The Demographic Characteristics and the Risk Factors of Dementia in SAUDI Elderly

There is a little information about dementia in Saudis. This is a retrospective chart review study from1995 -2010. to describe the demographic characteristics and the risk factors of dementia, the prevalence of different types of dementia, and the current clinical practice of dementia in Saudi tertiary care hospital. A total of 418 demented patients (236 males, 182 females) their mean age was 78.8. Prevalence of diabetes 32%, hypertension 71.53%, dyslipidemia 30.05% and depression 24.41%. Clinically 64.37% of patients had memory impairment, 54.25% had confusion and 34.63% had personality changing. The commonest type of dementia was mixed dementia 18.37% followed by Alzheimer disease15.87%. 16.10% of patients had received cholinesterase inhibitor and 9.78% had received memantine. Infection was the commonest cause of frequent admission (40%) Mortality rate was 77.99%. The commonest cause of death was infection (38.34%) followed by cardiovascular causes like stroke (23.34%) and cardiac diseases (17.48%). Conclusion: (1) Mixed dementia is the commonest type of dementia in Saudis due to high prevalence of cardiovascular diseases risk factors. (2) High prevalence of depression among demented Saudi patients. It requires early recognition and treatment. (3) Demented patients have frequent admissions and long stay in hospital which makes the economic cost is very high. (4) Mortality rate among demented patients is high and the outcome of dementia is expected to be poor. The underlying message of this study is to increase awareness of the public and health system about the impact of dementia in Saudis and the need for prevention strategies, trained physicians and more research.


Introduction
Dementia is characterized by the impairment of memory and learning and at least one other cognitive domain (i.e., aphasia, apraxia, agnosia or executive function), representing a highly severe functional deterioration that interferes with the patient's daily functional abilities and independence [1].
Dementia is a syndrome caused by different etiologies and it has a substantial medical and social impact [2]. Dementia prevalence has increased continuously over the past decades due to aging populations. The World Health Organization (WHO) estimated that the number of persons living with dementia worldwide (36 million in 2010) will double over the next 20 years [3]. Saudi Arabia is facing the challenge of an ageing population. According to the last Saudi census in 2011 the life expectancy at birth is 74. Increased in elderly population will have an impact on health care and social services. There is a little information about dementia in Saudis [4]. We have scanty data regarding the demographics characterizing this population or the etiologic diagnoses among those affected in Saudi Arabia.
The objective of this study is to describe the demographic characteristics and the risk factors of dementia, the prevalence of different types of dementia, and the current clinical practice of dementia in Saudi Arabia at tertiary care hospital.

Methods
It is a retrospective, cohort study utilized chart review of patients have dementia who received regular care at King Faisal Specialist Hospital and Research Centre (KFSH&RC) in Saudi Arabia from 1995 -2010. Exclusion criteria include depression without dementia and delirium due to acute illness or medications.

Statistical Analysis
For this study, all the statistical analysis of data was done by using the software package SAS version 9.4 (SAS Institute Inc., Cary, NC, USA). Descriptive statistics for the continuous variables are reported as mean ± standard deviation and categorical variables are summarized as frequencies and percentages. The categorical variables are compared by Chi-square test. The level of statistical significance is set at p < 0.05.

Results
A total of 418 demented patients (236 males, 182 females). The mean age was 78. 8

