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Journal of the Neurological Sciences 321 (2012) 11–16

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Journal of the Neurological Sciences


journal homepage: www.elsevier.com/locate/jns

Review article

Epidemiology of dementia in Asia: Insights on prevalence, trends and novel


risk factors
Joseree-Ann S. Catindig a, 1, N. Venketasubramanian a, Mohammad Kamram Ikram a, b, c, Christopher Chen d,⁎
a
Department of Medicine, 5 Lower Kent Ridge Road, National University Hospital, Singapore 119074, Singapore
b
Singapore Eye Research Institute, Saw Swee Hock School of Public Health, Centre for Quantitative Medicine, Duke-NUS, Singapore
c
Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
d
Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Block MD11, Clinical Research Center, #05-0910 Medical Drive,
Singapore 117597, Singapore

a r t i c l e i n f o a b s t r a c t

Article history: Asia is the most populous region in the world and its rapidly growing societies are the sources of global de-
Received 20 December 2011 velopment. However, accompanying this rapid growth is aging of the population with increasing occurrence
Received in revised form 19 May 2012 of diseases, of which dementia is the most prominent, which provide major challenges to healthcare systems.
Accepted 11 July 2012
Dementia prevalence in Asia has previously been found to be lower than Western populations, but recent
Available online 9 August 2012
studies show that age-specific prevalence rates are similar globally. Overall dementia prevalence is expected
Keywords:
to rise dramatically across Asia due to maturing populations.
Dementia Earlier Asian studies reported a lower prevalence of Alzheimer's disease (AD) and a higher prevalence of vas-
Cognitive impairment cular dementia (VaD). Recent studies, however, show a reversal of this ratio that now parallels that of West-
Alzheimer's disease ern countries. This change may be attributed to an altered demographic profile, urbanization, environmental
Vascular dementia reactions, ethnicity and advances in the use of neuroimaging modalities.
Prevalence Several factors may influence the results of epidemiological studies including changes in societal perception
Vascular risk factors of aging, family attitudes, validity of assessment tools due to language and literacy, and medical practitioners'
expertise in recognizing dementia. Nevertheless, epidemiological studies in Asia may reveal factors contrib-
utory to inter-ethnic differences in dementia. Potentially modifiable risk factors apparent only in low and
middle-income countries and gene–environment interactions may underlie these disparities and identifica-
tion of such factors may lead to effective treatments.
© 2012 Published by Elsevier B.V.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2. Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
4. Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
4.1. Prevalence of dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
4.2. Subtypes of dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
4.3. Vascular cognitive impairment (VCI) and modifiable vascular risk factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
4.4. Novel risk factors for dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
5. Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

1. Introduction
⁎ Corresponding author. Tel.: +65 65161291.
E-mail addresses: joseree_ann_catindig@nuhs.edu.sg (J.-A.S. Catindig),
Ramani_NV@nuhs.edu.sg (N. Venketasubramanian), kamram_ikram@nuhs.edu.sg
The population of Asia in 2009 is estimated at 4 billion, 59% of a
(M.K. Ikram), phccclh@nus.edu.sg (C. Chen). global total of 6.8 billion [1]. World population growth will be con-
1
Tel.: +65 67726076. centrated in low and middle-income areas with the largest absolute

0022-510X/$ – see front matter © 2012 Published by Elsevier B.V.


doi:10.1016/j.jns.2012.07.023
12 J.-A.S. Catindig et al. / Journal of the Neurological Sciences 321 (2012) 11–16

