Dr. Merilynn Gayathri, General Physician, MSc Gerontology & Ageing Studies, Brighton Healthcare, Cyberjaya
The 21st century’s biggest healthcare challenge
We are living in unprecedented times of population ageing, where the world currently has the largest proportion of older persons in the history of humankind. Population ageing has garnered much attention in recent years, as globally the number of older adults aged over 65 reached 901 million in 20151. In Malaysia, the older person’s population is currently at 5 percent, projected to increase to 14.5 percent in the year 2040. This effectively triples the number of older people in an immensely compressed period, making Malaysia an aged nation in the very near future.
Despite the positive perception of longevity, genetic risk factors coupled with biological insults over time makes health deterioration natural amongst older people. Hence, chronic degenerative diseases such as ischemic heart disease, strokes, diabetes and cancer account for the principal causes of death in Malaysia. Globally, however, rising life expectancies have contributed to a new age of neurodegenerative diseases, also known as dementia.
Dementia has overtaken heart disease as the leading cause of death in the United Kingdom since 2015.
The number of people with dementia worldwide is currently 46.8 million, expected to increase to 131.5 million in 20502. On an individual level, this translates to one new case diagnosed globally every 3 seconds! Dementia trends in Malaysia mirror that of developed countries, whereby the current number of 123,000 persons with dementia is expected to rise to 590,000 in 20503.
Dementia is an umbrella term for a syndrome characterized by progressive cognitive impairment due to brain diseases. The commonest cause for dementia is Alzheimer’s disease, others being vascular dementia, Parkinson’s dementia and frontotemporal dementia. These diseases cause a progressive mental decline in terms of memory loss, impaired perception and loss of motor skills, whereby over time the person is rendered dependent for activities of daily living. Although dementia is not exclusive to the older population over the age of 65, the stark reality is that no-one survives its diagnosis, leaving behind devastated caregivers, families, societies and economies.
DidYouKnow>>>> Alzheimer’s disease is the most common form of dementia which contributes up to 80 percent of dementias.
Genetic predisposition, vascular risk factors and ageing leads to the accumulation of amyloid beta plaques and neurofibrillary tangles, which further leads to oxidative stress and neuroinflammation. Its symptoms may initially mask that of normal ageing (Table 1).
Table 1: Signs of Normal Ageing versus Early Dementia
|Normal Ageing||Early Dementia|
|Cannot find keys||Routinely places keys, wallet in odd places|
|Trouble recalling names in general||Forgets names of family members and common objects|
|Forgets details of conversations||Frequently forgets entire conversations|
|Miscalculates cash||Cannot manage accounts or balance figures|
|Occasionally feels sad and lonely||Extremes of moods, from tears to rage|
|Cannot find a recipe||Unable to follow simple steps|
E.g., to make a cup of tea
|Occasionally makes a wrong turn||Gets lost in familiar places, prone to wandering|
The disease progression in dementia can be approximated over a decade, whereby the early stage of dementia is classified as the initial two years, the middle stage up to five years, and after that the third stage of dependence. Dementia is potentially the most feared disease of later life, as it is the leading cause of disability and dependency amongst the older person. As many persons with dementia (PWD) show varying levels of cognitive decline throughout the illness, the burden of care falls on family members as the condition progresses. The collateral damage in dementia is inevitable, leading to physical, psychological and financial stress in the carer.
The carer has to oversee a PWD’s difficulties in the initial stages of the disease, such as completing errands, managing simple tasks and understanding social cues. The dependence increases in the later stages of disease especially with basic activities of daily living such as dressing, eating, and toileting. Psychiatric symptoms may manifest later in disease progression, referred to as behavioral and psychological symptoms of dementia (BPSD). Evidence of BPSD includes depression, paranoia, delusions, hallucinations and personality changes.
