LETTER TO THE EDITOR
Prevalence and management of dementia in nursing home residents in Tunisia Introduction Although dementia is common in the general population, its prevalence seems to be higher in nursing homes. Yet, despite its high prevalence and its major impact on daily activities and on the patient’s autonomy, dementia remains largely underdiagnosed and therefore undertreated in nursing homes throughout the world (Bergh et al., 2012) and probably also in Tunisia. Methods A cross-sectional study was performed from September to October 2012 among all consenting residents of Manouba nursing home. Cognitive functions were assessed using the Montreal Cognitive Assessment (MoCA) test. We excluded subjects who could not take the MoCA test because of a severe sensory deficit or a severe psychiatric condition. Population characteristics
At the time of the study, the population of Manouba nursing home residents consisted of 116 subjects (73 males and 43 females). After applying the exclusion criteria, we retained 77 subjects. The average age was 72.6 years +/ 10.3. Results The prevalence of dementia in our population was 58.4% (n = 45). Among the 45 demented subjects, only three (or 6.7% of dementia cases) were already diagnosed as such. Of these three subjects, three had severe dementia (MoCA scores of 3 and 5). The third had a MoCA score of 19. The prevalence of dementia did not differ significantly by gender, age, marital status, level of education, profession, current financial situation, or depending on the participation in the activities at the center. Patients with dementia received significantly fewer visits and were taking significantly fewer drugs than patients without dementia (Table 1). Copyright # 2014 John Wiley & Sons, Ltd.
Only one patient was on anticholinesterase treatment: donepezil at the dose of 5 mg qd. This subject had a MoCA score of five. None of the three patients known to have dementia had any contraindication to a cholinesterase inhibitor treatment. Discussion Dementia is the most common neuropsychiatric disorder nursing homes, with a median prevalence of 58% in all studies (which corresponds to the proportion found in our study) (Seitz et al., 2010). These high figures are explained not only by the steady increase in the prevalence of dementia in the general population but also by a greater risk of institutionalization in demented versus non-demented subjects (Cheng et al., 2012). In our population, only one patient with dementia out of five was diagnosed as such at the time of the study. This underdiagnosis of dementia in nursing homes is commonly reported in the literature worldwide (Cheng et al., 2012). Factors associated with underdiagnosis of dementia in institutionalized old patients include mild to moderate cognitive impairment, low disability as well as absent or mild behavioral disturbances (Cherubini et al., 2012). Physicians without special training in diagnosing dementia might be unable to recognize the cognitive symptoms, especially at an early stage or in frail complex subjects (Cherubini et al., 2012; Cheng et al., 2012). In our population, only one subject was prescribed anticholinesterase treatment. In the study by Cherubini et al. (Cherubini et al., 2012) in Italy, only 5% of demented subjects received specific anti-dementia treatment. However, cholinesterase inhibitors are now recommended in patients with Alzheimer’s disease, especially in cases with mild to moderate severity and to a lesser extent in severe cases. There is some evidence that these drugs are more effective when initiated early in the course of the disease (American Psychiatric Association, 2007). This underprescription of anti-dementia drugs among nursing home residents is probably due to Int J Geriatr Psychiatry 2014; 29: 877–879
878
Letter to the Editor Table 1 Sociodemographic and clinical factors associated with dementia Participants with dementia
Participants without dementia
p value
26 (58% ) 19 (42% ) 73.4
22 (69% ) 10 (31% ) 71.5
0.352
Married Divorced Single Widow(er)
2 (4% ) 16 (36% ) 13 (26% ) 14 (28% )
3 (9% ) 13 (41% ) 15 (42% ) 1 (3% )
0.18
Illiterate Primary Secondary Higher education
23 (51% ) 16 (36% ) 5 (19% ) 1 (4% )
20 (63% ) 8 (25% ) 3 (19% ) 1 (6% )
0.749
Rural Urban
21 (47% ) 24 (53% )
12 (38% ) 20 (63% )
0.488
No Yes
33 (73% ) 12 (27% )
26 (81% ) 6 (19% )
0.299
1.6
3.4
0.023
40 (89% ) 5 (11% ) 4.8
28 (88% ) 4 (13% ) 4.2
0.236
3.2
2
0.02
34 (76% ) 11 (24% )
29 (91% ) 3 (9% )
0.13
40 (89% ) 5 (11% )
30 (94% ) 2 (6% )
0.69
35 (78% ) 10 (22% ) 4.4
30 (94% ) 2 (6% ) 4.3
0.11
Gender Males Females Mean age Marital status
0.462
Educational level
Geographic setting Financial autonomy
Mean number of received visits (per month) Participation in the activities at the center No Yes Mean Cumulative Illness Rating Scale modified for Geriatrics (CIRS-G) score Mean number of prescribed drugs Antidepressants No Yes Benzodiazepines No Yes Antipsychotics No Yes Mean Katz Index of Independence in Activities of Daily Living (ADL) score
several factors including underdiagnosis of dementia, the high proportion of patients with severe dementia as well as the complexity and frailty of nursing home residents, possibly contraindicating these drugs. Furthermore, many doctors in nursing homes lack an appropriate training for the use of these drugs. Several studies emphasize the importance of specialized training in the diagnosis and management of dementia for doctors working in nursing homes (Cheng et al., 2012).
