Non-existence of Departments of Geriatric Medicine fails to focus on healthcare needs of elderly


 Prevention of Dementia

Non-existence of Departments of Geriatric
 fails to focus on healthcare
needs of elderly

Prof. Emeritus Lt. Gen. Mahmud Ahmad Akhtar
Former Surgeon General Pak Army/DGMS(IS)

The disorder of dementia is increasing in Pakistan. There is a lack of awareness about dementia both in the general population as well as the physicians. There is a lack of focus on geriatric medical education due to non -existence of departments of geriatric medicine in the medical institutions. There is acute need to have these departments. It is estimated that 50% of dementia patients fall under the category of Alzheimer's disease followed by 18 to 20% for vascular disease and 12% for “front-temporal dementias” (FTD). One should try to find out the treatable causes of dementia. Due to increase in age and high prevalence of metabolic syndrome disorders, the incidence of dementia is increasing.

Lt. Gen. (R) Mahmud Ahmad Akhtar

 The sequelae of the metabolic syndrome i.e.  diabetes mellitus, hypertension, dyslipidemias, strokes, heart attacks, fatty liver are on the increase in Pakistan -in fact one of the highest in the world. One should endeavour to look and investigate for medical causes of cognitive impairment.

In Pakistan the incidence and prevalence of metabolic syndrome is very high -can be prevented and treated - including electrolytes, like calcium, magnesium and phosphate, serum B12 , folate levels, liver ,renal and thyroid function tests. A thorough history taking and physical examination is a must. One should carefully note the difference between the normal process of aging and dementia which often needs, a good clinical assessment. There should also be detailed neuro-psychiatric evaluation for the detection of co-existing depression, psychosis, agitation, restlessness, delirium and other disorders.

Diseases of the body and mind cannot be separated. The low and middle-income countries like Ethiopia, Niemba, Cuba and many others have achieved remarkable successes in patient care by having education and practicing integrated system i.e. holistic medicine. Recent studies have shown that dementia is largely a disease of old age. Rarely the onset can occur in 50’s with strong family history. Prevalence usually doubles in every five years after the age of 65 years, by age 85 to 90, up to 50% of individuals will meet criteria for dementia often with mixed features of Alzheimer's disease and cerebrovascular disease -the dire need for prevention of those.

It has long been a belief that brain function is at its peak during early adult-hood and -then gradually declines. However seminal studies done by the Canadian psychologist which came to be known as Hebbian Learning. He has proved that the brain actually keeps evolving by building new connection to strengthen memory as one ages, the phenomena is called neuroplasticity.

Research further shows that, one can increase brain’s ability to change and reorganize itself and its function (i.e.  neuroplasticity) at any time in life by simply staying engaged in new activities, learning new skills and interacting with other people (social mobility)-even with strangers; all of these things result in beneficial effects across the brains structure. The brain memory center the hippocampus, is particularly capable of growing new cells, in fact it regenerates throughout entire lifetime provided the brain is given appropriate stimuli to guard against degeneration. The process is known as neurogenesis in which the brain re-organizes itself by forming new neural connections. The key to neuroplasticity is to learn new things every day and to challenge yourself to think in new ways and about new things.

 Regular learning changes the brains structure, improves our speed of thought, decision making abilities and comprehension of events as they occur around us. Prevention in fact is the real answer to the myriad problems afflicting the people of Pakistan. It is the real cure and the only cure- it is cost-effective. The treatment of most disorders is very expensive- not affordable by the majority of the people. By employing “Preventive measures provided at the National level and individual levels, this problem has been tackled successfully not only by the high income progressive countries but also by the low income countries like Cuba, Sri -Lanka, Ethiopia, Niemba etc. Their health indicators approaching the highly developed countries. Primary cum secondary Health-care system forms 99% of the health-care system while the tertiary only one percent.

As diet is important for the physical body so is for the Brain/nervous system. As Aristotle said, “Diet is medicine and diet is health.” It has been aptly said by a scholar in every 19th century that we dig our graves with our teeth much before the term, junk, food was evolved. Diet should consist of complex grains of low-glycemic index not of high glycemic index which many of our people consume mostly in the form of white atta, maida, Nans, kulchas, Bakar-khani, Puri etc. not whole wheat, white rice(not brown )high amounts of sugars as sweets, bakery products , drinks/particularly  more harmful carbonated ones including diet ones/equally harmful)Even in tea , four to six teaspoon full of sugar are added in a cup of tea /taken many times ,a day. I advised a patient about not using too much sugar in the tea. He replied that he takes tea for the sake of sugar. Rather than it should be the other-way around. While other-nations avoid adding sugar to tea to enjoy proper aroma and taste of tea, in our culture for every event sweets are used profusely. It needs change amongst the complex carbohydrate, barley the grams, corn, oats, millets etc. have low glycemic index. One should use multigrain bread or porridge. Other low glycemic index grains or corn, oats, millet etc. We should have drinks of lemonade, low-fat, milk, yoghurt, fresh fruit juices (not tinned with added sugars and chemicals).

There should be consumption of at-least five portions of fresh raw vegetables or steamed ones and fruits (mostly vegetables low cost+ low sugar ), pulses / beans , lentils ,peas , nuts are very useful peanuts are affordable and equally useful, seeds like Flax (called Alsi)chia (called tukhan langans), pumpkins, melons, seasame etc. provide vitamins, anti-oxidants, proteins , carbohydrate , minerals etc, are inexpensive should be useful particularly for those who cannot afford food rich in proteins  like meats, fish etc.

