Decline in Incidence and Prevalence of Dementia

An Analysis of Outpatient Claims Data

Background: An increase in dementia is expected worldwide because of the aging of the population. However, recent studies suggest that its incidence is declining.

Methods: Claims data from the German statutory health insurance system (covering 88% of the population) were analyzed for the years 2015 to 2022. Insurees aged 65 and older were included for whom a confirmed diagnosis of dementia was documented in at least two of four consecutive quarters. The incidence and prevalence of dementia were calculated and standardized by age and sex.

Results: The incidence of dementia declined by 26% percent (95% confidence interval: −26.2; −25.3), from 2020 per 100 000 insured individuals in 2015 to 1500 per 100 000 in 2022. Over the same period, its prevalence fell by 18% [−18.6; −18.2], from 10 380 to 8470 per 100 000 insured individuals. These trends were more pronounced in younger age groups and in women and were particularly evident in primary care practices. The number of individuals with a documented diagnosis of dementia fell from 1.56 million in 2015 to 1.43 million in 2022, corresponding to a decline by 8.4% [−8.5; −8.3]. Over the same period, the number of people with a diagnosis of mild cognitive impairment (MCI) increased by 62%, albeit from a very low initial level.

Conclusion: Despite the aging of the population, the incidence and prevalence of diagnosed dementia in German primary care practices are declining. Further analysis is needed to determine whether this is due to a lower individual risk of dementia, changes in diagnostic behavior, or structural factors, such as a shift to specialized memory clinics.

Cite this as Michalowsky B, Hoffmann W, Riedel-Heller S, Kohring C, Teipel S, Akmatov M, Bohlken J, Holstiege J: Decline in incidence and prevalence of dementia: An analysis of outpatient claims data. Dtsch Arztebl Int 2025; 122: 373–8. DOI: 10.3238/arztebl.m2025.0090

Worldwide, demographic trends mean that an increase in the prevalence of dementia is expected or even likely (1). Currently, 55 million people worldwide have dementia. This number is set to double over the next 30 years (2). A comparable increase from currently 1 .8 million people with dementia to 3 million people with dementia in 2050 is expected in Germany too (3, 4). Implicitly this prognosis is based on the assumption of a largely stable age-specific incidence. Recent studies, however, have reported declining incidence rates, especially in high-income countries (5, 6, 7, 8, 9), and indicate that better education, lifestyle interventions—such as reducing smoking rates—and improved treatment options for cardiovascular risk factors may be associated with a reduction in the risk of dementia. It remains to be studied how a decline in incidence affects the population-based prevalence of dementia. Beerten et al. (10) showed that the prevalence of dementia doubled from 1.2% in 2000 to 2.4% in 2021. A closer look, however, shows a significant drop in its incidence since 2017, which kept the subsequent prevalence almost constant.

Such cohort studies do, however, not reflect what is actually going on with diagnoses in healthcare practice. A study by Eichler et al. (11) conducted in Germany showed that 60% of people with dementia in the early stage of the disease remain undetected in primary care. A meta-analysis by Lang et al. (12) confirmed this. In spite of a low detection rate in the general and specialist diagnostic setting, the dementia prevalence there grew by 40% and 53% between 2005 and 2015 (13), which is consistent with the predicted numbers. Billing data, however, gave rise to the suspicion that a part of this increase can be explained with improved reimbursement for cognitive screenings (14).

Insights regarding trends in the incidence and prevalence of dementia diagnoses over the past 10 years in German primary care practices are lacking. This analysis aimed to show trends in the incidence and prevalence of diagnosed dementia in recent years on the basis of all members of statutory insurance schemes in Germany.

Methods

Study design

The study is based on nationwide claims data from the German statutory health insurance system (according to § 295 SGB [social code] V) for the reporting period 2015–2022. The dataset covers almost 88% of the German population, which in 2022 totaled 73 109 811. It includes among others diagnoses (ICD-10-GM) from general and specialist practices that were documented with additional information on the diagnostic certainty (confirmed diagnoses, suspected or exclusion diagnoses according to ICD10-GM) and demographic characteristics of the insured individuals (sex, year of birth). In our analysis we included confirmed diagnoses only.

Study population

We included insured individuals aged 65 years and older who had accessed statutory healthcare in the actual reporting year as well as in the calendar year three years previously at least once. In this way we included only insured individuals who were still alive in the respective reporting year and for whom a pre-observation period of at least three calendar years could be assumed because of claims data from the statutory health insurers. Insured individuals were considered as having dementia if they had a confirmed dementia diagnosis (ICD-10: F00, F01, F02, F03, F05.1, G23.1, G30, G31.0, G31.82) in at least two quarters within a time period of four consecutive quarters (rolling pick-up beyond the year-end).

