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Abdulrazak Abyad MD, MPH, MBA, AGSF, AFCHSE

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Volume 8, Issue 1, June 2017

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Alzheimer's in the Middle East - the Future



A. Abyad



Correspondence:
A. Abyad, MD, MPH, MBA, DBA, AGSF, AFCHSE
CEO, Abyad Medical Center
Chairman, Middle-East Academy for Medicine of Aging http
President, Middle East Association on Age & Alzheimer's
Coordinator, Middle-East Primary Care Research Network
Coordinator, Middle-East Network on Aging

Email: aabyad @cyberia.net.lb

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ABSTRACT


Middle Eastern countries have certain cultural, social and economic characteristics in common with similar aspirations. The percentage of elderly in the Middle East is expected to increase with improvement of the health care delivery in the area. The region, like other developing countries, needs to define the policies and programs that will reduce the burden of aging populations on the society and its economy. There is a need to ensure the availability of health and social services for older persons and promote their continuing participation in a socially and economically productive life. There is a recent increase in the number of Alzheimer's patients in the region owing to increased longevity and awareness in addition to better diagnosis.


Background

By 2050, the world population is expected to reach 9.1 billion. The world's elderly population is quickly growing, both in its absolute numbers and in its percentage relative to the younger population (1). It is estimated there will be more than 4.5 million hip fractures annually and more than 36 million patients with dementia, which are profoundly disabling conditions explaining the concerns of an imminent pandemic of frailty, co-morbidity, and disability (2). It is currently estimated that more than half (58%) of all people who are 65 years and older live in developing nations. The world's older population experiences a net increase of 1.2 million each month, 80 percent of which occurs in Third World nations (1,2,3). It is projected that by the year 2025, the total elderly population will reach 976 million with 72% living in developing regions (2-5).

The continued improvement of health care delivery in the region will lead to rapidly aging populations within the next few decades. It is projected that the population will grow from 600 million to 1.1 billion by 2050. So the greater Middle East is one of the fastest growing regions in the world (2). It is evident that chronic noncommunicable diseases are now the major cause of death among older people in both the countries of MENA region and rest of the world. Given this dynamic of population demography, the political, economic, and social leadership of the countries of MENA region would need to re-define and update the policies and programs that will reduce the burden of aging populations on the society and its economy

Policymakers must take two steps: Shift health-sector priorities to include a chronic-disease prevention approach; and invest in formal systems of old-age support.

More specifically, these countries should institute prevention planning and programming to delay the onset of chronic diseases, enhance care for the chronic diseases that plague elderly populations, and improve the functioning and daily life for the expanding elderly population (6-12).

Socioeconomic and Political Factors

Middle-Eastern culture ensures respect for the elderly and values highly the natural bonds of affection between all members of the family. The eldest members are a source of spiritual blessing, religious faith, wisdom and love. Despite the general feeling among most people in the region that sending an elderly parent to a nursing home violates our sense of sacred duty towards them, many individuals and groups are faced with situations, where they have no other alternative. Among such groups are those whose families are abroad, unmarried women, old people whose families cannot support them financially, and those who suffer from diseases where professional care is needed (13,14).

Elderly people in the area receive social and economic support from the informal sources of extended kin networks, and particularly from their own children. With smaller families being the trend, this will lead to fewer potentially supportive children available. Studies from developed countries reveal that where children are in a position to help their aged parents, the majority of them do so. However, traditional patterns of family responsibility will diminish with economic development (13,14).

Governments of the area are still assuming that families will take care of their own elderly. The changing economic and shifting migration patterns lead to the projection that the provision of long-term care will be an important part of health care planning (1,6-12).

The epidemiology of psychiatric disorders in the elderly

Psychiatric morbidity in the Arab world is underestimated. This is due to the fact that few epidemiological studies have been done in the field. Screening of representative samples of primary health care patients in Saudi Arabia and the United Arab Emirates (UAE) demonstrated psychiatric morbidity of 26 and 27.6 % respectively (13,14).

Unofficial data in different nursing home facilities in Lebanon revealed a 25 to 30 percent of depression among residents and 10 to 15 percent of dementia. At Ain WaZein elderly care centre the prevalence of dementia is almost 20 percent of the residents and depression is currently at 25 percent. Behavioural disturbances affect around 20 to 30 percent of residents in long term stay in Lebanon. Al-Ain Community study in the UAE revealed a prevalence of 2.6% memory problem in patients above the age of 60 years.

The Status of the elderly in the Arab Culture

Arab culture ensures respect for the elderly and values highly the natural bonds of affection between all members of the family. The eldest members are a source of spiritual blessing as well as models of piety, religious faith, wisdom and love. In his book entitled The Arab World: Society, Culture and State, Halim Barakat asserts that in Arab societies, "children change from being "iyal" (dependent kids) to "sanad" (supporters) once their parents reach old age. This explains why parents in some parts of the Arab world may refer to a child as "sanadi" (my support).