Discussion
78.8 is the mean age of patients and 63.41% of them diagnosed above age 65years. Older age is strongly associated with dementia and has been reported globally [5,6]. Dominant gender in this study is male 56.46%. Female sex is a dementia risk factor in many international studies [5]. In the Rotterdam Study the incidence of dementia is higher in women than men; age-specific incidence rates are very similar up to the age of 85years. Whereas in women it continued to rise above age 85, the difference could be explained by women living longer than men. Framingham study estimates of lifetime risks for dementia 18.4% and 31.8% for 75-year-old men and women, respectively [7].
The prevalence of cardiovascular diseases (CVD) risk factors like hypertension, dyslipidemia and diabetes mellitus (DM) are high in the current study. This may be responsible for the high prevalence of stroke and chronic renal diseases. It is reported that demented patients have a higher number of comorbidities and the two most frequent comorbidities both for men and women are hypertension and DM [8]. Patients with dementia usually have on average 2 to 8 chronic diseases (comorbidities). In our study 27.44% of patients have more than 3 risk factors comorbidities [9,10].
The prevalence of DM in general population in Saudi Arabia is 25.4% [11]. Another study showed the overall prevalence of DM in Saudis is 23.1%, obesity 31%, hypertension and coronary artery disease 25.1% in women, 36.5% in men [12]. Studies finding an association between obesity and incident dementia have usually measured body mass index (BMI) or adiposity in mid rather than late life. Most of these studies found that mid-life obesity increases the risk of dementia later in life. In this study there is no difference in mean BMI on presentation and 7 years later on [13,14]. Low BMI in later life is associated with the development of dementia, because weight loss is an early manifestation of the disease rather than a true risk factor [15].
Once Alzheimer's disease (AD) develops patients with higher education or occupational levels appear to experience more rapid cognitive decline as compared with those with less education [16,17]. Unfortunately the education level was not documented in 89.1% of patients.
The prevalence of depression in dementia is reported to be 20-60% [18]. The relationship between depression and dementia is complex [19]. The prevalence of depression in general Saudi population is 49.9% [20]. The prevalence in this study is 24.41% and 30.72% of them on treatment for depression. In cohort study depressive symptoms have an association with cognitive decline that is independent of the neuropathologic hallmarks of dementia [21]. Vascular and mixed subtypes of dementia have a higher prevalence of depression as compared to AD [22]. Treatment for depression can significantly improve quality of life.
Prevalence of seizure among patients is 18.93%. Epileptic events in dementia are frequent and under recognized. Epileptic seizures after stroke are independent predictors of new-onset dementia. The preexisting vascular pathologies that may predispose to both epileptic seizures and new-onset dementia could be white matter changes, silent infarcts, or microbleeds. This could be due to an underlying preclinical degenerative disorder such as Alzheimer's disease [23]. A seizure in dementia; particularly AD is established in many studies. Mechanisms underlying seizure pathogenesis are unresolved, but recent studies raise the possibility, that seizures are related to the same pathogenetic processes responsible for cognitive decline, Treatment of seizures in dementia remains empirical [24].
HIV prevalence in Saudi Arabia is very low 0.02% [25]. HIV associated neurocognitive disorder (HAND) encompass a hierarchy of progressively more severe patterns of neurological involvement. It can range from asymptomatic neurocognitive impairment (ANI) to minor neurocognitive disorder (MND) to more severe HIV-associated dementia (HAD) also called AIDS dementia complex (ADC) [26]. The incidence of ADC has dropped by antiretroviral therapy. In this study 8 patients are reported to have HIV and they had dementia when their age <65.
Dementia symptoms are cognitive changes and behavioral/ psychological Symptoms of dementia (BPSD). The commonest symptoms among demented patients in this study are memory impairment, confusion and personality changing. 27.66% of patients have more than 3 symptoms on presentation.
The difficulty in caring for patients with AD is more closely linked to the existence and intensity of the BPSD than the actual cognitive decline. Current treatment for these BPSD is difficult but is generally approached by medications and/or psycho-social support therapies. Several studies have estimated the prevalence of the neuropsychiatric symptoms of dementia to affect 50% to 80% of demented patients in the course of the disease [27]. Systematic reviews of the prevalence of BPSD in community-dwelling older people with dementia give widely ranging results, depending on which tools are used and the length of the observation period [28].
