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

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


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


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


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

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Data availability

Data SharingThe GBD 2019 data resources are openly available at, reference number [8].


  1. Lucca U, Tettamanti M, Tiraboschi P et al (2020) Incidence of dementia in the oldest-old and its relationship with age: the Monzino 80-plus population-based study. Alzheimers Dement 16:472–481.

    Article  PubMed  Google Scholar 

  2. Rocca WA (2017) Time, sex, gender, history, and dementia. Alzheimer Dis Assoc Disord 31:76–79.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Avan A, Hachinski V, Brain Health Learn and Act Group (2022) Brain health: key to health, productivity, and well-being. Alzheimers Dement 18:1396–1407.

    Article  PubMed  Google Scholar 

  4. Avan A, Hachinski V (2023) Global, regional, and national trends of dementia incidence and risk factors, 1990–2019: a Global Burden of Disease study. Alzheimers Dement 19:1281–1291.

    Article  PubMed  Google Scholar 

  5. Avan A, Aamodt AH, Selbaek G et al (2023) Decreasing incidence of stroke, ischemic heart disease and dementia in Norway, 1990–2019, a Global Burden of Disease Study: an Opportunity. Eur J Neurol.

    Article  PubMed  Google Scholar 

  6. Population Reference Bureau (2023) Countries with the oldest populations in the world | PRB. Accessed 19 Mar 2023

  7. Raggi A, Monasta L, Beghi E et al (2022) Incidence, prevalence and disability associated with neurological disorders in Italy between 1990 and 2019: an analysis based on the Global Burden of Disease Study 2019. J Neurol 269:2080–2098.

    Article  PubMed  Google Scholar 

  8. Institute for Health Metrics and Evaluation (IHME) (2020) GBD results tool. IHME, University of Washington, Seattle

    Google Scholar 

  9. Mansournia MA, Altman DG (2018) Population attributable fraction. BMJ 360:k757.

    Article  PubMed  Google Scholar 

  10. Stevens GA, Alkema L, Black RE et al (2016) Guidelines for Accurate and Transparent Health Estimates Reporting: the GATHER statement. Lancet 388:e19–e23.

    Article  PubMed  Google Scholar 

  11. GBD 2019 Diseases and Injuries Collaborators (2020) Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet 396:1204–1222.

    Article  Google Scholar 

  12. GBD 2016 Neurology Collaborators (2019) Global, regional, and national burden of neurological disorders, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol 18:459–480.

    Article  Google Scholar 

  13. GBD 2019 Stroke Collaborators (2021) Global, regional, and national burden of stroke and its risk factors, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Neurol 20:795–820.

    Article  Google Scholar 

  14. Eurostat (2019) EU population up to over 513 million on 1 January 2019: More deaths than births. Eurostat Press Office

  15. De Vogli R, Kouvonen A, Gimeno D (2014) The influence of market deregulation on fast food consumption and body mass index: a cross-national time series analysis. Bull World Health Organ 92(99–107):107A.

    Article  PubMed  Google Scholar 

  16. Feigin VL, Owolabi MO, World Stroke Organization–Lancet Neurology Commission Stroke Collaboration Group (2023) Pragmatic solutions to reduce the global burden of stroke: a World Stroke Organization-Lancet Neurology Commission. Lancet Neurol 22:1160–1206.

    Article  PubMed  Google Scholar 

  17. Di Carlo A, Baldereschi M, Amaducci L et al (2002) Incidence of dementia, Alzheimer’s disease, and vascular dementia in Italy. The ILSA Study. J Am Geriatr Soc 50:41–48.

    Article  PubMed  Google Scholar 

  18. Ravaglia G, Forti P, Maioli F et al (2005) Incidence and etiology of dementia in a large elderly Italian population. Neurology 64:1525–1530.

    Article  CAS  PubMed  Google Scholar 

  19. Villani S, Ferraro OE, Poloni TE, Guaita A (2022) Dementia and risk factors: results from a prospective, population-based cohort study. Life (Basel).

    Article  PubMed  PubMed Central  Google Scholar 

  20. World Health Organization (2022) National report of the Italian Health Equity Status Report. Executive summary. World Health Organization, Copenhagen

    Google Scholar 

  21. Brenna E (2021) Should I care for my mum or for my kid? Sandwich generation and depression burden in Italy. Health Policy 125:415–423.

    Article  PubMed  Google Scholar 

  22. Vaccaro R, Borrelli P, Abbondanza S et al (2017) Subthreshold depression and clinically significant depression in an Italian population of 70–74-year-olds: Prevalence and Association with Perceptions of Self. Biomed Res Int 2017:3592359.