The recent cultural changes

The family has always been the mainstay of the frail elderly in the Arab world, but events are gradually eroding this support system. Factors such as youth migration for employment and educational gaps between family members account for the erosion of the family support system. (13,14). Families face great difficulties in supporting their dependent elderly. Morbidity patterns have changed and lead to prolonged states of chronic disease, psychiatric illnesses, dependency and loss of autonomy for growing numbers of Arabic elderly. Women, who traditionally bear the main responsibilities for providing family care, enter the labour force for reasons of personal choice and economic necessity and are no longer available to care for aged relatives (1).

It is important to achieve a balance of care between community and institutional services, both for humanitarian and economic reasons. Given the growth of the aging population in the Arab World, especially the oldest, with expected multiple chronic illnesses, the need for intermittent or continuous long term care services will undoubtedly grow including nursing facilities and home or community-based long term care.

How prevalent is Alzheimer's in the Middle East

In 2008, the World Health Organization (WHO) declared dementia as a priority
Condition through the Mental Health Gap Action Programme (15). Dementia, including Alzheimer's disease, is one of the biggest global public health challenges facing our generation. Today, over 35 million people worldwide currently live with the condition and this number is expected to double by 2030 and more than triple by 2050 to 115 million. As a relatively young population, there is low awareness of Alzheimer's disease in the Middle East. It is a devastating disease and the region will eventually have to face the increasing burden of Alzheimer's as the population naturally ages. There are few statistics about the disease in the Middle East but we do see early incidence (up to 10 years earlier than in the West) of other age related diseases such as stroke and heart disease in Egypt, where statistics are available. Unfortunately, this suggests that the Middle East may face the burden of Alzheimer's disease and related dementias much earlier than in the West.

In the Middle East the population is aging gradually and the percentage of elderly will double in the coming ten years. There are no clear estimates in the region of the estimate of Alzheimer disease although we believe that the prevalence is similar to other developed countries but there are no major studies in the area on Alzheimer. There are very few sources of Alzheimer's statistics in the Middle East. None of the health authorities in the region release public figures on the numbers of people with dementia or Alzheimer's and there are no Alzheimer's associations or advocacy groups collecting data. The WHO dementia report says the Middle East and North Africa will see a 125 per cent increase in cases by 2050 and estimates that almost 6 per cent of those over 60 suffer from it.

However, a pilot study in Dubai revealed last year that the prevalence there was closer to 14 per cent, says Dr Mohammed Gamil Elnoamani, a senior geriatrician and head of medical affairs at Dubai's Family Gathering Centre, which runs a monthly support group for caregivers of Alzheimer's and dementia patients. A more worrying finding was that only about 12 per cent of people with the disease are receiving treatment.

In the Region Alzheimer disease does not get much attention owing to the fact that not a lot of people are aware of the disease in addition to the lack of the knowledge among the health care team how to deal adequately with the disease owing to the lack of training in the field. In addition in the Region there is lack of enough geriatricians (physicians specialized in the field of elderly care) and there is absence of geriatric teams within hospital and health center sboth at the governmental and private level. There is a need to raise awareness about the disease among the public and to train the existing health professionals in the field.

How can we help the caregivers

In the Middle East, there is an additional public health concern, one affecting caregivers. The World Alzheimer Report 2013 sent a very clear message about the future of Alzheimer's: "The traditional system of 'informal' care by family, friends, and community will require much greater support." This is particularly pertinent in this part of the world where residential care homes are few and far between, and the onus on caring for the elderly falls to the family.

Most often, spouses and other family members provide the day-to-day care for people with AD. As the disease gets worse, people often need more and more care. This can be hard for caregivers and can affect their physical and mental health, family life, job, and finances. There are not enough support groups, services, research centers, getting involved in studies, and publications about AD, in the region

The development of health and social services for demented patients in the Arab World

Health care systems in the region have ignored the needs of the elderly. There are only sporadic programs that take care of the elderly mainly initiated by the community or within the private sector. In Egypt for example there are 34 old people homes for over one million elderly people and some homes have waiting lists of over 1000 persons. The first specialised unit in Alzheimer that was established in the Middle East was established in the North of Lebanon.

Elderly patients with demented illness will need a wide range of professional services as well as the care of their families. In the process of developing adequate services, it is important to realize that home care and institutional services are complementary and multidirectional. Care of such patients needs the shared responsibility of both families and professional service providers. The role of those concerned with aging in Lebanon or the Arab world is to provide communities and concerned professionals with the knowledge and skills to solve their problems and only import solutions from developed countries after other more relevant alternatives have been explored. Psychogeriatrics, geriatrics and gerontological information should be part of the education of all health professions.

