November Issue 2017

“We met after a gap of several years,” related a woman, talking about her friend with Alzheimer’s disease. “We’d been inseparable all through college and university, and then had different lives, careers, marriage, and different groups of friends. Eventually, our get-togethers stopped, as we both became involved in the usual child upbringing and so on. Occasionally, we’d run into each other, glad that both of us were fine, and happy.”

“Then,” she added, “I started recalling Seema more often. I called, her husband answered, and we decided on a date to meet. I was looking forward to the meeting. But when we did, I was taken aback — the liveliness was missing from Seema, and she had lost weight. Her husband had warned me that Seema was at the early stages of Alzheimer’s. As we began talking, I sensed an emptiness; it was a strangely disorienting experience, to have someone sitting right there opposite you, and yet not there, as if it was just the empty shell of the person you were once so close to… I think of her often, and wish so much that diseases like this never existed.”

Respected medical journal, The Lancet, wrote in their December 17, 2005, issue that Alzheimer’s is one of the most disabling and burdensome health conditions worldwide. In an exhaustive and systematic study by 12 experts conducted over every World Health Organisation (WHO) region, for men and women in the age bracket, 60 to 84 years, it was estimated that 24.3 million worldwide suffer from dementia, and approximately 4.6 million new cases emerge each year. Current estimates are that the prevalence of affected people will double every 20 years, rising to 81 million by 2040. A major point of concern for us is that the study says that the majority of new cases will be in developing countries, including South Asia and Pakistan.

Alzheimer’s takes an enormous toll on the patient, family members and caregivers. In fact, caregivers are the cornerstone for Alzheimer’s treatment. This disease is most prevalent in Western Europe and North America, and least in sub-Saharan Africa. In Asia, Alzheimer’s is expected to rise with increasing longevity and increasing incidence of disorders such as diabetes, high blood pressure, stroke, and high cholesterol. It also affects more women than men: two out of three of all Alzheimer’s patients are women. It is the commonest form of dementia, affecting about one in 10 people. Globally, the cost of treatment and care of Alzheimer’s patients is estimated at a whopping $605 billion.

In Pakistan, a group of neurologists is so concerned that they launched the Pakistan Neurology Society, in August 2015, with a Dementia Awareness Programme. The Society plans to organise strong public awareness programmes on World Alzheimer’s Day — September 21 — every year, along with its regular scheduled events.

Society President, Dr Wasay Shakir, has said that 8 to 10 per cent of people over age 65 are at risk of Alzheimer’s or associated dementia. Neurologist, Dr Shahid Mustafa, concurs, adding that although there are no population baseline studies, the Society estimates that overall, there are about 0.2 million patients of Alzheimer’s, or dementia, in Pakistan. Dr Shakir also expressed that many of today’s budding, energetic young people may fall prey to dementia.

They consider it critically important to invest now in health campaigns, with programmes to increase public awareness about dementia, provide support services for patients, and counselling for family members and caregivers. Added Dr Mustafa, “We also need to train more doctors; they will be required in larger numbers in treating dementia-related diseases, as the population ages. People need to adopt more heart-healthy lifestyles, go easy on greasy and processed foods, and maintain physical activity.”

Some of the common symptoms of dementia include lack of sleep, aggressive behaviour, agitation, irritability. Patients may walk out of the house, thinking they’re going into the next room, or they may forget they just have had a full meal, and want to eat again.

Alzheimer’s can rip apart relationships; it is as if entire lives get wiped out, all those years — and memories — of productive, eventful, action packed lives. Patients can spend long stretches of time just staring at walls, unable to do even the simplest of tasks themselves. For caregivers, it can be a nightmare.

As with other diseases, hereditary factors can play a part in Alzheimer’s. Other predisposing factors include stroke, high blood pressure, high cholesterol. This progressive neurological disorder destroys memory cells in the brain, causing memory loss and cognitive decline, affecting the person’s thinking and behaviour. In the brain itself, abnormal clumps and inclusions are formed, which interfere with its normal functioning.

A close friend, describing the development of Alzheimer’s in a relative, talked about how the entire family felt devastated. “She’s relatively young–she was in her early 60’s when this began; at first we didn’t know what the problem was. She’s the last person one would have thought of for such a development, she was always so lively, so intellectual. Now, she’s bedridden and requires round the clock nursing care. The emotional pain for the immediate family is immense. Her children’s lives are passing her by, and she’s not aware of anything.”

Alzheimer’s is a tragic disease that develops almost imperceptibly. Yet, once the process starts, it escalates quite swiftly. Symptoms? Forgetfulness, which is hard to detect since we all suffer from occasional memory lapses; difficulty in putting a name to a familiar face; forgetting an errand or an essential item while shopping. When that memory loss becomes a constant, it is a matter of concern. Gradually, more symptoms appear; language capability is increasingly impaired, as is the ability to multi-task, such as in getting dressed.

There are many reasons why it’s important to seek a doctor’s diagnosis as early as possible. At the early stages, the damage caused by Alzheimer’s can be contained, and for that, the right medications are available. The tragic part of Alzheimer’s is that, currently, there is no medication available that can reverse the disease.

