Prevalence of dementia among the elderly and health care needs for people living with dementiain an urban community of central Vietnam
Doan Vuong Diem Khanh1*, Vo Van Thang1, Ho Dung1, Tran BinhThang1, Hoang DinhTuyen2, Hoang Dinh Hue2, Le Dinh Duong2
ABSTRACT
Introduction: Dementia is one of the major causes of disability and dependency among older people. There is little research on the prevalence of dementia, its related factors and health care needs for people living with dementia in Vietnam. Aims: The aims of this study are: (i) to examine the prevalence of dementia, its related factors among people aged 65 years and abovein Hue City of Vietnam, (ii) examine the needs of health care for dementia patients. Methods: 905 people aged 65 years and aboveliving in Hue City in central Vietnam were interviewed and examined. MMSE test (Mini Mental State Examination) was used as a screening instrument for dementia. Diagnosis of dementia was undertaken using ICD-10
research criteria. Results:Overall prevalence estimates for dementia was 9.4%. Age, medical history of stroke, physical activities and entertaining activities were significantly associated with dementia. The most common health care needs for people living with dementia were medication (76.5%), receiving consultation regarding how to care for people with dementia (75.3%), having support and professional advice on how to deal with mental and behavioral disorders (63.5%).
Conclusion: In this population, probable dementia is common. Comprehensive care delivery for people living with dementia is urgently needed in Vietnam.
Keywords: Dementia, prevalence, related factors, health care needs, Vietnam.
1 Institute for Community Health Research (ICHR), Hue University of Medicine and Pharmacy 2 Faculty of Public Health, Hue University of Medicine and Pharmacy
* Corresponding author: Doan Vuong Diem Khanh, Institute for Community Health Research (ICHR), Hue University of Medicine and Pharmacy (Hue UMP), 06 Ngo Quyen Street, Hue city, ThuaThien Hue province, Vietnam. Fax: 00-84-984- 118-925. Website: http://iccchr-hue.org.vn/ Email: [email protected]
INTRODUCTION
Life expectancy of human beings has been increasing worldwide. In Vietnam, people aged 60 years and over occupy 10.2% of population, whereas the percentage of people aged 65 years and over is 7.1%1. Vietnam is now in the period of aging population. The time for Vietnamese population to change from aging population into the aged population is predicted to be much shorter than many other nations1.
Challenges of aging population issue, including access to health care for the elderly, have been especially paid attention by many countries in general and Vietnam in particular.
Dementia is among the leading causes of disability and death among the elderly2. It not only affects seriously the patient’s quality of life but also physical, psychological and socioeconomic impact on caregivers, family members and society2.
Worldwide, there are approximately 35.6 million people living with dementia and 7.7 million new cases every year. Most of researches worldwide recognize that prevalence of dementia increases remarkably with increasing age. The prevalence of dementia is approximately 1% among people aged 60-64, 5-10% among people aged 65 and over, and up to 30-50% among people aged 85 and over2.
Up to now, there are very few studies in Vietnam regarding epidemiological aspects of dementia as well as the needs of health care for people living with dementia in Vietnam. A large study among 8,965 persons in an urban community in the north of Vietnam (Thai Nguyen city) in the year 2000 revealed that prevalence of dementia was 0.64% of the general population and 7.9% among the
elderly above 60 years old3.
A study on the prevalence of dementia in a rural area of Vietnam (Ba Vi district) conducted in 2005 among 5,712 adults aged 60 years and over in 2006 found that the prevalence of dementia was 4.6% among this population4. This prevalence of dementia increases with age. Prevalence of dementia among persons aged 65 years and over was 5.8%, among those aged 60-64 was 0.8%, aged 70-74: 3.8%, aged 75-79: 5.9%, aged 80-84:
8.5% and among those aged above 85 was 16.4%. Prevalence of dementia reduced among the group of the elderly with higher education: This prevalence was 9.7% among group of elderly who just knew how to read and write, among group of primary school was 2.4%, group of secondary school and above was 1.8%4.