Description of the incidence and prevalence of dementia

Insured individuals who met the case definition at least once in the reporting year and/or in the three preceding years were considered as prevalent. The prevalence was determined as a percentage share of the study population and number per 100,000 insured individuals. Insured persons who met the case definition for the first time in the reporting year were documented as incident. The cumulative incidence was determined as a percentage of the population at risk and the number per 100 000 insured individuals at risk—that is, those insured individuals who had met the case definition in the three preceding years. Incidence and prevalence were calculated, standardized by age and sex (standard populations: age and sex structure of the study population or population at risk in 2015).

Sensitivity analyses

To study the robustness of the data and further clarify the underlying causes of the incidence and prevalence trends, we undertook the following sensitivity analyses:

• Inclusion of cases who had a confirmed diagnosis of dementia in at least one quarter of the study period
• Separate analysis of cases in primary care practices
• Analysis of the proportion of unspecific versus specific diagnoses
• Number of cases documented mild cognitive impairment (ICD-10: F06.7) compared with the dementia diagnoses.

Results

Study population

Table 1 shows the characteristics of the study population. The number of insured individuals (≥ 65 years) rose by 6% between 2015 (15.0 million) and 2022 (15.9 million). Most (59%) were female. The mean age of the prevalent cases increased between 2015 (82.9 years [SD 7.2]) and 2022 (83.7 years [SD 7.1]) by just under a year (Table 1).

Table 1

Description of sample

Incidence trends

Between 2015 (2020 per 100 000 inured individuals) and 2022 (1500 per 100 000 insured individuals) the incidence declined by 25.7% (95% confidence interval: [−26.2; −25.3], which was higher in women (−26.3 versus −24.9%) and in younger age groups (65–69 years: −29.0% versus >94 years: −24.6%). A continuous decline in the incidence was observed between 2015 and 2021, the incidence rose slightly in 2022 (Table 2).

Table 2

Standardized incidence, prevalence, as well as number of persons with dementia (diagnosed cases in general and specialist practices)

Table 3

Number of persons with dementia (diagnosed cases in general and specialist practices)

Prevalence trends

The prevalence fell by 18.4% (95% CI: [−18.6; −18.2]) from 10 380 per 100 000 insured individuals in 2015 to 8470 per 100 000 insured individuals in 2022. Again, a tendentially greater fall was seen for women (−19.1% versus −17.1%). In the middle age group of those aged 75–79 years, the lowest relative decline in prevalence was seen compared with younger age groups (56–74 year olds: −24%) and older age groups (80–95 and older: −18%, −19%).

Trends in the number of persons with diagnosed dementia

The number of persons with diagnosed dementia increased from 1.56 million in 2015 to 1.59 million (+1.9%) in 2017 and then declined steadily to 1.43 in 2022. Altogether the number of persons with dementia fell by 8.4% (95% CI: [−8.5; −8.3]) (or 11.2% since 2017). Again the decline was more pronounced in women (−10.7% versus −4.1%) and the younger age groups (65–69 years: −10%, 70–74 years: −20%), especially in those aged 75–79 (−40%).

In the older age groups the number of persons with dementia declined at a later time. In 65–79 year-olds, the decline occurred between 2015 and 2017, whereas in the older age groups the number of diagnosed persons with dementia increased until 2020. In the age group of those aged 94 years and older, no decline in diagnosed cases was observed over the entire study period.

The trends in incidence and prevalence of dementia and in the number of diagnosed cases of dementia are shown in Table 2, eFigure 1, and Figure 2.

eFigure 1

Incidence (a-c) and prevalence rates (d-f) of dementia between 2015 and 2022

eFigure 2

Incidence (a) and prevalence (b) in diagnosed dementia as as well as numbers of persons diagnosed with dementia (c)

Sensitivity analyses

The prevalence and incidence rates in a one-time only dementia diagnosis confirmed the declining trends, which, however, were slightly less pronounced (eTable). The declining trends were seen mainly for general practitioners, whereas the documented cases treated by medical specialists declined only in the years of the coronavirus pandemic (eFigure 3). The declining trends did not affect the diagnostic specificity (eFigure 4). In mild cognitive impairment, an opposite rising trend was seen of altogether 61.6% (187 000 cases in 2015; 302 000 cases in 2022) (eFigure 5).

eFigure 3

Trends in documented incident cases as well as all cases specified by general an specialist practices and the diagnostic specificity in the respective practises

eFigure 4

Trends in diagnostic specificity in general and specialist practises

eFigure 5

Number of documented cases of mild cognitive impairment compared with dementias according to the "at least two quarters" criterion

eTable

Standardized incidence, prevalence, as well as persons with dementia under the "at least one quarter" criterion

Discussion

The incidence (−25.7%), prevalence (−18.4%), and number of diagnosed persons with dementia (−8.5%) declined in Germany’s primary care practices, especially among women, the younger age groups, and general practices. When extrapolating the study results, the number of persons with dementia (1.56 million) in 2015 is consistent with the estimates of the German Alzheimer Society, which at the time expected the number to be 1.5 million; the number for 2022 (1.4 million persons with dementia) would have been notably below the current prediction (4) of 1.8 million persons with dementia. For mild cognitive impairment, the opposite, strongly rising disease courses were seen.

