Losing your memory and the sudden onset of idiosyncratic behaviours are just some of the characteristics that are associated with the natural ageing process. “It’s just age,” many would say to explain changes that we might typically attribute to mental decline. But when do these behaviours become a disease?
The disease in question is dementia; an emerging condition that is being seen more in the global ageing population. Undoubtedly, more people live longer today; due to advancements in science and technology. Even with Sub-Saharan Africa having the smallest portion of older people, the United Nations Department of Economic and Social Affairs estimates a 10% increase in the number of older people (over 60 years of age) by 2030.
Therefore, as life expectancy increases, birth rates decline, and more importantly, the burden of disease transitions from infectious disease to chronic non-communicable disease; thus making dementia a health priority in Nigeria and the world, at large. September 21st marks World Alzheimer’s Day, an internationally recognised day set aside to bring awareness to Alzheimer’s disease; the most common type of dementia.
An old woman lives alone in a Nigerian community. She is known by her neighbours as one to act ‘strangely’. She spoke to herself. Often looked lost, confused and wondered. Some even branded her a witch. This old woman had dementia. In better-organized climes, an old woman, alone, behaving ‘strangely’ will more than likely attract the attention of social services and receive appropriate care. In Nigeria, her story is a forlorn one. She will very likely die alone, before her time, lonely and uncared for.
What is dementia?
Dementia is simply the umbrella term for a group of chronic conditions that are characterised by deteriorating cognitive function. The ailment is the result of damaged brain cells or neurons (nerve cells). The brain has various regions, each with its purpose. When the cells of a part of the brain are damaged, signals, just as you would imagine in a computer, become crossed; thus, the symptoms of dementia ensue.
The different types of dementia are categorised by the part of the brain affected. The most known example of this disease is Alzheimer’s disease. With Alzheimer’s, an area of the brain known as the hippocampus which deals with memory is primarily affected. Alzheimer’s accounts for up to 70% of dementia diagnosed cases worldwide. Other types of dementia also include vascular dementia, Lewy body dementia and frontotemporal dementia. While people can have more than one type of dementia, it is not possible to tell unless with a posthumous examination of the brain.
Just how common is this condition?
Globally, about 50 million people are living with dementia. And, this figure is not decreasing as the United Nations forecasts this number to increase to 82 million in 2030 and 152 million in 2050. 2030 is only ten years away! These are 32 million more people who will undoubtedly require care from their respective health systems; meanwhile, current care provision for the millions of people who have dementia is subpar. Add to the fact, UN statistics show the number of individuals aged 60 years and over numbered at 962 million in 2017, will likely double by 2050, entering billion figures. The relevance of the previous statistic stems from the fact that evidence suggests a direct correlation between dementia and age.
Dementia is especially prevalent in the global north, as statistics indicate a prevalence of 7.5 million in Western Europe. While in Nigeria, one study looking at the period between 1995 to 2015 has put the prevalence at 4.9%. The study also noted that dementia is higher in women than in men, and was more likely in persons over 80years. Findings also revealed that over these two decades, dementia has risen over 400% in the country, 63 512 in 1995 to 318 011 in 2015 among persons aged 60 years and over.
In Sub-Saharan Africa, estimates from studies show a rate of between 2 to 5%, perhaps also showing a similar trend.
Signs someone might have dementia
Memory loss is the most noticeable sign. However, according to the World Health Organisation (WHO), it affects many areas of a person’s cognition. Dementia affects general thinking, orientation, comprehension, calculation, learning capacity, language and even judgement. The region of the brain affected, generally, predicts the symptoms for an individual. Depending on the severity, some people with dementia can also experience a change in personality altogether.
The severity is determined by the stage in the progression of the condition. In the early stage, a person’s functioning is affected. Thus the sign in this stage is forgetfulness. In the middle stage, an individual may have difficulties with language and behavioural changes such as repeating stories. In the late stage of dementia, individuals lose sight of time and place; they are unable to recognise loved ones; they have difficulty walking, confusion, agitation and possibly outbursts. It is also typical of people in the later stages of dementia to require more assistance for daily activities that they otherwise would have been able to do themselves.
At the later stages, the impact of this condition is principally on personal relationships. Parents forget children’s names, faces and change behaviours, personality and emotions; many of the things that make them who they are. This deterioration can be quite distressing for the family. More so, the affected are also left dependent and vulnerable.