Dementia diagnosis is based on structured history, neurological examination and neuropsychological assessment. Neuroimaging will support for but did not change the clinical diagnosis. Laboratory investigations may help to rule out secondary causes of dementia.
The commonest type of dementia among patients is mixed dementia followed by AD. High prevalence of mixed dementia could be related to high prevalence of CVD risk factors like hypertension, dyslipidemia and diabetes mellitus among Saudis. Stroke is reported in15.03% of our patients and stroke is well known to doubles the risk of developing dementia [29]. Dementia medications can temporarily improve symptoms and slow the progression of the disease process. 25.88% of patients have received treatment for dementia, 16.10% have received cholinesterase inhibitor, 5.22% have received memantine. Duration of treatment in 10.79% of patients is <5 years and in 8.63% of patients is > 5 years.
Feeding can be difficult in demented pateints.30.45% of patients on gastrostomy tube (GT) feeding. In observational studies, tube feeding has not been shown to prevent aspiration, heal pressure wounds, improve nutritional status, or decrease mortality in persons with advanced dementia. Previous study in Saudi patients reported that 38.1% of demented patients are on tube feeding and 51% of them have stroke. Demented patients who have difficulty swallowing or reduced food intake often receive feeding tubes [30]. Demented patients are admitted to hospital two to three times more often than people of the same age without dementia. In the USA, admissions to hospital for people over the age of 85 years with dementia increased from 700 000 in 2000 to 1.2 million in 2008. Prevalence of demented patients' admission is 40 -43% in the UK, Italy and Switzerland [31]. The commonest cause of frequent admission among patients is infection (aspiration pneumonia, urinary tract infection and bed sores infection). Infection is the commonest cause of frequent admission as reported in the literature. Frequent admissions and long stay in hospital make the economic cost is high [32]. The caregivers in 50.24% of patients are family members. Caregivers of demented patients are faced with a number of challenges that can affect their own health and wellbeing which needs further research. 11.78% of demented patients stay at hospital for long nursing care which make the cost is high because no nursing home in Saudi Arabia.
Dementia is a major risk factor for death in advanced age.
Moderate and severe dementia was associated with an increased mortality risk even after appropriate control of comorbid conditions [33]. Mortality rate among our patients is high. The mean age at death is 77.4. The mean age at death of HIV patients with dementia is 45.5. The commonest cause of death is infection followed by cardiovascular causes like stroke and cardiac diseases. No matter what care is offered, the outcome of dementia is likely to be poor. Half of people with moderate dementia admitted with acute illness such as hip fracture or pneumonia will die within 6 months [34]. There is an apparent difference in survival between AD patients with onset of illness before 75 years and those after 75 years: the younger patients have a longer life expectancy. However, there are conflicting data on survival (in years) comparing male and female patients and comparing patients of different ethnicities [35]. Dementia increases the mortality risk at ten years in the NEDICES Study as in other cohort studies. Age and co-morbidity are associated with higher mortality in dementia patients. One third of deaths in persons over 85 years-old could be attributable to dementia [36].

Conclusion
This study has some limitations. It is a retrospective chart review where some missing data are expected and poor documentation is common. Since this study was performed at tertiary care hospital, generalizability may be limited due to sample size. No autopsy is available. Despite these limitations, up to our knowledge this study is the first data study in Saudi Arabia that highlights the following: (1) Mixed dementia is the commonest type of dementia in Saudis due to high prevalence of cardiovascular diseases risk factors. Prevent and control these risk factors may help to prevent vascular dementia. (2) High prevalence of depression among demented Saudi patients. It requires early recognition and treatment. (3) Despite lack of evidence that feeding tubes benefit patients with dementia, patients who have difficulty swallowing or reduced food intake often receive feeding tubes, the use of feeding tubes are expected to increase. (4) Demented patients have frequent admissions and long stay in hospital which makes the economic cost is very high. There is an urgent need to have national strategies to open nursing homes in Saudi Arabia. (5) Mortality rate among demented patients is high.
The underlying message of this study is to increase awareness of the public and health system about the impact of dementia in Saudis and the need for prevention strategies, trained physicians and more research.

Conflict of Interest
The authors declared that there is no conflict of interest