapolis. And that is what we have been following for 

the past 20 years. And over that period of time, we have seen over 

4,000 people at each side over a long period of time. 

So what did we find? Well, the first thing we found was Dr. 

Osuntokun was wrong, that Alzheimer’s disease was, indeed, 

present in Yoruba, and Alzheimer’s disease was producing serious, 

significant defects for the families. The families were in great distress because of the behavioral symptoms that have been described 

before by Daisy Acosta. But the rates were lower in Yoruba at that 

time than the rates in African-Americans. 

I should be very cautious about this. When we compare them 

with all of the rates of all the different countries in the world that 

have been published, they weren’t out of the boundaries. So that 

the Yoruba were at the lower level of rates, the African-Americans 

were at the higher level, but they were all within the ballpark. 

There was nothing new. 

But the other thing that was surprising about this or was interesting about this was, it wasn’t just rates of Alzheimer’s disease 

that were lower; rates of diseases which are considered risk factors 

for heart disease were also lower, so lower rates of hypertension, 

lower rates of diabetes, lower rates of stroke. Actually, at that time, 

they were skinnier, their BMI was lower. The few studies we did 

of cholesterol levels showed that cholesterol levels were also lower. 

And there are a lot of different lifestyle factors involved with that, 

particularly diet. And we can talk about the diet issues later. 

So we were excited about that, and we thought there was clearly 

a connection between the heart and brain. That was relatively new 

at the time we talked about it, but now it is, as you see, pretty 

well-established. In fact, I think Bill Thies once said, ‘‘What is good 

for the heart is good for the brain,’’ which was a nice way to summarize the information. 

So what we planned to do at that stage was we would increase 

the intensity of looking at risk factors for heart disease in our populations. So we would do biomarkers, diseases, and so on, biomarkers of lipids and inflammatory markers and so on. 

But then what we were confronted with was the genetic explosion. All of a sudden, a huge amount of information became available in genetics. First of all, they found this remarkable finding 

that this form of a gene, APoE-e4, increased the risk dramatically 

for Alzheimer’s disease. Not just in the United States but in almost 

any other country that we measured, there was almost no exceptions to the rule that e4 increased the disease. 

And then, for us, even maybe a more exciting finding from the 

population geneticists, the population geneticists then said, maybe 

the anthropologists are right, that it looks as if modern human 

beings arose in Africa and migrated not terribly long ago, about 

150,000, 200,000 years ago. So that if you want to study chronic 

illness, the likelihood is that all of the genes for chronic illness 

59

were present in the African population, and you should try to incorporate the African population when you are studying the genesis 

of chronic illness throughout the world, including Alzheimer’s disease, which made us, of course, very happy. And we incorporated, 

then, into our study a large genetic component, as well as the biomarker component that we talked about before in the risk factors. 

So, building upon that, we said, well, we are going to look at the 

biomarkers for cardiovascular disease, and we are going to look at 

the genetics of Alzheimer’s disease, and we are going to look particularly at those genes that people had picked out, the APoE-e4 

and so on, that were big risk factors. And this is the model we were 

going to use. 

If you really want to understand Alzheimer’s disease rates in any 

community, you would have to look at both. You look at genetics, 

look at environmental factors, and, even more importantly, see how 

they interact with each other. And if I had to bet what is going to 

happen in research in the next 10, 15 years—it is already happening—is how do genes and the environmental factor interact and 

alter gene function in the process and may produce illness. 

So what did we find? Very quickly, well, with the biomarkers, 

some surprises, but some not. So when we looked at all of the cholesterol levels, the lipid levels, and so on, they were lower in Yoruba than they were in the African-Americans—not surprising because of their diet. Surprising that one-quarter of African-Americans were now on statins. Even with the statins, there were still 

lower levels in Yoruba. 

And, by the way, in 1991 when we started, the number of African-Americans on statins was almost zero. In 2001, when we did 

that, a quarter of the population were now taking statins—a very 

dramatic increase. 

