Bulgaria

Bulgaria’s dementia response is shaped by a medical core with weak systemic follow-through. Diagnosis usually starts through a general practitioner to specialist pathway, and the National Health Insurance Fund (NHIF) reimburses key medicines for dementia treatment, providing a basic level of clinical access. Beyond this point, however, the absence of an adopted national dementia strategy results in fragmented and uneven post-diagnostic care, with limited coordination between health and social services and wide regional disparities in support. In practice, this shifts the long-term challenge of care onto families, who often provide intensive home-based care with little formal assistance, while access to community services, respite care, and specialized facilities remains inconsistent. These structural gaps are compounded by low public awareness, persistent stigma, and limited trust in institutional care, which delay diagnosis and reinforce social isolation, prompting non-governmental organisations to call for nationwide awareness campaigns, standardized care pathways, and stronger state-led support frameworks to reduce inequities and improve outcomes for people living with dementia and their carers.

Overall
AD Rating
Diagnostic Pathway
Bulgaria maintains a formal primary care-to-specialist referral route utilising standard structural imaging and cognitive screens, though access remains highly unequal across regions and advanced biomarkers are unavailable in routine care.
Specialized Care
The National Health Insurance Fund (NHIF) subsidises standard symptomatic medications, but families must still absorb substantial co-payments and the financial burden of long-term supportive care.
Caregiver Support
State-level aid and structured respite services are largely non-existent, leaving families to bear the caregiving burden with non-governmental organisations acting as the primary source of practical and psychological relief.
National Policies
Bulgaria does not have an active national dementia strategy, leaving its public health response fragmented across general mental health, social services, and disability legislation.
Access to ATT-s
Multiple therapies approved; limited or no reimbursement.
Organizations are listed for informational purposes based on publicly available sources. Inclusion does not necessarily indicate affiliation with or endorsement by Alzheimer’s Disease International (ADI).

Highlights

Health system
Universal, Mixed Funding (Mixed Provisions)
National dementia plan
Dementia plan funding
No plan
Dementia prevalence rate
1456
Dementia incidence rate
255
*per 100k Population
Prevalence Rate (per 100,000): 
This measures the total number of existing cases (both old and new) in a population at a specific point in time, divided by the total population and multiplied by 100,000. It tells you the overall "burden" or how widespread a condition is at that moment.
Incidence Rate (per 100,000): 
This measures the number of new cases that develop in a population over a specific period (usually one year), divided by the population at risk and multiplied by 100,000. This tells you the "speed" or risk of contracting the condition.

Population

6,689,647

Median age

45

Health expenditure (% of GDP)

7.7

Diagnosis

Dementia entry pathways begin at general practitioners, who refer suspected cases to urban-concentrated neurology or psychiatry services for validation. Cognitive assessments utilise locally adapted versions of the MMSE and MoCA. Structural imaging via CT and public MRI scans is accessible through hospital specialists, whereas functional PET scans, fluid biomarkers, and routine genetic risk testing remain limited to minor research settings. Public diagnostic pathways are administratively complex, forcing households to fund private specialist consultations and out-of-pocket neuroimaging fees to achieve timely results.

Diagnosis pathway

Bulgarian dementia diagnosis begins with general practitioners who recognise symptoms and initiate referrals. Patients are typically routed to neurologists or psychiatrists for confirmation, though access and continuity vary heavily by geography and hospital capacity. Due to the absence of a codified national pathway, families must navigate the system using personal networks. When the public sector proves too slow or administratively burdensome, families opt for private, out-of-pocket care or informal caregiving. The Alzheimer Bulgaria Association plays a compensatory role, providing information, carer support, and advocacy to fill systemic gaps.

In Bulgaria, the general practitioner (GP) is typically the first point of contact and plays a central role in recognizing early cognitive symptoms and initiating referrals. People are then usually referred to neurology or psychiatry services for diagnostic confirmation and follow-up. In practice, however, the pathway is highly dependent on geography, with access, speed, and continuity of care shaped by local specialist availability, hospital capacity, and urban-rural disparities. The absence of a clearly codified national dementia pathway means that families often have to navigate the system themselves, relying on informal knowledge, personal networks, or trial-and-error to access appropriate services.

Where public sector navigation is slow, fragmented, or administratively burdensome, families frequently turn to private, out-of-pocket pathways for specialist consultations, diagnostics, and ongoing support, or alternatively rely almost entirely on informal family caregiving. In this context, civil society plays a compensatory role: the Alzheimer Bulgaria Association is a long-standing national non-governmental organisation (NGO) that provides information, carer support, and advocacy, partially filling gaps left by limited system coordination and weak post-diagnostic support structures.

Wait times

Long wait time (expected)

Bulgaria does not publish open, standardised national data on waiting times for dementia-specific specialist consultations or neuroimaging. Evidence of access pressures therefore emerges indirectly, through NGO reporting, academic research, and carer testimony, which consistently highlight late presentation, prolonged diagnostic trajectories, and strong regional inequalities. These patterns suggest that delays are primarily structural, reflecting limited specialist capacity, weak coordination between primary and secondary care, and the absence of prioritized dementia pathways, rather than isolated individual barriers.

Diagnosis cost

Partially covered

While the National Health Insurance Fund reimburses core pharmacological treatments, coverage for the diagnostic process itself remains incomplete. Individuals frequently face out-of-pocket expenses for specialist consultations, repeat visits, and neuroimaging, especially when navigating public sector delays or bureaucratic barriers. Private diagnostic routes offer quicker access but impose heavy financial burdens on households. Non-medical expenses like transport and carer time are excluded from public schemes, meaning the total cost falls disproportionately on families, worsening socioeconomic inequalities regarding timely diagnosis and follow-up.

