Discussion

The prevalence of dementia in the Arab world has become an increasingly important public health issue, as evidenced by the growing number of affected individuals and the associated economic burden on societies. This paper seeks to emphasise the significant issue of dementia in the Arab world, with the goal of attracting the attention of decision makers to invest in research and specialised services for older adults, particularly those affected by dementia. The choice of this topic was based on the scarcity of research focusing on dementia in the Arab world. A systematic review by El-Metwally et al found only 18 studies that investigated the prevalence of dementia in the region, with only six of them being community based.^{Reference El-Metwally, Toivola, Al-Rashidi, Nooruddin, Jawed and AlKanhal22–Reference Farrag, Farwiz, Khedr, Mahfouz and Omran28} A 2017 review of dementia prevalence studies in Egypt found that dementia prevalence ranged from 2.01% to 5.07%.^{Reference Elshahidi, Elhadidi, Sharaqi, Mostafa and Elzhery29} One study from the upper desert areas of Egypt reported that the total prevalence of Alzheimer's dementia was 1% among the population aged 50 years and more, reaching 2.9% at 70–79 years.^{Reference EL Tallawy, Farghaly, El Hamed, Badry, Usama and Shehata30}

Although the main focus of this study was the prevalence of dementia, encompassing both diagnosed and undiagnosed cases, it is worth briefly mentioning the challenge of undiagnosed dementia. As underscored in the World Alzheimer Report 2021: Journey through the Diagnosis of Dementia, obtaining a diagnosis remains a significant issue for people living with dementia; Alzheimer's Disease International (ADI) estimates that globally, 75% of people with dementia are not diagnosed, with that percentage believed to be as high as 90% in some lower- and middle-income countries.^{Reference Gauthier, Rosa-Neto, Morais and Webster5} Despite the limited data and the focus of the ADI report on diagnosis rates rather than dementia prevalence, the authors anticipate a considerably high percentage of undiagnosed cases in the Arab world.

According to our estimates, there were 1 329 729 individuals with dementia in the Arab world in 2021. The prevalence of dementia varied across countries, with the highest rates observed in Tunisia (4.20%) and the lowest rates in Qatar (1.57%). The prevalence of dementia in the Arab world was 2.16% in those aged 50+ years and 3.84% in those aged 60+ years. The highest estimates of those living with dementia above the age of 50 and 60 years were in Egypt (312 399), Algeria (169 784) and Morocco (159 890), whereas Comoros had the lowest number (1166). There were differences in dementia prevalence rankings between the 50+ and 60+ age groups across different countries. For instance, the United Arab Emirates experienced a significant increase in ranking, moving from fourth place with a 1.33% prevalence in the 50+ age group to 18th place with a 4.09% prevalence in the 60+ age group. Conversely, Morocco saw a considerable decrease in ranking. However, some countries, including Qatar, Kuwait, Tunisia, Syria and Lebanon, showed no difference in their rankings between the two age groups. These variations in dementia prevalence rankings between age groups can be attributed to factors such as population age distribution, dementia risk factors, access to healthcare and support services, and cultural and lifestyle factors. In this study, the differences in ranking were probably due to demographics, specifically the differences in population age distribution between the countries. A larger proportion of older adults in the 60+ age group could lead to a substantial increase in dementia prevalence, owing to the increased risk of dementia with age, whereas countries with a younger population might have a lower prevalence, resulting in a smaller change in ranking.

This study found an economic burden of dementia for those aged 50 years and above amounting to a total of 10.43 billion USD in the best-case scenario and 13.90 billion USD in the worst-case scenario for the year 2021. It is important to note that these costs are estimates rather than precise calculations. Using a comparable methodology, the cost estimates for the year 2009 in the Arab region were found to be 4.212 billion USD for the best-case scenario and 6.707 billion USD for the worst-case scenario. There are several reasons for this significant increase in the economic burden of dementia, including demographic changes; for instance, the total population above the age of 60 in 2021 was about 2.5 times that in 2009. The correlation between GDP per capita and direct cost has also been updated, and an increase in the average GDP per capita estimate for the region was found. The direct costs of dementia care in Arab countries are influenced by each country's GDP per capita and income classification, with higher costs observed in high-income countries such as Saudi Arabia (2039 USD per capita) and the United Arab Emirates (2371 USD per capita). By contrast, lower costs were seen in lower-middle-income countries such as Yemen (223 USD per capita) and Djibouti (256 USD per capita).

Indirect costs, which include loss of productivity due to caregiving, can also significantly contribute to the overall economic burden of dementia. These costs are typically higher in countries with larger proportions of informal care provision by family members or friends. For instance, informal caregiving costs were found to be exceptionally high in certain countries, including Egypt, Algeria and Morocco; by contrast, the direct costs, which are correlated with GDP per capita, were much lower in those countries. These observations probably reflect the prevailing structure of care services, which tend to rely heavily on informal rather than formal caregiving arrangements.

