Dementia is a syndrome usually of a chronic or progressive nature, beyond what might be expected from the usual consequences of biological aging (WHO, 2021). It is not a single disease but an overall term like heart disease. It generally covers a wide range of specific medical conditions, including Alzheimer’s disease, that are caused by abnormal brain changes (Alzheimer’s Association, 2019). These changes can trigger a decline in thinking skills and lead to loss of memory, thinking, orientation, comprehension, calculation, learning capacity, language, judgment, problem-solving and other thinking abilities that are severe enough to interfere with daily life (Alzheimer’s Association, 2019). They also affect behaviour, feelings and relationships.

Statistics and Economic burden

Figure 1: Dementia statistics (Alzheimer’s Disease International, 2015)

Globally:

1, Over 55 million people currently live with dementia (with 60% of them living in low- and middle-income countries); in addition, approximately 10 million new cases occur every year (WHO, 2021)

2, Dementia is the seventh leading cause of death among all diseases and one of the major causes of disability and dependency among older people globally. It has physical, psychological, social and economic impacts, not only for people living with dementia but also for their carers, families and society at large (WHO, 2021)

3, The current estimates from the World Health Organization (WHO) indicate that by 2050, 150 million persons, representing a 204% increase from 2017, will be living with dementia (WHO, 2017). 

4, Recent estimates also suggest that more than US$818 billion is spent annually on dementia-related care worldwide and by 2028 the worldwide cost of dementia care is estimated to be >US$2 trillion (Wimo, 2017). These include direct medical and other formal and informal health and social care costs.

In Sub-Saharan Africa:

1, An estimated 2.13 million people were living with dementia in 2015, with numbers projected to nearly double every 20 years, increasing to 3.48 million by 2030 and 7.62 million by 2050 (Alzheimer’s Disease International, 2017)

2, The regional estimate of age-specific dementia prevalence in people aged 60 years and over is now 6.38%, doubling with every 7.2-year increment in age (Alzheimer’s Disease International, 2017). 

3, Current incidence estimates from Sub-Saharan Africa (SSA) are similar to that for other Low-Medium Income Countries (LMICs) at 13.26/1000 person-years implying 367,698 new cases each year (Guerchet, 2017)

4, The total costs of dementia in sub-Saharan Africa were an estimated US$6.2 billion in 2015, of which 70% is attributable to the cost of informal care most often provided by relatives and families of people living with dementia (Guerchet, 2017)

5, A two-fold increased mortality risk for people living with dementia in SSA was estimated. Relatively similar mortality hazards have been reported in other low and middle countries (Alzheimer’s Disease International, 2017).  

6, Similar to prevalence, the reported annual incidence rates of dementia in Africa are generally lower than rates reported among populations of older persons living in Europe and North America.

In Nigeria:

1, A study looking at the period between 1995 to 2015 put the prevalence at 4.9%. This study also noted that dementia is higher in women than in men, and was more likely in persons over 80 years. Findings also revealed that over those 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 (Davies, 2019)

2, Differences in diet and burden of cardiovascular risk factors, medical comorbidities, access to quality health care, and mortality have been suggested as possible reasons for the lower incidence of dementia in Africa compared to higher-income regions of the world (Ogunniyi, 2011).

Figure 2: Absolute number of cases of dementia in Nigeria among persons aged 60 years or more, 1995 and 2015 (Davies, 2019).

Figure 2 above shows that the total number of people with Dementia in Nigeria in the year 2015 (318,011) was 5 times more than what it was in 1995 (63,517). It also shows that in both years, there were more women than men with dementia, in Nigeria.

Figure 3: Estimated number of people with dementia worldwide in 2018, 2030, and 2050 (Source Statista: John Elflen, 2019)

Figure 3 above shows the estimates for the total number of dementia sufferers worldwide in the years 2018, 2030 and 2050. It is estimated that there will be around 82 million people suffering from dementia in 2030.

Figure 4: Number of dementia sufferers worldwide in 2015, 2030, and 2050, by region in millions (Source Statista:  Statista Research Department, 2015).

Figure 4 gives a forecast for the number of dementia sufferers worldwide, by region, in the years 2015, 2030 and 2050. From figure 4, Asia has the highest number of dementia sufferers in  2015 (22.85), 2030 (38.53), and 2050 (67.18), while Africa has the least number of sufferers across the 3 years above. It is estimated that there will be nearly 39 million dementia sufferers in Asia in 2030.