Since the causes of dementia can be several, symptoms need to be watched, to determine the exact form of required treatment. There are even conditions and diseases that can mimic Alzheimer’s symptoms, but, fortunately, are reversible. Currently available treatments for Alzheimer’s offer hope, in that they can successfully stem the onslaught of this disease, even if they can’t entirely cure the patient.

While there have been significant advances in diagnostic testing methods for Alzheimer’s that use brain scans and spinal taps, and such methods may be useful even at the pre-clinical stage, at present there is no single test that can diagnose Alzheimer’s disease with 100 per cent accuracy. Doctors must use a variety of assessments and laboratory measurements to make, what is referred to as, a “differential diagnosis.” This way, they are able to rule out other possible causes for the symptoms. Presently, a definitive diagnosis of Alzheimer’s is possible only by examining brain tissue after death.

The social and economic costs of this disease are immense: life expectancy changes with Alzheimer’s, averaging four to eight years following onset–which is also why early diagnosis is important; it enables patients and their families to take action to prepare for worsening symptoms and make appropriate plans for the future. Family members and caregivers face very high emotional stress. There are often additional health costs, especially with frequent hospitalisation.

Experts estimate that by 2060, 68 per cent of people could be living in highly populated, low income, developing countries. Pakistan is a prime example, with an alarmingly high population growth rate of 2.4 per cent per annum. As stated by Dr Shakir and Dr Mustafa, roughly eight to 10 per cent of the population will be affected by Alzheimer’s; that’s several millions.

Worldwide, there could be many more millions suffering from Alzheimer’s, especially those in the above 85 age group. A well-known organisation, Alzheimer’s Disease International (ADI), advises that research funds be invested in critically needed dementia risk reduction strategies; they have a launched a programme on Global Action Against Dementia, which needs to be operationalised in all countries, including Pakistan.

The WHO has also given a Call for Action — they advise the medical profession and state policy makers that people must be put at the centre of health policies, so as to be able to provide improved services and support.

Alzheimer’s is one of the diseases that can neither be prevented or cured, which is why research on risk reduction is so important. Research is constantly ongoing; possible future remedies include studies on life-extending proteins, and key genetic changes that may point to the future possibility of getting Alzheimer’s.

Research even includes a tool that can be used on adults and children, which, by identifying their navigation skills, can point to the future possibility of Alzheimer. If this proves successful, risk reduction for such people can be specifically focused upon at early stages. Lack of vitamin D may also play a part–and Pakistanis suffer from this shortage in large numbers. Pharmaceutical products are also being studied; arthritis and anti-inflammatory drugs, for instance, could possibly offer protection against Alzheimer’s. Our desi diets, with daals, vegetables, spices are also considered beneficial–as long as we go easy on the fat content!

While scientists are desperately trying to find a panacea for the disease, it is critically important for the indispensable caregivers to have a hopeful, upbeat attitude.

The Benefits of Bridge

By Minhaj Qidwai

Recent research has found that playing bridge has a statistically significant and positive effect on our mental and emotional wellbeing. This has special significance for those of us trying to allay the sometimes inevitable onset of loneliness as a corollary of old age, and especially in the prevention of dementia. There are some prestigious evidence-based research studies that have been carried out that prove that bridge is not merely a sport of cards.

– Stirling University, UK, in conjunction with the English Bridge Education and Development, undertook a survey of over 7,000 people, most of whom were bridge players. A majority of respondents indicated that playing bridge brought benefits to them personally in the form of the game having a competitive element; facilitating socialising and deriving enjoyment in being with friends in an enjoyable activity; and — the most commonly attributed benefit — being mentally stimulating and invigorating. This contributed to a greater sense of wellbeing than average.

– Comparison was possible with data from the English Longitudinal Study of Aging. It was proven that undertaking some form of activity that tests mental agility on a daily basis helps to protect the elderly population from dementia and Alzheimer’s. There is also a body of research which demonstrates that social interaction among the elderly can stave off cognitive decline. Bridge does both, such is its format. The study shows that bridge provides both mental stimulation and social engagement. Although not a cure for dementia, there is scientific evidence that playing bridge can contribute to helping to keep the brain healthy.

– Studies at Berkley confirm that playing contract bridge increases immune cells in the regular players. “Contract bridge was ideal for what we were after,” said the researchers. Bridge players have to plan ahead, they use working memory, they deal with sequencing, initiation and numerous other higher order functions with which the dorsolateral cortex is involved.

– The study also found that seniors, who regularly engaged in pastimes that stretched their minds lowered their risk of developing Alzheimer’s disease and other dementias by as much as 75 per cent, compared with those who didn’t exercise their mind. Chicken-and-egg problem… Do mental activities really prevent dementia, or does dementia cause people to lose interest in mental activities? By screening out anyone who might have had dementia at the outset from their analysis, the researchers showed that leisure activities influenced dementia in their study, and not the other way around. Internationally, bridge is a part of the Olympics and Mind Sports along with scrabble and chess. It needs to be promoted in Pakistan as a healthy mental exercise to socialise, to network and to keep the brain cells multiplying in order to avoid dementia. Those who would like to participate in a drive to promote a more mentally and emotionally healthy society in Pakistan, by promoting Mind Games, should think of promoting and teaching a wider audience how to play bridge. At least it will bring four people together — and that can’t hurt.

Note: The writer is a medical doctor and the President of the Karachi Bridge Association.