DEMENTIA
Prevalence studies from the region have indicated a lower prevalence of dementia when compared to developed countries. However, there are wide variations in reported rates, ranging from 1.4% to 4.4%2–7. One study reported an incidence of Alzheimer’s disease (AD) of 3.24 per 1000 person-years for those aged 65 years8. Dementia incidence is predicted to increase in the developing world in tandem with the ageing population and the increasing burden of vascular risk factors9. It is estimated that there are already about 1.5 million people with dementia in India and this number is likely to increase dramatically in the next four decades1. The major causes of dementia in the region are AD and vascular dementia. One study from Kerala reported that vascular dementia was more common than AD in a rural community sample6. A cross-national study compared APOE*4 –AD epidemiological associations in India and the United States. Frequency of APOE*4 was significantly lower (p < 0.001) in India. Correspondingly, the frequency of probable or possible AD was also lower in the Indian samples10. However, although there was a very low prevalence of AD in the Indian sample, the association of APOE*4 with AD was of similar strength in Indian and US samples.
A challenge for the diagnosis of dementia, which relies heavily on interview-based examination, is the cultural and educational factors such as illiteracy. Several efforts have been made to improve the detection and diagnosis of dementia in this context. Screening questionnaires such as the Mini-Mental State Examination have been translated and validated for use in a North Indian population11. A scale for activities of daily living has also been developed by the same investigators12. In an epidemiological survey with a largely illiterate sample of 5126 individuals aged 55 and older in the rural community of Ballabgarh in northern India, the Hindi version of the MMSE, a neuropsychological battery, and the Everyday Abilities Scale for India (EASI) had sensitivities of 81.3%, 81.3% and 62.5%, respectively, with specificities of 60.2%, 74.5% and 89.7%, respectively. The combination of all three was 93.8% sensitive and 41.8% specific13. An advantage of the EASI was that it could also be administered to informants of subjects who were cognitively not testable. In this largely illiterate community, with a low prevalence of dementia, the combination of cognitive tests and a functional ability questionnaire had substantial value for population screening.
The 10/66 Dementia Research Group interviewed 2885 persons aged 60 and over in 25 centres, including several in India, China and South East Asia. The sample included 729 people with dementia, and three groups free of dementia; 702 with depression, 694 normals with high education and 760 normals with low education. Experienced local clinicians diagnosed dementia and depression. The Geriatric Mental State, the Community Screening Instrument for Dementia and the modified CERAD 10 word list-learning task were then administered by an interviewer, masked to case status. Each measure independently predicted dementia diagnosis. An algorithm derived from all three performed better than any individually and identified 94% of dementia cases with false positive rates of 15%, 3% and 6% in the depression, high education and low education groups. The algorithm developed and tested in this study provides a sound basis for culture and education-fair dementia diagnosis in clinical and population-based research in India14.
Dementia remains a largely hidden problem in India. People do not differentiate between normal ageing and phenomena that are secondary to conditions like dementia15. Even when it is identified, it does not lead to caregivers receiving practical advice or longer-term support16. Given the low awareness about mental disorders in elders, there is a need to develop culturally sensitive methods for identification of probable cases. Shaji et al. have described a simple, cost-effective method of training community health workers to identify dementia in Kerala17. After two and a half hours of formal training, local community health workers in rural Kerala were asked to identify possible cases of dementia from the community they served. Diagnoses were then verified by a senior local psychiatrist with clinical and research interests in old age psychiatry. This method was found to have a positive predictive value of 64.7%. Later in this chapter, we will review the evidence on the burden of dementia, services for people with dementia, and innovative new strategies for addressing the needs of families affected by dementia.
There are a growing number of epidemiological studies of depression or common mental disorders (a broad diagnostic term which encompasses mood and anxiety disorders) in elders in the region, which have sampled general populations and clinical populations. Prevalence rates vary even more widely than those for dementia: rates in a community sample of elders vary from 6% in South India18 to over 50% in rural West Bengal19. Median prevalence rates tend to be higher in clinical populations20–23. One of the largest recent population-based studies was carried out with 1000 participants aged over 65 years from Kaniyambadi block, Vellore, India24. The prevalence of depression (ICD-10) within the previous one month was 12.7% (95% CI 10.64–14.76%).
The common presenting complaints are tiredness, sleep complaints, aches, tingling numbness in the hands, and palpitations25. The hallmark cognitive feature is anhedonia or loss of interest. Suicidal feelings and agitation are also common18. The suicide rate is nearly twice as high in the 50+ age group (12/100 000) as compared to the national average (7/100 000). Co-morbidity with physical ill health is common; by some estimates, more than 90% of elders with a psychiatric disorder also have some physical disorder18. Risk factors for depression include female gender, low education, poverty, social isolation, chronic diseases such as diabetes, and family discord20,21,23– 26. Nuclear family structures, in particular, appear to be associated with a higher risk20. The latter is on the rise as a result of the breakdown of traditional community structures as a result of the massive migration of younger productive members of families to urban areas and reduced economic activity in rural areas15. Older women face a triple jeopardy: that of being old, of being women, and of being poor. Elders living in rural areas may represent another risk group because rural areas lack resources, and with agriculture being the main occupation, there is neither income security nor any systematic provision for old age27. One outcome study was carried out with a sample of patients attending psychiatry services of a tertiary care hospital in India. After 12 months, only 28% of patients had recovered. Factors predicting good outcomes were shorter duration of episode and living in a joint family system28.
Help-seeking is not uncommon for somatic complaints associated with depression. However, the commonest treatments in primary care are symptomatic. Thus, benzodiazepines for insomnia and vitamins and ‘tonics’ for tiredness are among the commonest prescriptions for common mental disorders in general health care, while antidepressants or psychotherapy are rarely offered29. Detection rates are very low, but there is good evidence that short screening questionnaires can considerably improve detection rates in primary care30
Related posts:
The Care Home Experience Alisoun Milne
The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) Nicolas Cherbuin andAnthony Francis Jorm
The Lundby Study Mats Bogren, Cecilia Mattisson and Per Nettelbladt
Environmental Factors, Life Events and Coping Abilities Toni C. Antonucci and James S. Jackson
Sleep and Ageing: Disorders and Management Helen Chiu and Joshua Tsoh
Training Requirements for Old Age Psychiatrists in the UK Susan Mary Benbow and Aparna Prasanna
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