Israel

In Israel, cognitive screening tests that are either used or validated for use include the following:

(1) Hebrew and Arabic versions of the Mini-Mental State Examination (MMSE)
(2) Hebrew and Arabic versions of the Montreal Cognitive Assessment (MOCA)
(3) Brookdale Cognitive Screening Test (BCST)
(4) Hebrew version of Addenbrooke’s Cognitive Examination (ACE – III)
(5) Hebrew version of Cambridge Cognitive Examination (CAMCOG)
(6) Kohlman Evaluation of Living Skills (KELS)
(7) Hebrew version of the Boston Naming Test (BNT)

Diagnostic imaging services are readily available in Israel – both in the public and private sectors. Yet, compared to countries at similar per capita income levels, Israel ranks rather low in terms of the penetration of diagnostic imaging facilities. Per one million inhabitants, Israel has 10.28 CT units, 6.28 MRI units and 1.96 PET units. Currently, there is a severe shortage of radiologists and nuclear medicine technologists in Israel. Consequently, radiologists in Israel are in high demand – according to the OECD, radiologists perform significantly more CT, MRI and PET scans per a thousand inhabitants than those in countries with greater diagnostic imaging capacities.

Genetic testing – such as APOE genotype investigation – for the purposes of diagnosing Alzheimer’s disease and related dementias is primarily concentrated in research settings. For example, a number of Israeli studies studying the relationship between apolipoprotein E ε4 allele frequencies and the onset of Alzheimer’s disease have been produced . Genetic testing is used in clinical settings – being available in larger specialised hospitals upon request. But as it is generally not considered to be part of the standard diagnostic pathway for dementia, it is not included in the standardised basket of services covered by the kupot holim.

CSF testing designed to detect β-amyloid and phosphorylated tau (p-tau) protein deposits is commonly used in larger specialised hospitals to diagnose Alzheimer’s disease and related dementias. Total t-tau, hyperphosphorylated tau (p-tau181), and amyloid-β 42 (Aβ42) tests are among those used. Physicians within these institutions generally recommend lumbar punctures to diagnose Alzheimer’s disease – as the procedure is fully covered by public insurance, with only the biomarker analysis covered out-of-pocket. Some innovative blood-based biomarkers have also been used in Israeli clinical settings – such as the AD-Detect test – designed to detect β-amyloid and phosphorylated tau (p-tau) proteins.

In Israel healthcare facilities are open to adopting new, cost-effective technologies and procedures. The Israeli Ministry of Health actively monitors the quality of primary care, publishing comparative quality data for institutions affiliated with each of the kupot holim. In addition, the Ministry of Health publishes comparative, hospital-specific quality data – the number of quality indicators and of the types of services covered has been growing rapidly in recent years. The kupot holim also maintains internal data on regions, clinics and individual physicians – working closely with them to improve the quality of healthcare provision.

Israel established a network of memory clinics – which are usually wards within large hospitals, specialising in the provision of early diagnosis of dementia, comprehensive treatment and care services, as well as education and training for medical professionals in relation to the disease. In memory clinics, patients can benefit from personalized “brain activation plans”, developed in consultation with their physicians. Their goal is to delay and manage the symptoms of Alzheimer’s disease as effectively as possible. The therapeutic intervention includes sessions dedicated to teaching strategies for improving memory and integrating them into daily life. People are invited for regular examinations in order to diagnose any changes in their condition, and – in some cases – the clinic also provides them with medications that slow cognitive deficit and can improve quality of life and functioning. Some people also come to the clinic to practice with an occupational therapist, while others use the services of a resident social worker to clarify their rights.

According to the Alzheimer’s Association of Israel (EMDA), there are currently 19 memory clinics in the country. Some of the most prominent Israeli memory clinics include:

(1) Tel Aviv Sourasky Medical Centre – more widely known as the Ichilov Hospital – is known for being the first medical centre outside the United States that received approval to treat people living with Alzheimer’s disease with lecanemab, an innovative treatment targeting amyloid plaques. Its Cognitive Neurological Unit is considered to be one of the most advanced treatment facilities for memory and attention deficit disorders in the world.

