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Journal of Alzheimer’s Disease xx (20xx) xx–xx DOI 10.3233/JAD-142655 IOS Press

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Prevalence of Mild Cognitive Impairment and Dementia among the Elderly Population of Qena Governorate, Upper Egypt: A Community-Based Study

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a Departments

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of Neuropsychiatry, Faculty of Medicine, Assiut University, Assiut, Egypt and head of Departments of Neuropsychiatry, Faculty of Medicine, Aswan University, Aswan, Egypt b Departments of Neuropsychiatry, Faculty of Medicine, Sohag University, Sohag, Egypt c Departments of Neuropsychiatry, Faculty of Medicine, South Valley University, Qena, Egypt d Public Health and Community Medicine, Assiut University Hospital, Assiut, Egypt

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Eman Khedra,∗ , Gharib Fawib , Mohammed Abd Allah Abbasc , Talal A. Mohammedc , Noha Abo El-Fetoha , Ghada Al Attard , Mostafa Noamana and Ahmed F. Zakic

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Accepted 12 November 2014

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Keywords: Alzheimer’s dementia, dementia, non-Alzheimer’s dementia, prevalence, Qena/Egypt, vascular dementia

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Abstract. Background: There are only a few reports which provide prevalence rates of mild cognitive impairment (MCI) and dementia specifically in Arabic countries. Objective: This study is aimed at estimating the prevalence of MCI and dementia among subjects aged ≥60 years using door-to-door survey in Qena Governorate/Egypt. Methods: We conducted a door-to-door survey with multistage probability random sampling. Screening of all subjects aged ≥60 years (n = 691) employed a simple questionnaire including changes in memory, behavior, and daily activity as well as the Mini-Mental State Examination. Suspected cases were referred to the hospital for full clinical examination, DSM-IV diagnostic criteria, Hachinski Ischemic Score, neuroimaging, and laboratory investigations if indicated. Results: Of the 691 participants, 12 cases had MCI, giving a crude prevalence rate (CPR) of 1.72/100 and 35 were identified as positive for dementia with a CPR of 5.07/100. The highest age-specific prevalence rates were recorded among subjects ≥85 years old (100/100). The CPRs were significantly higher in urban than rural areas (7.1 versus 3.27/100, respectively; p = 0.03), in industrial areas than non-industrial areas (13.23 versus 1.99; p = 0.00001), and in illiterate than literate participants (10.12 versus 2.25/100; p = 0.00001). Conclusion: Overall, the prevalence rate of MCI and dementia were lower in Qena/Egypt than in other countries. Advanced age, illiteracy, and living in an industrial area were found to be associated with dementia.

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INTRODUCTION ∗ Correspondence

to: Eman M. Khedr, Prof. of Neurology, Department of Neurology, Assiut University Hospital, Assiut, Egypt, and head of departments of Neuropsychiatry, Faculty of Medicine, Aswan University, Aswan, Egypt. Tel.: +02 088 2 333355; Fax: +02 088 2333327; E-mail: [email protected].

The prevalence of age-related health problems is becoming an important public health concern as the proportion of older individuals grows in populations worldwide [1]. Dementia is a complex syndrome characterized by global and irreversible cognitive decline

ISSN 1387-2877/14/$27.50 © 2014 – IOS Press and the authors. All rights reserved

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SUBJECTS AND METHODS

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are situated at Qift and Nagh Hammadi districts where there are sugarcane factories, aluminum processing, spinning and weaving, paper, natural gas, and light tar factories. The aluminum complex is one of the largest industrial areas in the Middle East. The sample size was based on an expected prevalence of 4% among elderly, with a 2 percentage point error and a 95% confidence interval, allowing for a 10% refusal to participate. The study was conducted over a two-year period from September 1, 2011 to August 31, 2013. The last day of survey is considered the prevalence day. The local ethics committee of South Valley University, Faculty of Medicine approved the study stressing that consent for various steps of the work.