But some surprises, like we would have thought oxidative stress 

would be lower in the Yoruba than it is in African-Americans because of the diet again. It wasn’t. The measures of oxidatives were 

higher in the Yoruba. So it is sometimes very puzzling. Inflammatory markers were just as common in the Yoruba as the AfricanAmericans. So one of the nice things to think about research and 

this kind of research is it often gives you unusual results that 

allow you to explore it further. 

So the big finding when you put everything together was APoEe4, the big risk factor for almost the rest of the world, was not a 

risk factor for the Yoruba—not a risk factor for dementia, not a 

risk factor for Alzheimer’s disease, not a risk familiar for cognitive 

decline, not a risk factor for mortality—whereas it was in the African-American population and most of the other populations. 

And some of the other findings—you mentioned hypertension, for 

instance. That is one of the nice things I think you can do when 

you look at different populations—a little sad, in a way, because 

the Yoruba population, alas, doesn’t get the treatment for hypertension that we get in our country. And, in fact, now it looks as 

if hypertension in old people is definitely a risk for dementia in Nigerians, and once they get above systolic levels of 160 or so on, they 

ought to be treated. And that information is now being conveyed 

to the faculty and group at the university hospital. 

60

But, again, a surprise was, when we looked at the lipids, there 

was an interaction between lipids and—you couldn’t understand 

the effects of the lipids without taking into consideration APoE-e4. 

So there was some interaction between the both of them. If you 

added APoE-e4, lipid levels didn’t make any difference in the two 

communities. If you didn’t add APoE-e4, lipid levels when they rose 

increased the risk for dementia. So that made us puzzle, is there 

some sort of link between e4 and lipid levels, and could this explain 

some of the differences in the communities? 

So one of the things we are going to now look at is we are trying 

to figure out what is going on. And one of the things going on is 

that there may be—if e4 is not a risk, there may be other genes 

that are present that are much more easily identifiable in Nigerians because they are not overwhelmed by the e4 risk. There may 

be gene clusters that protect against e4 that is particularly seen in 

the Nigerian population but it would also be seen in others. And, 

again, as we said, the environmental factors may result in alterations in gene function. 

And at the moment what we are doing is we are now expanding 

the GWAS studies that Dr. Hodes talked about before, both for the 

African-Americans and for the Nigerians, looking at their generic 

structure to make new associations. We hope, by combining that 

genetic information with all of the information we have available 

at the moment, we will be able to come up with better models of 

the disease. 

Thank you. 

[The prepared statement of Dr. Hendrie follows:]

61


67052h-1.eps
62


67052h-2.eps
63


67052h-3.eps
64


67052h-4.eps
65


67052h-5.eps
66


67052h-6.eps
67

Mr. SMITH. Dr. Hendrie, thank you very much. 

I would just say to my colleagues that I have been advised that 

we will have a series of votes that will last for well over an hour, 

beginning around 4:10, 4:20. We would need to leave here by about 

4:20 or so. So I thought what we might all do, if it is okay, is just, 

we will all ask our questions, and if you don’t just mind then responding just so that everyone gets an opportunity to pose. 

I will ask just a couple. Dr. Frisoni talked about the research not 

being coordinated. It is detached, to use his words. If you could 

maybe speak to what kind of prioritization you think other countries are doing. You know, if any of you would want to—perhaps, 

Dr. Acosta, you would be the one. 

What countries are doing the best? Is it the U.K.? Is it some 

other country? You know, a list of, perhaps, some of those countries. Have WHO, PAHO, and other regional health bodies 

prioritized Alzheimer’s sufficiently well, or are we in the beginning 

stages of getting them to embrace it? 

Mr. Vradenburg, you talked very eloquently about bringing members of the Treasury Department and others. Maybe others might 

want to respond to that, because I think the fiscal crisis parallels 

the health crisis. And if we underestimate CBO, CMS, and all the 

other agencies that do numbers-crunching, they will miss by a mile 

the impact, the devastating impact, that Alzheimer’s will have. 

