South Korea

Under the provisions of the National Dementia Early Detection programme, all South Korean residents older than 60 could access cognitive screening tests for free once every two years in nearby local dementia centres. In addition, the National Health Insurance Service (NHIS) provides screening tests to people once they turn 66, which is regarded as an important transition time to old age.

In South Korea, the most commonly used cognitive screening tests are the following:

(1) Korean version of the Mini Mental State Examination (MMSE), abbreviated to K – MMSE
(2) Montreal Cognitive Assessment (MoCA)
(3) Korean Dementia Screening Questionnaire (KDSQ)
(4) Cognitive Impairment Screening Test (CIST – K).

When suspecting the presence of cognitive impairments among patients, South Korean physicians commonly administer the following neuropsychological tests in follow up examinations:

(1) Seoul Neuropsychological Screening Battery (SNSB), in its most recent iteration (SNSB – II).
(2) Korean version of the Consortium to Establish a Registry for Alzheimer’s Disease (CERAD) test, abbreviated to CERAD – K.
(3) Literacy – Independent Cognitive Assessment (LICA), which is usually administered to illiterate patients, or those with low educational attainment.
(4) Occasionally, the Alzheimer’s Disease Assessment Scale – Cognitive Subscale (ADAS – Cog) is administered. However, in South Korea, it is only used by tertiary general hospitals, and in clinical trials only.

When it comes to dementia severity assessments, physicians in South Korea primarily rely on the Clinical Dementia Rating (CDR) and the Global Deterioration Scale (GDS).

Individuals older than 60, earning less than 120% of the median income, are eligible for a subsidy for specialist neuropsychological assessments, which are generally not covered by the National Health Insurance Service (NHIS). A subsidy ceiling of 150 thousand KRW (ca. US$110) applies for diagnostic evaluation.

The capacity to confirm Alzheimer’s disease through neuroimaging tests in South Korea is high, as the country has one of the highest rates of MRI, CT, PET and SPECT scanners per million inhabitants among the Organisation for Economic Co-operation and Development (OECD) countries. Commonly used neuroimaging tests in South Korea are MRI tests, including magnetic resonance angiography (MRA), CT tests, including single photon emission computed tomography (SPECT) and PET neuroimaging, primarily in the form of amyloid PET scans. F-FDG PET neuroimaging is less common, and most South Korean physicians do not consider it essential.

Almost all physicians in South Korea include apolipoprotein E (APOE) genotype investigation in the diagnostic workup for dementia. South Korean physicians consider it essential, most likely because of the advent of amyloid – targeting disease modifying therapies (DMT). Carriers of the APOE ε4 allele are considered to be at greater risk of amyloid-related imaging abnormalities (ARIA), which is why APOE genotyping is crucial. It is important to note that facilities for APOE genotyping are readily available and affordable in Korea, supporting its routine use in the diagnostic process.

Physicians in South Korea do not consider fluid biomarkers to be an essential part of the dementia diagnostic process, but they are available and occasionally used in the diagnostic workup. Blood-based measurement of plasma Aβ oligomerisation tendency is most common, followed by CSF testing. In Korea, just 1% of patients underwent lumbar puncture in clinical practice, and patients were found to be strongly averse to them. Hence, the potential of CSF testing as a scalable and inexpensive modality for fluid biomarker testing is considered to be limited. Innovative biomarker diagnostics, such as plasma Aβ, plasma p-tau are still rarely used in practice.

At present, South Korea currently has a three tier dementia management system, comprising a National Institute of Dementia (NID), 17 Provincial (or Metropolitan) Dementia centres and 256 Local Dementia centres. While the National Institute of Dementia is tasked with the creation and administration of a national dementia management system, Provincial and Local Dementia centres serve as its local level coordinators. Their primary role is to provide dementia-related services, such as early screening, dementia prevention, case registration and management, daycare services and family support.

The National Institute of Dementia was established by the Ministry of Health and Welfare and the National Medical centre (2012), with an aim to create an effective dementia service network for elderly Koreans. It is responsible for predicting research demands, monitoring international advancements, creating national research plans, and supporting public participation in dementia projects. One of its core functions is the development of dementia-related research and policy initiatives grounded in solid evidence and data. To that end, the National Institute of Dementia publishes the Korean Dementia Observatory, an annual report that provides comprehensive national statistics and trend analyses on dementia in South Korea. Another core duty of the National Institute of Dementia is to oversee the operations of Provincial and Local Dementia centres, while developing standardised protocols for their operation, and, in turn, dementia management in South Korea.

Provincial (or Metropolitan) Dementia centres represent the second tier of the South Korean dementia management systems, and are tasked with the coordination of dementia prevention efforts and public awareness initiatives in each Korean province or metropolitan area. Other core functions performed by the Provincial Dementia centres include the (1) education and training of field workers within Local Dementia centres, (2) provincial dementia management planning and the (3) provision of technical support towards the implementation of national and provincial dementia management strategies.