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First stage: Selection of the study sites A simple random sample of 10 study areas was selected from Qena Governorate. First, according to the geographic location, we selected three districts randomly of 11 districts, then we selected two villages (areas) from each district, that were Nagada (in the west bank of Nile), Qift (in the east of Nile), and Dishenna (in the north bank of the Nile) with a total of six villages considered as rural populations. We selected urban areas from each city (Qena city and Nagh Hammadi city), with a total of four urban areas using simple random technique and according to local security safety.

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that is severe enough to undermine daily functioning [2]. The worldwide prevalence of dementia is 6.2% for those ≥65 years of age (8.8% women, 3.1% men). Current age-adjusted estimates of the prevalence of dementia in 65 year olds are high (≥5%) in Europe [3, 4], the United States [5, 6], and certain Asian and Latin American countries, but consistently low (1–3%) in India [7] and sub-Saharan Africa [8]. In the Upper Egypt (Assiut), the age-adjusted prevalence of dementia in people aged 65 years and older was 5.9% [9]. However, two other recent Egyptian studies in Al-Quseir city and Al Kharga District [10, 11] reported a prevalence 2.01 and 2.26%, respectively, in people aged ≥50 years. Among Arabs living in Wadi Ara, a community south of Haifa in Israel, the crude prevalence rate (CPR) estimate for all dementias was 21% in those aged over 60 years [12], which is considered to be the highest prevalence rate in the world. Increasing age is the most consistent risk factor for dementia worldwide. In addition, whereas illiteracy or low educational achievement has been shown to be a robust risk factor for dementia [13], intellectually stimulating, socially engaging, or physical activities might lower the risk of dementia [14]. Vascular factors, such as hypertension [15], dyslipidemia [16], type 2 diabetes [17], subclinical atherosclerosis [18], and arrhythmias [19] are associated with greater risk of cognitive impairment and dementia. In light of the continuing rise in the population of elderly persons in Egypt and the impact of impaired cognitive function on quality of life, accurate and effective prevalence for early recognition of mild cognitive impairment (MCI), Alzheimer’s disease (AD), and non-Alzheimer’s dementia is desirable. The aim of the present study was to estimate the prevalence of MCI and dementia among the elderly population (≥60 years) of Qena Governorate (Nile valley) and to compare it with other studies in different countries. We hope that this study will inform decision makers and the public on services needed for dementia sufferers.

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A cross sectional community based study was implemented in Qena governorates in Southern Egypt. The Nile valley is at its narrowest in Egypt here and the arable land, a green strip only 1 or 2 km on either side of the river, is bordered by barren desert on both sides. Qena is an agricultural and industrial governorate. There are two industrial zones in the governorate; these

Selection of the households A systematic random sample of households in the 10 areas was then taken by selecting every third household in each of the 10 study sites. If families refused the examination, we replaced them with the family next door [20]. Out of the 10 study areas, 691 individuals aged ≥60 years were recruited out of a population of 8,027. Second stage Initial diagnosis was based upon a general two-part screening questionnaire with part I recording sociodemographic details and part II involving a screening questionnaire specially designed to detect cognitive impairment. It included the Memory and Executive Screening test (MES) to detect MCI and early dementia [21] and the Mini-Mental State Examination (MMSE) [22]. Both screening tests were applied to all persons at or above the age of 60 years, at their homes, to pick up suspected cases of MCI and dementia. MES

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This involved neurological examination of all positive cases after referral to the Neuropsychiatric Department at South Vally University Hospital. For individuals with suspected cognitive impairment, history, clinical and neurologic evaluations, computed tomographic or magnetic resonance imaging (MRI) scans, and review of laboratory data were performed for each individual. Evaluation employed: 1) DSM-IV [23] criteria to confirm the diagnosis and differentiate different, types of dementia; 2) the Hachinski Ischemic Score [24] to differentiate vascular dementia (VaD) from other types of dementia (a score of 7 or higher indicates VaD, a score of 5 or 6 indicates mixed dementia, and a score lower than 5 indicates AD); 3) logical memory score of WMS-III [25]; 4) Clinical Dementia Rating scale (CDR) [26]; and 5) the Instrumental Activities of Daily Living Scale [27], which provides a

