Rufus Akinyemi is a professor of geriatric neurology and translational neuroscience and the lead for the Africa Dementia Consortium. In this interview with SADE OGUNTOLA, he said dementia is becoming a public health emergency all over the world, with two-thirds of the projected 152.8 million cases by 2050 projected to be in low- and middle-income countries. Excerpts:
WHAT can you say generally about Alzheimer’s disease?
Alzheimer’s disease is the most common subtype of dementia, a degenerative disease of the brain. It occurs due to degeneration in different parts of the brain. Dementia describes the loss of cognitive functioning, thinking, remembering and reasoning, to such an extent that it interferes with a person’s daily life activities, including occupational and social functioning.
It ranges in severity from the preclinical stage, when it is just beginning and individuals experience cognitive problems but still maintain functioning, to mild stages when functioning becomes affected to the late stages when the person must depend completely on others for basic activities of daily living, such as bathing and feeding. The person may even be bedridden and becomes confined to an institutionalised care home in high income settings.
Dementia has become a public health emergency all over the world and about 55 million people currently live with this condition globally. The number of people living with dementia is projected to grow up to over 150 million by the year 2050. It is worrisome that about two thirds of the projected cases of dementia will be in low- and middle-income countries due to the combination of population growth and population aging interacting with other factors. The contribution of population growth to the increase in the number of dementia cases is highest on the African continent, particularly in western and eastern Africa. Besides population growth, the proportion of people who are living to attain old age is also on the rise in several regions of Africa
How many people in Africa, Nigeria in particular, have dementia?
There are limitations to knowing exactly the burden of dementia in Africa. But a recent meta–analysis of available research data put the prevalence rate of dementia at about five percent among people who are 65 years and older. For Nigeria, in 1995, the prevalence of dementia in Nigeria was about 2.9 percent, that is, less than three percent of people 65 years old and above had dementia. By 2015, the proportion had increased to about five percent based on another meta-analysis that pooled data from multiple researches. This implied that in Nigeria, the number of people with dementia in 1995 was just about 63,000. By 2015, which was 20 years after, the number had increased to about 320,000. That increment is almost 400 percent. As of today, the number of people living with dementia in Nigeria may be over 500,000.
A 2022 study published in the Lancet Public Health projected that by the year 2050, there may be up to 400 percent increase in the number of people living with dementia in some parts of the African continent, meaning that dementia is going to become a big problem in Africa, Nigeria inclusive. That surpasses the rate of increase in North America or Europe.
What are the common signs and symptoms of dementia that individuals should look out for?
Basically, there are different types of dementia and so the signs and symptoms that an individual will experience will depend on what type of dementia he or she has or is developing. Alzheimer’s disease is the most common subtype of dementia and it is caused by degeneration of cells in the brain and the abnormal build-up and deposition of certain proteins inside the brain. Other forms of dementia include vascular dementia, frontotemporal dementia, dementia with Lewy bodies, Parkinson’s disease dementia and mixed dementias, which could be due to a combination of two or more types of dementia pathologies. These have different causes including conditions that damage blood vessels in the brain or interrupt the flow of blood and oxygen to the brain like stroke from hypertension and diabetes. Dementia may also complicate conditions like HIV/AIDS or COVID-19 infection.
However, some conditions that cause dementia or dementia- like symptoms are reversible with treatment. This includes vitamin deficiencies, brain tumour, medication side effects, abnormal build-up of the cerebrospinal fluid in the brain and heavy alcohol use.
Generally, the symptoms of dementia depend on the subtype and stage of the disease, whether it is mild, moderate or in the severe. In the mild stage, there may be memory loss, misplacing things, difficulty performing familiar tasks like handling finances, problems with language, disorientation to place and time, poor or decreased judgment, hallucinations, inattention or changes in mood or behaviour. In the moderate stage of the disease, a person living with dementia may exhibit additional symptoms including lack of personal hygiene, wandering and inappropriate behaviours while, in the late stage of the disease, the person may become mute, unable to recognise even close relatives and becomes totally dependent.
The dominant symptoms in the subtypes are memory loss for Alzheimer’s dementia, problems with mental flexibility, decision making and judgment for vascular dementia, behavioural and language problems in frontotemporal dementia and fluctuating cognition and visual hallucinations for dementia with Lewy bodies.
In a study we undertook over 10 years ago at the Aro Neuropsychiatric Hospital in Abeokuta, Ogun State, we compared our findings among hospital dementia patients with those living with dementia in the community. We found that those who come to the hospital actually have more behavioural and psychological symptoms than those in the community. Many of them were brought to the hospital because their family members had become frustrated and they didn’t know what else to do.
Of course, there are many people in the community who should actually be seen by the doctor, but people don’t know that what they have is dementia. They either think that they are just aging or because of aging, they are behaving like children.
Are there predisposing factors for Alzheimer’s disease?
There are known risk factors for dementia. These include older age, being female, low educational attainment, parental history of dementia, air pollution, history of diabetes, stroke, depression, hypertension, obesity, social isolation, excessive alcohol use, poor physical activity and unhealthy diets. Getting old is the most consistent risk factor across all studies.
According to recent data published by the Lancet Commission for Dementia Prevention, Treatment and Care, we can divide the risk factors for dementia based on different stages along the life course. These risk factors were divided into what stage of life that they are most prominent. In early life, low education, especially before the age of 15, is contributory to dementia. In mid-life, risk factors that predispose to dementia include hypertension, obesity, traumatic brain injury, excessive alcohol use (> 21 units per week) and hearing impairment. Later in life, beyond the age of 65, factors like diabetes mellitus, low physical activity, social isolation, air pollution, depression and smoking are important risk factors.