And, Dr. Cummings, when you talked about all of the risk factors, since Africa has disproportionately suffered so much trauma—

you mentioned DR Congo, 4 million dead due to its wars, ongoing 

violence against women and all people—is there any indication that 

that is now manifesting in additional cases of Alzheimer’s going 

forward? 

I do have a lot of other questions, like about effective drugs, but 

in the interest of my colleagues, I would like to yield to Mr. Payne, 

Mr. Marino, who was here and I am sure will be back, Mr. 

Connolly, and certainly a good friend and colleague, Mr. Markey. 

Please. 

Mr. CONNOLLY. Mr. Markey has switched sides, obviously. 

Mr. SMITH. He has seen the light. 

Mr. PAYNE. When I was listening to your comments, Dr. 

Vradenburg, about the people living to be 110, 120, I was cringing 

when I thought maybe Mr. Ryan would hear about these numbers 

and we would be in pretty bad shape. 

Let me just ask regarding the studies, Dr. Hendrie—very interesting. And the majority of studies on dementia were conducted in 

the developed world, but, as you mentioned, estimates of the prevalence of dementia in sub-Saharan Africa are based on limited and 

dated studies. Your research was a few years ago, and conducted 

involving Nigeria—still a key source of information. 

And do you know, actually, about the prevalence of Alzheimer’s 

in Africa? Has it increased? 

In your opinion, what are the greatest challenges in conducting 

Alzheimer’s prevalence studies in the developing world? And what 

might you expect? I expect that we can focus more attention on 

these studies that were conducted before we can sort of rev it up 

again. 

68

I have a number of questions, but let me just stop there. If there 

is time left, then we could ask another question. But I will just end 

there, and we can just let other members——

Mr. SMITH. Mr. Markey? 

Mr. MARKEY. Thank you so much. 

And thank you all for your excellent testimony. 

Dr. Cummings, you have worked to expand the use of brain imaging and biomarker technologies to allow Alzheimer’s to be diagnosed earlier than before. How do we get more people in the United 

States and abroad involved in these modern scans to detect plaques 

and tangles in the brain before they show up as symptoms? 

Mr. SMITH. And Mr. Connolly? 

Mr. CONNOLLY. Thank you, Mr. Chairman. 

And thank you for letting me participate in the subcommittee. I 

am here because I bumped into Daisy Acosta and my friend George 

Vradenburg in the cafeteria, and I was not aware of the fact you 

were having this hearing. And I think it is a very important hearing. Sooner or later, Alzheimer’s touches everybody’s life. 

And maybe I could put a question to Mr. Vradenburg, and that 

is if you might comment on, where are we from 

USAgainstAlzheimer’s point of view and other advocates in terms 

of research dollars in the United States? And are they going to the 

right kinds of research, in terms of efficacy? 

Thank you, Mr. Chairman. 

Mr. SMITH. Please proceed. 

And, Dr. Frisoni, if you wanted to chime in and answer any of 

the questions, please jump in. 

Mr. VRADENBURG. Let me quickly respond to a couple of those. 

Has WHO prioritized Alzheimer’s? The answer is no. They have 

one person who has a—John Beard, you mentioned him—a Life 

Course and Ageing portfolio. They do not have any resource applied 

to studying the incidence or prevalence of this disease or how to 

treat it at WHO. And, indeed, they have reached out for private resources, including mine, to help them finance a study at WHO. If 

my mother were alive and I told her that the World Health Organization at the United Nations was coming to me for finance on how 

to figure out a study on this problem, she would be surprised. 

CBO and OMB will miss this by a mile, you are absolutely right. 

We do think short term in this country. If, in fact, you talk the 

word ‘‘investment’’ right now, if you can’t show a return within a 

year, you are having a hard time crossing any of the hurdle rates. 

So, in fact, you know, arguing for additional resource to NIH, or 

to NIA in particular, is a very hard lift, even though you could say, 

just by looking at historic examples, investment makes a difference. As Dr. Thies pointed out, $6 billion for cancer and $4 billion for heart and $3 billion for AIDS and $450 million for Alzheimer’s. 