(2) Hadassah Medical Centre at Mount Scopus is a private, non-profit hospital located in Jerusalem. It features a modern Neurogeriatric and Memory Clinic, which conducts international and multicentre clinical studies on Alzheimer’s disease.

(3) Rambam Health Care Campus is a public, non-profit teaching hospital, located in Haifa. Rambam is known for featuring a Fortified Underground Emergency Hospital, activated for use during times of conflict. In terms of dementia treatment and care, Rambam features a well-known Cognitive Neurology Unit, which is a leader in dementia research in Israel.

Israel recognizes the right of people living with dementia to access palliative care in a variety of strategic documents. Since 2009, the Israeli Ministry of Health mandates institutions to provide palliative care to people living with dementia, while the National Programme for Addressing Alzheimer’s Disease and Other Types of Dementia (2013) outlines the need for providing home or hospice care to people living with late-stage dementia. In Israel, caring for terminally ill confined to homes is mainly done by home care units, and, in some cases, by home hospice units, which are an alternative palliative care service. Home care for people living with late-stage dementia is provided to all everyone by the kupot holim as part of their basic medical insurance, but this generally does not include specialised end of life care. Home care units usually consist of nurses and physicians who, during planned visits every 3 to 4 months, evaluate the person and treat them as needed. The visits can become more frequent if necessary, up to several times a week, but are generally limited to clinic hours. An alternative, uncommon service is provided by home hospice units, specialising in palliative care for people with an estimated 6 month survival prognosis. This service is generally available, for both planned and urgent home visits, also being provided by the kupot holim as part of the standardised health service basket. Determining eligibility for these services differs across the kupot holim, however.

When it comes to long-term care, Israel features a network of 174 day care centres (2021) for older adults. This service was initially developed and implemented by the Association for the Planning and Development of Services for the Aged in Israel (ESHEL). These provide sociocultural activities, personal care services, meals and professional therapeutic services for older adults – all under one roof. Day care centres are part of the basket of services offered to older adults eligible under the Long-Term Care Insurance Law. Day care centres are commonly used by mentally frail elders living in the community, with their families receiving a respite through this service. Almost a third of all day care centres have a special department for the mentally frail people living with dementia or have a separate wing for this population.

The National Health Insurance Law (1995) defines a standardised health services basket that any subscriber to a kupot holim is entitled to – including a list of medications deemed essential. Donepezil, rivastigmine and galatamine are part of the standardised health services basket, meaning that Israelis can access them at little to no cost – a co-payment can occasionally be required. On the other hand, memantine and lecanemab are not part of the standardised health basket, requiring out-of-pocket or taking out private insurance. Israelis with supplementary insurance plans through their kupot holim or other providers are usually entitled to reduced co-payments, or could get some of these medications for free.

The Israeli National Insurance Institute administers a robust social safety net for Israeli citizens and permanent residents, who are entitled to a number of benefits meant to facilitate treatment and care of long-term illnesses, including Alzheimer’s disease and related dementias. The Long-Term Care Insurance Law mandates a variety of benefits to eligible people, usually those who have reached retirement age. A formal assessment by a kupot holim is required to determine the level of dependency of a given person and, in turn, the scope of support provided free of charge to them. This support can include various services, such as assistance from a local carer for allocated hours, attendance at day care centres (where available) or even the provision of care, especially when round the clock care and supervision is needed. A full list of services is readily available on the National Insurance Institute website. It is important to note that navigating the benefits provided by the National Insurance Institute can sometimes be complex, so it is advisable to seek assistance from social workers or relevant organisations in doing so.

People living with dementia could also choose to receive their benefits in cash, with the compensation depending on their level of dependency from other adults. In addition, they are entitled to an additional benefit in case they employ a full-time carer – with the compensation height associated with their dependency level and whether the carer employed is Israeli or a foreigner – one ranging between NIS 1,659 and 7,238.