    Article  PubMed  PubMed Central  Google Scholar 

  23. DalleCarbonare L, Maggi S, Noale M et al (2009) Physical disability and depressive symptomatology in an elderly population: a complex relationship. The Italian Longitudinal Study on Aging (ILSA). Am J Geriatr Psychiatry 17:144–154.

    Article  Google Scholar 

  24. Scafato E, Galluzzo L, Ghirini S et al (2012) Changes in severity of depressive symptoms and mortality: the Italian Longitudinal Study on Aging. Psychol Med 42:2619–2629.

    Article  CAS  PubMed  Google Scholar 

  25. Ferre F, de Belvis AG, Valerio L et al (2014) Italy: health system review. Health Syst Transit 16:1–168

    PubMed  Google Scholar 

  26. Rotulo A, Paraskevopoulou C, Kondilis E (2022) The effects of health sector fiscal decentralisation on availability, accessibility, and utilisation of healthcare services: a panel data analysis. Int J Health Policy Manag 11:2440–2450.

    Article  PubMed  Google Scholar 

  27. Rolandi E, Zaccaria D, Vaccaro R et al (2020) Estimating the potential for dementia prevention through modifiable risk factors elimination in the real-world setting: a population-based study. Alzheimers Res Ther 12:94.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Hachinski V, Initiative DP (2022) The Comprehensive, Customized, Cost-effective APproach (CCCAP) to prevention of dementia. Alzheimers Dement 18:1565–1568.

    Article  PubMed  Google Scholar 

  29. Hachinski V (2023) Integral brain health: cerebral/mental/social provisional definitions. Alzheimers Dement 19:3226–3230.

    Article  PubMed  Google Scholar 

  30. Hachinski V (2023) Towards a more inclusive definition of brain health. Neurology.

    Article  PubMed  Google Scholar 

  31. World Health Organization (WHO) (2022) Optimizing brain health across the life course: WHO position paper. WHO

    Google Scholar 

  32. Brooker D, Peel E, Erol R (2015) Women and Dementia: A global research review. Alzheimer’s Disease International (ADI), London

  33. GBD 2019 Demographics Collaborators (2020) Global age-sex-specific fertility, mortality, healthy life expectancy (HALE), and population estimates in 204 countries and territories, 1950–2019: a comprehensive demographic analysis for the Global Burden of Disease Study 2019. Lancet 396:1160–1203.

    Article  Google Scholar 

  34. Cislaghi B, Cislaghi C (2019) Self-rated health as a valid indicator for health-equity analyses: evidence from the Italian health interview survey. BMC Public Health 19:533.

    Article  PubMed  PubMed Central  Google Scholar 

  35. World Health Organization (2022) Healthy, prosperous lives for all in Italy: National report of the Italian Health Equity Status Report. World Health Organization

    Google Scholar 

  36. GBD 2017 Italy Collaborators (2019) Italy’s health performance, 1990–2017: findings from the Global Burden of Disease Study 2017. Lancet Public Health 4:e645–e657.

    Article  Google Scholar 

  37. Tanner L, Kenny R, Still M et al (2022) NHS Health Check programme: a rapid review update. BMJ Open 12:e052832.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  38. Yach D, Hawkes C, Gould CL, Hofman KJ (2004) The global burden of chronic diseases: overcoming impediments to prevention and control. JAMA 291:2616–2622.

    Article  CAS  PubMed  Google Scholar 

  39. Roland M (2004) Linking physicians’ pay to the quality of care–a major experiment in the United Kingdom. N Engl J Med 351:1448–1454.

    Article  CAS  PubMed  Google Scholar 

  40. One Health High-Level Expert Panel (OHHLEP), Adisasmito WB, Almuhairi S et al (2022) One Health: a new definition for a sustainable and healthy future. PLoS Pathog 18:e1010537.

    Article  CAS  Google Scholar 

  41. Hachinski V (2021) Brain health-curbing stroke, heart disease, and dementia: the 2020 Wartenberg Lecture. Neurology 97:273–279.

    Article  PubMed  Google Scholar 

  42. Statista (2023) Distribution of Body-Mass-Index (BMI) in Italy 2021, by region. Accessed 11 Aug 2023

  43. Ancidoni A, Lacorte E, Bacigalupo I et al (2023) Italy’s actions on dementia. Lancet Neurol 22:111.

    Article  PubMed  Google Scholar 

  44. Laccetti R, Pota A, Stranges S et al (2013) Evidence on the prevalence and geographic distribution of major cardiovascular risk factors in Italy. Public Health Nutr 16:305–315.

    Article  PubMed  Google Scholar 

  45. Ministero della Salute (2020) Piano nazionale della Prevenzione, 2020 - 2025. Ministero della Salute

  46. Kuźma E, Lourida I, Moore SF et al (2018) Stroke and dementia risk: a systematic review and meta-analysis. Alzheimers Dement 14:1416–1426.