increase coming from Asia [1]. Asia's societies are rapidly aging in tan- articles: authors, country/region, date of publication, screening tool and
dem with global trends: there was in 2010 an estimated 760 million diagnostic criteria used, population age, sample size and prevalence data.
elderly (≥60 years), 11% of the total global population. This number
is projected to double to 1.4 billion in 2030 and triple to 2 billion in 3. Results
2050 (16.5% and 22% of the total global population respectively).
Asia's elderly will also increase dramatically from 414 million in A total of 142 citations were initially identified. A total of 84 irrel-
2010 to 829 million and 1.2 million in 2030 and 2050 — with the pro- evant and duplicate citations were excluded upon review of the titles
portion rising from 10% to 17% and 24% of the total Asian population and abstracts by the authors (JAC, NV, MKI, CPLHC). Finally, a total of
respectively [2]. The largest number of elderly is currently from the 58 papers were included in this present review.
East Asia region, which is also the region which will experience the
greatest absolute increase of elderly between 2010 and 2050 of 4. Epidemiology
279 million (243%) [3].
Asia's elderly currently comprise primarily of the younger segments 4.1. Prevalence of dementia
of the old-age population group. However, the greatest increases will
occur in the oldest age groups (>80) over the next few decades with There was a wide variation in crude dementia prevalence rates
the proportion of the oldest age group expected to increase sub- across Asian countries, ranging from 0.03% to 33.2% [5,7–28] as shown
stantially from 15% in 2000 to 27% in 2050 [3]. The old-age dependency in Tables 1a–1c. Across all studies, age, female gender and low educa-
ratio (number of ≥65 years old/the number of gainfully employed 14– tion were the most consistent risk factors for dementia [5,7–27]. The
64 years old) will likewise increase. In 2010, the global old-age depen- wide range of prevalence may be attributed to differences in study
dency ratio was 12/100 compared to 10/100 in Asia and is expected to methodology and study design. The majority of articles included in
increase to 18/100 globally and 17/100 in Asia in 2030. this review as summarized in Tables 1a–1c utilized 2-stage or multi-
As age is the major risk factor for dementia [4,5,7–27] this is of stage research study designs to estimate the prevalence of dementia.
particular concern in Asia since decline in cognition is associated Participants are from a sample of the general population, thus, results
with a loss of independent function which not only affects individuals are highly generalizable. However, one major limitation of these
but also family members, the healthcare system and society as a methods is the low response rate of the participants from one stage to
whole. the other that can affect the estimate of prevalence.
A study using the Delphi consensus method in 2005 reported that In the study by Rodriquez et al. [16] comparing the use of the Diag-
an estimated 24.3 million people have dementia, with 4 to 6 million nostic and Statistical Manual of Mental Disorders 4th Edition (DSM IV)
new cases every year and the number of persons affected is expected criteria and the 10/66 dementia protocol, there was a marked 10 fold
to double every 20 years to 81.1 million by 2040 [4]. Sixty percent of difference of 0.9% using DSM IV compared to 9% using the 10/66 demen-
all people with dementia live in developing countries with Asian na- tia protocol in India and a 2 fold difference in China. This difference may
tions such as China, India, Japan and Indonesia in the top 7 countries be due to the DSM IV criteria focusing attention on memory impairment
having the largest number of people with dementia. whilst lacking operational criteria for the co-primary criteria of disabil-
Dementia is the leading cause of disability for people ≥ 60 years ity. By contrast, the 10/66 dementia protocol was developed to be