Bulgaria’s dementia care framework includes National Health Insurance Fund (NHIF) reimbursement for core anti-dementia pharmacological treatments. However, coverage of the diagnostic process itself is less comprehensive, and people frequently encounter out-of-pocket costs for specialist consultations, repeat visits, or faster access to neuroimaging and assessments, particularly when public-sector waiting times are long or administrative navigation is complex. Private diagnostic pathways, while offering shorter delays, shift substantial financial costs onto households, and additional non-medical costs, such as transport, carer time, and paid support services, are rarely accounted for within public reimbursement schemes. As a result, despite nominal insurance coverage, the total cost of diagnosis and early management often falls disproportionately on families, reinforcing socioeconomic inequalities in the timing of diagnosis, continuity of follow-up, and access to supportive care.

Cognitive tests

Available

Formal dementia diagnosis in Bulgaria follows a model of GP-led recognition with specialist confirmation, in which cognitive testing is a core component of the specialist assessment. Although public policy documents do not prescribe a single national cognitive test battery, clinical practice commonly relies on internationally established screening and assessment tools such as the Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), and related instruments adapted to local language and educational contexts. These tests are used to document cognitive domains such as memory, executive function, attention, and visuospatial abilities, and to support differential diagnosis between mild cognitive impairment and dementia.

Imaging tests

Commonly used

Neuroimaging plays an important supportive role in the diagnostic pathway for dementia in Bulgaria, primarily to exclude alternative causes of cognitive impairment (such as tumors, hydrocephalus, or extensive vascular damage) and to assess patterns consistent with neurodegenerative disease. Structural imaging, most commonly computed tomography (CT) and magnetic resonance imaging (MRI), is available within the public system and is typically accessible through referral by a neurologist or psychiatrist. Major public hospitals with established imaging capacity include Alexandrovska University Hospital, Military Medical Academy, University Hospital St. Ivan Rilski, St. Marina University Hospital, and University Hospital St. George, all of which provide CT and MRI services relevant to dementia work-ups. MRI is preferred where available, as it allows better assessment of hippocampal atrophy, white-matter changes, and cerebrovascular pathology, while CT remains more commonly used in routine practice due to faster access and lower cost.

Positron emission tomography (PET) imaging, including fluorodeoxyglucose (FDG)-PET or amyloid PET, is available only in a very limited number of centers in Bulgaria and is not routinely used in standard diagnostic pathways. PET studies are typically accessed through research projects, private payment, or cross-border referral, making them largely inaccessible for most people. As a result, while basic neuroimaging is generally obtainable within the public system, advanced functional imaging remains marginal and does not yet play a systematic role in dementia diagnosis in Bulgaria.

Genetic tests

There is no evidence that genetic testing, including apolipoprotein E (APOE) genotyping or testing for autosomal dominant Alzheimer’s disease mutations, is integrated into routine, publicly funded dementia diagnostics in Bulgaria. Genetic investigations, when undertaken, are typically confined to research settings, academic centers, or highly selected clinical cases, such as suspected early-onset or familial dementia. National policy discourse does not frame genetic testing as a standard diagnostic or risk-stratification tool, reflecting both cost considerations and limited clinical utility for the majority of people within current care pathways. Research papers confirm the analysis of genes like APOE, APP, PSEN1, and PSEN2 in Bulgarian cohorts, indicating local research and potential clinical applications, though it is often for risk assessment (like APOE ε4) rather than definitive diagnosis, guided by neurologists for early-onset cases or strong family history.

Biomarker tests

Rarely used

Bulgarian dementia policy and advocacy sources do not describe routine use of cerebrospinal fluid (CSF) or blood-based Alzheimer’s disease biomarkers as part of standardized diagnostic pathways. While such biomarkers are increasingly recognized internationally for improving diagnostic certainty, particularly in early or atypical cases, their use in Bulgaria appears limited, non-systematic, and concentrated in selected specialist or research contexts rather than embedded in everyday clinical practice. The absence of national guidance, reimbursement frameworks, or laboratory capacity planning for biomarkers reinforces a diagnostic model that remains predominantly clinical and imaging-based, with advanced biomarker tools playing only a marginal role.

Cognitive Tests

Available

Formal dementia diagnosis in Bulgaria follows a model of GP-led recognition with specialist confirmation, in which cognitive testing is a core component of the specialist assessment. Although public policy documents do not prescribe a single national cognitive test battery, clinical practice commonly relies on internationally established screening and assessment tools such as the Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), and related instruments adapted to local language and educational contexts. These tests are used to document cognitive domains such as memory, executive function, attention, and visuospatial abilities, and to support differential diagnosis between mild cognitive impairment and dementia.

Imaging Tests

Commonly used

Neuroimaging plays an important supportive role in the diagnostic pathway for dementia in Bulgaria, primarily to exclude alternative causes of cognitive impairment (such as tumors, hydrocephalus, or extensive vascular damage) and to assess patterns consistent with neurodegenerative disease. Structural imaging, most commonly computed tomography (CT) and magnetic resonance imaging (MRI), is available within the public system and is typically accessible through referral by a neurologist or psychiatrist. Major public hospitals with established imaging capacity include Alexandrovska University Hospital, Military Medical Academy, University Hospital St. Ivan Rilski, St. Marina University Hospital, and University Hospital St. George, all of which provide CT and MRI services relevant to dementia work-ups. MRI is preferred where available, as it allows better assessment of hippocampal atrophy, white-matter changes, and cerebrovascular pathology, while CT remains more commonly used in routine practice due to faster access and lower cost.