In Israel, families with a person living with dementia benefit from the robust social safety net administered by the National Insurance Institute – taking advantage of home care or hospice care services designed for these people. However, carers often have to rely on social services and non-governmental organisations in order to access needed support. EMDA is one such organisation, providing a variety of services to carers and families of people living with dementia, such as carer meetings, support groups, counselling and a phone helpline. In addition, EMDA is heavily involved in dementia education and training, producing resources for people living with dementia, their families, care partners and medical professionals in English, Hebrew, Arabic and Russian, while also running a Dementia Friends programme. Organisations such as ESHEL or the Israeli Alzheimer’s Medical Centre also run day care centres for the elderly, which provide cognitive stimulation activities for people living with dementia, while also offering respite to carers.

In 2013, Israel launched its National Programme for Addressing Alzheimer’s Disease and Other Types of Dementia – aimed at improving the lives of people living with dementia, their families and carers by developing a robust dementia management system, comprised of a network of high-quality services, ranging from prevention and early detection to end of life care. Key programme areas include:

(1) Raising public awareness of dementia and reducing the stigmatization of people living with dementia, their families and care partners
(2) Improving the array of community health services offered – with the aim of providing care at every stage of the illness
(3) Updating legislation governing the provision of support to people living with dementia, their families and care partners (e. g. the Long-Term Care Insurance Law)
(4) Developing responses to support family carers directly
(5) Adapting the array of long-term care services in view of changing needs
(6) Promoting and enhancing dementia care training among caregivers, medical professionals and, more broadly, the wider Israeli society
(7) Supporting critical research needed for policy planning and service development

Almost a decade after its launch, a Knesset Research Department study assessed the implementation of the National Programme for Addressing Alzheimer’s Disease and Other Types of Dementia. The findings revealed that while dementia awareness has increased and some limited progress has been made, the programme has largely lacked proper funding and comprehensive implementation. With few exceptions, it has not been adequately budgeted or implemented, and there is no evidence of comprehensive, long-term planning and budgeting based on assessed needs. Consequently, implementation has focused on less costly measures like professional training and caregiver support, rather than more substantial investments in diagnostic and treatment infrastructure.

The Schwartz Lab at the Weizmann Institute of Science is researching the use of immune checkpoint blockades – specifically targeting PD-1 – to boost systemic immunity and activate the choroid plexus, facilitating immune cell entry into the brain to clear amyloid plaques and mitigate cognitive decline in Alzheimer’s disease models .

A global team of researchers – led by the Hebrew University of Jerusalem (HUJ) – is studying distinct cellular pathways in the brain that indicate markers for future onset of Alzheimer’s disease, some 20 years before symptoms would be exhibited. This early detection could eventually lead to a treatment to prevent the degenerative disease. Another group of researchers from the HUJ discovered a direct link between a family of mitochondrial origin RNA fragments and the rate of dementia progression in women.

Tel Aviv University researchers have found that suppression of neuronal activity in a small nucleus within the thalamus caused a decrease in pathological activity in the hippocampus, preventing the deterioration of the memory in Alzheimer’s disease in an animal model.

Researchers from the Faculty of Biology at the Technion have discovered new mechanisms that affect protein synthesis folding and assembly in cells – processes essential for proper function and the prevention of neurodegenerative diseases.

Researchers from the Molecular Cognition Lab at Ben Gurion University of the Negev have developed a peptide, which is one of the fundamental substances in the production of proteins, with potential to prevent the PTEN protein – which weakens neural synapses at the onset of Alzheimer’s disease – from degrading memory.

The Neurodegenerative Diseases research group of the National Institute for Biotechnology in the Negev is working on the development of innovative immune-modulating and peptide-based therapeutic strategies for Alzheimer’s disease – utilizing model systems to unveil mechanisms of neurodegeneration and assessment of naturally occurring plant extracts to halt cell loss.

Medical professionals and researchers at Tel Aviv Sourasky Medical Centre conducted a pioneering study focusing on real world outcomes for lecanemab treatments in people living with early-stage Alzheimer’s disease. To facilitate the study, the Cognitive Neurology Unit established an infrastructure to facilitate advanced treatments for Alzheimer’s disease, utilizing a multidisciplinary approach to patient screening, diagnosis, treatment initiation and follow up. The findings suggest a differential response across age groups, consistent with clinical trial data. Continued longitudinal follow-up is needed to assess long term efficacy and safety of lecanemab treatments.