Types of Dementia

1, Alzheimer’s disease: This is the most common cause of dementia, accounting for 60 to 80% of cases. Although not all causes of Alzheimer’s disease are known, experts do know that a small percentage are related to mutations of three genes, which can be passed down from parent to child. While several genes are probably involved in Alzheimer’s disease, one important gene that increases the risk is apolipoprotein E4 (APOE) (National Institute on Aging, 2021). The trademark symptom is trouble remembering recent events, such as a conversation that occurred minutes or hours ago, while difficulty remembering more distant memories occurs later in the disease. Other concerns like difficulty with walking or talking or personality changes also occur at later disease stages. Family history is the most important risk factor. Having a first-degree relative with Alzheimer’s disease increases the risk of developing it by 10 to 30% (CDC, 2019).

Figure 5: Various forms and types of Dementia (Alzheimer Association, 2021)

2, Vascular dementia: About 10% of dementia cases are linked to strokes or other issues with blood flow to the brain. Diabetes, high blood pressure and high cholesterol are also risk factors. Symptoms vary depending on the area and size of the brain impacted. The disease progresses in a stepwise fashion, meaning symptoms will suddenly get worse as the individual gets more strokes or mini-strokes (CDC, 2019).

3, Lewy body dementia: Lewy bodies are abnormal balloonlike clumps of protein that have been found in the brains of people with Lewy body dementia, Alzheimer’s disease and Parkinson’s disease (AskMayoExpert, 2020). In addition to more typical symptoms like memory loss, people with this form of dementia may have movement or balance problems like stiffness or trembling. Many people also experience changes in alertness including daytime sleepiness, confusion or staring spells. They may also have trouble sleeping at night or may experience visual hallucinations (CDC, 2019).

4, Fronto-temporal dementia: This is a group of diseases characterized by the breakdown of nerve cells and their connections in the frontal and temporal lobes of the brain. It often leads to changes in personality and behaviour because of the part of the brain it affects. People with this condition may embarrass themselves or behave inappropriately (AskMayoExpert, 2020). For instance, a previously cautious person may make offensive comments and neglect responsibilities at home or work. There may also be problems with language skills like speaking or understanding (CDC, 2019).

5, Mixed dementia: Sometimes more than one type of dementia is present in the brain at the same time, especially in people aged 80 and older. For example, a person may have Alzheimer’s disease and vascular dementia. It is not always obvious that a person has mixed dementia since the symptoms of one type of dementia may be most prominent or may overlap with symptoms of another type. Disease progression may be faster than with one kind of dementia (CDC, 2019).

6, Reversible causes: People who have dementia may have a reversible underlying cause such as side effects of medication, increased pressure in the brain, vitamin deficiency, and thyroid hormone imbalance. Medical providers should screen for reversible causes in patients who are concerned for dementia (CDC, 2019).

7, Other disorders linked to dementia include: traumatic brain injury, Huntington’s disease, Parkinson’s disease and Creutzfeldt-Jakob disease (WHO, 2021).

Causes of dementia

Dementia is caused by damage to brain cells. Although certain dementia types or dementia-like symptoms are treated by eliminating the cause itself, such as metabolic problems or hormone-related diseases (Synlab, 2020). This damage interferes with the ability of brain cells to communicate with each other (Alzheimer’s Association, 2019). Depending on the area of the brain that’s damaged, dementia can affect people differently and cause different symptoms AskMayoExpert, 2020).

Risk factors of Dementia

1, Aging: This is the strongest known risk factor for dementia. With most cases affecting those of 65 years and older (CDC, 2019). However, dementia isn’t a normal part of aging, and dementia can occur in younger people.

Figure 6: Prevalence of Dementia in male and female across age groups in 2017 (NATSEM calculations using ABS population projections, 2017)

The figure above (figure 6) shows that in 2017, a higher number of women than men had dementia between the ages 30-70 and from 75-85 and above. Although, in the same year there were more men within the ages 70-74 with dementia than women of the same age range.

2, Family history: Those with parents or siblings with dementia are more likely to develop dementia themselves (CDC, 2019). There are tests to determine whether you have such genetic mutations that could cause dementia.

3, Diet and exercise: Research has shown that lack of exercise can increase the risk of dementia. Research indicates that there is a greater incidence of dementia in people who eat an unhealthy diet when compared with those who follow a Mediterranean-style diet rich in produce, whole grains, nuts and seeds (Coupland, 2019).

4, Traumatic brain injury: Head injuries can increase the risk of dementia, especially if they are severe or occur repeatedly.

5, Cardiovascular risk factors: These include high blood pressure (hypertension), high cholesterol, buildup of fats in your artery walls (atherosclerosis) and obesity.

6, Down syndrome: By middle age, many people with Down syndrome develop early-onset Alzheimer’s disease.

7, Diabetes: Having diabetes may increase the risk of dementia, especially if poorly controlled (AskMayoExpert, 2020).

8, Sleep disturbances: People who have sleep apnea and other sleep disturbances might be at higher risk of developing dementia.

9, Medications that can worsen memory: Avoid over-the-counter sleep aids that contain diphenhydramine (Advil PM, Aleve PM) and medications used to treat urinary urgency such as oxybutynin (Ditropan XL) (Coupland, 2019).

