Diagnosing And Treating Diagnosing And Treating Alzheimer Disease: Alzheimer Disease:

A Jordanian A Jordanian ExperienceExperience

Marina Hadidi, M.D., Ph.D.Marina Hadidi, M.D., Ph.D.Amman, JordanAmman, Jordan

Istanbul, September 2005Istanbul, September 2005

Jordan:Jordan: Area – 97, 740 km2 Area – 97, 740 km2

Facts about Jordan:Facts about Jordan:

Population:Population: 5,7 mln (2005) 5,7 mln (2005) Capital:Capital: Amman (1,8 mln) Amman (1,8 mln) Life expectancy:Life expectancy: M - 71 y, F – 74 y. M - 71 y, F – 74 y. Population growth rate:Population growth rate: 2,8% per 2,8% per

yearyear Annual income per capita: 1,813 $Annual income per capita: 1,813 $

Jordan: Majority of Jordan: Majority of population is under the age population is under the age

of 35of 35

Current Situation: Diagnosis of Current Situation: Diagnosis of ADAD

Low awareness about AD in the populationLow awareness about AD in the population No data about incidence or prevalence of No data about incidence or prevalence of

MCI and dementia of Alzheimer type but MCI and dementia of Alzheimer type but professionals dealing with it has a common professionals dealing with it has a common impression of increasing incidence impression of increasing incidence

No studies about prevalence of different No studies about prevalence of different types of dementiatypes of dementia

Lack of validated psychometric tests. Lack of validated psychometric tests. Individually modified MMSE, clock drawing Individually modified MMSE, clock drawing and 3 word recall test are most often used.and 3 word recall test are most often used.

Current Situation: Treatment Current Situation: Treatment of ADof AD

Patients with AD are treated mostly by Patients with AD are treated mostly by neurologists and psychiatristsneurologists and psychiatrists

Rivastrigmin, Galantamin and Donepezil Rivastrigmin, Galantamin and Donepezil are officially registered in Jordan/are officially registered in Jordan/

Memantin is in the process of Memantin is in the process of registrationregistration

There are very few geriatric nursing There are very few geriatric nursing homes and no specialized centers for homes and no specialized centers for AD patients so they stay with the family AD patients so they stay with the family till very late stages .till very late stages .

Illiteracy: potential Illiteracy: potential implicationsimplications

Still a very common phenomenonStill a very common phenomenon Associated with age > 65, female gender, Associated with age > 65, female gender,

non-urban dwelling non-urban dwelling (Gomez et al 2001, Bowirrat (Gomez et al 2001, Bowirrat et al, 2001)et al, 2001)

Strongly associated with life expectancy in Strongly associated with life expectancy in both developed and developing countries both developed and developing countries (Messias, 2003)(Messias, 2003)

Major socio-economic risk factor for Major socio-economic risk factor for development of dementia in different development of dementia in different ethnic groups ethnic groups (Carnero-Pardo, 2000, Bowirrat, (Carnero-Pardo, 2000, Bowirrat, Friedland 2002)Friedland 2002)

Prevalence of Illiteracy in Prevalence of Illiteracy in Middle East Countries:Middle East Countries:

(United Nations Statistics (United Nations Statistics Division, 2005)Division, 2005)

CountrCountryy

JordaJordann

Saudi Saudi ArabiArabiaa

TurkeTurkeyy

EgyptEgypt UAEUAE

MM 4,5%4,5% 15,9%15,9% 5,6%5,6% 32,8%32,8% 24,424,4%%

FF 14,1%14,1% 30,5%30,5% 21,5%21,5% 56,4%56,4% 19,319,3%%

Retrospective Analysis Of Retrospective Analysis Of 70 Consecutive Patients 70 Consecutive Patients Diagnosed As AD In Our Diagnosed As AD In Our

Clinic In 2002-2005Clinic In 2002-2005 Age 57 – 80 y (mean age 68 y)Age 57 – 80 y (mean age 68 y) Jordanian residents only; patients Jordanian residents only; patients

from other Arab countries not from other Arab countries not includedincluded

M – 46 %, F – 54 %M – 46 %, F – 54 % Total illiteracy – 20 % (M – 13%, F – Total illiteracy – 20 % (M – 13%, F –

26%) 26%)

Does Illiteracy Affect Time Does Illiteracy Affect Time Of Diagnosis?Of Diagnosis?

