(Focus - India)
We present to you our discussion with Dr. Sridharan Ramaratnam, an esteemed Neurologist from India, who has shared his insights about the reasons for the underdiagnosis of dementia in India.
Dr. Sridharan Ramaratnam is a senior consultant Neurologist currently serving in The Nerve Centre, Chennai, Tamil Nadu, India.
Awareness of dementia among the general public is low; people think that their parents have a good memory because they can recall childhood events, though people with dementia have difficulty in remembering the recent events.
Studies show that the mean age of dementia presentation is relatively younger at 66.3 years in India, about ten years lesser than in developed countries [1]. What factors are contributing to the early expression of dementia in India?
Dr. Sridharan: Life expectancy in India is lower by around ten years compared to the Western Countries. Vascular risk factors such as hypertension, diabetes, dyslipidemia, truncal obesity, etc., are common in India and could lead to dementia in later life. Premature atherosclerosis and nutritional deficiencies could also be contributory factors.
Most patients are brought for medical help when their dementia is advanced in India [2]. What are the reasons for the underdiagnosis of dementia in India?
Dr. Sridharan: Awareness of dementia among the general public is low; people think that their parents have a good memory because they can recall childhood events, though people with dementia have difficulty in remembering the recent events. Many general practitioners do not know to pick up early symptoms of dementia. The medical curriculum at the undergraduate level does not focus much on diseases of aging, though the number of elderly populations are increasing. People seek attention when behavioural problems and personality changes affect family relationships rather than when memory alone is affected.
Are there any risk factors one should be aware of for seeking timely medical help?
Dr. Sridharan: The underdiagnosis or late diagnosis can be due to multiple reasons. People who are homozygous for Apolipoprotein E epsilon 4 or with head injury, substance abuse, and Down's syndrome are at risk of developing Alzheimer's disease (AD). Vascular diseases such as hypertension, diabetes, sedentary lifestyle, and obesity are also the risk factors for dementia.
Education of the general public regarding symptoms of dementia, such as recognizing early memory loss, subtle personality, and behavioural changes, and consulting a neurologist, will help to diagnose the disease early.
In the future, we will have the facilities to test biomarkers such as amyloid-β (Aβ42), total tau (T-tau), and phosphorylated tau (P-tau) in cerebrospinal fluid (CSF) and probably in blood as well.
Many vaccines (Flu, Pneumococcal, Tdap7, etc.) have been reported to reduce the risk of Alzheimer's Disease. Vaccination may modulate neuroinflammation, resulting in a reduction of AD pathogenesis.
The treatment gap for dementia in India is nearly 90%, with only one in 10 people with dementia receiving a diagnosis, treatment, or care [3]. What is the reason behind the treatment gap for dementia in India?
Dr. Sridharan: Some of the reasons for the high treatment gap are:
Lack of awareness of the disease
Unawareness of advances in management of dementia
Delayed diagnosis
Lack of expertise in treating dementias among general practitioners
High cost of treatment in tertiary care/corporate hospitals
According to the Global Burden of Disease study published in the Lancet Public Health, people living with dementia in India will triple to 11 million by 2050 [4]. So, how Indian Government is working towards a "Dementia Friendly India"?
Dr. Sridharan: The Indian Government is ramping up the health system and improving the facilities at the primary health centres and district hospitals. The Ayushman Bharat Scheme of the Government of India covers over 100 million poor and vulnerable families (approximately 500 million beneficiaries), providing coverage for secondary and tertiary care hospitalization. The scheme should be further reinforced to cover more people and include outpatient care. Focusing on wellness and a healthy lifestyle will help delay the onset of dementia.
Doctor, a new study from University of Texas Health Science Center at Houston says that flu vaccination is linked to a 40% reduced risk of Alzheimer's disease [5]. Also, research shows that different vaccines, from tetanus to tuberculosis, have all been associated with lower rates of dementia [6]. What are your thoughts on the association between vaccination and dementia?
Dr. Sridharan: Many vaccines (Flu, Pneumococcal, Tdap7, etc.) have been reported to reduce the risk of AD. Vaccination may modulate neuroinflammation, resulting in a reduction of AD pathogenesis.
What would be your takeaway message for older people and dementia patients?
Dr. Sridharan: Elderly people must keep their brains "active" – and they should read books, mix with people, and do intellectually challenging tasks; physical activity, treatment of hypertension, diabetes, and proper sleep are also important. Avoid consumption of alcohol and sedatives.
Loneliness, anxiety, depression, and social isolation worsen cognitive functions. Medications such as rivastigmine, donepezil, and memantine are available to prevent the deterioration of the disease.
Thank you for your insights, Doctor!
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