old. It is estimated that dementia care costs US$ 1521 annually in a cross-culturally sensitive and hence was able to capture cases of de-
low-income country [5]. Since the annual average per capita gross na- mentia that DSM IV criteria may have missed.
tional income in East Asia and Pacific countries is USD$ 2182 [6] and The use of different diagnostic criteria for dementia may also con-
ranges from USD$ 550 in Cambodia to USD$ 6420 in Malaysia, the tribute to changes in prevalence over time [29]. The commonly used
economic burden of dementia poses great challenges in many coun- classification systems, Diagnostic and Statistical Manual of Mental
tries [6]. Disorders 3rd Edition — Revised (DSM III-R), DSM IV, International
The aim of this paper is to review the prevalence of dementia in Statistical Classification of Disease 9th Edition (ICD 9), International
Asia by providing insight into the causes for differences in prevalence Statistical Classification of Disease 10th Revision (ICD 10), and Cam-
of dementia in various regions in Asia, dementia subtypes and novel bridge Examination for Mental Disorders of the Elderly (CAMDEX),
potentially modifiable risk factors that may suggest strategies for bet- have been shown to give markedly varying proportions of patients di-
ter allocation of healthcare resources as well as improved treatments agnosed with dementia ranging from 3.1% using the ICD 10 to 29.1%
for dementia in Asia. with the use of DSM III-R [28]. A systematic review of dementia prev-
alence studies performed in China [15] from 1980 to 2004 identified
25 studies, of which 9 have been published since 2000. Of these, 2
2. Methodology used the ICD 10 and showed a mean prevalence of 2.7% whilst 7,
which used the DSM III-R, showed a higher mean prevalence of 3.8%.
We performed a systematic literature review to identify all recent Another factor contributing to differences in the prevalence is edu-
studies that had ascertained the prevalence of dementia in Asia. Journal cation that affects performance on psychological assessments without
articles were retrieved using PubMed (http://www.ncbi.nlm.nih.gov/ associated disability or loss of function. Most cognitive instruments pre-
pubmed/) to identify relevant epidemiologic studies of dementia and cog- sume familiarity with paper and pencil tasks, numeracy and knowledge
nitive impairment in the various regions in Asia. The inclusion criteria for of (as well as interest in) current events. Hence, incorporating addition-
articles to be included in this review are as follows: a) published within a al assessments to detect decline in functional abilities such as the Infor-
period of 2000–2010, b) written in the English language, c) population- mant Questionnaire on Cognitive Decline in the Elderly (IQCODE) may
and/or community-based study and d) study performed in any Asian re- be useful in Asian elderly with low educational status [30]. In a study
gion. MESH terms used were (prevalence OR epidemiology) (dementia from Thailand, illiterate subjects were excluded giving a prevalence es-
OR cognitive impairment) (population-based OR community-based) timate of 2.4% [26]. By comparison, a 2-fold increase in the prevalence
combined with the names of each of the various countries in Asia. Addi- estimate (5.2–9.0%) was found in South Korean studies [17–20] where
tionally, hand-search of the bibliographies of identified articles was uti- illiterate elders were included. As the majority of the elderly in Asia
lized to identify other relevant studies. All articles were gathered by the have no formal education, excluding illiterate subjects may have a
first author (JAC) and presented to all co-authors (NV, MKI, CPLHC) for major impact on the study population.
consensus discussion as to which pertinent articles will be included in Moreover, dementia prevalence rates may also be affected by cul-
this review. We extracted the following information from the appraised tural factors such as a protective attitude towards the elderly and the
J.-A.S. Catindig et al. / Journal of the Neurological Sciences 321 (2012) 11–16 13

