ABSTRACT | PDF
GUEST GALLERY
Challenge of new millennium: dementia
Debajit Gogoi
Assistant Professor of Psychiatry
MAPIMS, Melmaruvathur, T.N.
Are we really concerned? Dementia is primarily a disease of old age. There is no doubt that its prevalence and incidence is increasing in an alarmingly high rate. With the increasing life expectancy, as more and more people lived to advanced age, prevalence of dementia will increase. For example, in between 1985-2025, developed countries like the USA is expected to experience a 125%, UK 23%, Canada 135% increase in size of the over 65 years population. The changes in developing countries, where recent progress in public health has extended longevity, the increase will be even more striking; for instance, India 264% increases in their elderly individuals (Cummings et al. 1995).
It is an established fact that the prevalence of dementia doubles every five years starting from one per cent at age 60 to two per cent at 65 to about 30-40% by 85 years. The economic cost of dementia is huge and which includes the expense of caring for the disabled individuals for a long time. Developing countries like India whose mental health policy is still in the infantile stage the economic cost of dementia is only imaginable. And that is why there is no doubt that dementia is a major public health issue for 21st century (Cummings et al. 1995). It’s a real threat to the well being of the elderly people, and yes a tragedy for its victim and their families as well as to the caregivers. Already more than 60% of people with dementia live in developing countries, but by 2040 this will rise to 71%. The fastest growth in the elderly population is occuring in countries like China, India, other south-east Asian and Latin American countries (Ferri et al. 2005).
Indian scenario In India, according to 1981 census, out of the total population of 682.2 million, 44 million i.e. 6.4% people were aged over 60 years. According to 1991 census, 55.3 million people (6.6%) were elderly over 60 years. Their number has increased up to 60 million i.e. 7.5% by 2000 AD. Thanks to medical science’s stupendous discoveries and in lieu of its impact in public health which directly as well as indirectly has increased the life expectancy of common man. So, it is certain that the size of the elderly population is going to increase further and further. It is of no doubt that with the increase of vulnerable population, the prevalence of dementia will certainly increase in India.
Prevalence studies done in India for population of 65 years and above suggest figures like 2.7% in Chennai (Rajkumar et al. 1996), 3.39% in rural Kerela (Shaji et al. 1996), 3.5% in Thirupurur (Rajkumar et al. 1997), 3.4% in Cochin (Seji et al. 2001), 0.84% in rural north India, in persons 55 years and above and 1.36% in rural India in persons 65 years and above (Chandra et al. 1998). Sadly no data was found to represent from north-east Indian states!
Anyhow, the above data suggests that dementia assumes a great significance in Indian scenario, considering its large elderly population, which is ever growing in numbers with the life expectancy fast approaching to late 70’s (i.e. currently in India an estimated 10-15% of our population is affected by dementia). Hence, now the awareness of this disease among medical professionals and society at large is highly relevant (Gopinathan et al. 1998).
Agony? Yes, but invisible Even if dementia has a relatively high prevalence, often these patients are not identified at all or not picked up early. While most of the elderly patients in the community are not identified as having dementing illness, even then many of them who attend hospitals for treatment of various physical ailments, the symptoms of dementia is missed. In one hand the symptoms are kept under the carpet as age related or in the other hand they received less or no attention at all in the presence of passing concerns of physical ailments or sensory impairments, which most of the elderly at that age suffer.
One of the main reasons for which this happens is that there is lack of awareness in the community. But lack of orientation among health care professionals regarding dementia is debatable at this age of information and technology. Most of the time it is sad to hear that for busy practitioner / physician / or so called consultants who “do not have time” to ask simple question regarding any behavioural abnormality in the patient’s part. Because evidence is there that most of the dementia initially or at the earliest always presents with abnormal behaviour not with memory impairment.
Problem is multifaceted Dementia is a multifaceted disorder. Its management requires attention to the underlying disorder, behavioural and psychiatric symptoms, cognitive impairment, consequences of disability and associated conditions. Care of the caregivers or family members is also to be looked for.
The causes of dementia are multifactorial, ranging from genetic, metabolic, infective to exposure to various toxins (Lishman 1987). The symptoms of dementia present in various combinations and in different rates of progression while the core clinical feature remains the same. Often this makes clinical diagnosis a puzzling task, at least initially (Kar et al. 2000).
Therapeutic nihilism? It is said that a therapeutic nihilism is often encountered amongst clinicians in the management of dementia. Though there are many medicines available as cognitive enhancers, the response of those, the stage of illness, cost benefit ratio and affordability (especially in developing countries like India) are many issues that weighs heavily in the processes of clinical decision making. Besides the cognitive impairment, neuro-behavioural and psychological symptoms associated with dementia come as a major concern not only for the caring family members but also for the treating professionals. Most of the dementia patients in their advanced age are so vulnerable to side effects (Cheong et al. 2004), that it is almost impossible to balance between risk and benefit. Behavioural intervention is time consuming and improvements, if there is any seem so minimal and that fade so quickly that it often tests the patience of treating professionals and care givers. In addition, there are other management issues like capacity for decision making especially for specific treatments and legal matters. Therapeutic nihilism can be changed to “therapeutic optimism” only if dementing illness is picked up early.
What are the challenges ahead? Dementia robs all that makes someone a unique being with dignity. With the cognitive capabilities drained gradually, so also the person behind the human form fades away. Though in bites and pieces, so much remains intact in a disordered frame. While more and more human beings are living longer, the more and more people are becoming helpless victims of dementia. The blank stares of the victims tell that there is so much to be done.
More research is needed to understand the aetiologies, and the risk factors, development of newer molecules and methods to treat the pathology receive main impetus now. But before being so much optimistic, issues of care of these patients and their care givers are also to be looked at systematically as these issues bring in the real challenge before not only the families and professionals but also to the state and its economy. Predicting accurately, and identify those at definite risk, and methods to delay the onset of illness are also research issue now. Reversing the pathological process and prevention may sound ambitious aims at present, but these demand research and more research. But who knows what might be achieved!!!
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