Country
Year 2000 population ≥60 years in thousands
Year 2025 population ≥60 years in thousands
% increase over 5 years in people ≥60 years
% increase of general population
Algeria
1,838
4,852
260
140
Kenya
1,260
2,166
170
120
Nigeria
5,599
10,944
200
170
CAR
180
261
150
130
South Africa
3,006
4,875
160
80
In Africa, older people typically constitute the poorest groups of society. For example in Uganda according to the ‘Uganda Reach The Aged Association’, over 64 % of the older persons survived on less than one Dollar ($1) a day [19]. They did not have access to regular income and the majority did not benefit from social security provisions. The vast majority lived in rural areas where over 85 % of the active ones were engaged peasant subsistent farming. Many depended on one meal a day; others survived on one meal in two or more days, a situation that affected their health negatively [4, 8]. Various studies have found the elderly to often have many untreated health problems such as hypertension, stroke, diabetes, heart diseases, eye problems (trachoma and blindness), which diseases often lead to complications and permanent incapacitation [10]. Some of the most common mental health issues and concerns were depression, dementia, various psychoses, delirium and substance abuse (www.Agingcare.com). In Uganda, studies conducted at Mulago National Referral Hospital in Kampala reported similar findings with a reported 48 % prevalence of psychiatric morbidity among the elderly patients admitted on the non-psychiatric wards [12]. Depression and dementia were the most common mental health problems with a prevalence of 13 % and 8 % respectively [12].
Psychiatric services are poorly distributed in Africa, concentrating in urban areas and leaving many rural communities with no services [1]. Such services for the elderly are even more scarce. The vulnerability of the elderly in Uganda has increased especially over the last 30 years with elderly women bearing the brunt of it [1]. It is compounded by triad of “a culture which denies inheritance rights to women, the burden of HIV/AIDS orphans under their care and the absence of government run Social Security provision”. Thus to be elderly and mentally ill in Africa, e.g. with dementia, is to live a life of misery, suffering and penury [1].
Traditionally, Africa had had established social networks that protected the elderly. These systems ensured strong bonds within the extended African family system consisting of multiple generations of the old, the grownups, the youths and the children [3]. These relationships provided for the needs of the old. The elderly were regarded with the utmost of respect as they were seen as the repository of knowledge and wisdom. However socio-demographic changes in Sub Saharan Africa have caused the elderly to be neglected resulting in much misery and penury with no economic security, no health care and no social supports [1]. The main causes of this problem has been the changed economic system (to a cash economy), massive rural-to-urban migration, the brain drain, relentless wars, political instability, the HIV/AIDS epidemic and the failure of Sub Saharan African governments to put in place and implement programs that address the needs, concerns and care of older persons [1]. This has thus left the burden of care for the elderly to relatives. With the African extended family system rapidly disintegrating, the demented elderly in Africa have suffered the most with these changed circumstances as they have become a burden to everyone. The HIV/AIDS epidemic has added more insult to injury by leaving the elderly to look after the many AIDS orphans whose parents have died [1]. There is also now a new sub-epidemic of the elderly HIV-positive individuals with significant HIV-associated neuro-cognitive disorders (HAND) which complicates the clinical picture and care of dementia in the African elderly [15]. Thus in summary, today the elderly in Africa are no longer playing the important role in society they used to. They are not acknowledged and the prevailing negative attitude towards them causes them much suffering, poor health, depressive disorders and somatic illnesses. The elderly are often segregated and marginalized leading to loneliness, loss of self-esteem and economic deprivation [3, 5–9, 11]. They are often abuse, exploited or their property stolen. Older women have even been abused sexually and physically, the latter following allegations of witchcraft practice and sorcery. A number of older persons have lost their lives, property or have been maimed in such circumstances [11].