Positron emission tomography (PET) imaging, including fluorodeoxyglucose (FDG)-PET or amyloid PET, is available only in a very limited number of centers in Bulgaria and is not routinely used in standard diagnostic pathways. PET studies are typically accessed through research projects, private payment, or cross-border referral, making them largely inaccessible for most people. As a result, while basic neuroimaging is generally obtainable within the public system, advanced functional imaging remains marginal and does not yet play a systematic role in dementia diagnosis in Bulgaria.

Genetic Tests

There is no evidence that genetic testing, including apolipoprotein E (APOE) genotyping or testing for autosomal dominant Alzheimer’s disease mutations, is integrated into routine, publicly funded dementia diagnostics in Bulgaria. Genetic investigations, when undertaken, are typically confined to research settings, academic centers, or highly selected clinical cases, such as suspected early-onset or familial dementia. National policy discourse does not frame genetic testing as a standard diagnostic or risk-stratification tool, reflecting both cost considerations and limited clinical utility for the majority of people within current care pathways. Research papers confirm the analysis of genes like APOE, APP, PSEN1, and PSEN2 in Bulgarian cohorts, indicating local research and potential clinical applications, though it is often for risk assessment (like APOE ε4) rather than definitive diagnosis, guided by neurologists for early-onset cases or strong family history.

Biomarker Tests

Rarely used

Bulgarian dementia policy and advocacy sources do not describe routine use of cerebrospinal fluid (CSF) or blood-based Alzheimer’s disease biomarkers as part of standardized diagnostic pathways. While such biomarkers are increasingly recognized internationally for improving diagnostic certainty, particularly in early or atypical cases, their use in Bulgaria appears limited, non-systematic, and concentrated in selected specialist or research contexts rather than embedded in everyday clinical practice. The absence of national guidance, reimbursement frameworks, or laboratory capacity planning for biomarkers reinforces a diagnostic model that remains predominantly clinical and imaging-based, with advanced biomarker tools playing only a marginal role.

Treatment & Care

Bulgaria completely lacks a state-mandated, nationwide network of specialised memory clinics, meaning medical care is absorbed by general hospital neurology and psychiatric departments. Reimbursed pharmaceutical solutions provided under specific National Health Insurance Fund protocols include donepezil, memantine, rivastigmine, and galantamine. While basic medical treatments are covered, long-term post-diagnostic support and multidisciplinary social coordination remain unfunded. Families encounter substantial drug co-payments, transportation costs, and lost caregiver income, forcing them to provide intense home care without structured state or community assistance.

Specialized facilities and services

Bulgaria does not have a clearly articulated, nationwide memory clinic network embedded in national dementia policy or planning documents. Instead, dementia care is delivered through general specialist pathways, primarily neurology and psychiatry services within hospital or outpatient settings, supplemented by long-term and social care arrangements that vary widely by region. In practice, the absence of dedicated memory clinics or coordinated multidisciplinary services means that diagnostic, treatment, and follow-up functions are often fragmented, with limited continuity between medical and social care. Research and advocacy consistently highlight that where formal services are insufficient or difficult to access, responsibility for long-term care defaults to families, reinforcing a model in which institutional support is partial and uneven rather than comprehensive and systematized.

Approved medication

Generic Name Trade Name Used for
Donepezil Aricept, Aricept ODT, Adlarity, Eranz, Memac, Alzepil, Davia, Donecept, Donep, Donepex, Donesyn, Dopezil, Yasnal, Memorit, Pezale, Redumas, Zolpezil, Namzaric* Donepezil is indicated for the symptomatic treatment of mild to moderately severe Alzheimer’s dementia.
Rivastigmine Exelon, Exelon Patch, Prometax, Rivastach, Nimvastid Symptomatic treatment of mild to moderately severe Alzheimer’s dementia.
Symptomatic treatment of mild to moderately severe dementia in patients with idiopathic Parkinson’s disease.
Galantamine Razadyne, Razadyne ER, Reminyl, Reminyl XL, Nivalin, Lycoremine, Galsya Galantamine is indicated for the symptomatic treatment of mild to moderately severe dementia of the Alzheimer type.
Memantine Namenda, Namenda XR, Ebixa, Memary, Axura, Akatinol, Maruxa, Nemdatine, Namzaric* Treatment of adult patients with moderate to severe Alzheimer’s disease.

*Namzaric = combination of Donepezil and Memantine

Treatment cost

The National Health Insurance Fund covers basic public medical services, specialist consultations, and standard anti-dementia medications under specific protocols. However, public coverage targets core medical treatment, leaving long-term follow-up and supportive services largely unaddressed. ATTs are not covered. Families face frequent co-payments for medications and monitoring, alongside higher fees if using private options for faster care. Direct costs are compounded by indirect expenses like transport, paid care, and lost caregiver income. Ultimately, limited post-diagnostic support shifts the financial burden of ongoing treatment heavily onto households.

In Bulgaria, NHIF generally covers basic outpatient and inpatient medical services related to dementia, including consultations with specialists such as neurologists or psychiatrists, limited diagnostic procedures within the public system, and reimbursement for several standard anti-dementia medications under specific clinical protocols. However, coverage is largely focused on core medical treatment, while long-term follow-up, multidisciplinary care, and supportive services remain only partially addressed.