Mono-saturated/poly-unsaturated oils should be used mostly mono-saturated. Canola oil has a high smoking point therefore used for high temperature cooking. In Pakistan while most varieties of olive oil break down at high temperature- not good for high temperature cooking. In our milieu Harmful hydrogenated oils are used too much. Salt should be used in low quantities. In our country too much salt is used even added to fruits etc.  increasing the incidence of hypertension and its complication including dementia. There should be zero tolerance for trans-fatty acids as those raise LDL levels (bad cholesterol) and lower HDL levels (good cholesterol). Use of oils heated again and again in preparing pakoras, Samosa, Jalebis, kachori , fried chips etc., produce trans-fatty acids  causing heart attacks , strokes, Parkinsonism   neuro-degenerative diseases. Trans- fatty acids also cause increased incidence of breast carcinoma which is very high in our country, prostate carcinoma, liver disorders etc. Avoiding deficiencies of vitamin like B12, Folic acid, Vitamin C, E etc. and of mineral is preventive. Replacement of deficient hormones like thyroid, cortisone etc.  is useful.

Fatty fish is a good source of healthy proteins and omega-acids which are health protective, should be taken at least two to three times a week. Red meat should be taken in low amounts and occasionally, low fat- dairy products should be taken, condiments like ginger, turmeric, garlic etc.  may be used. These are possibly protective. Water should be taken in adequate amounts, round the clock to avoid dehydration. As brain contains about 80% water even mild dehydration effects its structure and function. Mrs. Obama carried out a campaign amongst the school children of the USA for drinking adequate water.

The brain like other health muscles needs exercise and oxygen. Healthy mental habits enhance the quality of life by increasing the acuity, agility and memory capacity. Dementia, the old degenerative, debilitating disease is prevented through life-long practice which provide brain vigorous challenges. Healthy reading, exercises plan the path-hoods of mind to grow. In junk food, mind is further harmed.

Good quality sleep of at least 7 to 8 hours duration a day following the circadian rhythm is very important. During sleep brain carries out recovery processes. Tensions, anxieties, conflicts, stresses should be avoided -  these affect hippocampus, amygdala adversely. Exercises, stretching, aerobic, muscle strengthening/ stretching and relaxation are very important. These help prevent dementia through their indirect and direct effect on neurons. Even the dementia patients get benefit in symptoms and in slowing progression by doing exercises. Exercise is an important as diet and sleep. One should not sit for more than 40 minutes at a stretch - get up stretch and move about .Brain exercises should be based on novelty and complexity; Think deeper and read more. Brain needs continuous stimulation. Learning new words, foreign new- languages and using two or more languages is preventive. Learning poetry by heart or writing poetry and prose  are helpful. Writing on any subject, facts, fiction, music professional etc. is useful. Learning particularly new musical instrument and even listening to music is beneficial. Arts like painting new things, new embroidery designs etc. are useful games; playing video games, chess, puzzles, etc.  help a lot. Learning new things as an example taken new routes for destinations, helps in developing new neurons connections in the white matter of the brain, eating with left hand, using it for jobs  done by right hand helps  the same way.  

Teaching, sharing, empathizing helps in developing new neurons.  A brain that is fully engaged socially, mentally and spiritually is more resilient. The worst thing in older adults is isolation. We all have our ability to shape our brains for health. According to a recent report about 26% of the old population struggle with everyday basic needs for health care and medicine. A large number of old people feel humiliated by the younger members of the family. Pakistan urgently needs to develop clear and comprehensive or institutional arrangement for the protection of human rights of older persons including  guaranteed minimum pension  in everyone and specialized and affordable geriatric health -care provisions.

In our neighboring country the elderly people enjoy a lot of benefits, benefits for old age travelling concessions etc.  for the last over 50 years but nothing tangible has been done in Pakistan only empty rhetoric. Even though Pakistan is party to a number of Human Rights treaties which talk about the rights of older people, the rulers have done shamelessly little to implement these laws. Old people subjected to stress of life- style from distress, anxieties and depression are predisposed to dementias.

Drugs Management

Patient’s should be kept in contact with the outside world, people, places, surroundings etc.  should have proper sleeping time. Acetylcholinestrase inhibiting   drugs are used in the treatment (preventive) of Alzheimer disease, specifically for mild to moderate disease. Rivastigmine is also licensed for mild to moderate dementia associated with Parkinson’s disease. The evidence to support the use of these drugs relates to their cognitive improvement. Benefit is assessed by repeating the cognitive assessment at around three months. Such assessment cannot demonstrate how the disease may have progressed in the absence of treatment but it can give a good guide to response up to half the patients given these drugs will show a slower rate of cognitive -decline. Drugs in dementia should be discontinued in those thought not to be responding. Many specialists repeat four to six weeks after discontinuation to assess deterioration of significant deterioration occurs during the period, consideration should be given to restart therapy.

Memantine hydrochloride is a glutamine receptor antagonist. It is used in moderate to severe dementia in Alzheimer’s disease. It can be used in patients who are unable to take acetyl-cholinestrase inhibitors and for patients with severe disease. These should be used only by specialists. (Nice technology appraisal, CTAC). Unfortunately in Pakistan the Pharma companies are promoting these drugs aggressively for all sorts of conditions even for ordinary memory lapses etc. and also amongst general practitioners using corrupt practices. The so- called “Drug Regulatory Authority” does not apply any regulatory measures. It is also mostly manned by incompetent members with no clinical pharmacologist, clinical pharmacist, and competent specialists on its panel.

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