African experiences in non-communicable diseases

BGS Spring meeting

28 April 2017

Professor Richard Walker Consultant Physician and Honorary Professor of Ageing and

International Health

Northumbria Healthcare NHS Foundation Trust/Institute of Health and Society, Newcastle University

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Presentation outline • The aging population in low and middle

income countries (LMIC) • Conducting epidemiological research in Africa

– stroke as an example • Interventions for non-communicable disease

(NCD) in Africa – Parkinson’s disease (PD) as an example

• Health beliefs and how these effect health seeking behavior

• Geriatrics and the role of geriatricians in Africa BGS Spri

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Background • Nearly 2/3 of the world’s population > 60 years live in developing countries, and this population is growing at 2.27% per annum (faster than the growth in the general population)1

• In 2010 10 million of these lived in sub-Saharan Africa (SSA), with 139 million predicted by 2050

•Nigeria is expected to have a very large rise in the number of >75 years - increase of 526% from 1980 to 2025

1 United Nations world population prospects (2013) BGS Spri

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Recent changes in life expectancy

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Mortality

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Non-communicable diseases

• World-wide, by 2030, the 10 diseases

causing the most disability-adjusted life years in low-income countries will include depression, IHD, stroke and cataracts

• UN high level meeting 2011: governments worldwide must plan to reduce risk factors for non-communicable disease BGS Spri

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Sustainable Development Goals (SDG)

• Formulated in 2015 to follow on from Millennium Development Goals which did not mention the elderly or NCDS

• SDG3 “Ensure healthy lives and promote well-being for all at all ages”

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The burden of stroke in population

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Stroke mortality • Stroke mortality rises rapidly with age.1

• In industrialised countries stroke is the third leading cause of death (10-12% of all deaths) - 88% are over 65 years.

• Stroke mortality in the US is significantly higher in African Americans than in caucasians.2

1 Bonita et al. 1992 Population Based Studies of Stroke pp. 1-30

2 Gillum RF 1999 Stroke 30 1711-1715 BGS Spring

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Incidence - developed countries

• 2/1000/year - increases steeply with age.

• 75% are first-ever strokes. • TIA incidence = 25% of stroke

incidence. • US African Americans compared to US

caucasians: – 35-74 years - 2 times. – 33-44 years - 3-4 times.

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Incidence - Harare • First-ever strokes in blacks resident in Harare

from reviewing hospital admissions and post mortem register for 19911.

• 273 cases (142 men and 131 women). • Total crude incidence rate per 100,000 = 30.7

(29.7 for men and 32 for women). • 96 (35%) died within the first week.

1 Matenga 1997 S A M J 87 606-609 BGS Spring

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Trends in stroke admissions at KCMC, Tanzania1

• Medical records audited for the years 1974-76, 1984-86, 1994-95 and 2008

• All inpatients with a primary diagnosis of stroke • Data collected - age, sex, stroke sub-type,

predominant side of symptoms and survival to discharge

• Number of admissions annually rose from mean of 1.3 for years 1974-75 to 153 in 2008 with increase in mean age and proportion of females

Richard Walker et al. Tropical Medicine and International Health 2015 (in press)

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Age and sex distribution of stroke

admissions to Kilimanjaro Christian Medical Centre during the years studied

Decade Number of

admissions

(mean/year)

Number of

males (%)

Mean age in years

(standard deviation,

range)

Number of stroke in

people aged 60 years and

over

1970s 4 (1.3) 4 (100%) 52.3 (19.655, 40 to 75) 1 (25.0%)

1980s 61 (20.3) 36 (59.0%) 62.1 (15.813, 22 to 85) 35 (57.4%)

1990s 87 (43.5) 52 (59.8%) 62.5 (15.150, 22 to 106) 52 (59.8%)

2000-2009 153 77 (50.3%) 67.9 (16.625, 17 to 100) 108 (70.6%) BGS Spring

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Hypertension management

• Population or opportunistic screening • Three separate blood pressure

measurements • Non-pharmacological treatment, e.g.