As this study examined dementia prevalence in 2021, when the COVID-19 pandemic was raging, it is essential to acknowledge the potential influence of the pandemic on dementia care and its costs. One cannot attempt to ignore the devastating impact of the COVID-19 pandemic on humanity during 2020 and 2021. This global crisis has strained healthcare systems and posed significant challenges for most individuals, especially those living with dementia and their caregivers. Factors such as heightened social isolation, disrupted healthcare services and increased stress levels may contribute to the exacerbation of dementia symptoms and increase the risk of developing the condition. Furthermore, COVID-19 infections have been linked to higher risk of cognitive decline, particularly among older adults.^{Reference Azarpazhooh, Amiri, Morovatdar, Steinwender, Ardani and Yassi31,Reference July and Pranata32}

Matias-Guiu et al found that living in care homes was the most significant factor for increased risk of infection and death among dementia patients.^{Reference Matias-Guiu, Pytel and Matías-Guiu33} This finding suggests that the pandemic may have disproportionately affected individuals with dementia in care facilities, which could have implications for the costs of dementia care. Cascini et al^{Reference Cascini, Agabiti, Marino, Acampora, Balducci and Calandrini34} assessed the incidence of SARS-CoV-2 infection and COVID-19-related death among dementia patients, identifying risk factors for both infection and mortality. Whereas this discussion paper does not directly investigate the relationship between COVID-19 and dementia prevalence or care in the Arab world, future research should explore the influence of the pandemic on the overall dementia landscape in the region, taking into account its potential impact on the cost of dementia care.^{Reference Matias-Guiu, Pytel and Matías-Guiu33,Reference Cascini, Agabiti, Marino, Acampora, Balducci and Calandrini34}

The present study had some limitations, including its reliance on secondary data sources for population, prevalence and cost estimates. This may have introduce some inaccuracies in our calculations, as the quality and completeness of the data varied among countries. In addition, the cost estimates may not fully capture the complexity of dementia care provision in each country, as they were based on GDP per capita and income classification rather than detailed cost data from individual countries. This analysis focused on the Arab world, and our findings may not be generalisable to other regions with different demographic, economic and healthcare characteristics owing to economic or political instability in some of the Arab countries, potential bureaucratic or regulatory hurdles, and a lack of standardised neuropsychometric research instruments in the region.^{Reference Al Sinawi, Qassem and Al Harrasi35,Reference Javaid, Al-Zahmi and Abbas36} Another limitation to consider is the potential influence of the COVID-19 pandemic on dementia care and its costs during the study period, which examined dementia prevalence in 2021 when the pandemic was still ongoing. The pandemic has strained healthcare systems and introduced additional challenges for individuals living with dementia and their caregivers, as discussed earlier. Factors such as heightened social isolation, disrupted healthcare services and increased stress levels could have affected dementia symptoms and risks, and such effect may not have been fully captured in our analysis. Moreover, the implications of the pandemic for the cost of dementia care, as suggested by Matias-Guiu et al and Cascini et al,^{Reference Matias-Guiu, Pytel and Matías-Guiu33,Reference Cascini, Agabiti, Marino, Acampora, Balducci and Calandrini34} might not be adequately reflected in our estimates. Future research should further investigate the influence of the pandemic on the overall dementia landscape in the Arab world, considering its potential impact on care costs as a factor within the study's limitations.

Despite these limitations, we hope this study will provide useful insights into the prevalence and costs of dementia in Arab countries. These findings could help to inform policymakers, healthcare providers and researchers in their efforts to address the challenges posed by dementia in the region. As the population in Arab countries continues to age and the prevalence of dementia risk factors increases, it is crucial to invest in prevention, early detection and support services to reduce the impact of dementia on individuals, families and society. To tackle the growing issue of dementia in the Arab world, we make the following recommendations. (a) Enhance investment in dementia research to increase understanding of regional prevalence, risk factors and cultural aspects. This will aid in creating targeted interventions and policies for dementia prevention and care. (b) Strengthen national dementia strategies by improving early diagnosis, offering integrated care services and fostering dementia-friendly communities. This will reduce stigma, enhance quality of life for people with dementia and support their caregivers. (c) Create and implement training programmes for healthcare professionals, particularly in primary care settings, to improve dementia diagnosis and management. In accordance with the World Alzheimer 2022 report, emphasise person-centred care, caregiver support, evolving clinical roles and dementia education. This will result in a stable, effective, and cost-efficient care economy for people with dementia and their families.^{Reference Gauthier, Webster, Servaes, Morais and Rosa-Neto37} (d) Develop specialised mental health services for older adults, focusing on early identification, prevention and intervention. Collaborate with multidisciplinary teams to provide comprehensive, integrated care promoting mental well-being and quality of life for older persons in the Arab world. (e) Promote collaboration between governments, researchers, non-governmental organisations and international organisations to share best practices, resources and data on dementia care and support. (f) Increase funding for public awareness campaigns to enhance dementia knowledge and encourage early detection and intervention, reducing the societal and economic impact of dementia in the Arab world. (g) Implement dementia-friendly environment design principles from the World Alzheimer Report 2020 to improve quality of life for people with dementia and help them to maintain their abilities.^{Reference Zeisel, Bennett and Fleming38}

In conclusion, this paper highlights the significant issue of dementia in the Arab world and underscores the urgent need for action from decision makers to invest in research and specialised services for older adults, particularly those affected by dementia. With the projected increase in the prevalence of dementia in the coming decades, addressing this public health challenge is critical to ensuring the well-being of older adults and reducing the economic burden on societies in the region.