This study tries to examine the prevalence of dementia, its associated risk factors and determine the needs of health care for patients living with dementia in Hue city, Vietnam. The study will provide importance evidence regarding the burden of this syndrome, the related factors and the extent to which people living with dementia is in needs of health care.
This will help policy makers to design practical strategies and activities to improve mental health care and quality of life for thousands of people in central Vietnam.
METHODS
A cross sectional study was carried out in Hue city, central Vietnam between June and August 2014. Multi-stage cluster sampling method was used. Stage 1: 6 quarters in Hue city were randomly selected. Stage 2: from each quarter, 5 sub-administrative units were randomly selected. Stage 3: From 30 sub-administrative
units selected, a total of 905 individuals aged 65 and above, who were permanent residents, were randomly selected (based on the list of the elderly provided by the local commune health centers). A response rate of 98.7% was obtained. Data collection was undertaken using face to face interview at participants’
households with the assistant of family members when necessary. Diagnosis of dementia was undertaken using a two phase process. The first phase was the screening one for dementia using MMSE test (Mini Mental Status Examination). MMSE has been used widely in Vietnam and internationally. It is a brief 30-point questionnaire test. The total score ranges between 0-30. A total of 878 persons among 905 undertook MMSE test.
Individuals who had a total score of MMSE <
24 (MMSE positive) were recruited to enter the second phase to diagnose dementia by using ICD-10 criteria5. 280 persons did diagnostic test (253 persons with MMSE< 24 plus 27 persons not did MMSE). Individuals who could not undertake MMSE for any reasons were also examined for diagnosis of dementia (impairment of visual or hearing capacity).
Data analysis was undertaken using SPSS.16.
Descriptive statistics were used for presenting prevalence of dementia and demographic characteristics distribution of the study sample. Simple regression was undertaken for exploring associated factors of dementia (including age, sex, religion, occupation, education level, perceived household economic situation, family history of dementia, living situation, history of hypertension, heart disease, stroke, diabetes, blood lipid disorder, Parkinson; habits of smoking, drinking, physical and entertainment activity). Factors statistically associated with dementia were then entered into the multiple
logistic regression model to examine simultaneously factors associated with dementia while controlling for the effects of other factors.
ETHICAL APPROVAL
The study was approved by the Research committee of Hue University of Medicine and Pharmacy.
RESULTS
The sociodemographic characteristics of the participants were presented in Table 1. There are a majority of participants being females (64.6%) and a high percentage of them was
Table 1. Socio demographic chararteristics of the sample
widowed (39.9%). Most participants were Buddhism (67.3%). Regarding education level, nearly 20% were illiterate, 21.3% knew how to read and write and 24.2% attended primary school. 29.1% of participants’s main occupation (during lifetime) were farmers;
60.4% perceived their family economic situation as moderate. There were 9.1% of the elderly in this sample currently living alone.
PREVALENCE OF DEMENTIA AND ASSOCIATED FACTORS
Our results revealed that prevalence of MMSE positive (MMSE < 24) was 28.8%.
Prevalence of dementia and 95% CI are reported in Table 2. The overall prevalence estimates for dementia was 9.4% (12% in women and 4.7% in men). This ranged from 0.5% among people aged 65-69 years to 37.7%
among those aged 90 years and above.
Mean values for age of onset and total years living with dementia were 76.6 years
(SD=17.8) and 8 years (SD=15.0) respectively (results not shown in the tables)
Simple logistic regression revealed that age, sex, marital status, occupation, education level, living situation, medical history of stroke, habits of physical activities and habit of entertainment activities were statistically associated with dementia (p<0.05).