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measure of social and occupational functioning that is used as a threshold for accepting a cognitively impaired subject as being demented. To screen for mood disorders, individuals with a cut-off score +11 in the Hospital Anxiety and Depression Scale (HADS) [28] were excluded. The following criteria was required for inclusion within the MCI group: 1) A recent history of symptomatic worsening in memory, which was supported by information from one of their relatives, with MES total score, 75–62; 2) an objective memory impairment (at least 1 standard deviation below control group) as demonstrated by logical memory test from the WMS-III; 3) a CDR global score of 0.5 (questionable dementia) with a memory score of at least 0.5; 4) failure to meet DSM-IV criteria for dementia; and 5) absence of other factors that may provide a better explanation for memory loss (e.g., depression as measured by HADS). The following criteria were required for inclusion within AD group: 1) a history of progressive cognitive worsening for at least 1 year; 2) Hachinski score of ≤4; 3) a CDR global score of 1 or more with a memory score of at least 1 (mild AD); and 4) DSM IV criteria for AD after full workup including neurologic, imaging, and laboratory tests. For diagnosis of VaD, the following criteria were required for inclusion: 1) DSM IV criteria for diagnosis of VaD; 2) Hachinski Ischemic Score of 7 or higher. The diagnostic criteria for Parkinson’s disease dementia (PDD) were as follows: 1) patients fulfilled the U.K. Parkinson’s Disease Brain Bank Criteria for idiopathic PD [29]; 2) the CDR of PDD was ≥1; and 3) they met criteria for PDD on the DSM-IV. Twenty five subjects aged 60 years or older who had MES scores exceeding 75 were recruited from the survey and used as a control group. The following criteria were required for inclusion within the control group: 1) did not meet DSM-IV criteria for dementia; 2) had normal/near normal independent function; 3) had no objective memory impairment demonstrated by performance of story (logical memory) subtest from WMS-III; 4) had a CDR global score of 0; and 5) did not meet criteria for MCI.

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was developed in which the instruction and content were acceptable for illiterate and low-educated people. There are three indicators for cognition evaluation. One sentence with ten main points is remembered three times and free delay recalled two times. The summation of the five recall scores is MES-5R. This reflects instant and delayed memory and learning ability. The four subtests of the MES-EX are the category fluency test, the sequential movement tasks, conflicting instructions task, and Go/No-go task. This reflects executive function. The total possible score is 100, with 50 each for the MES-5R and MES-EX. In terms of the MES total score, 75–62 appears to be the range for patients with MCI. Subjects exceeding 75 were usually considered as normals, and subjects scoring less than 62 may be suspected as having dementia. As most of the studied population was illiterate, we reduced the full score on the MMSE to 28 instead of 30 points as recommended by Farrag et al. [9]. Thus, in suspected cases of dementia, we considered the lower value equal to 23/30 points for educated subjects (≥6 years education) and 21/28 points for illiterates. Staging of dementia was done according to the results of MMSE. For the illiterate participants, we defined a score of 17–21 for mild, 9–16 for moderate, and less than 9 for a severe degree of dementia. These values correspond to the values of 19–23, 11–18, and less than 11 for mild, moderate, and severe dementia on the full score of 30 points in educated people. The team workers received three weeks of training on how to carry out the protocol before starting the study.

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Statistical analysis Analysis followed after data verification and correction. All data were analyzed with the aid of the SPSS version 16 (http://www.spss.com). Chi-square test (p < 0.05) was used to analyze differences in CPR between proportions of men/women, industrial/non-