Importantly, traumatic brain injury, for instance, from a road traffic accident is also now recognised as a risk factor for a person to develop dementia. Air pollution is also an important emergent risk factor. Advances in science have shown that about 40 percent of dementia risk is preventable and about 60 percent is not preventable and this may be due to genetic and other factors that are yet to be discovered.
Can forgetfulness in individuals be equated to dementia?
Forgetfulness is human; anybody can forget things for different reasons. Just forgetting things once in a while, that is not due to dementia but when it becomes consistent and gets worse over time, it needs to be investigated to rule out dementia. Before a diagnosis of dementia is made, we listen to the person’s complaints or concerns about memory changes, we also hear from a close family member or caregiver and we then run a battery of tests to assess the individual’s cognitive functions. So, I will not attach so much importance to the case unless over time, there is a worsening situation of this forgetfulness.
Are there existing treatments or cures for dementia?
Unfortunately, we don’t have a cure for dementia yet. But dementia researchers are working assiduously to find a cure for this disease that is no respecter of persons. However, there are treatment approaches we use to manage the condition. Disease – modifying treatments are beginning to emerge, including Aducanumab which was recently approved by the US Food and Drug Administration and which works by removing abnormal amyloid protein deposits in the brain. Otherwise, most of the currently available treatments just improve the memory symptoms or delay the progression of disease slightly. There are also medications to ameliorate behavioural and psychological symptoms or improve blood flow to the brain. For people who have risk factors like hypertension, abnormal lipids and diabetes, we also give medications to treat these conditions that predispose to dementia.
In the US and Europe, people that are 65 years and above may constitute up to as much as 20 percent of their population. So dementia is a big problem in these places and the financial cost of dementia globally has been estimated by the World Health Organisation (WHO) to be as much as $1.7 trillion by the year 2030.
In Africa, it has been estimated that it costs as much as $8,000 per year to take care of people with dementia, when you put together both the direct and indirect costs of care. Of course, it is a burden, not just for the individual, but also the family and the community. Some people actually stop working to look after the father, mother or spouse who has dementia.
In fact, over 90 percent of cases are looked after at home in many low- and medium-income countries, unlike the developed world where up to 50 percent are admitted to institutional settings or homes, where health and social care providers look after them. We think that homecare may be the best for this environment, only that we can now combine that with visits from nurses and doctors to them. But beyond this, there are also dedicated clinics for elderly people who have memory problems.
What challenges are encountered in the treatment and prevention of the disease?
Starting from the level of the community, one major challenge is the low awareness or low public literacy about dementia. People in the community just assume that persons with dementia are just getting old; some may even be labelled as witches. When people get demented, they begin to say things that do not make sense, some begin to confess things they never did and may end up being stoned to death or burnt alive. People who have dementia are stigmatised. The public needs to be aware that this is a disease and not a possession by an evil spirit. They need to be aware of its signs and symptoms, and come out so that they can be diagnosed and take adequate care of it.
Are there efforts underway, globally or locally, to reduce risk to Alzheimer’s disease in Africa?
Over the years, quite a lot of research has been undertaken by the likes of the late Professor Benjamin Osuntokun, Professor Adesola Ogunniyi, Professor Segun Baiyewu and others, to establish the epidemiology of dementia in Nigeria and in Africa, including prevalence, incidence, risk factors and mortality. But newer studies are now in place to unravel the genetic architecture of Alzheimer’s disease among Africans and how this differs from those of the Caucasians in a bid to understand the disease better and develop new treatments. Genetic risk factors are very important in the causation of the disease.
What can the community or the government do regarding dementia risk reduction?
Risk reduction is actually the focus of this year’s World Alzheimer’s day. About 40 percent of dementia risk is modifiable. For instance, we can prevent the cardiovascular risk factors like hypertension, diabetes and obesity, to reduce the risk of dementia considerably. Also, physical activity and being intellectually and socially engaged is also very important across the life course, and especially for widows, widower and people who live alone, to stimulate the cells of the brain to function better.
We also need to reduce air pollution; everybody has to be involved to reduce air pollution in our environment. Of course, being physically active and policies to help all children go to school and have a minimum of secondary education. Keeping the brain active throughout life is another strategy to avoid dementia. Now, adequate sleep is also important to ensure that the brain gets enough time to recover, consolidate learning and remove waste products that accumulate in the brain. Also, a low-fat diet that is rich in fruit, fibres and green leafy vegetables enhances a healthy brain.
Are people that drink excessive alcohol or drink to stupor at risk of dementia?
Yes, excessive intake of alcohol (more than 21 units per week) is actually one of the risk factors of dementia. Excessive alcohol use is dangerous to the brain. It doesn’t only predispose to stroke, it can also predispose to dementia. So, as much as possible, people should avoid excessive alcohol use. It is very dangerous and it can also lead to dementia.
Will you say the older person actually becomes a child because of the way they behave? Is it also a sign of dementia?
The question is why would somebody behave like a child? How do children behave? A child, until he matures, is dependent and achieving independence in every facet of life is actually a mark of maturity or adulthood. So, in a way, we can say that if an elderly person begins to behave like a child again, becoming dependent, not being able to make decisions to manage life by himself, this may be a red flag that the person actually has dementia and needs to be evaluated by dementia care providers.
and then