10, Excessive alcohol use: Drinking large amounts of alcohol has long been known to cause brain changes.

11, Depression: Although not yet well-understood, late-life depression might indicate the development of dementia (Coupland, 2019).

12, Smoking: Smoking might increase the risk of developing dementia and blood vessel diseases (AskMayoExpert, 2020).

13, Air pollution: Studies in animals have indicated that air pollution particulates can speed degeneration of the nervous system (Coupland, 2019)

14, Vitamin and nutritional deficiencies: Low levels of vitamin D, vitamin B-6, vitamin B-12 and folate can increase the risk of dementia (Coupland, 2019).

Symptoms of Dementia

Figure 7: Signs of Dementia (WHO, 2020)

Dementia affects each person in a different way, depending upon the underlying cause. The signs and symptoms linked to dementia can be understood in three stages:

1, The Early Stage: Common symptoms may include:

-Forgetfulness

-Losing track of the time

-Becoming lost in familiar places (WHO, 2021).

2, The Middle Stage: As dementia progresses to the middle stage, the signs and symptoms become clearer and may include:

-Becoming forgetful of recent events and people’s names

-Becoming confused while at home

-Having increasing difficulty with communication

-Needing help with personal care

-Experiencing behaviour changes, including wandering and repeated questioning (WHO, 2021)

3, The Late Stage: The late stage of dementia is one of near-total dependence and inactivity. Memory disturbances are serious and the physical signs and symptoms become more obvious and may include:

-Becoming unaware of the time and place

-Having difficulty recognizing relatives and friends

-Having an increasing need for assisted self-care

-Having difficulty walking

-Experiencing behaviour changes that may escalate and include aggression (WHO, 2021).

Other symptoms include: Difficulties in problem-solving, challenges in planning and organization, confusion and impairment in orientation, changes in personality and being suspicious of people around them, symptoms that present as depression and anxiety, etc (Synlab, 2020).

Diagnosis

There is no one test to determine if someone has dementia. Doctors diagnose Alzheimer’s and other types of dementia based on a careful medical history, a physical examination, laboratory tests, and the characteristic changes in thinking, day-to-day function and behaviour associated with each type (Alzheimer’s Association, 2019). The series of tests and evaluations that can guide a doctor’s diagnoses are:

Cognitive and neuropsychological tests: Doctors will evaluate thinking ability through a number of tests to measure thinking skills, such as memory, orientation, reasoning and judgment, language skills, and attention (AskMayoExpert, 2020).

Neurological evaluation: Doctors evaluate memory, language, visual perception, attention, problem-solving, movement, senses, balance, reflexes and other areas (AskMayoExpert, 2020).

Brain scans: Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) scans can check for evidence of stroke, bleeding, tumours or hydrocephalus (AskMayoExpert, 2020). Positron Emission Tomography (PET) scans can show patterns of brain activity and whether the amyloid or tau protein, hallmarks of Alzheimer’s disease, have been deposited in the brain (AskMayoExpert, 2020).

Laboratory tests: Simple blood tests can detect physical problems that can affect brain function, such as vitamin B-12 deficiency or an underactive thyroid gland. Sometimes the spinal fluid is examined for infection, inflammation or markers of some degenerative diseases (AskMayoExpert, 2020).

Psychiatric evaluation: A mental health professional can determine whether depression or another mental health condition is contributing to your symptoms (AskMayoExpert, 2020).

Care and Treatment

Treatment of dementia depends on its cause. In the case of most progressive dementias, including Alzheimer’s disease, there is no cure (Alzheimer’s Association, 2019), but the following treatments below can be employed for the other types of dementia:

1, Medications: The following groups/types of medications can be used to temporarily improve dementia symptoms:

Memantine: it works by regulating the activity of glutamate, another chemical messenger involved in brain functions, such as learning and memory (McShane, 2006)

Cholinesterase inhibitors: these medications — including donepezil (Aricept), rivastigmine (Exelon) and galantamine (Razadyne) — work by boosting levels of a chemical messenger involved in memory and judgment (Raina, 2008).

Other medications that treat symptoms or conditions, such as depression, sleep disturbances, hallucinations, parkinsonism or agitation (Alzheimer’s Association, 2021).

2, Clinical trials: After several research on the prevention, treatment and cure of Dementia have been conducted, clinical trials are carried out to test the effectiveness of potential medications and treatments plans for various dementia types. If successful, a new cure/treatment is developed for dementia. Globally, there are several ongoing clinical trials for dementia

3, Therapies: Several non-drug approaches might be used to treat dementia symptoms and related behavioural problems.

Modifying the environment: reducing clutter and noise can make it easier for someone with dementia to focus and function. Objects that can threaten safety, such as knives and car keys, need to be hidden.