Even where anti-dementia medications are reimbursed, patients and families frequently face co-payments and additional expenses related to treatment, monitoring, and supportive services. Like in rest of EU, ATTs are not covered. Costs rise further when families rely on private sector pathways to secure faster consultations, follow-up visits, or complementary services not fully covered by public insurance. These direct medical expenses are compounded by indirect costs, including transportation, paid caregiving, and lost income for family members providing care. This cost structure reflects a broader pattern identified in Bulgarian dementia care research: post-diagnostic support is limited, and the expenses of treatment and care is shifted significantly onto households rather than absorbed by the health or social care system.

Caregiver support

Carer challenges are a central and repeatedly documented issue in Bulgaria’s dementia landscape, with studies and NGO reporting emphasizing limited community-based services, scarce respite care, and insufficient structured training for informal carers. Families are often expected to manage complex care needs with minimal professional support, leading to emotional, physical, and financial strain. In this context, civil society plays a critical mitigating role: the Alzheimer Bulgaria Association provides information, peer support, awareness activities, and advocacy for both people living with dementia and their carers. Bulgarian and broader European reporting consistently underline the need to expand carer education, psychosocial support, and community-based services in order to reduce reliance on informal care and improve sustainability of dementia care over time.

Policy

Bulgaria lacks an operational national strategy due to the political stagnation of comprehensive drafts proposed in 2014 and 2019. Policy targets are currently being integrated into a holistic National Brain Plan framework. Regulatory gaps are severe, as general health and social acts exclude explicit dementia categories, respite entitlements, or legal navigation pathways for guardianship. Culturally, dementia is treated as an isolated household burden hidden due to stigma. Deep-seated distrust of public institutions and publicised facility abuses make residential long-term care socially unacceptable.

National dementia plan

Bulgaria currently lacks an adopted national dementia strategy. A comprehensive draft framework addressing early diagnosis, memory centres, legislation updates, and long-term care facilities was submitted in 2014 but never implemented. Similarly, a 2019 draft aligned with World Health Organisation goals failed to achieve operational status. Consequently, national dementia policy remains fragmented across generic health, social, and disability statutes. This gap between clinical expertise and political uptake leaves care delivery entirely dependent on localised practices and civil society rather than state mandates.

Bulgaria does not currently have an adopted national dementia strategy. Policy development efforts date back at least to 2014, when the Bulgarian Government reviewed a Draft National Strategy for the Diagnosis, Treatment and Care of Patients with Alzheimer’s Disease and Other Forms of Dementia. The draft was submitted to the Council of Ministers in January 2014 and prepared by a dedicated Working Group by medicine professors from the University of Sofia, with participation from the Alzheimer Bulgaria Association and other experts. The proposed strategy was structured around several core objectives: improving early and very early diagnosis:
1. Establishing a national network of diagnostic, memory, and day centers.
2. Creating an integrated information system for people living with dementia and their families.
3. Developing a network of temporary and long-term care facilities.
4. Updating relevant legislation and introducing quality standards for dementia services.
5. Strengthening scientific and clinical dementia research.

Despite the strategic breadth and alignment with international good practice, the draft was never formally adopted or implemented, and no subsequent national dementia strategy has been published. As a result, Bulgaria’s dementia response continues to rely on fragmented sectoral policies and civil-society initiatives rather than a unified, state-mandated framework.

In 2019, the Bulgarian Society of Dementia, together with the organization “Living with Dementia” developed a Draft National Dementia Strategy for People with Dementia and Their Families, aligned with the World Health Organization (WHO) Global Dementia Action Plan, and formally submitted it to the Ministry of Health. Despite this initiative, the draft strategy was not adopted or operationalized as a binding national framework. As a result, dementia policy in Bulgaria remains fragmented across general health, social, and disability legislation, without a single coordinating instrument to standardize diagnostic pathways, post-diagnostic support, carer entitlements, or integration between health and social care. The persistence of repeated draft efforts without formal adoption underscores a structural gap between policy expertise and political uptake, leaving implementation dependent on local practice and civil society initiatives rather than national mandate.

Upcoming plans

Bulgaria’s future dementia framework is shaped by two policy tracks. First, renewed calls for a dedicated national dementia strategy have intensified following the country’s first national dementia survey, which highlighted vast care gaps and caregiver challenges. These demands are strongly driven by the Alzheimer Bulgaria Association and Alzheimer Europe. Second, experts are advocating for a broader National Brain Plan concept targeting neurological and mental health throughout life. While not dementia-specific, this life-course framework could incorporate key dementia priorities like prevention and long-term care planning if political momentum continues.

Recent public materials point to two visible forward-looking policy tracks that could shape Bulgaria’s future dementia response. First, renewed calls for a comprehensive national dementia strategy have emerged following Bulgaria’s first national dementia survey, which documented significant care gaps, late diagnosis, and carer challenges. These calls are prominently reflected in reporting and advocacy by the Alzheimer Bulgaria Association and echoed by Alzheimer Europe. Second, Bulgarian experts have increasingly referenced a broader “National Brain Plan” concept, aligned with international brain-health policy trends, which aims to address neurological and mental health conditions across the life course. While not dementia-specific, this brain health umbrella could provide an enabling policy platform into which dementia priorities, such as early detection, prevention, and long-term care planning, might be integrated if political momentum is sustained.

Policy gaps

Legal barriers

Without a unified strategy, dementia regulations are fragmented across generic legislation. The Public Health Act and Health Insurance Act do not define dementia-specific pathways or standardised entitlements, leaving care to regional discretion. The Social Services Act lacks distinct care categories or respite entitlements for dementia. Furthermore, court-based guardianship and capacity procedures under the Persons and Family Act are slow and stigmatising. Disability benefits fail to map progressive cognitive decline. Legal guidance is absent from healthcare pathways, forcing families to navigate complex legal protection mechanisms completely alone.