Stage At Stage At DiagnosisDiagnosis

LiterateLiterate IlliterateIlliterate

MildMild 12 (85%)12 (85%) 24 (43%)24 (43%)

ModerateModerate 2 (15%) 2 (15%) 30 (53%)30 (53%)

SevereSevere -- 2 (4%)2 (4%)

Does Illiteracy Affect Does Illiteracy Affect Treatment Choice and Treatment Choice and

Compliance?Compliance?LiterateLiterate IlliterateIlliterate

Started on Started on AChEIAChEI

50 50 (90%)(90%)

12 12 (85%)(85%)

Reported Reported positive chan-positive chan-ges after 3 mges after 3 m

38 38 (70%)(70%)

2 2 (15%)(15%)

Uninterrupted Uninterrupted treatment for treatment for > 9 months> 9 months

3434 (60%)(60%)

1 1 (7%)(7%)

Limitations:Limitations:

Our group is not representative of the Our group is not representative of the whole population of Jordanian whole population of Jordanian patients with dementia because of:patients with dementia because of:

- small size of group- small size of group

- patients seeking help from a private - patients seeking help from a private doctor doctor

- predominantly urban patients- predominantly urban patients

Illiteracy in Jordanian Illiteracy in Jordanian patients with AD patients with AD (preliminary (preliminary

conclusions)conclusions) Illiteracy is more common in female Illiteracy is more common in female

than male AD patientsthan male AD patients Illiterate patients were more often Illiterate patients were more often

diagnosed in moderate and severe diagnosed in moderate and severe stage, as opposed to mildstage, as opposed to mild

Illiterate patients and their relatives Illiterate patients and their relatives less often report improvement on less often report improvement on treatment with AChEI and are less treatment with AChEI and are less probable to remain on it for the probable to remain on it for the prolonged period of timeprolonged period of time

Converging Pathogenic Converging Pathogenic Mechanisms Of Vascular Mechanisms Of Vascular Dementia And Stroke VS Dementia And Stroke VS

Neurodegenerative DementiaNeurodegenerative Dementia

VaD Stroke

AD

HypertensionDiabetes

Hyperlipidemia

Hypertension:Hypertension: Elevated midlife systolic blood Elevated midlife systolic blood

pressure is an independent risk pressure is an independent risk factor for AD, according to several factor for AD, according to several prospective population-based studies prospective population-based studies (Kivipelto et al, 2001, Skoog et al, 1996)(Kivipelto et al, 2001, Skoog et al, 1996)

Antihypertensive treatment may Antihypertensive treatment may protect against demetia in older protect against demetia in older patients with systolic HTN, according patients with systolic HTN, according to Syst-Eur study (to Syst-Eur study (ForetteForette etet alal, , 20022002))

Diabetes Mellitus:Diabetes Mellitus:

Diabetes increases risk of AD Diabetes increases risk of AD according to epidemiological studies according to epidemiological studies (Knopman et al, 2002; Arvanitakis et al, (Knopman et al, 2002; Arvanitakis et al, 2004)2004)

Possible mechanisms may include Possible mechanisms may include IDE (insulin-degrading enzyme) IDE (insulin-degrading enzyme) which hydrolyses several regulatory which hydrolyses several regulatory peptides including insulin, glucagone, peptides including insulin, glucagone, Ab and APP intracellular domain Ab and APP intracellular domain (Duckworth et al 1998, Tanzi et al 2004).(Duckworth et al 1998, Tanzi et al 2004).

Modifiable Risk Factors Modifiable Risk Factors In 1 In 1stst Ever Ever Ischemic StrokeIschemic Stroke

UK :UK : Hypertension -52%Hypertension -52% CAD or MI -38%CAD or MI -38% Current smoking -27%Current smoking -27% Diabetes Mellitus -10%Diabetes Mellitus -10% TIA -14% TIA -14%

P.A.G.Sandercock P.A.G.Sandercock et.al,1989et.al,1989

Jordan:Jordan: - 57%- 57%

- 36%- 36%

- 41% - 41% - 55% - 55%

- 5%- 5%

M.Hadidi,200M.Hadidi,20011

Prevalence of Diabetes Prevalence of Diabetes Mellitus In 70 Jordanian Mellitus In 70 Jordanian

Patients Diagnosed With AD Patients Diagnosed With AD in 2002-2005in 2002-2005

Alzheimer Patients - 21%Alzheimer Patients - 21% Ischemic Stroke Patients - Ischemic Stroke Patients -

55%55% Controls (non-stroke, non- - 17% Controls (non-stroke, non- - 17%

AD patients ) AD patients )

Future StepsFuture Steps

Jordanian Alzheimer Association is in Jordanian Alzheimer Association is in the process of establishing. It will the process of establishing. It will include interested professionals, include interested professionals, caregivers and social workers.caregivers and social workers.

Epidemiological study evaluating Epidemiological study evaluating prevalence of MCI and dementia in prevalence of MCI and dementia in Jordanian population and investigation Jordanian population and investigation into a possible risk factors is underway into a possible risk factors is underway

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