Occupational therapy: An occupational therapist can show loved ones/caregivers of dementia patients how to make the home safer and teach coping behaviours. The purpose is to prevent accidents, such as falls; manage behaviour and prepare them for dementia progression.

Simplifying tasks: breaking tasks into easier steps and focusing on success, not failure. Structure and routine also help reduce confusion in people with dementia (AskMayoExpert, 2020).

4, Lifestyle and home remedies

Encourage regular exercise.

Engaging in activities that the individual with dementia enjoys and can do, such as dancing, painting, gardening, cooking, singing and other activities can be fun, and can help them connect with their loved ones (Livingston, 2020).

Enhance communication by maintaining eye contact, speaking slowly in simple sentences, not rushing when responding, presenting one idea or instruction at a time and using gestures and cues, such as pointing to objects (Alzheimer’s Association, 2021).

Keeping a calendar which helps loved ones remember upcoming events, daily activities and medication schedules (Livingston, 2020).

5, Other therapies: The following may assist in reducing agitation and promote relaxation in people with dementia.

Music therapy, which involves listening to soothing music

Watching videos of family members

Pet therapy, which involves the use of animals, such as visits from dogs, to promote improved moods and behaviours in people with dementia

Aromatherapy, which uses fragrant plant oils

Massage therapy

Art therapy, which involves creating art, focusing on the process rather than the outcome (AskMayoExpert, 2020).

Living with dementia

Receiving a diagnosis of dementia can be devastating. A lot of details concerning dementia need to be considered in order to ensure adequate preparedness for dealing with a condition that’s very unpredictable and progressive. Below are some suggestions to help people with dementia cope with the disease:

1, Learn about memory loss, dementia and Alzheimer’s disease.

2, Write about feelings in a journal.

3, Join a local support group.

4, Get individual or family counseling.

5, Talk to a member of the spiritual community or another person who can help with spiritual needs.

6, Stay active and involved, volunteer, exercise, and participate in activities for people with memory loss.

7, Spend time with friends and family.

8, Participate in an online community of people who are having similar experiences.

9, Find new ways of self-expression, such as painting, singing or writing.

10, Delegate help with decision-making to a trusted person (Livingston, 2020).

To help someone living with dementia, listen and reassure the person that he or she still can enjoy life. Be supportive and positive, and help the person retain dignity and self-respect (AskMayoExpert, 2020).

Living with Dementia in Africa

A common problem in Africa and probably other LMICs for persons living with dementia is grappling with stigmatization. Limited studies have reported that stigmatization is rooted in belief systems, commonly cultural (Brooke, 2020) or supernatural (Spittel, 2019), where persons with dementia are thought to be witches. Even though the role of traditional healers, community leaders, and faith healers in health promotion cannot be overlooked, there is nevertheless evidence that these community opinion leaders commonly do not view dementia as a specific disease but rather a feature of normal aging (Yusuf, 2012).

Conclusion and recommendations

There is often a lack of awareness and understanding of dementia, resulting in stigmatization and barriers to diagnosis and care. Studies show that a large percentage of those who live with dementia are not aware of the condition at a very early stage or until diagnosed (Synlab, 2020). The following points should be taken seriously in order to provide adequate dementia care:

1, Early diagnosis in order to promote early and optimal management

2, Optimizing physical health, cognition, activity and well-being

3, Identifying and treating accompanying physical illness

4, Understanding and managing behaviour changes

5, Providing information and long-term support to carers.

References

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Alzheimer’s Association. (2021). What Is Dementia?. Retrieved from https://www.alz.org/alzheimers-dementia/what-is-dementia 

AskMayoExpert. (2020). Dementia (adult). Mayo Clinic. Retrieved from https://www.mayoclinic.org/diseases-conditions/dementia/symptoms-causes/syc-20352013  

Brooke J, Ojo O. Contemporary views on dementia as witchcraft in sub-Saharan Africa: a systematic literature review. J Clin Nurs. 2020; 29: 20- 30. https://doi.org/10.1111/jocn.15066.

Center for Disease Control and Prevention. (2019, April 5th). What Is Dementia?. Retrieved from https://www.cdc.gov/aging/dementia/index.html

Centers for Disease Control and Prevention. (2011). Creuzfeldt-Jakob disease, classic (CJD): Occurrence and transmission. Retrieved from https://www.cdc.gov/prions/cjd/occurrence-transmission.  

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Davies A, Asa A, Martinsixtus E, Ayo O, Michael H, Igor R, and Kit Yee C. (2019). Prevalence of dementia in Nigeria: a systematic review of the evidence. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6746335/.  

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National Institute on Aging. Assessing risk for Alzheimer’s disease. Retrieved from https://www.nia.nih.gov/health/assessing-risk-alzheimers-disease.  Accessed Feb. 8, 2021.

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