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RESULTS A total of 8,027 (1,076 families) inhabitants were included in the study. If an inhabitant refused to participate (40 families), they were replaced by the next-door family in the survey. Of the study population, 691 (8.6%) were age ≥60 years of age. MCI was recorded in 12 cases out of 691 with a CPR of 1.74/100 inhabitants, while dementia was diagnosed in 35/691 inhabitants giving a CPR of 5.07/100. Another seven cases were excluded after reevaluation by clinical examination, HADS, and laboratory investigations, five cases were diagnosed with depression, and two cases had renal impairment. The highest CPR was recorded for AD (1.74/100) followed by VaD and PDD (1.3/100 and 1.01/100, respectively). For VaD, the CPR of cognitive deficits following a single stroke was slightly higher than multi-infarct dementia (0.72 versus 0.58/100). Mixed dementia was recorded in four cases with a CPR of 0.58/100. The prevalence among females

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was slightly, but not significantly, higher than for males (5.41/100 versus 4.7/100). The CPR was significantly higher in urban than rural areas (7.1 versus 3.27 /100, respectively; p = 0.03; OR = 2.26 with 95%CI of 1.11–4.62 95%). In addition, the CPR in industrial areas (Qift and Nagh Hammadi) was higher than non-industrial areas [13.23 versus 1.99; p = 0.00000; OR = 7.59 (95% CI 3.53–15.95)]. Illiterate participants had a significantly higher CPR than those who were literate [10.12 versus 2.25; p = 0.000015; OR = 4.89 (95% CI 2.31–10.36)] (Table 1). AD represented 34.3% of all types of dementia, followed by VaD (25.7%), PDD (20%), and mixed dementia (11.4%). In general, the prevalence rate steadily increased with age for both genders but then rose more rapidly among those 80–84 years old (33.3/100) and ≥85 years (100%). The CPRs for the five years age groups from 60 years to 85 and over were 2.37, 3.32, 5.56, 6.25, 33.3, and 100, respectively. The increase in the CPR is shown in Table 2. Patients with MCI had a mean age of 67.3 ± 7.1 years, with a male/female ratio of 7/5. Most of them were illiterate (8/4), from urban areas (urban/rural: 10/2), or from industrial areas (industrial/ nonindustrial: 7/5). Most of them had at least one risk factor: hypertension was the most common (four cases) followed by two cases each of diabetes mellitus,

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Table 1 The crude prevalence rate (CPR) of different types of dementia in Qena Governorate/Egypt

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industrial, illiterate/literate, and urban/rural. ANOVA test was used to analyze differences between the three main groups of dementia. Odds ratio (OR) and their associated 95% confidence intervals (95% CI) were computed using descriptive statistics. The results were expressed as mean ± SD.

CPR (number of cases /number of population) CPR of mild cognitive impairment 12/691 [m/f; 7/5] CPR of dementia 35/691 CPR of primary degenerative dementia 21/691 CPR of Alzheimer’s disease 12/691 CPR of Parkinson’s disease dementia 7/691 CPR of corticobasal ganglionic degeneration 2/691 CPR of vascular dementia 9/691 CPR of post stroke infraction dementia 5/691 CPR of multiple lacunar infarction 4/691 CPR of mixed dementia 4/691 CPR of neoplasm dementia 1/691 CPR of Dementia among gender distribution Male 16/340 Female 19/351 CPR of Dementia in relation to residence Urban 23/324 Rural 12/367 CPR of Dementia in relation to education Illiterate 25/247 Literate 10/444 CPR of Dementia in relation to industrial/non-industrial areas Industrial 25/189 non-Industrial areas 10/502

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CPR/100

95%CI

1.7 5.07 3.04 1.74 1.01 0.29 1.3 0.72 0.58 0.58 0.14

0.75–2.72 3.39–6.74 1.74–4.34 0.75–2.72 0.26–1.76 0.0–0.69 0.45–2.15 0.09–1.36 0.01–1.15 0.01–1.15 0.0–0.43

4.71 5.41

2.4–7.01 2.98–7.85

7.1∗ 3. 27

4.2–10 1.42–5.12

10.12∗∗∗ 2.25

6.15–14.1 0.86–3.65

13.23∗∗∗∗ 1.99

8.04–18.4 0.76–3.23

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Table 2 Age- and gender-specific crude prevalence rate (CPR) of dementia