Local Dementia centres, otherwise known as Community Dementia Reassurance centres (Chime Ansim), represent the third tier of the South Korean dementia management system, and provide one-stop dementia-related services to patients, their families and caregivers. Most crucially, the Local Dementia centres provide free cognitive screening tests for all South Korean residents aged 60 and over, thus encouraging regular assessments of cognitive health. Moreover, community residents are able to speak to onsite specialists after screening, who can, in turn, refer them to further neuropsychological assessments. Another core duty of the Local Dementia centres is the acquisition of epidemiological data on dementia, making them invaluable towards the creation of future dementia management strategies in South Korea. Finally, Local Dementia centres serve as community building hubs for people living with dementia, organising various activities for them, with the aim of keeping them cognitively active. Centres also offer programs for family members of people living with dementia, providing them with access to expert consultations, conducting screening tests for caregiver stress, and also organising group sessions or gatherings, as a means of exchanging experiences in caring for people living with dementia. Activities of Local Dementia centres can broadly be divided into six categories, (1) public awareness promotion, (2) dementia prevention, (3) early screening and diagnosis, (4) case registration and management, (5) family support, and the (6) provision of daycare services for dementia patients not supported by long-term care insurance (LTCI).

Local Dementia centres are aiming to expand services to residents in rural areas and single households. Certain rural regions with high rates of elderly residents are assigned with a dementia reassurance village, where additional services are provided in connection with the centres. These villages are planned to expand along with the dementia centres.

Outside the three tier national dementia management system, South Korea boasts well developed dementia treatment facilities with its university and general hospitals — most of which are privately operated. Many of them feature their own memory centres, which are specialised departments treating people living with dementia at varied levels of severity. Some of the most prominent institutions for dementia treatment include the CHA Bundang Medical centre (CBMC), which was the first to treat memory loss in Korea, the member hospitals of the National Brain Biobank of Korea (NBBK), which stand at the forefront of dementia research in South Korea, and the Asan Medical centre, the largest teaching hospital in the country.

Long-Term Services and Supports (LTSS) programs providing hospice and palliative care are currently underused, providers may hesitate to devote resources to meeting these patients’ needs. Secondly, family members and patients may find it difficult to forgo further curative treatments.

A 2021 study found that the health-economic cost of dementia in South Korea increased by about 1.5 times between 2016 and 2021, estimated to be about US$4.218 billion. Direct costs, that is, medical and transportation expenses paid for dementia treatment, represented 52% of the entire cost burden, with their proportion steadily increasing, while indirect costs, that is, productivity loss of people living with dementia and their family caregivers accounted for 48% of the burden. Dementia-related economic cost per capita was found to approximately amount to US$695,730. Recent research estimates that the annual cost of dementia care will increase from 0.9% to 3.8% of South Korean gross domestic product (GDP) between 2019 and 2050.

South Korea introduced mandatory long-term care insurance (LTCI) in 2008, and in 2014, eligibility was extended to people living with dementia, including those living with mild dementia. Prior to the revision, people living with cognitive disorders but without severe physical disability were not eligible for long term-care insurance. The revision enabled access to appropriate long-term care for many people living with dementia, including features such as cognitive function training programs and home nursing services. People living with Alzheimer’s disease with mild symptoms and families of people living with dementia were also covered under the revision. In South Korea, long-term care insurance is funded by contributions paid by the insured, government subsidies, and co-payments by beneficiaries.

Since the cost of nursing facilities is supported by health insurance in South Korea health insurance can increase dramatically when patients start to receive formal care from institutions such as nursing facilities and geriatric hospitals. This indicates the importance of identifying people living with dementia in the early stages and slowing their progression.

Under the provisions of the Fourth National Dementia Plan, South Korea aims to provide coverage for 90% of healthcare costs associated with severe dementia within its National Health Insurance (NHI) framework. In addition, it aims to reduce the financial burden of long-term care, and expand coverage of welfare supplies for older people living with dementia at home. In practice, opportunity costs for family caregivers remain high, and considering that users of the long-term care insurance pay 15% to 20% of treatment costs in the form of co-payments, their economic burden can be significant.

Approximately 55% to 85% of people living with dementia are taken care of by family members in South Korea, and many of them face significant opportunity costs. Confucianism has a strong impact on caregiving in Korean culture. Families are regarded as the first agent of care for the elderly, an idea based on the traditional Confucian practice of filial piety, moral and ethical norms for parent – child relationships.