low salt diet, weight loss, exercise • Drug treatment - costs, monitoring,

compliance - high default rates

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Burden of Stroke

• Mortality • Prevalence • Incidence

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The burden of stroke in population

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Three project areas Population as of 30/11/1993 (mid point of 3

years of data presented)

• Dar-es-Salaam 65,826 (16,123 households)

• Hai 142,414 (30,643 households) • Morogoro 100,000 (25,149 households)

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Verbal autopsy

• An open account recorded of deceased’s final illness

• Check list of symptoms and chronic diseases

• Cause of death coded independently by 2 physicians (ICD9). If disagreement case referred to third physician for adjudication BGS Spri

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Crude and age-adjusted rates (new Segi world

population) aged 15-64 years, for males and

females for Dar-es-Salaam, Hai district, Morogoro rural

district and E & W (1993)

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Men

15 and above 15 – 64 years

Crude (CI) Age adjusted (CI)

Crude (CI) Age-adjusted (CI)

Dar-es-Salaam 87 (66 – 110) 42 (275 – 565) 44 (28 – 61) 65 (39 – 90)

Hai district 106 (87 – 125) 138 (113 – 163) 44 (31 – 57) 44 (31 – 56)

Morogoro 57 (41 – 74) 95 (63 – 127) 37 (23 – 51) 35 (22 – 48)

E & W 112 (111 – 114) 122 (107 – 137) 15.6 (15.0 – 16.2) 10.8 (10.0 – 11.6) BGS Spring

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Women

15 and above 15 – 64 years

Crude (CI) Age-adjusted (CI) Crude (CI) Age-adjusted (CI)

Dar-es-Salaam 75 (51 – 93) 317 (203 – 430) 40 (24 – 56) 88 (48 – 128)

Hai 93 (77 – 110) 131 (108 – 155) 33 (23 – 43) 33 (22 – 43)

Morogoro 38 (25 – 50) 55 (33 – 76) 28 (17 – 40) 27 (16 – 38)

E & W 180 (178 – 182) 115 (106 – 124) 126 (121 – 132) 8.6 (7.9 – 9.3) BGS Spring

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Place of death for people dying from stroke in Dar-es-Salaam, Hai district and Morogoro rural district

Area Hospital Home Other Total

No % No % No %

Dar-es-Salaam 31 (30) 68 (65) 5 (5) 104

Hai 133 (56) 101 (43) 1 (1) 235

Morogoro 10 (12) 71 (85) 1 (2) 82

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Prevalence of stroke with residual impairment – Tanzania • Rural population of 148,135 in Kilimanjaro region1 • House-to-house survey • Crude prevalence for those aged 15 and over

(85,152) was 127 (155 for men and 103 for women) • Prevalence for those aged 55 and over was 566 (623

for men and 510 for women) • More than half had never had their blood pressure

measured prior to stroke

1Walker RW et al. 2000 JNNP 68 (6): 744-749

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Tanzanian Stroke Incidence Project

• All incident strokes in Hai and Dar-es-Salaam AMMP project areas

• History, examination, blood tests, DNA, ECG, echocardiogram and CT head scan

• Follow up at 1 month and 6 months • Two age and sex matched controls from

AMMP database for each patient - all investigations except CT head scan BGS Spri

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Richard Walker, David Whiting, Nigel Unwin, Ferdinand Mugusi, Mark Swai,

Eric Aris, Ahmed Jusabani, Gregory Kabadi, William K. Gray, Mary Lewanga,

George Alberti. Stroke incidence in urban and rural Tanzania.

Lancet Neurology 2010 9, 786-792

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Comparison of age-specific stroke rates for those ≥ 45 years in Hai, Dar-es-Salaam and African-Americans in

Northern Manhattan

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Aetiology in Africa

Author Publication Country Type of study No. of strokes

No. of CT scans

PICH (%)

Infarct (%) [emboli]*

Matenga et al.

1986 Zimbabwe Prospective 93 80 31 69

Rosman 1986 RSA Prospective 116 92 33 67 [14]

Joubert 1991 RSA Prospective 250 250 29 71 [24]

Nyame et al.

1998 Ghana Retrospective 907 907 60 40

*As percentage of total number of strokes

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Aetiology in Africa

Author Publication Country Type of study No. of strokes

No. of CT scans

PICH (%)

Infarct (%) [emboli]*

Matenga et al

1986 Zimbabwe Prospective 93 80 31 69

Rosman 1986 RSA Prospective 116 92 33 67 [14]

Joubert 1991 RSA Prospective 250 250 29 71 [24]

Nyame et al

1998 Ghana Retrospective 907 907 60 40

Walker et al

2011 Tanzania Prospective 18 82

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Carotid ultrasound • Duplex ultrasound scan • Consecutive Hai patients in final year of

study1 • 1/56 (56 year old woman) had 50% right

internal carotid artery stenosis • 55/56 showed no evidence of stenosis of

common or internal carotid arteries

A Jusabani et al. Post-stroke carotid ultrasound findings from an incident Tanzanian population. Neuroepidemiology 2011 ; 37 (3-4): 245-248 BGS Spri

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Risk factors • 2 age - and sex – matched community-based

controls recruited for each stroke patient1 • Risk factors similar at both sites • Significant independent risk factors for stroke:

previous cardiac event (OR 7.39, 95% CI 2.42 – 22.53), HIV infection 5.61 (2.41 – 31.09), high ratio of total cholesterol to HDL cholesterol 4.54 (2.49 – 8.28), smoking 2.72 (1.49 – 4.96) and hypertension 2.14 (1.09 – 4.17), all p < 0.001

R Walker et al. Stroke risk factors in an incident population in urban and rural Tanzania: a prospective, community-based case-control study. Lancet Global Health, volume 1, Issue 5, pages e282-e288, November 2013. BGS Spri

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Kaplan – Meier survival curve (> 7 years)1

Walker RW et al. Case-fatality and disability in the Tanzanian Stroke Incidence Project cohort. Acta Neurol Scand. 2015 (published online May 5th)

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Cause (Dar) • Stroke widely understood to be caused by

demons • Many also reported that stroke is caused by

witchcraft (kulogwa) – Jealousy of property or progress is the main

motivating factor for stroke related witchcraft

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“Stroke cause is similar to convulsions…we say it is mdudu (insect)...we say it is an animal…meaning it is a bad devil or in other formal language it is a demon…when it attacks you, it either stays in all your body part, legs and arms or in one part of your body” [65 years old male stroke patient]

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Cause of elderly medical admissions in Africa1

• All emergency medical admissions of people aged 60 years and over

• Federal Medical Centre, Idi Abba, Abeokuta, Nigeria, Soba University Hospital, Khartoum, Sudan and KCMC, Tanzania

• 6 months from 1 March to 31 August 2012 • Main cause of admission along with

secondary causes listed

Akinyemi et al Journal of the American Geriatrics Society 2014

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Reasons for admissions to sites in Africa in those aged over 65 years

Nigeria (n=152) Sudan (n=364) Tanzania (n=358) Non-communicable disease

N = 128, 84.2% N = 294, 80.8% N = 286, 79.9%

Cerebrovascular accident 24, 15.8% (23 stroke, 1

transient ischaemic attack)

113, 31.0% (112 stroke, 1

transient ischaemic attack)

87, 24.3% (84 stroke, 3

transient ischaemic attack)

Cardiac/circulatory dysfunction (hypertension, heart failure)

36, 23.7% 29, 8.0% 85, 23.7%

Diabetes mellitus 17, 11.2% 15, 4.1% 19, 5.3%

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Who looks after older people in African hospitals?