    Article  PubMed  Google Scholar 

  47. Nucera A (2010) Alice: the Italian association against stroke. The Emilia Romagna program for prevention, treatment and post stroke care. Int J Stroke 5:PO20163.

    Article  Google Scholar 

  48. Global Burden of Disease Long COVID Collaborators, Wulf Hanson S, Abbafati C et al (2022) Estimated Global Proportions of Individuals With Persistent Fatigue, Cognitive, and Respiratory Symptom Clusters Following Symptomatic COVID-19 in 2020 and 2021. JAMA 328:1604–1615.

    Article  PubMed Central  Google Scholar 

  49. Mental Health and Substance Use WHO team (2022) Optimizing brain health across the life course: WHO position paper. World Health Organization, Geneva

    Google Scholar 

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Dr. Avan is supported by the grant TR202092 provided by the Weston Family Foundation through the Weston Brain Institute. Dr. Rocca is partly funded by the Ralph S. and Beverley E. Caulkins Professorship of Neurodegenerative Diseases Research of the Mayo Clinic, in Rochester, Minnesota (USA). Dr. Raggi is supported by the Italian Ministry of Health (RRC). Role of the Funder/Sponsor: None of the funders had a role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and the decision to submit the manuscript for publication.

Author information

Authors and Affiliations



Concept and design were performed by VH, AA, and AN; extraction and curation of data and drafting of the manuscript, tables, and figures were carried out by AA; expert panel was provided by all authors; critical revision of the manuscript for important intellectual content and approval of the final version were approved by all authors.

Corresponding author

Correspondence to Vladimir Hachinski.

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Conflict of interest

Giancarlo Logroscino has served as investigator for clinical trials sponsored by Biogen Pharmaceuticals, Axovant, Alector, Denali, Roche, Eisai, Genentech, Amylyx, and PIAM Farmaceutici SpA. He has served as a consultant and has given Lectures for EISAI, Roche, Lilly, Piam Farmaceutici Spa, and Biogen. Other authors did not report any conflicts of interest.

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Ethical approval was not necessary for this study.

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Expert Panel

Expert Panel

Expert Panel: highlights, taken measures in Italy, and lessons for global implications

Dementia disproportionately affects women [32]. Women live longer than men [33], though their longer years of life are not necessarily in good health [34]. The overall health of people in Italy has been improving over the last decades, with a reduction in mortality and disability separately or combined [35, 36]

Most caregivers are women (i.e., two-thirds of primary caregivers) contributing to a physical and psychological burden that can lead to caregivers' personal and economic burnout. A woman may have a full-time job, but be forced to work part-time or leave the workforce, with a loss of income and a corresponding contribution to the economy

Thoughtful consideration should be given to the adoption of cardiovascular risk management screening programs focusing on hypertension and other major risk factors among adults, similar to the UK NHS Health Check Program [37], to mitigate the potential long-term impact of well-established risk factors and risk conditions for stroke, ischemic heart disease, dementia, and other chronic diseases [38]. Successful initiatives adopted in other countries to improve prevention and quality of care in primary care, such as the Quality and Outcomes Framework in the UK [39], could apply in Italy and translate into a long-term reduction in dementia, ischemic heart disease, and stroke burden

The underlying principle is health in all policies which clearly shows that prevention should be an action that engages with a ONE health approach and all stakeholders [40]. Despite a national health system, Italy relies on regions to implement the plan requiring an organization able to provide equity of access to all citizens. In the World Health Organization (WHO) Health Equity Status Report [35], consideration of all the drivers of health equity is highlighted, namely the factors fundamental to creating more equitable societies, such as policy coherence, accountability, social participation, and empowerment [20]

Italy’s life expectancy has increased to 83 years and the birth rate decreased to 1.3 per woman. This creates an “opening scissor curve” of the growing number of older adults and fewer young people to support them. This calls for an urgent action plan to make the holistic brain health (cerebral, mental, and social) approach through the lifespan [31], so that small gains among all ages can translate into big gains in health, productivity, and well-being [3]. Dementia, ischemic heart disease, and stroke share treatable or modifiable risk factors [41]. Therefore, preventing one helps prevent the others. There is immense potential at the community level through a systematic, comprehensive, customized, cost-effective approach to joint prevention of the three conditions [28], demanding a focus on the message of integral (holistic) brain health [29]

Our findings should prompt a meticulously designed study of historical records in Italy and other regions and nations to determine whether the estimated trends are accurate to foresee implementing required prevention