Dementia in Africa
Dementia is defined as progressive global cognitive impairment, principally presenting as increasing forgetfulness and the problems which ensue hence from. The problem of dementia in Africa is increasing, especially with the increasing population of older people, the relentless HIV/AIDS epidemic which is now in its fourth decade and the increasing numbers of man-made accidents [1]. There are thus various causes of dementia in Sub-Saharan Africa. These include trauma, infections (especially HIV/AIDS), substance abuse (alcohol), CNS neoplasm, cardiovascular disease but most importantly for the old, the age-related brain degenerations. It is this last factor, the care for those suffering from the dementias of old age in Sub Saharan Africa, that this chapter will focus its concentration.
Gerontological Studies in Africa: The Case of Uganda
Studies addressing the elderly in Sub Saharan Africa are few and scattered, especially those addressing care burden. Najjumba-Mulindwa (2003) found that the elderly sick in Uganda lacked social support and care, always had feelings of negativity, frustration and powerlessness, were poor and often went hungry [11]. In a study of the elderly hospitalized on general hospital wards, Nakasujja et al. (2007 found a prevalence of depression at 13 % and dementia at 8 % [12]. The factors associated with the elderly’s psychological distress were poverty, lack of social support and female gender [12].
Musisi et al. [16] in a Ugandan study of the elderly accessing psychiatric care at Mulago National Referral Hospital found the most common disorders to be Dementia at 46 % and Depression at 30 %. These were followed by alcoholism, bipolar disorder, anxiety disorder and psychotic disorder, with each being at about 6 % on average. Of these elderly psychiatric patients, the Male:Female ratio was 2:3, again showing that there were more elderly women than men. Their age range was 60–96 years (Mean = 74.1) with about half of them (49.1 %) being married. Of the married, the majority were men (77 %). Of the rest who were not married, the majority were widowed (40 %) with the biggest majority of this group being women (85 %). These figures suggested that among the elderly in Uganda, men remained married or remarried after losing their spouses but the elderly women remained unattached hence calling for care from others, mainly family. Only 6 % of the elderly were either divorced or separated and only 2 % were never married and these were Catholic nuns who lived in institutional care at their denominational mission stations. Thus in terms of care of these elderly, the majority of whom suffered either dementia or depression, the burden of care fell to the family with only 2 % being in institutional care. The question then was “Who, among the family members, actually looked after the elderly?” Table 21.2 shows the sources of care and support for the elderly psychiatric patients in Musisi’s study [16].
Table 21.2
Sources of care for elderly psychiatric patients
Males (N = 22) | Females (N = 31) | Total (N = 53) | |
---|---|---|---|
Source of support a | n (%) | n (%) | n (%) |
Daughter | 2 (9) | 15 (48) | 17 (32.3) |
Son | 6 (27) | 8 (25.6) | 14 (26.6) |
Spouse | 8 (36) | 3 (9.6) | 11 (20.9) |
Self | 4 (18) | 4 (12.8) | 8 (15.2) |
Grandchildren | 2 (9) | 1 (3.2) | 3 (5.7) |
Others | 1 (4.5) | 1 (3.2) | 2 (3.8) |
As Table 21.2 shows, in that study, Musisi et al. (2008) found that the majority of the elderly, (58.9 %), were being looked after by their children especially daughters (32.3 %) who looked mostly after their ageing widowed mothers in about half (48 %) of the cases [16]. The sons looked after their ageing parents in 26.6 % of the cases and they did this in almost equal numbers (25.6 % mothers and 27 % fathers). Spouses looked after the elderly in 20.9 % of the times but this was mainly (younger) wives looking after their (elderly) husbands (36 %), meaning that men tended to remarry in old age but the widowed or separated/divorced elderly women remained unattached. About 15 % of these elderly looked after themselves with no one else to help and 6 % were found to be in extreme states of neglect with dementia, malnutrition and in very poor states of clothing, self-care and household environment. For these, only the neighbors paid cursory calls to them once in a while to give them food, water or do some house chores like laundry. The following case report illustrates this point.
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