Table 1a
Dementia prevalence in East Asia region.

Study Region/country Criteria Screen Age Sample Dementia prevalence ADa prevalence VaDb prevalence Other prevalence
tool size (%) (%) (%) (%)

Ikeda et al. [7] Nakayama, Japan DSM III-Rc 3 stage >65 1438 60 (4.2) 21 (1.5) 28 (1.9) 11 (0.8)
NINCDS-ADRDA
DSM IVd
Meguro et al. [8] Tajiri, Japan DSM IVd 1 stage >65 1654 141 (8.5) 120 (7.2) 21 (1.3) –
NINCDS-ADRDAe
NINDS-AIRENf
Meguro et al. [9] Osaki-Tajiri, Japan DSM IVd 2 stage >65 539 141 (26) 86 (16) 25 (4.6) 30 (5.6)
Hasegawa et al. Kanagawa Perfecture, DSM IIIg 1 stage >65 1498 70 (4.7) 17 (1.1) 29 (2) 24 (1.6)
[10] Japan
Ikeda et al. [11] Nakayama, Japan DSM III-Rc 2 stage >65 1438 60 (4.2) 21 (1.5) 28 (1.9) 11 (0.8)
NINCDS-ADRDAe
DSM IVd
Yamada et al. Hiroshima, Japan DSM IVd 2 stage >60 13,446 206 (1.5) 130 (0.9) 76 (0.6) –
[12] NINCDS-ADRDAe
NINDS-AIRENf
Matsui et al. [13] Hisayama, Japan DSM III-Rc 2 stage >65 828 275 (33.2) 124 (14.9) 81 (9.8) 70 (8.5)
NINCDS-ADRDAe
NINDS-AIRENf
Ikejima et al. [14] Ibakari Perfecture, DSM IIIg 2 stage 20– 1,799,340 617 (0.03) 158 (0.009) 262 (0.015) 197 (0.011)
Japan 64
Zhang et al. [15] China NINCDS-ADRDAe 2 stage >55 34,807 1027 (2.9) 732 (2.1) 295 (0.8) –
NINDS-AIRENf
Dong et al. [16] China DSM III-Rc 1 stage >60 87,761 2437 (2.8) 1525 (1.6) 663 (0.8) 912 (0.4)
NINCDS-ADRDAe
NINDS-AIRENf
Rodriguez et al. China DSM IVd 1 stage >60 2162 59 (2.7) – – –
[17] 10/66 dementia 137 (6.3)
Kim et al. [18] Busan, S. Korea DSM III-Rc 2 stage >65 1101 82 (7.4) – – –
Suh et al. [19] Yonchon, S. Korea DSM III-Rc 2 stage >65 1037 74 (7.1) 45 (4.2) 26 (2.4) –
NINCDS-ADRDAe
NINDS-AIRENf
Jhoo et al. [20] S. Korea DSM IVd 2 stage >65 714 37 (5.2) 28 (3.9) 7 (0.9) 2 (0.3)
NINCDS-ADRDAe
NINDS-AIRENf
Choi et al. [21] Busan, S. Korea DSM IV-TRh 2 stage >65 175 16 (9.0) – – –
NINCDS-ADRDAe
NINDS-AIRENf
Lam et al. [22] Hong Kong DSM IVd 2 stage >60 737 143 (19.4) 105 (14.3) 32 (4.3) 6 (0.8)
NINCDS-ADRDAe
NINDS-AIRENf
a
AD, Alzheimer's Disease.
b
VaD, Vascular Dementia.
c
DSM III‐R, Diagnostic and Statistical Manual of Mental Disorders 3rd Edition — Revised.
d
DSM IV, Diagnostic and Statistical Manual of Mental Disorders 4th Edition.
e
NINCDS‐ADRDA, National Institute of Neurological and Communicative Disorders and Stroke–Alzheimer's Disease and Related Disorders Association.
f
NINDS‐AIREN, National Institute of Neurological Disorders and Stroke and Association Internationale pour la Recherché et l'Enseignement en Neurosciences.
g
DSM III, Diagnostic and Statistical Manual of Mental Disorders 3rd Edition.
h
DSM IV‐TR, Diagnostic and Statistical Manual of Mental Disorders 4th Edition — Text Revision.

Table 1b
Dementia prevalence in South Asian region.

Study Region/ Criteria Screen Age Sample Dementia prevalence ADa prevalence VaDb prevalence Other prevalence
country tool size (%) (%) (%) (%)

Vas et al. [23] Mumbai, DSM IVc 3 stage >50 24,488 105 (0.4) 62 (0.3) 23 (0.09) 20 (0.8)
India NINCDS-ADRDAd
NINDS-AIRENe
Shaji et al. [24] Kerala, India DSM IVc 3 stage >65 1934 56 (2.9) 30 (1.6) 22 (1.1) 4 (0.2)
ICD 10f
Das et al. [25] Kolkata, India DSM IVc 2 stage >50 52,377 46 (0.09) – – –
Rodriguez et al. India DSM IVc 1 stage >60 2004 17 (0.9) – – –
[17] 10/66 dementia 181 (9.0)
De Silva et al. [26] Sri Lanka DSM IVc 2 stage >65 703 28 (4.0) 20 (2.8) 4 (0.6) 4 (0.6)
NINCDS-ADRDAd
a
AD, Alzheimer's Disease.
b
VaD, Vascular Dementia.
c
DSM IV, Diagnostic and Statistical Manual of Mental Disorders 4th Edition.
d
NINCDS‐ADRDA, National Institute of Neurological and Communicative Disorders and Stroke–Alzheimer's Disease and Related Disorders Association.
e
NINDS‐AIREN, National Institute of Neurological Disorders and Stroke and Association Internationale pour la Recherché et l'Enseignement en Neurosciences.
f
ICD‐10, International Statistical Classification of Disease 10th Edition.
14 J.-A.S. Catindig et al. / Journal of the Neurological Sciences 321 (2012) 11–16

Table 1c
Dementia prevalence in Southeast Asia region.