Special Training programs in the Region

In an attempt to cover the gap, the Middle East Academy for Medicine of Ageing was founded to stimulate the development of health care services for older people in the region. It was established by a number of professors and teachers from the Middle East and Europe. The first postgraduate course took place between 2003 and 2005, whereas the second course between 2007-2009, and the third course is running now between 2010-2012. The course has been built up with 4 sessions, on each of 4 days, that cover important topics of health-related problems in older people (16). This intensive study course composed of four sessions is directed towards physicians, nurses, social workers, and health care officers, responsible for the health care of older people.

Special Organisations

The Middle East Association on Aging and Alzheimer's (MEAAA)
In attempt to answer some of the deficit in the region, the MEAAA was established in order to support various activities in the field of aging and Alzheimer's disease.MEAAA helped in co-organizing the first and the second Middle East Congress on Aging in Istanbul and Tripoli.

The Middle East Journal of Age and Ageing (ME-JAA)
The Middle-Eastern Journal of Age and Ageing started in July 2004. The Mission of the Journal is to promote geriatric medicine, gerontology and ageing related issues in the Middle-East.

The Middle East Journal of Pyschiatry and Alzheimer's
The Middle-Eastern Journal of Pyschiatry and Alzheimer's started in July 2008. The Mission of the Journal is to promote pyscho geriatric and Alzheimer's care in in the Middle-East.

The Middle East Network on Aging research ( MENAR)
Despite the fact that 93% of potential years of life lost are in developing countries, only 5% of research dollars are spent on health problems of developing countries(1). There is a substantial research need in the ageing field in the Middle-East.

Conclusion

The demographic changes and social and economic developments in the Region have created new realities in an unprecedented growth of the elderly population. Trends, such as rapid urbanisation, a move from extended families to nuclear families, and technological developments make the problem of aging in the Middle East an acute one. Inappropriate application of costly technology could easily result, accompanied by diversion of resources from existing primary-care services in deterioration of the existing health care system. Many of the most effective measures promoting independence and autonomy promise to result from environmental changes and community organisations, e.g., transportation and physical adaptations for those with impaired mobility, provision of appropriate technology for the hearing or visually impaired, encouragement of mutual help groups. What is essential is to ensure the best possible quality of life for the greatest possible number of our aged.

The governements need to promote basic competency among physicians and other healthcare professionals in early detection of dementia in primary care services. There is a need to create networks of specialist diagnostic entres to confirm early-stage dementia diagnosis and formulate care management plans, in addition to increasing awareness about the availability of evidence-based interventions that are effective in improving cognitive function, treating depression, improving caregiver mood and delaying institutionalisation.

References

1. United Nations Population Division, World Population Prospects: The 2004 Revision (NewYork: United Nations, 2005).
2. Davidson I, Richardson R. Dietary and nutritional aspects of palliative medicine. In:Doyle D, Hanks,G, Cherny,N, Calman, K, ed. Oxford textbook of palliative medicine.
Oxford: Oxford University Press, 2005: 546-52.
3. Kinsella KG. Aging in the Third World. Center for International Research. US Bureau of the Census. Staff Paper No. 35, vii-ix, pp1-23. 1988
4. WHO Expert Committee. Health of the elderly, Technical Report Series 779. Geneva: World Health Organization, 1989.
5. The worldwide trends in population aging in Kevin Kinsella et al., An Aging World: 2001 (Washington, DC: Government Printing Office, 2001).
6. World Health Organization (WHO), Preventing Chronic Disease: A Vital Investment (Geneva:WHO, 2005).
7. Abyad, A. (2012). Geriatrics & Gerontology in the Middle East. Arab Health Magazine, 1, 62-66.
8. Abyad, A. (2003). An Age-Old Problem. Arab Health, 3, 30-31.
9. Abyad A. Health care services for the elderly a country profile-Lebanon. Journal Of the American Geriatrics Society. Oct-2001. 49: 1366-70.
10. Abyad A. Geriatric in Lebanon the Beginning. Int J Aging hum Dev. 1995; 41(4): 299-309.
11. Abyad A . Geriatric in the Middle-East the Challenges. The Practitioner-East Mediterranean Edition. Vol 6, No 12, Dec 1995. pp 869-70.
12. Abyad A. The Lebanese Health Care system. Fam Pract. 1994; (2): 159-161.
13. Abyad, A. Age and aging in the Arab world. Caring for Arab Patients a Biopsychosocial Approach Ed Laeth Sari Nasir and Arwa Kayed Abdul-Haq, 2008. Radcliff Publishing.
14. Abyad, A.; Ashour A.M; Abou-Saleh M.T. Psychogeriatrics in the Arab World pp: 175-188. Images in Psychiatry: An Arab perspectives. Ed: Okasha A, Maj M. World Psychiatric Association. June 2001.
15. World Health Organization. WHO Mental Health Gap Action Programme (mhGAP) 2008. http://www.who.int/mental_health/mhgap/en/
16. Duursma S, Abyad A, Amin F. The Middle-East Academy for Medicine of Ageing. J Nutr Health Aging. 2005; 9(4): 269-271

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