Diagnosing dementia and the impediments that are beliefs
Dementia is closely associated with the ageing process and even perceived by some to be the norm. However, the World Health Organization makes it clear that age is simply a significant risk factor for developing dementia. Other identified risk factors include family history, smoking, and alcohol use and cardiovascular risks, but age remains the most critical factor.
In Nigeria, many individuals still believe that dementia is part of a normal process of ageing. To this, some might point to the fact that there are people who live up to their 80s with no signs of cognitive difficulties. Essentially, the difference between the brain of a person with dementia and a person without is that while a person without dementia may lose neurons in their old age; someone suffering from dementia loses far more.
This problematic thinking leaves those suffering from dementia in a disadvantageous position. They do not receive medical intervention due to these beliefs, and the warning signs elude their family and friends. Though the WHO makes it clear, “it [dementia] is not an inevitable consequence of ageing”. It is also important to note that while health authorities diagnosed a majority of dementia cases in those aged 65 and older, early-onset dementia accounts for 9% of the incidences.
The misperceptions do not stop there. In instances where the family and caregivers of a person with dementia do not attribute symptoms to ageing, they fall back on an even more dangerous assumption- witchcraft. Findings show the prevalence of these false assumptions lies in patients with deviant behaviour.
How is dementia diagnosed?
According to the leading authority on mental and neurological disorders- The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the diagnostic criteria for dementia is exhibiting cognitive deficits that interfere with one’s ability to be independent.
There is usually no one test for diagnosing dementia. Instead, doctors carefully look at one’s history, day to day functions, and cognitive abilities. Tests such as the 10‐Word Delayed Recall Test and the Clinician Home‐based Interview have been devised to assess function in these areas.
It is also worth noting that several conditions are known to mimic dementia symptoms, fuel misdiagnosis and delay treatment further. Vitamin deficiency, infection, brain tumour or thyroid disease are just some of them.
Therefore, family members ought to bring to a Doctor’s attention, any suspecting or bizarre symptoms noticed in a loved one.
Care and treatment
Dementia is irreversible. Thus, the appropriate treatment once identified, is comprehensive care and management of symptoms. This management approach is vital after diagnosis to improve health outcomes for the person. Medications used can come in the form of memory enhancers which address memory loss, confusion and enhance thinking and reasoning. Behavioural therapy targets behavioural and personality changes, and has also shown positive results.
Bringing it home, what obtains in Nigeria?
Concerning care, this, stereotypically, in an African household, is provided by family members and the occasional community caregivers. They would often give support to the patient in completing daily tasks such as eating. In more severe cases of dementia, care from family and caregivers is not enough for a patient. In such instances, the consensus suggests checking in your loved one into a care home where round-the-clock care is available. It is worth noting that only one geriatric care centre exists in all of Nigeria. This one geriatric care centre is in Ibadan, the University College Hospital.
Dr Blaise Umoren, a doctor who works at the University College Hospital, Ibadan provided some insights on a suspected dementia patient’s experience at UCH. To diagnose dementia, he said, “we do a full blood count test, an ECG, CT scan and Mini-mental state examination (MMSE). A doctor will also delve into the patient’s medical history. So possible family history of the disease and other investigations”. On diagnosing the patient with dementia based on this criteria, he added that “we are of course obligated to explain to the patient that this is a condition of gradual decline in memory and explain the progression to them, all the way to end stage dementia”.
It is worth noting that only one geriatric care centre exists in all of Nigeria.
The subsequent management, proceeding a diagnosis is crucial for a patient’s quality of life. Dr Umoren said “a priority of ours is ensuring that the patient has support or family. However, management usually depends on what stage of dementia a patient has. So for instance someone in the early stage of dementia can cope at home if they are independent and don’t have any comorbidities. But someone with hypertension or falls or mobility issues in conjunction with dementia would be recommended to a care home regardless of the level of dementia. However, these patients are at a great disadvantage as there is not enough care support in the country to address their needs”.
This is consistent with our findings. The federal government, though, has announced plans to establish six geriatric centres in tertiary hospitals for each of the six geopolitical zones. Until this is done, only one care centre will remain. This is evidently insufficient for the growing number of dementia sufferers in the country. Nigeria must also accord dementia or even geriatric care national strategic importance as this has not yet been done.8