The death rates: Cancer going down, generally, not across the 

board, but generally; heart death rates going down. Indeed, heart 

used to be the highest cost to Medicare; it is now 14th in cost. 

HIV/AIDS has gone from 60,000, 70,000, 80,000 people dying a 

year to 10,000. Its cost is now not even in the top 15—or the mortality is not even in the top 15. A hundred billion dollars invested 

69

in HIV/AIDS research saved us $1.4 trillion in terms of costs. But 

those things would not have been scored by CBO or OMB. 

To your point, Mr. Connolly, there is absolutely no question that 

this aging phenomenon has overcome us, in terms of our research 

portfolio. We invested in a lot of the diseases that were—the war 

on cancer was 1971, the efforts against heart were in the 1980s–

1970s, HIV/AIDS was 1980s to 1990s. Alzheimer’s has sort of come 

too late in the public and political consciousness to catch up to 

those diseases, in terms of our investment. As a consequence, we 

are way underinvested in terms of the aging agenda and the Alzheimer’s agenda. 

Mr. HALL. If I may with some of these other disease states that 

we talked about, the funding came about because there was a cry 

from the people who were impacted by these diseases and thereby 

really sort of forced everyone’s hand to sort of move. 

The problem we have with our population is that the people with 

the disease are unable to speak for themselves, so you are not 

going to have a rally of the 5 million here in DC, of them gathering. And, additionally, you are not going to have even their families who are impacted rallying, as well, with such enormous numbers to really push the agenda, because they are engaged 24/7 in 

the care of the population, the care of their loved one with the disease. 

With these other countries that have designed their own Alzheimer’s project acts and have put together a plan and moved it 

forward, the ones that have been most successful, in my estimation, are the ones that have really strong political resolve to get 

it done. 

And it really takes leadership, enormous leadership, to push this 

disease, especially when you are not going to have that large of a 

cry from constituents, you know, to say that this needs to get done, 

because they are not able to rally. But, at the same time, based on 

everything that you have heard here and things that we have 

heard for years before this meeting, as well, about the growing population, it really does take enormous political resolve to get this 

done. 

Dr. ACOSTA. I think that by history the World Health Organization and most health systems in all governments in all countries 

pay more attention to illnesses who have a higher burden on mortality than on disability. But that is definitely changing, because 

now the most common cause of ill health are chronic illnesses. The 

WHO had launched the MHA guide last October, and they developed packages of cure for different chronic illnesses. Dementia was 

one of those seven illnesses. 

So I really do encourage all of you to take a look at all of those 

packages of care when you are developing your national plan because they are set for different countries, a different level according 

to the budget of each country. I think it is very important. 

Dr. CUMMINGS. You asked about other countries and were other 

countries getting it right. A few examples that I think are important. President Sarkozy will come to the ICAD meeting in July and 

address us, and he really gets it about Alzheimer’s disease. I think 

he understands the importance. He has championed that in the European Commission as well as in France. 

70

The Queen Sofia Alzheimer’s Disease Center in Madrid I think 

is a centerpiece for Alzheimer’s disease care, and she is trying to 

proliferate that in other cities in Spain. Both Italy and Germany 

have made new recent progress in terms of creating Alzheimer’s 

disease centers throughout their countries. 

So I think we have done a lot, and the NIA program, the other 

programs you have heard about are terrific. There is more to be 

done, and there is a lot to be learned from other countries. 

Dr. HENDRIE. I would like to respond to Congressman Payne’s 

questions about frequency of Alzheimer’s disease in Africa. Just a 

couple of things about our own study. When we do studies here, we 

like to get what we call representative samples. So we will look 

over the population, like our African-Americans in Indianapolis, 

who are representative of African-Americans throughout our State 

of Indiana. You can’t do that in Africa because we don’t have a 

good enough census. So what you do is you take one particular district or area, and then you try to make sure you see every person 

in the area, which is a very good way to do it, but it means you 

can’t generalize. So we can’t say from our study what it would be 

like in other parts of Africa or even other Yoruba communities. 