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5.07 4.71 5.41

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2.37 2.45 2.3

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2.63 1.26 1.37

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ischemic heart disease, and hyperlipidemia. Patients with AD had mean age of 69.3 ± 7.7 years, with a male/female ratio of 5/7. Most of them were illiterate (9/3), and from urban (urban/rural: 8/4) or industrial areas (industrial/ non-industrial: 10/2). Five cases had one risk factor (diabetes mellitus or hypertension). Details included in Table 3. Patients with VaD had a mean age 71.3 ± 7.1 years, with a male/female ratio of 5/4. Most of them were illiterate (6/3) and from urban (urban/rural: 5/4) or industrial areas (industrial/non-industrial: 5/4). All of them had at least one or two risk factors: hypertension was the most common (eight cases), followed by history of previous stroke (five cases), and two cases each of ischemic heart disease, diabetes mellitus, and hyperlipidemia. Patients with PDD had mean age of 83.75 ± 4.8 years, with a male/female ratio of 5/2. Most of them were illiterate (5/2) and from urban (urban/rural: 2/5) or industrial areas (industrial/ non-industrial: 4/3). All cases had at least one risk factor (diabetes mellitus and/or hypertension) and one case had ischemic heart disease. Details illustrated in Table 3.

95%CI

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% of studied population (n = 5920)

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Number of inhabitants (population at risk)

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6.25 5.88 6.67

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DISCUSSION This study is a part of a large project to estimate the CPR of major neurological disorders in Qena Governorate/Upper Egypt. With improvements of general healthcare in Egypt over the last decade, the size of the elderly population has increased with a consequent increase in incidence of dementia. MCI is also an emerging interesting topic and a transient status between normal aging and dementia. People with MCI develop dementia at a rate of 10–15% per year, while the rate for healthy controls is 1–2% per year [30]. Indeed, the risk of dementia is higher in persons with MCI compared to cognitively normal individuals [31–33]. In the present study, 12 cases had MCI giving a CPR of 1.74/100 for persons aged ≥60 years, which is lower than that reported by other studies [6, 34, 35]. The prevalence rate of MCI in the general aging population (older than 65 years) has been reported to be 3.1% in the United States and 4.9% in Japan [36, 37]. A systematic analysis of 22 studies in China described a pooled prevalence of MCI of 12.7% among older individuals [38]. Similar studies

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E. Khedr et al. / Prevalence of Dementia in Qena/Egypt Table 3 Demographic and clinical data of mild cognitive impairment and the main types of dementia

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1 (8.33%) 4 (33.3%) – – – –

Parkinson’s disease dementia plus (n = 7)

p value between the three groups of dementia

71.3 ± 10.4 2.7 ± 1.1 20.2 ± 3.3 19.75 ± 4.1 5/4 5/4 6/3 5/4

83.75 ± 4.8 3 ± 0.8 18 ± 3 19.5 ± 2.9 5/2 2/5 5/2 4/3

0.001 0.010 0.033 0.151 0.450 0.272 0.916 0.315

2 (22.2%) 8 (88.8%) 2 (33.3%) 5 (55.5%) 1 (11.1%) 2 (22.2%)