The complexity and paucity of available support in managing dementia have led to poor outcomes, especially caregiver distress. At some point, the PWD will require full-time care at home or be institutionalized, and with current health and social care initiatives advocating ageing at home, family members inadvertently play the role of full-time carers. The late stage of dementia sees the PWD in near total dependence, inability to recognize families and friends, and possibly aggression. Caring for the individual at this point gives rise to caregiver burden, leading to social isolation, strained relationships, negative psychological and mental health effects in the carer.
DidYouKnow >>> A cure for dementia has yet to be found.
“In the face of a multitude of drug failures, prevention may prove the best way to manage the dementia epidemic,”4 Scientific American (2017).
However, the silver lining in dementia research is that transitional phases between normal brain health and cognitive decline of up to twenty years have been implied, providing a window for early intervention. Many screening facilities and memory clinics are now operating at the level of primary care and as part of hospital outpatient services, providing neurocognitive and functional assessments to streamline the need for timely intervention. Furthermore, the effects of dementia can be mitigated by screening for diabetes, hypertension and depression, as these are the major risk factors for Alzheimer’s disease and vascular dementia. Increasing service provision and accessibility to memory clinics within the community targets preventive strategies even at the midlife population.
Novel treatment modalities such as cellular therapy, gene therapy and immunotherapy have demonstrated promising prospects in modulating the course of dementia5. These therapies have shown results in terms of enhancing hippocampal neurogenesis, increasing synaptic plasticity, and amyloid beta plaque clearance6,7. Various animal studies to date have also shown the therapeutic effects of stem cells, hence currently human clinical trials using stem cells to treat Alzheimer’s disease and vascular dementia are underway, results expected to be released in 20188.
The success story of population ageing will enable the average Malaysian’s life expectancy to reach 80 years old by 2020. Unfortunately, dementia prevalence continues to rise in tandem, with a global cost to society postulated at USD818billion9. In lieu of the economic consequences posed, the facilitation of memory clinics and biomedical research must be made a priority for this disease of unmet needs. Not only that, public, social and personal responses are crucial in fostering empowerment and independence in later life. Only then can the true meaning of the World Health Organization’s ‘adding life to years, and not just years to life’ be a living reality10.
- United Nations. (2015). World Population Ageing: Highlights. Retrieved from http://www.un.org/en/development/desa/population/publications/pdf/ageing/ WPA20 15_Highlpdf
- Alzheimer’s Disease International. (2015). The Global Impact of Dementia: An analysis of prevalence, incidence, cost and trends. Retrieved May 1, 2017, from https://www.alz.co.uk/research/WorldAlzheimerReport2015.pdf
- Alzheimer’s Disease Foundation Malaysia (2017). Retrieved October 5th, 2017, from http://www.adfm.org.my/Home/about-alzheimer-s
- Scientific American. (2017). A Rare Success against Alzheimer’s. Retrieved October 5th, 2017 from https://www.scientificamerican.com/article/a-rare-success-against- alzheimer-rsquo-s/
- Destefani, A. et al. (2017). Cell and Gene Therapies for Alzheimer’s disease: a Review of Cancer Therapy & Oncology International Journal. Vol 3: 1.
- Tang, J. (2012). How close is the stem cell cure to the Alzheimer’s Neural Regeneration Research. 2012 Jan 5; 7(1): 66–71.
- Lee, J. et al. (2016). Stem Cell Therapy: A Prospective Treatment for Alzheimer’s Disease. Psychiatry Investigation. 2016 Nov; 13(6): 583–589.
- Duncan, T. & Valenzuela, M. (2017.) Alzheimer’s disease, dementia, and stem therapy. Stem Cell Research & Therapy. 8:111.
- Alzheimer’s Disease International. (2009). Worldwide Cost Estimate For Alzheimer’s and Dementia is USD315.4 Billion. Retrieved October 15, 2017 from https://www.alz.co.uk/media/090324
- World Health Organization. (2012). World Health Day 2012: ‘Add life to years, not years to life’ says WHO India. Retrieved October 20, 2017 from http://www.thehealthsite.com/diseases-conditions/world-health-day-2012