Table 3 presents the multiple logistic regression model examining the associated factors of dementia. Only independent variables which were statistically associated with dementia were presented in the table. The model found that only age, medical history of stroke, habits of physical activity and entertainment activity were statistically associated with dementia. The elderly aged 75 and above had higher risk of acquiring dementia compared to those of 65 to 69 years old. People with a history of stroke were 16 times higher probability of suffering from dementia than those without stroke. People
Table 2. Crude prevalence of dementia by sex
and age group Table 3. Multi-logistics regression model examines the associated factors of dementia.
lacking of physical activities and entertainment activities were associated with 1.9 and 2.0 fold higher probability of acquiring dementia than those engaging in physical activities and entertainment activities.
Independent variables included in the model:
age, sex, marital status, occupation, education level, living situation, medical history of stroke, habits of physical activities and habit of entertainment activities. Only independent variables which were statistically associated with dementia were presented in the table. NS:
non-significant
HEALTH CARE NEEDS FOR PEOPLE LIVING WITH DEMENTIA
Among 85 people living with dementia identified by this study, only 18.8% (n=16) had ever been examined and received some treatment for dementia; just 9.4% (n=8) reported having adequate treatment by health professionals.
Methods of treatment among group received treatment were medication only (87.4%), combination between medication and occupational therapy (6%), and occupational therapy only (6.3%). No cases received psychotherapy.
Health care needs for people living with dementia were presented in Table 4. The most common health care needs for people living with dementia (reported by patients and family members) were medication (76.5%), receiving consultation regarding how to care for people with dementia (75.3%), having support and professional advice on how to deal with mental and behavioral disorders of dementia patients (63.5%). Needs for psychotherapy, occupational therapy and physical therapy were identified by
approximately 42.4%, 29.4% and 29.4% of respondents respectively.
DISCUSSION
Prevalence of dementia and associated factors:
The overall prevalence of dementia in this study was 9.4% (95% CI, 7.6%-11.5%).
Compared with other studies conducted in Vietnam, this prevalence appears to be higher.
For example, one previous study conducted in 2006 among the elderly aged 65 years and above in a rural community of North Vietnam reported the prevalence of dementia of 5.8%4. One other study conducted in 2000 among the elderly above 60 years old in an urban community in North Vietnam reported dementia prevalence of 7.9 %3.
Findings of the prevalence of dementia in our study are in line with the range reported internationally, which indicated that prevalence of dementia among 65 years of age and above ranged between 5% - 10%2. One systematic review and meta-analysis of 11 epidemiological studies on dementia in Korea published in 1990-2013 found the pooled dementia prevalence among the elderly (aged
≥ 65 yr) was 9.2% (95% CI, 8.2%-10.4%), which was quite similar to that of our study6. Table 4. Health care needs for people living
with dementia
However, it is difficult to have an accurate comparison between studies due to differences regarding methodology, sampling methods, diagnostic criteria and age structure.
The findings that prevalence of dementia increased remarkably with the increasing of age in this study was consistent with the previous studies conducted in many other countries, such as China7, Tanzania8, Turkey9, India10. As prevalence of dementia increases with age, it is more accurate to compare the age specific prevalence of dementia between studies. One meta-analysis of dementia prevalence surveys, published between 1980 and 2010, among a total elderly population of 105,866 in 48 studies covered 21 provinces and municipalities in China7 showed that the pooled prevalence of dementia were 1.3%, 3.1%, 19.7% and 26.3% among the elderly aged 65- 69, 70-74, 80-84 and 85+ respectively, which appeared to be higher than those found in our study (0.5%, 1.5%; 13.1% and 25.3%
respectively). However, the prevalence of dementia among group aged 75-79 in our study was higher than that reported in the study of China (12% vs. 9.3%). Other recent study in rural China in 2011 also reported higher prevalence of dementia among groups aged 80- 84, 85-89 and 90+ compared to those revealed in our study (23.5%, 29.1%, 40.0% vs. 13.1%, 16.9% and 37.7% respectively11).