4 (57.14%) 4 (57.14%) 1 (14.28%) – – –

regions, with the highest prevalence in Israel (Wadi Ara with CPR 21%) [12]. In European countries, where a larger number of studies have been performed, considerably higher estimates of CPR have been noted ranging from 5.7% (>65 years old) to 17.8% (>75 years old) as recorded by Gabryelewicz [44] in Poland and Helmer et al. [45] in France. In the United States, a CPR of approximately 8%, with a range from 6.8% [5] to 13.9% [6], has been reported in people aged 70 years or older. In Asian countries, a considerable variation of CPRs has been noted, with the lowest prevalence (2.7%) in India [7, 46–49] and the highest prevalence in Israel (21%) [12]. In 2005, a cross sectional prevalence survey in four cities in China reported a prevalence of 5% for all dementia types with 3.5% for AD and 1.1% for VaD among people aged 65 years and over [50]. The same range of variation was seen in Latin America: Rosselli et al. [51] recorded a prevalence of 1.8% in Colombia whereas Pages-Larraya et al. [52] recorded a prevalence of 11.5% in Argentina. In Africa, there were only a few studies. A systematic review found a range of CPR for dementia ranging from 0 to 10% in Sub Saharan Africa (Benin, Botswana, the Central African Republic, the Congo and Nigeria) [8]. Three studies have been reported in Egypt with CPR ranging from 2.0–5.9% [9–11]. In the present study, the CPR in Qena governorate was 5.07/100 (5.4% women, 4.7% men) which is the same as in our previous study [9]. The differences in CPR of dementia may be related to different studied population and to the diagnostic criteria utilized, educational level, and socioeconomic state. The association between genderand risk of dementia was not significant in the present study which

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69.3 ± 7.7 2.1 ± 0.6 22 ± 2.7 22.67 ± 2.7 5/7 8/4 9/3 10/2

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conducted in Beijing [39] and Guangzhou [40] found the prevalence of MCI to be 8.9% and 5.47%, respectively. Many population-based studies suggest that the prevalence of MCI can be more than double that of dementia [41]. Paradoxically, in the present study, the prevalence of MCI was equal to that in AD and lower than the CPR of dementia. However, prevalence rates are highly dependent on the diagnostic criteria applied. The wide range in the CPR of MCI in different studies is mainly because of non-standardized methodology as well as varying definitions of MCI. The lower prevalence of MCI in the present study may be attributed to the younger age group (>60 years) in comparison to other studies (many older than 65 years). A second factor could be the low education level since many of our patients were illiterate. It may be that the screening questionnaire used to recruit cases was insufficiently sensitive to detect changes in memory, behavior, and daily activity in illiterate patients as these might be considered a normal phenomenon of aging in our community. In general, education is not consistently related to the prevalence of MCI. Higher prevalence rates among low levels of education [42] as well as the opposite pattern [43] have been reported. In the present paper, patients with MCI had at least one risk factor; hypertension was the most common followed by diabetes mellitus and ischemic heart disease. The Beijing study [39] indicated that stroke and hypertension are independent risk factors for MCI among older individuals. Age-standardized prevalence for those aged ≥60 years varied in a narrow band, 5–7% in most world

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2 (16.66%) 4 (33.3%) 2 (16.66%) 1 (8.33%) 1 (8.33%) 2 (16.66%)

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67.3 ± 7.13 2 ± 0.7 23.3 ± 1.9 23.14 ± 4.4 7/5 10/2 8/4 7/5

Vascular dementia (n = 9)

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Alzheimer’s disease (n = 12)

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and 7.3% for urban and rural localities, respectively [70]. A positive association between exposure to solvents and dementia was also found in a case-control study among members of a health maintenance organization in Seattle [71]. A Danish study of geriatric patients with dementia found a crude relative risk of 2.0 for always versus never exposed to solvents in the longest held job, as estimated by a job exposure matrix [72]. Aluminum accumulates in the brain with age [73] and exposure is associated with a number of neurodegenerative diseases [74]. It has also been shown to be associated with both the plaques and tangles in brains of people with AD. Occupational exposure to aluminum has been linked with neurodevelopmental effects [75], although there are very limited data to describe brain aluminum content in occupationally exposed individuals. Recently Exley and Vickers [76] reported that a Caucasian man who died with AD had significantly elevated brain aluminum content through occupational exposure to aluminum dust. They suggested a prominent role for the olfactory system and lungs in the accumulation of aluminum in the brain. From a clinical point of view, it is important to distinguish between types of dementia, as this has direct implications for prognosis and treatment. In the present study, the highest CPR of dementia was recorded among AD (1.74/100) followed by VaD and PDD (1.3/100 and 1.01/100) patients. AD represented 34.3% subtype of all types of dementia, followed by VaD (25.7%), PDD (20%), and mixed dementia (11.4%). Although AD is the most recognized form of dementia, VaD is the second most common form of dementia. The high prevalence of VaD in our community may be due to the high prevalence of stroke in our community [20, 77]. Both AD and VaD share similar risk factors (e.g., advancing age and hypertension, and diabetes mellitus) and overlapping clinical symptoms. Yet, a steady progressive decline is still considered characteristic of AD while a stepwise deterioration characterized by periods of sharp decline alternating with plateaus or periods of minimal decline is characteristic of VaD [78]. In the present study, risk factors for VaD included cerebrovascular disease (hypertension, diabetes, and hyperlipidemia) and coexisting conditions related to atherosclerosis (ischemic heart disease). The Hachinski Ischemic Score is a good bedside tool to help differentiate AD from VaD. In the present study, the CPR of dementia following a single stroke was slightly higher than multi-infarct dementia (0.72 versus 0.58/100). On the other hand, the