Study Region/ Criteria Screen Age Sample Dementia prevalence ADa prevalence VaDb prevalence Other prevalence
country tool size (%) (%) (%) (%)

Wangtongkum et al. Thailand DSM IVc 1 stage >45 1492 35 (2.4) 24 (1.6) 4 (0.3) 7 (0.5)
[27]
Sahavedan et al. [28] Singapore DSM IVc 2 stage >50 14,817 234 (1.6) 127 (0.9) 107 (0.7) –
NINCDS-ADRDAd
e
NINDS-AIREN
a
AD, Alzheimer's Disease.
b
VaD, Vascular Dementia.
c
DSM IV, Diagnostic and Statistical Manual of Mental Disorders 4th Edition.
d
NINCDS‐ADRDA, National Institute of Neurological and Communicative Disorders and Stroke–Alzheimer's Disease and Related Disorders Association.
e
NINDS‐AIREN, National Institute of Neurological Disorders and Stroke and Association Internationale pour la Recherché et l'Enseignement en Neurosciences.

belief that cognitive impairment is part of normal aging. These cultur- criteria, epidemiological methods, demographics caused by the aging
al factors, which may differ between Asian countries, in addition to population and mortality rate [34].
genetic and environmental factors may influence how ethnicity may
play a role in dementia prevalence. As shown in Tables 1a–1c, differ- 4.2. Subtypes of dementia
ences in prevalence estimates exist across regions in Asia with higher
prevalence reported in East Asia compared to South Asia. By contrast, Studies conducted prior to 1990 showed national differences in
a study in Singapore, a multi-ethnic country, and age adjusted de- the subtypes of dementia with a higher frequency of vascular demen-
mentia prevalence was significantly higher among Indians (1.9%) tia (VaD) in Chinese and Japanese compared to Western populations
compared to Malays (1.6%) and Chinese (1.2%) [27]. [30]. The proportion of Alzheimer's disease (AD) to VaD was reported
Finally it should be appreciated that the population age distribution in Europe and North America to show a predominance of AD with an
affects crude dementia prevalence rates. When age-specific dementia overall ratio of 2:1. By contrast, studies in Japan and China showed
prevalence rates are compared, there is no significant difference across the reverse with an overall 2:1 ratio for VaD. However, the dementia
regions in Asia with prevalence rates ranging from 3.2% in East Asia to subtype pattern appears to have changed over time with AD becom-
3.6% in South Asia and 4.8% in South-East Asia compared to a global ing more prevalent in East Asian countries since 1990 [35].
prevalence rate of 4.7% and an overall Asian prevalence of 3.9%: the esti- A change in environmental exposure could explain the changing
mated prevalence of dementia for those aged over 60 years, standard- patterns of dementia subtype. Chinese in the northern region had a
ized to non-Asian region population (see Table 2), is comparable higher risk of developing VaD compared to the Chinese living in the
across all global regions with figures ranging from 3.2% to 4.8% in Asian south [15] which may be accounted for by differences in lifestyle
regions compared to 6.2% in Europe, 6.4% in Australasia and 6.5% in the and food preference. Likewise, Japanese–Americans living in Hawaii
Americas [5]. had a higher prevalence of AD and a lower prevalence of VaD com-
There has been much progress since the 1980s regarding the epi- pared to Japanese living in Japan [36]. This difference in subtypes of
demiology of dementia, particularly in Asia. Dementia in East Asia dementia may be explained by the differences in lifestyle – such as
was reported in the 1980 to1990s as having an overall prevalence diet – as well as differences in access to healthcare education and vas-
ranging from 0.5 to 10.8% compared to Western countries which cular risk management which has been incorporated into the
range from 0.4 to 11.9% [31,32]. However, an international compari- American healthcare system as a preventive strategy for lowering
son concluded that (i) prevalence and incidence show little geo- vascular complications.