The absence of an adopted National Dementia Strategy means that Bulgaria lacks a single binding legal or policy instrument to coordinate dementia care across sectors. Instead, relevant provisions are dispersed across general health, social, and disability legislation. The Public Health Act regulates access to medical care and patient rights in general terms but does not define dementia-specific diagnostic pathways, continuity-of-care obligations, or multidisciplinary coordination. Similarly, the Health Insurance Act governs NHIF reimbursement mechanisms but does not establish standardized diagnostic entitlements, timelines, or post-diagnostic support packages specific to dementia, leaving significant discretion to providers and regional practice.

On the social care side, the Social Services Act provides a framework for community and residential social services, yet dementia is not operationalized as a distinct care category with guaranteed service bundles, respite care entitlements, or carer-support obligations. Legal issues around decision-making capacity, guardianship, and property management are primarily governed by the Persons and Family Act and the Civil Procedure Code, which rely on court-based incapacity procedures that are often described in research as slow, stigmatizing, and poorly adapted to progressive cognitive conditions. Disability-related benefits are regulated through the People with Disabilities Act and associated medical assessment ordinances, but dementia-specific functional trajectories are not clearly translated into tailored eligibility pathways.

Bulgarian dementia care research and NGO reporting consistently note that families frequently need legal and financial guidance after diagnosis, covering capacity assessment, guardianship, consent for medical decisions, access to social benefits, and long-term care planning, yet such legal-navigation support is not formally embedded in healthcare or social-care pathways. As a result, families must navigate fragmented legal frameworks on their own, reinforcing inequality, delaying protective arrangements, and increasing carer challenges. This legal fragmentation is repeatedly cited as a structural weakness that a dedicated national dementia strategy or dementia-specific legal amendments would be expected to address.

Cultural barriers

Dementia is culturally viewed as a private family problem, meaning care remains hidden within households due to stigma or shame. Filial norms demand heavy family sacrifices, disproportionately affecting women who manage multi-generational care alongside employment. Deep distrust of public health and institutional settings—fueled by bureaucratic complexity, quality disparities, and publicized abuses—makes residential care socially unacceptable. These factors cause families to avoid formal help-seeking, while general societal stigma around cognitive impairment discourages forward planning regarding legal capacity or end-of-life care preferences.

In Bulgaria, dementia is still widely perceived as a private family issue rather than a public or social responsibility, unlike conditions such as cancer or physical disability that have gained greater visibility and institutional support. Public attention to dementia has been rare and fragmented, limited to a few isolated awareness initiatives, which has reinforced stigma and silence around the condition. Deeply rooted norms of filial duty and family responsibility mean that care is expected to remain within the household, even when the disease becomes severe. As a result, dementia care is largely hidden from public view, with families often concealing the diagnosis due to shame, fear of judgment, or the unpredictable behaviour associated with the dementia.

This cultural framing places a challenge on families, especially women in the so-called “sandwich generation”, who balance employment, childcare, and full-time dementia care. Care is frequently described in moralized terms as “sacrifice” or “heroism,” yet this over commitment leads to exhaustion, social isolation, lost employment opportunities, and mental health problems among carers. At the same time, strong distrust of institutional care, driven by limited availability of specialized facilities, uneven quality, high private costs, and widely publicized abuses makes residential care socially unacceptable and emotionally traumatic. Together, these factors trap dementia care within the private sphere, delaying diagnosis, discouraging help-seeking, and leaving families to bear the full emotional, social, and financial costs in the absence of a supportive public system.
A related barrier is low trust in public health and social services, shaped by past experiences of bureaucratic complexity, uneven service quality, and regional disparities. Families may perceive formal services as inaccessible, ineffective, or stigmatizing, leading them to rely on private solutions or informal caregiving for as long as possible. Public advocacy by the Alzheimer Bulgaria Association and European reporting further highlight persistent stigma surrounding dementia, which discourages open discussion, disclosure of symptoms, and forward planning around care, legal capacity, and end-of-life preferences.

Research

Dementia studies are anchored across major medical faculties, including Sofia, Pleven, Plovdiv, and Varna universities. Clinical drug trials are monitored nationally by the Executive Agency on Medicines via the European Information System portal. Scientific research is observational, genetic, or adaptive; notable methodologies include the landmark April 2025 national representative survey tracking undiagnosed populations. Additionally, researchers tested a successful combination of natural antioxidant ingredients in animal models. Non-pharmacological innovation is led by the digital and arts-based AIDA project to build dementia-friendly public spaces.

Clinical trials and registries

As a member state of the European Union, Bulgaria’s clinical trials are regulated and made transparent through EU Clinical Trials Information System (CTIS). The Executive Agency on Medicines is the national regulatory authority responsible for authorising and overseeing the safety of clinical trials within the country. While they handle national regulatory approvals, the European CTIS portal remains the best search tool for patients and families.

Selected innovative methods

In April 2025, a landmark nationally representative survey of 1,000 adults revealed low national diagnosis rates, highlighting that 32 percent of symptomatic relatives lacked formal diagnoses. Pharmaceutically, a 2023 study successfully tested a natural combination ingredient therapy including alpha-lipoic acid and green tea extract in animal models, showing enhanced memory retention and brain chemistry defense. Socially, the Alzheimer Bulgaria Association introduced the interdisciplinary AIDA project at international conferences, combining digital tools and art-based therapies to foster non-pharmacological care and establish dementia-friendly spaces.

