A Case of Alzheimer’s Dementia in Uganda

Fig. 17.1

Image of S.N.’s brain CT scan

The Lateral and 3rd ventricles are widened. The 4thVentricle is normal. The ambiens and basal cisterns are normal. The Sylvian fissures are prominent. The midbrain, cerebellum are normal There is sulcial widening of =11 mm. Features are suggestive of Brain Atrophy more marked in the Frontal and Temporal lobes.

A diagnosis of Alzheimer’s dementia complicated by depression was made. S.N.’s biological management included administering the cholinesterase inhibitor Donepezil and the antidepressant Imipramine. Social management involved psycho-education of the family about the nature of AD illness, its course and prognosis and how to care for him including Activities of Daily living (ADL)

At 1 month follow up S.N. reported improved sleep and mood and the antidepressant of Imipramine was later withdrawn after a few months. However, the memory was still impaired. He later developed behavioral and psychological symptoms of dementia (BPSD), which included wandering away from home, talking to himself, easily getting irritated and wanting to strike out. Risperidone was added to his treatment with good effect. Later memantine was added to the Donepezil as the two anti-dementia cholinesterase inhibitor drugs of choice in the maximum recommended dosages. However compliance with medication was a problem because of the use of alternative herbal medicine as suggested by his relatives who were alarmed by his progressive deterioration. At his last clinic visit he had been off the prescribed drugs for 4 months, and his memory was grossly impaired. He was stammering grossly in his and his ADLs had deteriorated necessitating more assistance in his daily care. At times he would urinate in presence of his grandchildren and had to be assisted for dressing, although he could feed and bathe himself. S.N died 3 years after diagnosis of AD.

Discussion

This is a case of Alzheimer’s dementia with typical clinical presentation. This patient reportedly developed symptoms at the age of 68 years which falls in the age range of onset of Alzheimer’s disease. For over a year, impaired memory was his first symptom and it went on deteriorating. He delayed seeking medical attention because family members thought his memory problems were associated to normal aging. He was involved in a police case after selling his land and denied the purchaser to access it, yet he acknowledged receipt of money and even had the signed land documents. This made the family realize that he could be having a problem of memory and comprehension.

In a Ugandan clinical setting, like in all low income countries, there is a limitation on biological investigations. For example we could not do MRI-scans. Alzheimer’s dementia is thus often a clinical diagnosis based on exclusion.

Legal complications often come in AD and often this poses legal wrangles for example whether this gentleman was in his rightful mind at the time he sold his land, or whether he was having a lucid interval. One usually has to rely on family understandings and agreements. In this case, the matter was resolved later between the family and the land purchaser who returned the money, and the family obtained their land.

In Africa, including Uganda, people have a culture of seeking alternative modes of treatment once they are diagnosed with chronic unrelenting illnesses with no medical cure. In this patient the family members resorted to use of traditional herbal medicine when they realized that their relative was diagnosed with an incurable disease. Sometimes, relatives often invoke witchcraft.

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