Conclusion Dementia is largely underrecognized in nursing homes in Tunisia as in other countries. Whereas anti-dementia drugs appear to be insufficiently prescribed, other psychotropic drugs are likely overprescribed. Copyright # 2014 John Wiley & Sons, Ltd.
1
0.867
Routine screening for cognitive impairment seems paramount in order to ensure early diagnosis. Management should rely on the latest guidelines, including both pharmacological and non-pharmacological treatment options. Conflicts of interest None declared. Key points
• •
Dementia is widely underrecognized in nursing homes in Tunisia as in most countries. Management of dementia in nursing homes in Tunisia is often delayed and inappropriate. Int J Geriatr Psychiatry 2014; 29: 877–879
Letter to the Editor
References American psychiatric association 2007. Treatment of patients with Alzheimer’s disease and other dementias, Second Edition. Bergh S, Holmen J, Saltvedt I, Tambs K, Selbaek G. 2012. Dementia and neuropsychiatric symptoms in nursing-home patients in Nord-Trondelag County. Tidsskrift for Den Norske Laegeforening 132: 1956–1959. Cheng ST, Lam LC, Chow PK. 2012. Under-recognition of dementia in longterm care homes in Hong Kong. Aging and Mental Health 16: 516–520. Cherubini A, Ruggiero C, Dell’aquila G, et al. 2012. Underrecognition and undertreatment of dementia in italian nursing homes. J Am Med Dir Assoc 13: 759 e7–759 e13.
Copyright # 2014 John Wiley & Sons, Ltd.
879 Seitz D, Purandare N, Conn D. 2010. Prevalence of psychiatric disorders among older adults in long-term care homes: a systematic review. Int Psychogeriatr 22: 1025–1039.
SAMI OUANES, FETEN FEKIH-ROMDHANE
AND
WAHID MELKI
Razi Hospital, Tunis, Tunisia *E-mail: [email protected] Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/gps.4119
Int J Geriatr Psychiatry 2014; 29: 877–879
Prevalence and management of dementia in nursing home residents in Tunisia Introduction Although dementia is common in the general population, its prevalence seems to be higher in nursing homes. Yet, despite its high prevalence and its major impact on daily activities and on the patient’s autonomy, dementia remains largely underdiagnosed and therefore undertreated in nursing homes throughout the world (Bergh et al., 2012) and probably also in Tunisia. Methods A cross-sectional study was performed from September to October 2012 among all consenting residents of Manouba nursing home. Cognitive functions were assessed using the Montreal Cognitive Assessment (MoCA) test. We excluded subjects who could not take the MoCA test because of a severe sensory deficit or a severe psychiatric condition. Population characteristics
At the time of the study, the population of Manouba nursing home residents consisted of 116 subjects (73 males and 43 females). After applying the exclusion criteria, we retained 77 subjects. The average age was 72.6 years +/ 10.3. Results The prevalence of dementia in our population was 58.4% (n = 45). Among the 45 demented subjects, only three (or 6.7% of dementia cases) were already diagnosed as such. Of these three subjects, three had severe dementia (MoCA scores of 3 and 5). The third had a MoCA score of 19. The prevalence of dementia did not differ significantly by gender, age, marital status, level of education, profession, current financial situation, or depending on the participation in the activities at the center. Patients with dementia received significantly fewer visits and were taking significantly fewer drugs than patients without dementia (Table 1). Copyright # 2014 John Wiley & Sons, Ltd.