Studies on the prevalence and incidence of dementia

Most predictive models expected a rise in the prevalence of persons with dementia between 2020 and 2023, of between 11% and 25% (3, 4). Even when studies showed rising trends in the prevalence of 1–2% and in the incidence of 4–6% (10), numerous published studies reported declining trends, especially in the incidence, during the past few years (up to 8%) (5, 6, 7, 8, 9, 15) but also in the prevalence (16). Weidung et al. concluded that cognitive health is probably changing in the current century (17). The prevalence estimates of Blotenberg et al. (4) also showed scenarios of declining prevalence rates of up to 8% for Germany.

Our study results add to the existing evidence, especially regarding the decline in incidence, which, however, at 25.7% over seven years is greater than in previous studies (about 13% over 10 years [6]). A consistent decline was seen, however, for the prevalence as well as the number of persons with dementia. This finding is new in its order of magnitude of a 26% and 18% reduction of the incidence and prevalence, respectively.. The Health Atlas Germany (compiled and published by WidO—the research institute of AOK, a system of 11 regional statutory health care funds in Germany) showed over time a decline in prevalence of 12.3% (>40 year-olds: 3.5% in 2017; 3.1% in 2022 [18]). Over the same time period, our data showed a more pronounced decline of 16.4%. Further cohort studies also showed lesser declines, but it is of note that our data refer to dementia diagnoses and not dementia cases. Furthermore, the observation period included the coronavirus pandemic, during which the consultation rates in primary care practices and the detection rate of incident dementias fell notably (19). Our analysis, however, showed a stable decline in the incidence and prevalence in general practices since 2016. Only for specialist practices did we find an abrupt decline in the incidence and prevalence from the start of the pandemic.

Modifiable risk factors for dementia as a possible cause

Mukadam et al. (7) and Röhr et al. (8) mentioned that modifiable risk factors—such as lower educational attainment and smoking—were rarer in the past decades and may have reduced the risk of dementia. In 2023, only 20% of adults in Germany were tobacco smokers, whereas in 1990 it was 38% (20). As regards educational attainment, the picture is similar. At the time of the study, 70.6% of 80-year-olds had no school leaving certificate or only one from second-level primary school, the proportion in 70-year olds fell to 43.6% (21). The younger birth cohorts may have a better cognitive reserve as a result (22). Similarly, professional practice and daily routines were shaped by life-long learning, which increases cognitive reserves and reduces the risk of dementia (22, 23).

The prevalence of other risk factors, such as diabetes mellitus and hypercholesterolemia, did, however, increase over time, which can be assumed to lead to a raised prevalence of dementia (5). A high cholesterol concentration was recently included as a new modifiable risk factor by the Lancet Standing Commission on dementia prevention, intervention, and care in its list of potentially modifiable risk factors for dementia (24). Improved control and healthcare provision regarding these risk factors may, however, have reduced the overall risk of dementia (25, 26, 27), as confirmed by Norten et al. (28). But a healthier diet (29), more exercise (30), improved treatment options for depression, and reductions in alcohol consumption can also have a positive effect on the dementia risk (24).

These factors may—in spite of increase in life expectancy (5) and continuing demographic change (31)—have contributed to the decline in the incidence and prevalence we showed in this study. The identified differences in the age groups support these results. Older groups show the positive trends with a delay, which implies a difference in risk accumulation between the birth cohorts. A recently published study by Stallard et al. (32) also showed that age-specific dementia prevalence rates in the US fell notably between 1984 and 2024, accompanied by declining incidence rates in Europe too. The diagnoses were based on standardized algorithms to document clinically significant cognitive impairments in large population-based studies—rather than on billing data. Stallard et al. also explain the decline with improved healthcare and a lower risk, which supports the hypothesis of a declining dementia risk.