History of stroke was found to be a very strong predictor of dementia in our study, which increased the risk of dementia by up to 16 times. The mechanism of stroke as a risk factor of vascular dementia was well established. This finding is in agreement with the previous studies, which found that personal history of stroke was associated with higher risk of cognitive impairment and dementia among the elderly11,12.
Lacking habits of physical activities were associated with higher risk of dementia in our study was also supported by several previous studies. One study in China among 1,264 people aged 55 and above in a highly educated community revealed that individuals without habits of physical activities had 2.2 higher risk of dementia compared to those having habits of physical activities12. Importantly, one longitudinal study in the Netherland among 4,406 inhabitants aged 55 years and older during a follow up period up to 14 years found a higher level of physical activities to be associated with a lower risk of dementia (adjusted for age, sex, education , smoking, APOE-е4 carrier status, hypertension, BMI, diabetes, total cholesterol, HDL-cholesterol)13. Having engaged in entertainment activities was associated with lower risk of dementia in this study. One longitudinal cohort study examined lifestyle factors and risk of dementia was conducted in Australia (first assessed in 1988, followed up 16 years) among 2,805 men and women aged 60 years and older14. The study found that, in a proportional hazards model for dementia, daily gardening predicted a 36% lower risk of dementia, daily walking predicted a 38% lower risk of dementia in men, but there was no significant prediction in women14. The effect of daily gardening and walking on reducing risk of dementia might be considered as the combination effect of both physical and entertainment activities.
Needs of health care for people living with dementia
This study found that access to diagnosis and treatment was very low among this population.
Only 18.8% dementia patients have ever been diagnosed and received some treatment and only 9.4 % of cases reported having complied
the treatment (results not shown in the table).
This raised a very important point for public health intervention that need to target in the future. Raising awareness and knowledge among the public for early detection and diagnosis as well as compliance of treatment of dementia should be taken into account.
Among dementia patients who received treatment in our study, medication was the most common ways of treatment; other types of treatment (occupational treatment) were very limited or unavailable. Especially no case has received psychotherapy.
Health care needs for dementia patient are presented in Table 4. Our study found that the needs for medication, receiving consultation on how to care for people with dementia, having support and professional advice on how to deal with mental and behavioral disorders of dementia patients were especially high (76.5%, 75.3% and 63.5% respectively).
Needs for occupational therapy and physical therapy were identified by approximately 1 in 3 respondents. Noticeably, most of relatives and caregivers of patients had not been provided necessary information and skills on how to care for patients with dementia. Up to 75.3% of relatives and caregivers would like to receive consultation on how to care for dementia patients. The needs of receiving support and professional advice on how to deal with mental and behavioral disorders were also very high (63.5%). Helping family members to know on how to give care to patients have not only benefits for patients but also for caregivers in reducing their psychological distress. One systematic literature review of studies reported between 1990 and 2009 revealed manifestation of depressive symptoms appeared among 1 in 3 caregivers and these manifestation appeared to
be higher among care givers of dementia compared to those of other chronic diseases15.
CONCLUSION/ RECOMMENDATION In conclusion, this study found that dementia is common among the elderly in Hue City of Vietnam. Age, history of stroke, habits of physical activities and entertainment activities were significantly associated with dementia.
Access to health care and treatment is very limited. This study pointed out some important recommendations which include strengthening health education for community in reducing risk factors of dementia (importantly, decreasing stroke among the elderly via management of hypertension, encouragement of physical activities and entertainment activities). Early diagnosis of dementia and providing comprehensive care delivery for people living with dementia are urgently needed in Vietnam.
LIMITATIONS
Some limitations of this study should be taken into account. First, this study was cross sectional study and we could not ascertain the time sequence between independent variables and dependent variable. Therefore, cause effect relationship could not be able to establish. Secondly, no subtype of dementia was clarified which might had different risk factors. We were not able to include hospitalized people in our sample as well.
DECLARATION OF CONFLICTING INTERESTS
There are no known conflicts of interest and all authors claim responsibility for the manuscript.
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