Only one patient was on anticholinesterase treatment: donepezil at the dose of 5 mg qd. This subject had a MoCA score of five. None of the three patients known to have dementia had any contraindication to a cholinesterase inhibitor treatment. Discussion Dementia is the most common neuropsychiatric disorder nursing homes, with a median prevalence of 58% in all studies (which corresponds to the proportion found in our study) (Seitz et al., 2010). These high figures are explained not only by the steady increase in the prevalence of dementia in the general population but also by a greater risk of institutionalization in demented versus non-demented subjects (Cheng et al., 2012). In our population, only one patient with dementia out of five was diagnosed as such at the time of the study. This underdiagnosis of dementia in nursing homes is commonly reported in the literature worldwide (Cheng et al., 2012). Factors associated with underdiagnosis of dementia in institutionalized old patients include mild to moderate cognitive impairment, low disability as well as absent or mild behavioral disturbances (Cherubini et al., 2012). Physicians without special training in diagnosing dementia might be unable to recognize the cognitive symptoms, especially at an early stage or in frail complex subjects (Cherubini et al., 2012; Cheng et al., 2012). In our population, only one subject was prescribed anticholinesterase treatment. In the study by Cherubini et al. (Cherubini et al., 2012) in Italy, only 5% of demented subjects received specific anti-dementia treatment. However, cholinesterase inhibitors are now recommended in patients with Alzheimer’s disease, especially in cases with mild to moderate severity and to a lesser extent in severe cases. There is some evidence that these drugs are more effective when initiated early in the course of the disease (American Psychiatric Association, 2007). This underprescription of anti-dementia drugs among nursing home residents is probably due to Int J Geriatr Psychiatry 2014; 29: 877–879
878
Letter to the Editor Table 1 Sociodemographic and clinical factors associated with dementia Participants with dementia
Participants without dementia
p value
26 (58% ) 19 (42% ) 73.4
22 (69% ) 10 (31% ) 71.5
0.352
Married Divorced Single Widow(er)
2 (4% ) 16 (36% ) 13 (26% ) 14 (28% )
3 (9% ) 13 (41% ) 15 (42% ) 1 (3% )
0.18
Illiterate Primary Secondary Higher education
23 (51% ) 16 (36% ) 5 (19% ) 1 (4% )
20 (63% ) 8 (25% ) 3 (19% ) 1 (6% )
0.749
Rural Urban
21 (47% ) 24 (53% )
12 (38% ) 20 (63% )
0.488
No Yes
33 (73% ) 12 (27% )
26 (81% ) 6 (19% )
0.299
1.6
3.4
0.023
40 (89% ) 5 (11% ) 4.8
28 (88% ) 4 (13% ) 4.2
0.236
3.2
2
0.02
34 (76% ) 11 (24% )
29 (91% ) 3 (9% )
0.13
40 (89% ) 5 (11% )
30 (94% ) 2 (6% )
0.69
35 (78% ) 10 (22% ) 4.4
30 (94% ) 2 (6% ) 4.3
0.11
Gender Males Females Mean age Marital status
0.462
Educational level
Geographic setting Financial autonomy
Mean number of received visits (per month) Participation in the activities at the center No Yes Mean Cumulative Illness Rating Scale modified for Geriatrics (CIRS-G) score Mean number of prescribed drugs Antidepressants No Yes Benzodiazepines No Yes Antipsychotics No Yes Mean Katz Index of Independence in Activities of Daily Living (ADL) score
several factors including underdiagnosis of dementia, the high proportion of patients with severe dementia as well as the complexity and frailty of nursing home residents, possibly contraindicating these drugs. Furthermore, many doctors in nursing homes lack an appropriate training for the use of these drugs. Several studies emphasize the importance of specialized training in the diagnosis and management of dementia for doctors working in nursing homes (Cheng et al., 2012).
Conclusion Dementia is largely underrecognized in nursing homes in Tunisia as in other countries. Whereas anti-dementia drugs appear to be insufficiently prescribed, other psychotropic drugs are likely overprescribed. Copyright # 2014 John Wiley & Sons, Ltd.
1
0.867
Routine screening for cognitive impairment seems paramount in order to ensure early diagnosis. Management should rely on the latest guidelines, including both pharmacological and non-pharmacological treatment options. Conflicts of interest None declared. Key points
• •
Dementia is widely underrecognized in nursing homes in Tunisia as in most countries. Management of dementia in nursing homes in Tunisia is often delayed and inappropriate. Int J Geriatr Psychiatry 2014; 29: 877–879
Letter to the Editor
References American psychiatric association 2007. Treatment of patients with Alzheimer’s disease and other dementias, Second Edition. Bergh S, Holmen J, Saltvedt I, Tambs K, Selbaek G. 2012. Dementia and neuropsychiatric symptoms in nursing-home patients in Nord-Trondelag County. Tidsskrift for Den Norske Laegeforening 132: 1956–1959. Cheng ST, Lam LC, Chow PK. 2012. Under-recognition of dementia in longterm care homes in Hong Kong. Aging and Mental Health 16: 516–520. Cherubini A, Ruggiero C, Dell’aquila G, et al. 2012. Underrecognition and undertreatment of dementia in italian nursing homes. J Am Med Dir Assoc 13: 759 e7–759 e13.
Copyright # 2014 John Wiley & Sons, Ltd.
879 Seitz D, Purandare N, Conn D. 2010. Prevalence of psychiatric disorders among older adults in long-term care homes: a systematic review. Int Psychogeriatr 22: 1025–1039.
SAMI OUANES, FETEN FEKIH-ROMDHANE
AND
WAHID MELKI
Razi Hospital, Tunis, Tunisia *E-mail: [email protected] Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/gps.4119
Int J Geriatr Psychiatry 2014; 29: 877–879