It is not clear that caregivers in South Korea have the awareness, knowledge, and incentives to correctly identify and appropriately manage behavioral and psychological symptoms of dementia, in spite of having access to resources such as Local Dementia Centers. In practice, detection in health care settings remains challenging. An important aspect of the design and adoption of long-term care insurance in South Korea was the aim to encourage substitution between informal and formal care services, relieving the burden of informal care for family caregivers by subsidising formal care services, and thereby reducing the need for social hospitalisations. Some studies suggest that adding mandatory long-term care insurance to existing coverage by National Health Insurance did promote some cost reduction in terms of inpatient services, and, more generally, long-term care, while increasing others (outpatient care and pharmaceuticals).

Family caregivers are entitled to register to obtain consultation services and participate in support programmes from the Local Dementia centres, which include family caregivers education classes and self-help sessions. These services are covered by mandatory long-term care insurance. As of 2021, about 145 thousand caregivers registered with the system. Dementia caregivers may apply to become public guardians of people living with dementia through family courts. In that manner, incapable people’s rights are protected in terms of asset management and personal matters (e.g. medical, housing and social welfare). Between 2018 and 2022, 380 public guardianships for dementia were approved in South Korea.

In South Korea, dementia management is overseen by the National Dementia Management Committee, which was set up in accordance with the Dementia Management Act (2012) to deliberate on key matters regarding the establishment of National Dementia Plans. According to the Act, the Committee is chaired by the Vice Minister of Health and Welfare and consists of no more than 20 appointed members with good knowledge of and experience in dementia.

Since 2008, when it declared a War on Dementia, the South Korean government has continuously established and updated national policies for dementia care, with the main guiding document being the National Dementia Plan, which sets out a national strategy for dementia management during a 3 to 5 year period.

Currently, dementia management in South Korea is guided by the Fourth National Dementia Plan (2021 to 2025). Its vision is to build a “dementia-safe society for people living with dementia, their families and communities”, and one of its main goals is to ensure that over 80% of people living with dementia are registered in their Local Dementia Centers. It aims to institute customised systems and services for the elderly, and increase their uptake within the Local Dementia centre framework. Its objectives are divided into two thematic groups:

(1) Provision of specialised dementia management and care
(a) Preemptive dementia prevention and management, focusing on early detection of dementia and the development of cognitive training programs for at risk groups.
(b) Focus on early stages of dementia, and, in particular, the provision of highly qualified treatment and care for people living with dementia to prevent its progression.
(c) Heightening the capacity of dementia care in communities, by diversifying support services for people living with dementia in the community.
(d) Reducing the burden on families, through community-based support services for family caregivers.

(2) Strengthening the policy base for dementia
(a) Advancing the dementia management system, with a specific focus on the inclusion of related institutions
(b) Expansion and specialisation of the dementia management infrastructure, particularly in terms of workforce education and training, and improvements to nursing institutions
(c) Support for dementia research and technology development, by establishing a financial support system for dementia related statistics and research, and fostering the application of technology (AI) to support treatment and care.
(d) Establishment of a dementia-friendly society, with the aim of creating a social environment that embraces people living with dementia.

Since the Fourth National Dementia Plan expires in 2025, it is expected that a new National Dementia Plan will be released by the end of 2026. Expectations around the upcoming strategy include a focus on leveraging emerging technologies to improve service delivery to people living with dementia, and the enhancement of support for complementary medical care services and responses to additional health care needs such as on-site rehabilitation.

The South Korea Study to Prevent Cognitive Impairment and Protect Brain Health through Lifestyle Intervention (SUPERBRAIN) proved the feasibility of multidomain intervention for elderly people living with MCI. It examined the efficacy of a multidomain intervention tackling MCI through both face to face interactions and video communication platforms using a tablet or personal computer (PC) application.

Researchers in South Korea have recently developed an AI-based technology that can analyse the speech of the elderly to screen and detect those who are at high risk of mild cognitive impairment and dementia. The Electronics and Telecommunications Research Institute (ETRI), supported by the National Research Council of Science and Technology (NST), is conducting research on the development of an AI technology that can evaluate and predict brain function degeneration and brain-related diseases such as mild cognitive impairment, or dementia, by analysing the speech utterances of the elderly that can be obtained through their daily conversations.

QuantaMatrix, a Korean in-vitro diagnostics company, recently released its Alzheimer’s disease early detection test, AlzPlus, as a non-reimbursable service. AlzPlus was provisionally approved by the Ministry of Food and Drug Safety, and uses a blood test to detect the early accumulation of beta-amyloid, a key pathological factor in Alzheimer’s disease. Beta-amyloid accumulation can begin up to 15 years before dementia symptoms appear. Under the revised provisional approval notification, AlzPlus is designated for patients aged 55 or older suspected of having Alzheimer’s disease. Medical institutions are expected to widely adopt this blood test during the evaluation deferral period.