There hasn’t been any really—one other thing about our study is 

that we saw this link between hypertension and diabetes. In 20 

years since we started the study, our data and the data from other 

studies looking at hypertension in middle-aged people all come to 

the same conclusion. It is increasing dramatically in Nigeria and 

increasing dramatically probably in Africa. And if it is increasing 

dramatically, then I would bet a lot of money that Alzheimer’s disease and other dementing disorders are also going to increase rapidly. 

There have been a few other pilot studies. There was one very 

big study done in Egypt which came up with results very similar 

to the Europeans. Pilot studies in Kenya that we did and in Benin, 

and so on, came up with rates roughly comparable with ours, but 

relatively small populations. So rates that we had are the low estimate. And in the near future they are going to go up. 

Mr. SMITH. Yes. 

Dr. FRISONI. Mr. Chairman, may I add a comment? 

Mr. SMITH. Please do, Dr. Frisoni. 

Dr. FRISONI. Okay. Thank you. It seems to me that clearly Alzheimer’s is a global challenge that requires a global answer. These 

are times when funding agencies are short of money, and things 

may not improve dramatically in the foreseeable future. It seems 

to me from what has been said by a number of speakers that there 

are three levels of coordination that we can envision, coordination 

at the level of funding research, coordination at the level of doing 

research, and coordination at the level of applying the results of research. 

Now, the second level, the level of doing research, is the coordination among scientists, and is very good. The AAIC, the international meeting on Alzheimer’s has been repeatedly mentioned. 

And that is a place where scientists from all over the world align 

their ideas, align their minds. 

Coordination at the level of applying the results of research has 

been mentioned as an area that requires more coordination. What 

71

I have tried to advocate with my testimony is the increased coordination at the level of funding research. In Europe, there is awareness that countries, member countries, so-called member countries 

of the European Union, must fully join forces. But that will not be 

enough. Joined forces among European members will not be 

enough. I suspect, I strongly believe that it will be necessary to join 

forces between all Europe and the U.S.—at least to start with—at 

the level of funding agencies, with coordination. 

There is an initiative of the European Parliament to develop a 

directorate to coordinate research across the Atlantic. I believe that 

this is definitely a big challenge. It is a huge challenge. But it is 

something that is worth trying. 

Mr. SMITH. Dr. Frisoni, thank you so much. We only have about 

13 or 14 minutes left. We do have to report for a vote. But Dr. 

Thies. 

Mr. THIES. I would like to say there are two major barriers to 

progress in Alzheimer’s disease. There is clearly not enough money 

for basic research, and probably we could improve that by coordinating it with other countries. 

The second biggest barrier is not enough people in clinical trials. 

And while I am very unwilling to correct Dr. Cummings, there is 

a national recruiting program for Alzheimer’s trials called 

TrialMatch. You can access it at ALZ.org or at our 800 number. 

Mr. SMITH. Dr. Cummings and then Dr. Acosta. 

Dr. ACOSTA. I wanted to address Congressman Markey’s question, even though he is not here. He asked how could we get more 

people into these scans? And I think that is a real problem. I think 

many doctors in the United States still believe that cognitive decline is normal in aging. We have an enormous educational hurdle 

ahead of us. One of the things we are trying to do is to develop an 

electronic medical record that will actually guide people through 

the dementia workup so that if they don’t understand how to do 

this they could open up an application, maybe it could even be a 

phone app, and it would guide them through what a good mental 

status examination and diagnostic workup would be. 

So I think we can look to technology to advance us in some of 

these fields. But again we are still at a relatively primitive level, 

and we have an enormous hurdle ahead of us for detection of Alzheimer’s disease. 

Mr. SMITH. Thank you. Dr. Acosta. 