In April 2025, Alzheimer Bulgaria Association and a research agency conducted Bulgaria’s first nationally representative dementia survey, involving 1,000 adults. The results show low diagnosis and treatment rates despite significant family-level exposure: while only 0.2% reported to be living with dementia themselves, 14.4% said a close relative is diagnosed. Most people living with dementia are aged 60+ (average age 75), and care is provided primarily at home by family members (55%), with only 7% in specialised facilities. The study highlights major systemic gaps, as 39% receive no treatment and 32% have never received a formal diagnosis despite symptoms. Alzheimer Bulgaria stresses that the country lacks a coordinated national dementia policy and urges the development of a comprehensive national strategy covering early diagnosis, access to treatment, carer support, and community and residential services, framing dementia as an urgent public health priority in Bulgaria.

In 2023, Bulgarian research team from institutions including the Bulgarian Academy of Sciences (Institute of Neurobiology – Institute of Plant Physiology and Genetics), South-West University “Neofit Rilski”, and the National Sports Academy tested a new “combo” of natural and supportive ingredients in rats made to show dementia-like memory problems. The mix included alpha-lipoic acid, citicoline, olive leaf extract, green tea extract, vitamin D3, selenium, and an immune-supporting component. Compared with giving the ingredients one by one, the full combination helped the rats perform better on several memory and learning tasks, suggesting it had the strongest overall benefit. Laboratory tests also showed signs that the combination may work by supporting brain chemistry and reducing damage linked to dementia, such as lowering an enzyme that breaks down acetylcholine (important for memory) and boosting the brain’s antioxidant defenses. Importantly, the researchers did not find clear signs of harm in blood tests or organ checks, so it looked well tolerated in this animal study, but it is still early-stage research and would need further studies before any conclusions about people can be made.

In February 2023, Alzheimer Bulgaria Association showcased its innovative work at two major international scientific events, the 13th Panhellenic Conference on Alzheimer’s Disease (PICAD) and the 5th Mediterranean Conference on Neurodegenerative Diseases (MECOND) in Thessaloniki, Greece. The organization presented the AIDA project (Alzheimer Patients Interaction through Digital and Arts), which represents a novel, interdisciplinary approach combining digital technology, art-based methods, and clinical care to improve the quality of life of people living with dementia. The presentation highlighted how innovative, non-pharmacological interventions can complement medical care, support cognitive and emotional wellbeing, and contribute to more dementia-friendly communities. By participating in these conferences, Alzheimer Bulgaria Association positioned AIDA within the broader landscape of cutting-edge dementia research and emphasized the importance of creativity, technology, and cross-sector collaboration in addressing neurodegenerative diseases.

Support

Organizations are listed for informational purposes based on publicly available sources. Inclusion does not necessarily indicate affiliation with or endorsement by Alzheimer’s Disease International (ADI).

Community support is sustained by civil groups like the Foundation Compassion Alzheimer Bulgaria and the Bulgarian Society of Dementia. Key initiatives include the Let us Live Together campaign piloting dementia cafes, the BRIDGE project delivering non-pharmacological therapies, and the SWAN sport project introducing table tennis interventions. The Alzheimer Bulgaria Association organises the annual Let us outrun dementia together run and manages volunteer training programmes. No dedicated national dementia media outlets exist, restricting public information dissemination to NGO social media channels.

Selected national associations, patient family associations, NGOs:

Alzheimer Bulgaria Association Bulgarian Society of Dementia

Selected initiatives

Local societies launched the Let us Live Together awareness initiative in 2018, piloting community-based dementia cafes and anti-stigma GP training. The Compassion Alzheimer Bulgaria Foundation executed the BRIDGE project from 2024 to 2025, introducing art, music, and museum-based therapies across residential homes. They also lead the SWAN project, utilising structured table tennis to stimulate neural connections. Concurrently, the Alzheimer Bulgaria Association hosts the annual Let us outrun dementia together run, advances the cross-border cultural Memorable project, and deployed student-led non-medication therapies to eighty individuals.

Initiatives by The Bulgarian Society of Dementia and the organization “Living with Dementia”
The Bulgarian Society of Dementia and the organization “Living with Dementia”have been actively involved in a range of national dementia initiatives combining policy development, awareness-raising, education, and research. Their work includes drafting a National Dementia Strategy in 2019 in line with the Global Dementia Action Plan and submitting it to the Ministry of Health, as well as launching the “Let’s Live Together” initiative in 2018 to promote dementia awareness and dementia-friendly communities. Activities under this initiative included public film screenings and discussions during Alzheimer’s awareness periods, a pilot Dementia Cafe hosted in traditional local community centers (chitalishte), and the involvement of municipal authorities in community dialogue. The organizations have also delivered anti-stigma and early-diagnosis training for GPs and nurses, identified as good practice at both national and local levels, and have participated in research on young-onset dementia and a European epidemiological study on frontotemporal dementia, linking community action with scientific and policy-oriented work.
The BRIDGE project
The Compassion Alzheimer Bulgaria Foundation implemented the BRIDGE project (Building Resilience and Promoting the Rights of People with Dementia through Education) from January 2024 to June 2025 with support from Valdensian Church of Italy, aiming to strengthen dementia care through education, non-pharmacological approaches, and rights-based support. The project delivered international trainings for Bulgarian service providers, expanded Alzheimer’s Cafe meetings (online and in person), and continued legal and psychological counseling for families. Core activities focused on art therapy, museum-based interventions, and music therapy, delivered through dozens of structured sessions in residential homes in Varna, Razgrad, and Kazanlak, as well as for people living with dementia living at home. The project demonstrated clear positive effects on mood, engagement, emotional wellbeing, and social inclusion, enriched daily care programs, reduced stigma, and generated transferable good practice resources for professionals and caregivers, reinforcing the value of non-pharmacological, culturally grounded approaches in enabling people living with dementia to live with dignity and connection.
SWAN project - Spin for Well-being
The Compassion Alzheimer Bulgaria Foundation is a key partner in the SWAN project - Spin for Well-being, a 26-month Erasmus+ Sport initiative launched in December 2024 that promotes table tennis as a non-pharmacological approach to improving health and wellbeing among people living with neurodegenerative diseases, particularly Alzheimer’s and Parkinson’s diseases. The project develops, implements, and evaluates a structured table-tennis intervention that stimulates cognitive and motor function, supports the formation of new neural connections through physical activity, and encourages social inclusion and healthy lifestyles. Alongside a diverse European consortium of sports clubs, federations, universities, NGOs, care homes, and technical providers, the Foundation leads training-of-trainers, implementation, and curriculum evaluation, with the goal of producing practical guidelines that enable table-tennis-based programs to be scaled across community, sports, and care settings at local, national, and international levels.
The Alzheimer Bulgaria Association takes part each year in the 5km run event as part of its recurring campaign “Let’s outrun dementia together” which has become an established annual tradition. The event promotes preventive health through sport, emphasizing the benefits of regular physical activity for physical and mental wellbeing, disease prevention, and social connection for people living with dementia, their families, and carers. Through its consistent yearly participation, the association uses the run as a public awareness platform to reinforce the message of active lifestyles and collective engagement in reducing dementia risk and stigma.