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was similar to that noted in Italian [53] and Spanish [54] populations. However, female gender was a risk factor for both outcomes in many studies [55–58]. Older age was strongly associated with dementia and cognitive impairment in all studies and similar associations have been reported globally [13]. Age-specific estimates of dementia have been more consistent worldwide with a predicted exponential rise in dementia with age. Prevalence studies indicate that dementia doubles approximately every 5 years after the age of 65 [59]. Collapsing across studies from Europe, North America, Australasia, and Japan, prevalence rates for the five-year age groups from 65 years to 85 and over were found to be 1.4, 2.8, 5.6, 11.1, and 23.6, respectively [59]. A pooling of results from European studies found similar figures [60]. In the present study, the CPRs for the five years age groups from 60 years to 85 and over are found to be 2.37, 3.3, 5.56, 6.25, 33.3, and 100, respectively. Small sample sizes may also influence findings. Our results showed that illiteracy was associated with a higher risk of dementia, which was consistent with Shadlen and colleagues [61]. They performed a study in the United States and found that low education level (≤10 years) had twice the risk of dementia compared with high education level in Caucasians (10 years). This was consistent with studies that have shown education to have a protective effect with respect to dementia [62, 63]. However, some studies have shown that education does not have a protective effect against dementia [64, 65]. The cognitive reserve hypothesis postulates that a higher level of education increases neuronal plasticity and connectivity. However, gender, a confounding variable, was not taken into account in any previous study. Intellectual lifestyle (education, occupation, and current cognitive activity) explains more than 10% of the variance in an individual’s cognitive performance [66]. Innate cognitive ability is also important and can lead to higher education and better occupation. Indeed, low childhood mental ability and IQ is associated with lower cognitive ability in late-life [67] with an increased risk of dementia [68] and with increased mortality [69]. In the present study, there was a significantly higher CPR for dementia among urban versus rural areas, as well as in industrial areas (aluminum, cement, sugarcane industries) in comparison with non-industrial areas. The high prevalence in urban areas is most likely due to the presence of industries. A populationbased study conducted in Mexico for the assessment of dementia in the elderly shows prevalence rates of 7.4

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448 449 450 451 452 453 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499

502 503 504 505 506 507 508 509 510 511 512 513 514 515 516 517 518

prevalence of VaD was on average lower for women than men. The protective effect of estrogen for premenopausal women and earlier death for men from cardiovascular disease may partially explain these results. Dementia eventually develops in most patients with PD. Older age and the akinetic-rigid form of the disease are associated with higher risk. Diagnosis of idiopathic PD before the development of dementia is essential. In the present study, seven cases were diagnosed which was higher than that reported in other studies [79]. This may be explained by the high prevalence of PD in our community [80]. In conclusion, the overall CPR of MCI and dementia are lower in Qena/Egypt than other countries. Advanced age and stroke were found to be associated with dementia. Identifying individuals with MCI is crucial. It may be useful in developing new interventions.

[7]

[8]

[9]

[10]

[11]

[12]

[13]

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DISCLOSURE STATEMENT

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Authors’ disclosures available online (http://jalz.com/manuscript-disclosures/14-2655).

[14]

[15]

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