Regional differences might explain some of the rising trends. For instance, the five southern provinces (i.e., Basilicata, Compania, Calabria, Apulia, and Molise) have the highest share of the overweight population, including children obesity, in Italy [42]. They also lack sufficient resources for the management of ischemic heart disease, stroke, and their metabolic risk factors. There are other efforts to boost prevention in Italy, such as the effort to implement the National Dementia Plan in Puglia (comprising four million inhabitants in Southeast Italy,a a relatively disadvantaged area compared to other regions)

In 2014, an Italian National Dementia Plan was approved for supporting people with dementia and their caregivers [43]. In 2021, the Italian government provided a €15 million budget for the National Dementia Plan during 2021–2023, while the annual costs of dementia are estimated at €15.6 billion per year, with 80% born by families of people with dementia [43]. The costs will continue to rise unless the growing tide of dementia is slowed by a lifelong brain health approach [31]

The Italian National Dementia Plan focused primarily on dementia care to support patients and their families, rather than on prevention. The economic crisis in Italy might explain part of the reported unfavorable dementia figures. Our findings suggest that the increasing trends in dementia burden in Italy are likely driven by unfavorable trends in major behavioral risk factors at the population level, such as unhealthy dietary habits and high body mass index, especially among low-socioeconomic subgroups [44]. These results call for urgent implementation of public health nationwide initiatives, promoting the adoption of healthy lifestyles at the population level, from childhood through adulthood

Italy plans to contribute to the achievement of Sustainable Development Goals (SDGs) and the European Union (EU) Green Deal with the National Plan for Prevention (NPP) 2020–2025 (available on the website of the Minister of Health, Italy) [45]. The Italian NPP 2020–2025 reinforces a vision that considers health as the result of a harmonious and sustainable development of human beings, nature, and the environment. Therefore, recognizing that human, animal, and ecosystem health are interconnected, promotes the application of a multidisciplinary, cross-sectoral, and coordinated approach to address potential or already existing risks originating from the environment–animal–ecosystem interface

The potential role of volunteer lay organizations is underestimated. ALICeb (Associazione per la Lotta all’Ictus Cerebraleie, in Italian) meaning Association for the Fight against Stroke is the Italian Federation of Regional Association made up of doctors, nurses, stroke survivors, and volunteers ( It aims to improve the quality of life of people affected by stroke, their families, and people at risk. Since stroke doubles the risk of dementia [46], preventing stroke is one way of preventing some dementia. ALICe, for 10 years, screened over 10,000 patients and campaigned for awareness and prevention that were associated with a decrease in the number of patients hospitalized because of stroke [47]. This is an example of how volunteers and government organizations can work together

The Italian Ministry of Health and WHO Regional Office for Europe jointly launched the Italian Health Equity Status Report initiative (HESRi) [35], “Healthy Prosperous Lives for All in Italy,” to support decision-makers in Italy to create the conditions for every person to be able to flourish in health and life. The Italian HESRi is the generation of a new set of disaggregated indicators, derived specifically for the Italian HESRi analysis. This dataset brings together 1) indicators of the status and trends in inequities in health; 2) gaps and trends in the five essential conditions needed to live a healthy life; and 3) progress and trends in policy performance to reduce these inequities [35]

Until the Coronavirus disease (SARS-CoV-2; COVID-19) pandemic in 2020, life expectancy in Italy had been increasing, despite significant socioeconomic and regional inequities [35]. There is a clear social and educational gradient throughout most of the health indicators. Those with fewer years of education and less financial security, experience poorer health than those with more years of education and greater financial security. Italy entered the COVID-19 pandemic with multiple inequities (e.g., concerning the extent of non-communicable diseases, overweight and obesity, mental health issues such as depression, and risky health behaviors). Inequities in health were particularly apparent among women and young people, evaluated by education level, income quintile, and region

The potential impact of COVID-19 on cognition should be considered in future studies [48]

The WHO defines brain health as the state of brain functioning across cognitive, sensory, social-emotional, behavioral, and motor domains, allowing a person to realize their full potential over their life course, irrespective of the presence or absence of disorders [49]. Implementation needs to be at global, national, and community levels [28]. Moreover, brain health matters to all, and addressing the determinants of brain health through promotion and prevention can reduce the incidence of disorders that affect the central nervous system and should be practiced by all. Optimizing brain health improves mental and physical health and also creates positive social and economic impacts, all of which contribute to greater well-being and help advance society, irrespective of the presence or absence of disorders [49]. Healthier brains contribute to a healthier, happier society, and increased productivity in an increasingly digital and knowledge-based society [3]

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

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Avan, A., Nucera, A., Stranges, S. et al. Risk and sex-specific trends of dementia and stroke in Italy Compared to European and high-income countries and the world: global implications. J Neurol 271, 2745–2757 (2024).

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