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Memorable project
The Alzheimer Bulgaria Association is advancing its Memorable project, an Erasmus+ funded initiative delivered with partners from the Netherlands, Germany, Portugal, and Ireland, aimed at fostering a dementia-friendly society by training volunteers, informal carers, and arts and cultural professionals. The consortium has completed its first major output, a transnational report based on comparative research across partner countries, which underscores the value of dementia-friendly cultural spaces, maps current levels of participation by people living with dementia, and identifies practical challenges faced by cultural institutions. The report also showcases transferable good practices from partner countries, will be translated into Bulgarian and published on the project website, and will inform the next phase focused on developing training materials to equip cultural professionals with the skills needed to create inclusive cultural environments.
Student training
In early 2024, the Alzheimer Bulgaria Association launched the project “Non-medication therapies for the maintenance of cognitive abilities of people affected by dementia”, funded with nearly 15,000 BGN by the TELUS International Bulgaria Foundation. The project trained over 20 students from Sofia University St. Kliment Ohridski, New Bulgarian University, and Medical University - Pleven in psychology, social work, and health care, focusing on non-pharmacological dementia interventions. Following specialized training sessions held in Sofia and Pleven, students applied these methods during supervised visits to residential care services, delivering personalized activities to approximately 80 people living with dementia. The initiative aimed to build future professional capacity while improving participants’ cognitive abilities, emotional wellbeing, and quality of life through evidence-based, non-medication therapies.
Brain Awareness Week
Moreover, The Alzheimer Bulgaria Association participated in Brain Awareness Week 2023 with a week-long social media campaign focused on dementia prevention and risk reduction, sharing evidence-based facts and practical tips throughout the awareness week. The campaign emphasized the role of modifiable lifestyle factors, including cardiovascular health, healthy diet, physical activity, smoking cessation, cognitive stimulation, and social engagement, in reducing dementia risk and building cognitive reserve. By translating scientific evidence into accessible daily actions and encouraging public dialogue, the initiative highlighted how even small, incremental lifestyle changes can meaningfully lower dementia risk and support healthier ageing, including for individuals with genetic vulnerability.

Dedicated media outlets

There is no clearly documented dementia-specific national media outlet in Bulgaria comparable to dedicated Alzheimer’s disease or dementia news platforms seen in some other countries. Public communication and outreach therefore occur mainly through NGO channels, professional health-sector communications, conferences, and European-level platforms. This reliance on indirect dissemination limits sustained public visibility of dementia issues and reinforces the central role of civil society organizations in shaping public and policy discourse.

Understanding the terms

This section explains key terms used throughout the text to help readers better understand the exploration concepts.
Open Term Glossary
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Contents

Understanding the Terms

Terms used throughout this website are explained below.
A

Amyloid-Targeting Therapies (ATT): A class of disease-modifying treatments, primarily monoclonal antibodies, designed to identify and remove amyloid-beta plaques from the brain to slow cognitive and functional decline in early-stage Alzheimer’s. Examples include Lecanemab and Donanemab.

Aphasia: A language disorder that affects a person’s ability to communicate, often seen early in Frontotemporal Dementia.

APOE ε4 Allele: A genetic variant of the Apolipoprotein E gene that is a major risk factor for late-onset Alzheimer’s disease; while not a causative gene, its presence increases the likelihood of developing the condition.

Acetylcholinesterase Inhibitors: A class of medications, including Donepezil, Rivastigmine, and Galantamine, used to treat cognitive symptoms by increasing levels of chemical messengers in the brain.

Advance Directives (DAT): Legal documents, such as Disposizioni Anticipate di Trattamento in Italy, that allow individuals to specify their future medical treatment and care preferences while they still have the capacity to do so.

Alzheimer’s Disease (AD): The most common cause of dementia, characterized by a progressive neurodegenerative decline caused by the accumulation of amyloid plaques and tau tangles in the brain.

Amyloid-beta Plaques: Protein fragments that build up in the spaces between nerve cells, disrupting communication and triggering immune responses.