Dr. ACOSTA. I don’t want you to think of people with dementia 

as people who cannot have an input in helping you do what you 

want do. So it is important for you get the consumers’ perspective, 

to include them into their opinions. We have a board member with 

dementia, and they are excellent in giving us and leading our work. 

Mr. SMITH. Dr. Vradenburg? 

Mr. VRADENBURG. Mr. Chairman, I would urge you to consider 

the creation of a national goal to stop—by stop I mean prevent or 

control Alzheimer’s—by 2020. By setting a national goal, you will 

mobilize the resources necessary to do it. You will force a reexamination of the systems which are impeding the speed at which 

these developments occur, whether it is basic research, 

translational research, clinical trial development, or regulatory 

processes that themselves are sluggish. Capital is leaving this marVerDate 0ct 09 2002 14:27 Feb 16, 2012 Jkt 000000 PO 00000 Frm 00075 Fmt 6633 Sfmt 6633 F:\WORK\AGH\062311\67052 HFA PsN: SHIRL
72

ket because of the length and time of the cost and time to get to 

market. And researchers are not going to cure this disease. They 

may find pathways, but it will be companies that will invest in the 

drug treatments and other treatments necessary to cure this disease. By setting a national goal, you will mobilize the resources 

and you will examine the processes that are slowing or making 

sluggish our path to a solution. 

Right now we are building more nursing homes and we are 

building more care facilities, which is the equivalent of building an 

iron lung and leg brace industry. And we can think of that as jobs, 

jobs, jobs, but cures will drive economic growth. 

So I would urge your consideration, Mr. Smith, of adopting a national goal in this area. 

Mr. SMITH. Excellent idea. Thank you very much, Mr. 

Vradenburg. 

Dr. Acosta, could I just ask you briefly, Dr. Hodes said earlier 

that with adequate funding, twice as many outstanding research 

proposals could be resourced. What is the sense of what is happening in other countries? And anyone who would like to address 

this as well. Are they getting laudable proposals that are falling off 

the table? And we have not spoken at any length about what is 

happening in Central and South America. How prioritized is combating Alzheimer’s disease south of the border? 

Dr. ACOSTA. Definitely not prioritized at all. I think you should 

set the example. And I am not kidding about this. I will just give 

you an anecdote. It was very hard for me to get an appointment 

with our first lady in the Dominican Republic in order for me to 

propose to them a national plan. The first thing I was asked was 

what is the United States doing? I said they are working on it. I 

was never called back again. 

So I think you have an enormous duty not only with the United 

States, but also with other developing countries. 

Mr. SMITH. Thank you. 

Mr. THIES. I would just comment on the grant question. We just 

finished our funding for this year, and we will be at about the same 

stage as NIA. We probably will fund a little over 10 percent of the 

grants that come to us. I think Dr. Hodes is being characteristically 

conservative when he says double. I think it is three or four times, 

with really meritorious projects, and projects that would contribute 

significantly. 

And as a follow-on to George’s comment about the development 

of real medications, those do depend on the corporate sector. And 

we don’t really have any representatives of that sector here. 

Actually, I came from another meeting which is going on on the 

other side of Washington, which is academic scientists, corporate 

scientists, and regulators that are talking about particular barriers 

for making progress. We have an interest in investing in Alzheimer’s disease treatments from the corporate sector. They don’t 

have enough new ideas, and they don’t have certain types of technical ideas, and the reason they don’t is that we just don’t have the 

money to fund those. 

Mr. HALL. It is quite appropriate that the conversation here goes 

toward a discussion about research for treatments and a cure. Ultimately, that is what we all want. I would simply ask in the conVerDate 0ct 09 2002 14:27 Feb 16, 2012 Jkt 000000 PO 00000 Frm 00076 Fmt 6633 Sfmt 6633 F:\WORK\AGH\062311\67052 HFA PsN: SHIRL
73

versation going forward that we really need to stay also focused on 

families and their needs. The care giving burden is left to the family. There are needs for programs and services and some level of 

support. All the families I have met from coast to coast are not asking for anyone to do their work or their job for them. They fully 

accept their responsibility. They are simply asking for some help 

along the way. And so as much as we are focusing on research and 

cure, I would really like to focus on the role of the caregiver and 

supporting care giving as well. 

