8, Issue 1, June 2017
in the Middle East - the Future
A. Abyad, MD, MPH, MBA, DBA, AGSF, AFCHSE
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
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.
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).
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
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).
and Political Factors
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
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).
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).
epidemiology of psychiatric disorders in the elderly
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 %
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.
Status of the elderly in the Arab Culture
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).
recent cultural changes
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).
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.
prevalent is Alzheimer's in the Middle East
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.
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
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.
can we help the caregivers
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
development of health and social services for demented
patients in the Arab World
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.
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.
Training programs in the Region
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.
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.
Middle East Network on Aging research ( MENAR)
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.
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.
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
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