Amyloid PET Scan: A specialized nuclear imaging test that uses radioactive tracers to visualize and measure the density of amyloid-beta plaques in the living brain.

Atrophy: The wasting away or shrinking of brain tissue, often measured via MRI to support a clinical diagnosis of dementia or Alzheimer’s.

B

Biomarkers: Measurable biological indicators, such as proteins found in blood or cerebrospinal fluid, used to identify the underlying pathology of a disease.

Blood Biomarkers: Emerging, less-invasive diagnostic tests that measure specific proteins like p-tau or neurofilament levels in blood plasma to detect Alzheimer’s pathology.

C

CSF Analysis (Cerebrospinal Fluid): A diagnostic procedure involving a lumbar puncture to measure levels of tau and amyloid-beta proteins in the fluid surrounding the brain and spinal cord.

CT Scan (Computed Tomography): A diagnostic imaging test using X-rays to create detailed cross-sectional images of the brain; used primarily to rule out other causes of cognitive decline such as tumors or strokes.

Clock Drawing Test (CDT): A brief cognitive screening task where a patient is asked to ask to draw a clock face; it evaluates visuospatial and executive function.

Cognitive Screening: The process of using standardized tests to objectively measure an individual’s mental functions, such as memory, orientation, and attention.

Community-based Care: Healthcare and support services provided within the local community, such as daycare centers, home-based nursing, and local support groups, rather than in institutional settings.

Cube Copying Test: A visuospatial assessment task used during neuropsychological evaluations to test a patient’s ability to replicate geometric shapes.

D

Dementia: An umbrella term for a range of neurological conditions characterized by a decline in memory, language, and thinking skills severe enough to interfere with daily life.

Dementia-friendly Society: A community or national environment where citizens and businesses are trained to understand, respect, and support the needs of people living with dementia.

Disease-modifying Therapies (DMTs): A new class of treatments, such as monoclonal antibodies (e.g., Lecanemab), designed to target the underlying biological causes of Alzheimer’s rather than just managing symptoms.

E

Early-Onset Alzheimer’s: A form of the disease that affects people younger than age 65, often linked to the familial genes.

Executive Function: Higher-level mental skills including planning, focusing, and multitasking; these are often what the Clock Drawing Test evaluates.

F

FDG-PET: A type of PET scan that measures glucose metabolism in the brain to identify patterns characteristic of different dementia subtypes.

Familial Alzheimer’s Disease: A rare, genetic form of the disease linked to mutations in specific genes (APP, PSEN1, PSEN2) that typically presents with early-onset symptoms.

Frontotemporal Dementia (FTD): A type of dementia caused by progressive nerve cell loss in the frontal or temporal lobes, leading to significant changes in behavior, personality, and language.

G

General Practitioner (GP): A primary care physician who acts as the first point of contact and gatekeeper for dementia diagnosis, providing initial assessments and referrals to specialists.

Genotyping: The analysis of an individual’s DNA to identify specific genetic variations associated with dementia risk or causation.

H

Hidden Cost: The indirect economic impacts of dementia, such as the loss of income for family members who must reduce working hours or leave their jobs to provide care.

I

Informal Care / Informal Caregiver: Unpaid care provided by family members, spouses, or friends, which represents the vast majority of long-term support for people living with dementia.

J

Japanese Cognitive Function Test (J-Cog): A specialized cognitive assessment tool used to evaluate mental and functional status in specific research or regional contexts.

L

Lewy Body Dementia (LBD): A type of progressive dementia that leads to a decline in thinking, reasoning, and independent function due to abnormal microscopic deposits that damage brain cells.

Long-Term Care Insurance (LTCI): A specialized branch of insurance, found in systems like Germany and Singapore, that provides financial subsidies for daily living assistance and nursing care.

M

Memory Clinic: A specialized, often multidisciplinary center focused on the expert diagnosis, management, and treatment of dementia and cognitive disorders.

Mild Cognitive Impairment (MCI): An intermediate stage between normal aging and dementia where memory or thinking problems are noticeable but don’t yet prevent daily functioning.

Mini-Mental State Examination (MMSE): A 30-point standardized questionnaire used to measure cognitive impairment by testing orientation, recall, and attention.

Montreal Cognitive Assessment (MoCA): A cognitive screening tool designed to be more sensitive than the MMSE, particularly for identifying Mild Cognitive Impairment.

MRI Scan (Magnetic Resonance Imaging): A non-invasive technology using magnetic fields to produce detailed images of brain structure; used to assess brain atrophy and rule out secondary causes.

N

National Dementia Plan: A formal government strategy outlining a coordinated response to manage dementia diagnosis, care, research, and awareness at a national level.

National Health Insurance (NHI): A government-funded or regulated healthcare system providing universal or subsidized medical services to citizens.

Neuroimaging: The use of advanced techniques, such as CT, MRI, and PET, to visualize the structure and function of the brain for diagnostic purposes.

Neuroinflammation: The brain’s immune response to damage or protein buildup; while initially protective, chronic inflammation can accelerate neurodegeneration.

O

Out-of-Pocket Costs: Direct payments made by patients or their families for medical services, tests, or care that are not covered by insurance or public subsidies.

P

Preclinical Alzheimer’s: The stage where brain changes (like amyloid buildup) are present but no outward symptoms are yet visible.

S

Synaptic Loss: The destruction of synapses (the gaps where neurons communicate), which is often the strongest correlate to cognitive decline.

T

Tau Tangles: Twisted fibers of a protein called tau that build up inside nerve cells, destroying the cell’s transport system.

V

Vascular Dementia: The second most common type of dementia, caused by conditions that block or reduce blood flow to the brain, like strokes.