Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0117Dementia and Depression in AfricaOlusegun BaiyewuUniversity of Ibadan, Ibadan, NigeriaAfrica is a multicultural, multiracial society, consisting mainly ofNegroid people, although Arabs predominate in the north andwhite settlers constitute a minority in the south. There are nopolicies and programmes for old age in most countries of Africa,and the majority of elderly people live in often neglected ruralareas. Most older Africans are impoverished, have little or noeducation and depend on their children for sustenance. Provisionfor their medical care is grossly inadequate. In this chapter thesituation of the elderly in Nigeria will be used as a prototype forAfrica.Only about 3% of Nigerians are aged 65 years and older 1 . Thethrust of healthcare policy is towards communicable diseases inchildren, and geriatrics and geriatric psychiatry are both in theirinfancy. About the only policy document regarding old age carestates that nursing homes will be discouraged, while home visits toolder citizens will be encouraged and day care centres will beestablished. Federal, state and local governments are expected toshare responsibilities for the care of older citizens 2 ; however, aswith most policies, there is a big gap between conception andimplementation.RESEARCHAlthough geriatric research is limited, a number of studies havelooked into dementia and depression. Because of the low level ofeducation, most questionnaires designed in Western societies willrequire modification before application to older persons in Africa,especially in those that measure cognitive functions. Roleexpectations of older persons are also different, e.g. they are notexpected to do household chores in the multigenerational livingarrangements which are popular.DementiaInitial publications on dementia in Africa were about hospitalpatients, Lambo 3 in Nigeria and Ben-Arie et al. 4 in coloured olderpersons in South Africa. An earlier community study on dementiacreated the impression that Alzheimer’s disease (AD) was rare ornon-existent in Nigerians 5 . This conclusion is probably related tomethodological issues in the study.A major community-based study comparing older African-Americans in Indianapolis with older Nigerians in Ibadan hasbeen ongoing since 1992. Prevalence rates of both dementia andAD were significantly higher in Indianapolis compared withIbadan, 4.82% vs. 2.29% for dementia and 3.69% vs. 1.41% forAD 6 . More importantly, there was a progressive increase in theprevalence rates of both dementia and AD with increasing ageafter 65 years. Another important finding was that the Apoe4allele, which has been reported to be associated with AD in moststudies, was found to be unrelated to AD in Nigerians 7 . Importantrisk factors for dementia in Nigerians included age and female sexonly; other well-known risk factors were not identified 15 .Behavioural disorder symptoms were found both in Nigeriansand African-Americans but it was felt that Nigerians are generallymore tolerant of behavioural disorder symptoms in theirdemented family members, who are often not treated 8 .In another major community survey of people aged 60+ inEgypt, Farrag et al. 9 reported a prevalence rate of 4.5% for alldementias, 2.2% for AD and 0.9% for multi-infarct dementia. Inthat study also the rate of dementia doubled every 5 years.DepressionLambo 3 diagnosed more depression in hospital older malepatients compared to older females; Baiyewu et al. 10 reportedthat 5.4% of older Nigerians were depressed in a communitysurvey with a preponderance of males. Recently, Sokoya 11 alsoshowed that 5.4% of older primary care attendees were depressed,using AGECAT criteria 12 . Depression was related to low incomebut there was no gender difference. Depression was not oftenrecognized and treated.Nursing HomesNursing homes are very few in Nigeria, as in other Africancountries. However, in a study of psychiatric disorders in twoLagos nursing homes, using AGECAT and DSM-III-R 13 diagnoses,48% of patients had dementia and 17% had depression 14 .Although the sample size was small and it is difficult to generalize,the figures are close to those reported in centres in Westernsocieties, which may portend that the problem will become moreevident in future as the number of older persons increases.FUTURE TRENDSThere have been two major community studies on dementia inAfrica; the study among the Arabs of Egypt gave prevalence ratestwice as high as for Nigerians. There is an urgent need to havemore studies on psychiatric disorders among older persons inAfrica. Such studies will be informative on rates, patterns ofillness and risk factors, as well as assisting in policy formulation.Principles and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd