1. Diagnosing And Treating Alzheimer Disease: A Jordanian Experience Marina Hadidi, M.D., Ph.D. Amman, Jordan Istanbul, September 2005

2. Jordan: Area – 97, 740 km2

4. Facts about Jordan: Population: 5,7 mln (2005) Population: 5,7 mln (2005) Capital: Amman (1,8 mln) Capital: Amman (1,8 mln) Life expectancy: M - 71 y, F – 74 y. Life expectancy: M - 71 y, F – 74 y. Population growth rate: 2,8% per year Population growth rate: 2,8% per year Annual income per capita: 1,813 $ Annual income per capita: 1,813 $

5. Jordan: Majority of population is under the age of 35

7. Current Situation: Diagnosis of AD Low awareness about AD in the population Low awareness about AD in the population No data about incidence or prevalence of MCI and dementia of Alzheimer type but professionals dealing with it has a common impression of increasing incidence No data about incidence or prevalence of MCI and dementia of Alzheimer type but professionals dealing with it has a common impression of increasing incidence No studies about prevalence of different types of dementia No studies about prevalence of different types of dementia Lack of validated psychometric tests. Individually modified MMSE, clock drawing and 3 word recall test are most often used. Lack of validated psychometric tests. Individually modified MMSE, clock drawing and 3 word recall test are most often used.

9. Current Situation: Treatment of AD Patients with AD are treated mostly by neurologists and psychiatrists Patients with AD are treated mostly by neurologists and psychiatrists Rivastrigmin, Galantamin and Donepezil are officially registered in Jordan/ Rivastrigmin, Galantamin and Donepezil are officially registered in Jordan/ Memantin is in the process of registration Memantin is in the process of registration There are very few geriatric nursing homes and no specialized centers for AD patients so they stay with the family till very late stages. There are very few geriatric nursing homes and no specialized centers for AD patients so they stay with the family till very late stages.

11. Illiteracy: potential implications Still a very common phenomenon Still a very common phenomenon Associated with age > 65, female gender, non- urban dwelling (Gomez et al 2001, Bowirrat et al, 2001) Associated with age > 65, female gender, non- urban dwelling (Gomez et al 2001, Bowirrat et al, 2001) Strongly associated with life expectancy in both developed and developing countries (Messias, 2003) Strongly associated with life expectancy in both developed and developing countries (Messias, 2003) Major socio-economic risk factor for development of dementia in different ethnic groups (Carnero- Pardo, 2000, Bowirrat, Friedland 2002) Major socio-economic risk factor for development of dementia in different ethnic groups (Carnero- Pardo, 2000, Bowirrat, Friedland 2002)

12. Prevalence of Illiteracy in Middle East Countries: (United Nations Statistics Division, 2005) CountryJordan Saudi Arabia TurkeyEgyptUAE M4,5%15,9%5,6%32,8%24,4% F14,1%30,5%21,5%56,4%19,3%

13. Retrospective Analysis Of 70 Consecutive Patients Diagnosed As AD In Our Clinic In 2002-2005 Retrospective Analysis Of 70 Consecutive Patients Diagnosed As AD In Our Clinic In 2002-2005 Age 57 – 80 y (mean age 68 y) Age 57 – 80 y (mean age 68 y) Jordanian residents only; patients from other Arab countries not included Jordanian residents only; patients from other Arab countries not included M – 46 %, F – 54 % M – 46 %, F – 54 % Total illiteracy – 20 % (M – 13%, F – 26%) Total illiteracy – 20 % (M – 13%, F – 26%)

14. Does Illiteracy Affect Time Of Diagnosis? Stage At Diagnosis LiterateIlliterate Mild 12 (85%) 24 (43%) Moderate 2 (15%) 30 (53%) Severe- 2 (4%)

15. Does Illiteracy Affect Treatment Choice and Compliance? LiterateIlliterate Started on AChEI 50 (90%) 12 (85%) Reported positive chan-ges after 3 m 38 (70%) 2 (15%) Uninterrupted treatment for > 9 months 34 (60%) 1 (7%)

16. Limitations: Our group is not representative of the whole population of Jordanian patients with dementia because of: Our group is not representative of the whole population of Jordanian patients with dementia because of: - small size of group - patients seeking help from a private doctor - predominantly urban patients

17. Illiteracy in Jordanian patients with AD (preliminary conclusions) Illiteracy is more common in female than male AD patients Illiteracy is more common in female than male AD patients Illiterate patients were more often diagnosed in moderate and severe stage, as opposed to mild Illiterate patients were more often diagnosed in moderate and severe stage, as opposed to mild Illiterate patients and their relatives less often report improvement on treatment with AChEI and are less probable to remain on it for the prolonged period of time Illiterate patients and their relatives less often report improvement on treatment with AChEI and are less probable to remain on it for the prolonged period of time

19. Converging Pathogenic Mechanisms Of Vascular Dementia And Stroke VS Neurodegenerative Dementia Hypertension Diabetes Hyperlipidemia ADStrokeVaD

20. Hypertension: Elevated midlife systolic blood pressure is an independent risk factor for AD, according to several prospective population-based studies (Kivipelto et al, 2001, Skoog et al, 1996) Elevated midlife systolic blood pressure is an independent risk factor for AD, according to several prospective population-based studies (Kivipelto et al, 2001, Skoog et al, 1996) Antihypertensive treatment may protect against demetia in older patients with systolic HTN, according to Syst-Eur study ( Forette et al, 2002 ) Antihypertensive treatment may protect against demetia in older patients with systolic HTN, according to Syst-Eur study ( Forette et al, 2002 )

21. Diabetes Mellitus: Diabetes increases risk of AD according to epidemiological studies (Knopman et al, 2002; Arvanitakis et al, 2004) Diabetes increases risk of AD according to epidemiological studies (Knopman et al, 2002; Arvanitakis et al, 2004) Possible mechanisms may include IDE (insulin-degrading enzyme) which hydrolyses several regulatory peptides including insulin, glucagone, Ab and APP intracellular domain (Duckworth et al 1998, Tanzi et al 2004). Possible mechanisms may include IDE (insulin-degrading enzyme) which hydrolyses several regulatory peptides including insulin, glucagone, Ab and APP intracellular domain (Duckworth et al 1998, Tanzi et al 2004).

22. Modifiable Risk Factors In 1 st Ever Ischemic Stroke UK : Hypertension -52% Hypertension -52% CAD or MI -38% CAD or MI -38% Current smoking -27% Current smoking -27% Diabetes Mellitus -10% Diabetes Mellitus -10% TIA -14% TIA -14% P.A.G.Sandercock et.al,1989 P.A.G.Sandercock et.al,1989 Jordan: - 57% - 36% - 36% - 41% - 55% - 41% - 55% - 5% - 5% M.Hadidi,2001 M.Hadidi,2001

23. Prevalence of Diabetes Mellitus In 70 Jordanian Patients Diagnosed With AD in 2002- 2005 Alzheimer Patients - 21% Alzheimer Patients - 21% Ischemic Stroke Patients - 55% Ischemic Stroke Patients - 55% Controls (non-stroke, non- - 17% AD patients ) Controls (non-stroke, non- - 17% AD patients )

25. Future Steps Jordanian Alzheimer Association is in the process of establishing. It will include interested professionals, caregivers and social workers. Jordanian Alzheimer Association is in the process of establishing. It will include interested professionals, caregivers and social workers. Epidemiological study evaluating prevalence of MCI and dementia in Jordanian population and investigation into a possible risk factors is underway Epidemiological study evaluating prevalence of MCI and dementia in Jordanian population and investigation into a possible risk factors is underway

26. THANK YOU