• 25/43 African countries surveyed had

no geriatricians1 • Yet, most SSA medical schools do not

teach geriatrics (5/40 countries) • There are few specialty training

schemes in Africa for geriatrics (7/40 countries)

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Geriatricians in Africa • Replies from 40/54 countries (74%) • Data were obtained via an internet search

for a further three countries • Out of 43, 25 countries had no

geriatricians • 35/40 countries had no formal

undergraduate training for medical students on geriatrics

• 33/40 countries reported no national postgraduate training scheme for geriatrics

Dotchin et al Age and Ageing 2012 BGS Spri

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Survey of Geriatricians in Africa

Map (1): Map of Africa with shading representing number of geriatricians per country

Blue=0 Yellow=1-4

Light orange=5-9 Orange=10-100

Red=>100 White=no data

Map 2: African countries by World Bank Human Development Index

Key: blue = least developed, red = most

developed

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Nigeria (lower middle income)

• Population: 173.6 million • Life expectancy at birth: 52 • Population aged over 65 years: 5.2 million

(3%) • 218,736 deaths annually due to stroke, with

28-40% dead within 30 days • < 50 neurologists in the whole country • 1-4 geriatricians in the whole country

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Parkinson’s disease

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Screening questions 1. Do your arms or legs shake, except after drinking

alcohol? 2. Do you shuffle or take tiny steps when you walk? 3. Have you ever been told you have Parkinson’s

disease? 4. Do you have difficulty standing up or fall easily apart

from maybe when drinking alcohol? 5. Do you walk more slowly than other people your

age? 6. Does your head shake? BGS Spri

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Results • 33 patients with PD • All consented to take part in the study • Crude prevalence rate of PD = 20/100,000 • Age-standardised to UK population =

40/100,000 (males 63.5/100,000) • Male to female ratio = 2.3:1 • Mean age 74.5 years (range 38-94) • Mean duration of disease 5 years (0.25-19) • Median Hoehn and Yahr score 3 (2-5)

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Results continued

• No on treatment at time of study = 3/33 • No ever received treatment = 5/33 • No previously diagnosed = 8/33 • Treatments received: Benzhexol,

Sinemet • Traditional medications used by some • None had physiotherapy, occupational

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Beliefs1 • Many believe it is not a medical problem • Normal part of ageing process • Caused by evil spirits, witchcraft etc –

patients seek help from traditional healers

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Physiotherapy

• Cueing intervention with metronome brooch for all mobile patients giving consent

• Intervention acceptable to most patients • Excellent response in some individuals • How sustainable?

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Results: Effect of therapeutic cueing

Outcome Change P value Step length 0.7 m <.0001 Speed 0.17 m/s <.0001 Step frequency

7.8 steps/min 0.046

UPDRS III 6 0.004

Therapeutic cueing improved • Walking • Motor severity • ADL • Similar results for dual task gait

Rochester et al Movement Disorders 2010 BGS Spring

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Also measured prevalence of

• Epilepsy • Neurological disability in those aged 70

years and over – NB developed new tool for this

• Atrial fibrillation • Hypertension • Dementia BGS Spri

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Take home messages

• NCDs are a major, and increasing, problem in SSA

• Research is challenging but very rewarding (potentially writing chapters)

• The population is ageing in SSA but the services are not ready for this

• Major future role for geriatrics

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Next talk

• Opportunities for research • How this fits in with career structure

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Happy to hear from anyone interested in research in sub-

Saharan Africa – richard.walker@nhct.nhs.uk

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Hypertension

• Contributes to 57 million (3.7% total) disability adjusted life years, and 7.5 million (12.8%) premature deaths annually1

• Most powerful modifiable risk factor for ischaemic and haemorrhagic stroke

• Often asymptomatic – shortfall between levels of detection, treatment and control BGS Spri

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Methods1 • 12 randomly-selected villages in the Hai district

stratified for highland and lowland • All consenting individuals aged 70 years and over • 3 consecutive sitting blood pressure (BP)

measurements • Average of last 2 measurements taken • Prior diagnosis of, and treatment for, hypertension

recorded

• Dewhurst et al, The high prevalence of hypertension in rural-dwelling Tanzanian older adults and the disparity between detection, treatment and control: A rule of sixths? Journal of Human Hypertension 2013 Jun; 27(6):374-80 BGS Spri

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Rule of sixths

• 2/6 of hypertensives previously detected • 1/6 of those previously detected were on

treatment • 1/6 of those on treatment were adequately

controlled

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