Changes in diagnostic approaches and healthcare delivery in general and specialist practices as a possible cause

One possible explanation may be a changed diagnostic approach, particularly in the increasing use of the ATN classification (ATN: amyloid-beta, tau, neurodegeneration), as a result of which ever-increasing amounts of biological data are included in the diagnosis. As a result, it is possible to assess patients in a more differentiated manner, especially in specialized outpatient memory clinics. Even though the data of these clinics are not always included in the underlying data, the diagnoses after evaluation for dementia should be documented by the treating general or specialist practices. The switch to such biomarker-aided diagnostic evaluation might also explain a part of the decline in prevalence and incidence.

The results are based on billing data, which may have skewed the detected incidence and prevalence—for example, as a result of budgetary guidelines and inducements. Bohlken et al. (14) found in billing data a doubling of dementia diagnoses between 2012 and 2014, which was explained primarily with extrabudgetary compensation for cognitive screening tests. We cannot exclude the possibility that the observed decline may in part be due to insufficient reimbursement.

Further factors are an increased demand for outpatient services and higher patient numbers in doctors’ practices. In times of increasing staff shortages, more and more patients have to be dealt with using fewer resources and less time, which hampers the detection of dementias. The proportion of cognitive screening tests has, however, increased between 2015 and 2022 in the dataset of members of statutory health insurance schemes that we analyzed, as has documented mild cognitive impairment, which consequently does not explain the observed decline in incidence and prevalence (33).

Increased time pressures may have led to prioritization of acute symptoms, whereas incipient dementias were potentially given little attention (34). Furthermore, specialist healthcare is affected by higher patient numbers, and, in return, necessary referrals to investigate cognitive impairments and suspected diagnoses can be processed only slowly and with delays. In this setting, too, the focus of diagnostic evaluation in general practice may tend to be on acute problems, whereas longer-term complex problems, such as dementias, are possibly referred to specialist practices or are not stringently followed up (35). These factors may have led to a situation whereby cognitive impairments are detected more rarely and remain unnoticed, which may have contributed to a decline in diagnoses. The rise in cognitive tests as well as mild cognitive impairment in primary care practices mitigates this hypothesis, however (33).

A reduced focus on doctors’ part because of a lack of effective treatment options may also have affected diagnoses of dementia. In drug prescriptions, the relevant diagnosis is always coded. Studies have shown that guideline-conform prescription rates of antidementia drugs in general and specialist practices fell by 23% and 12% between 2010 and 2021, which supports this argument (36). Doctors may have concentrated on treating specific symptoms only, without diagnosing the underlying dementia (37). Clinical attention may therefore have shifted to disorders for which effective treatment options exist, which affects what happens diagnostically (38) and may have resulted in a lower incidence and prevalence. Wangler et al. (39) showed that a substantial proportion of general practitioners have withdrawn from the diagnostic testing for dementia and delegate this to specialist practitioners.

Limitations

Our results are based on billing data from the German statutory health insurance system and depend on coding practices and guidelines, reimbursement inducements and budgetary restrictions, as well as changes in the healthcare and documentation systems. This constitutes a bias and restricts the generalizability of the results as well as comparability with other studies, especially cohort studies. Furthermore, the actual diagnosis may now be made in inpatient settings, which are not included in this dataset. The criterion of “at least two quarters” cannot be considered as conclusively confirmed. For this reason we carried out two different sensitivity analyses, which confirmed the declining trends and support the interpretation of the results.

Conflicts of interest

W Hoffmann received institutional funding from the German Center for Neurodegenerative Diseases (DZNE, Deutsches Zentrum für Neurodegenerative Erkrankungen, Rostock/Greifswald site. He is chair of the German Health Services Research Network (DNVF, Deutsches Netzwerk Versorgungsforschung) and sits on the board of the Technology and Methods Platform for Networked Medical Research (TMF, Technologie- und Methodenplattform für Vernetzte Medizinische Forschung).

S Teipel received author/speaker honoraria from Thieme publishers and RG Ärztefortbildung [a provider of continuing medical education, online training courses and recordings], Lilly EISAI, and Helios Klinik Schwerin. Travel expenses and congress fees for him were reimbursed by the Alzheimer Forschungsinitiative e.V. [a German non-profit organization focused on funding Alzheimer‘s research] and the Department of Psychiatry and Psychotherapy, University Hospital, Ludwig Maximilian University (LMU) Munich. ST a member in a data monitoring committee of ENVISION Biogen and EU Clinical Trials Register. Furthermore, he is an advisory board member for Roche, Biogen, Grifols, EISAI, Lilly, and GE Healthcare.

The remaining authors declare that no conflict of interest exists.

Manuscript received on 17 October 2024, revised version accepted on 14 May 2025.

Translated from the original German by Birte Twisselmann, PhD.

Corresponding author
PD Dr. rer. pol. Dr. rer. med. habil. Bernhard Michalowsky

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