Mr. SMITH. Mr. Payne. 

Mr. PAYNE. Yeah, and actually in the 1960s and 1970s, when 

cancer started to be noticed, they had all kind of assistance for 

families, if you lived in the right place, to help pay your mortgage, 

et cetera, and so forth. 

It seems to me that Alzheimer’s, you know, if we could get a goal, 

it seems like it is a disease that impacts many people. And if there 

can be a profit. You know, we never saw much work on malaria 

because, well, even if they found the cure, the people that get it 

can’t pay for it, so no incentive for a company to go look at a cure 

for malaria. But it seems like Alzheimer’s, since it is so predominant across all countries, it seems like that would be financial incentive to these companies to do research. 

And the other thing too, Dr. Hendrie, and I probably won’t even 

have time for an answer, but what about the Western diet that has 

been introduced into say Africa, for example, or probably even 

China? You know, people were eating what was available, grains, 

maybe soy stuff, things that were more healthy I guess. Well, now 

they have become Westernized, and a lot of advertisement about 

eating what we eat, and so things like diabetes, or seems like those 

kinds of Western diseases are going to be introduced. Do you think 

that is a possibility? 

Dr. HENDRIE. Just very quickly, I do think that. It is very hard 

to know the extent in the relatively poor people we are studying 

just now. But I think there are more processed foods than were 

available before. You know, it used to be called the Nigerian paradox that in our country hypertension occurs most commonly in 

poorer people. In Nigeria, it occurred most commonly in richer people. And why was that? Because they were able to buy processed 

foods and foods that were heavily salted and so on. Now, whether 

that is true or not now, I don’t know. But the change in diet I think 

is certainly going to be significant. 

Mr. SMITH. Sadly, we are out of time. There are nine votes pending on the House floor. I do want to thank our august panel. You 

have been extraordinary. Your recommendations are all actionable. 

And I can assure you this subcommittee will do everything possible, and, with Mr. Markey joining on the Energy and Commerce 

Committee and others, I think we can be very successful. At least 

we will try. 

Without objection, I would like to include a report on a high level 

seminar at the European Parliament from January 26, 2011. A 

couple weeks ago I met with a member of the European Parliament, Mario Mauro. I will meet him next week in Brussels and 

talk further about how we can collaborate with our friends in the 

European Parliament as well as at the OSCE and other bodies 

74

where we can all work together on combating Alzheimer’s. Dr. 

Frisoni, thank you so much for joining us. And without further 

adieu, the hearing is adjourned. 

[Whereupon, at 4:30 p.m., the subcommittee was adjourned.] 

(75)

A P P E N D I X 

MATERIAL SUBMITTED FOR THE HEARING RECORD

76

f


67052n.eps
77

f


67052m.eps
78

f


67052i.eps
79

MATERIAL SUBMITTED FOR THE RECORD BY THE HONORABLE CHRISTOPHER H. SMITH, 

A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW JERSEY, AND CHAIRMAN, 

SUBCOMMITTEE ON AFRICA, GLOBAL HEALTH, AND HUMAN RIGHTS


67052j-1.eps
80


67052j-2.eps
81


67052j-3.eps
82


67052j-4.eps
83


67052j-5.eps
84


67052k-1.eps
85


67052k-2.eps
86


67052k-3.eps
87


67052k-4.eps
88


67052l-1.eps
89


67052l-2.eps
90


67052l-3.eps
91


67052l-4.eps
92


67052l-5.eps
93


67052l-6.eps
94


67052o-1.eps
95


67052o-2.eps
96


67052o-3.eps
97


67052o-4.eps
98


67052o-5.eps
99


67052p-1.eps
100


67052p-2.eps
101


67052p-3.eps
102

Æ


67052p-4.eps