graphical variation, as differences between countries seem to reflect Demographic changes previously described above may also contrib-
methodological rather than real differences; ii) both incidence and ute to the change in dementia subtypes. VaD due to stroke remains the
prevalence figures increase in age even in the advanced age; iii) most most common cause of early-onset dementia in the Japanese popula-
of the inconsistencies in results are due to dementia subtype, in particu- tion [13] whilst AD is more common in the elderly [7–10,12,13].
lar vascular dementia; iv) it remained uncertain if the higher frequency Hence an aging population may lead to a change in the pattern of de-
of vascular dementia in Asia is due to differential distribution of genetic mentia subtypes.
and/or environmental factors, or due to methodological differences; and Urbanization as part of the economic and social development in Asia
v) different dementia types might have different age distributions [33]. may also play a role in determining dementia subtypes. In China, VaD is
Hence, the variation in dementia prevalence was attributed to diagnostic more common than AD in rural compared to urban areas [35]. Given the
rapid pace of development in China, it is not surprising that the most re-
cent Chinese prevalence study showed an AD prevalence of 3.5% com-
Table 2 pared to 1.1% for VaD in those aged more than 65 years [14]. These
Alzheimer's disease international meta-analysis of dementia prevalence. patterns are repeated across Asian countries as shown in Tables 1a–1c.
Study Region/ Criteria Age Sample size Dementia
Furthermore, the use of different criteria for VaD may give rise to dif-
country prevalence ferent prevalence rates. When 5 different criteria for VaD were com-
(%) in 2010 pared in the same sample population, the prevalence rates varied:
ADI [5] Non-Asian regions 32.7% using the National Institute of Neurological Disorders and Stroke
Europe Meta-analysis >60 160,180,000 9,950,000 (6.2) and Association Internationale pour la Recherché et l'Enseignement en
America Meta-analysis >60 120,740,000 7,820,000 (6.5) Neurosciences (NINDS-AIREN), 36.4% by DSM III, 36.4% by ICD 10,
Africa Meta-analysis >60 71,070,000 1,860,000 (2.6)
86.9% by the Alzheimer's Disease and Diagnostic Treatment Criteria
Australia Meta-analysis >60 4,820,000 310,000 (6.4)
ADI [5] Asia (ADDTC) and 91.6% by DSM IV [37]. Moreover as dementia due to
East Asia Meta-analysis >60 171,610,000 5,490,000 (3.2) both AD and VaD (mixed dementia) is difficult to operationalise, diag-
South Asia Meta-analysis >60 124,610,000 4,480,000 (3.6) nosis especially in field studies is affected.
Southeast Asia Meta-analysis >60 51,220,000 2,480,000 (4.8) One major factor affecting these differences in the prevalence
Central Asia Meta-analysis >60 7,160,000 330,000 (4.6)
rates from different diagnostic criteria was evidence of relevant
J.-A.S. Catindig et al. / Journal of the Neurological Sciences 321 (2012) 11–16 15

cerebrovascular disease (CVD) on neuroimaging [37]. However, that influence the results of epidemiological studies. Nevertheless,
neuroimaging in field surveys is not always feasible because of Asian epidemiological studies may reveal potentially modifiable
cost and accessibility, especially in Asia. Hence, the low prevalence risk factors only apparent in low and middle-income countries as
of VaD in some studies could be attributed to limited use of neuro- well as interactions between genetic predisposition and environ-
imaging. Identification of subtypes of dementia without neuroimag- ment that may trigger these differences.
ing in China reported that 29% of demented patients had VaD [14] Genetics may also play a role in disease expression. It has been
compared to a higher VaD diagnosis rate of 47% among patients shown that the APOEε4 allele is a major risk factor for AD in all-ethnic
who underwent brain computed tomography (CT) in Japan [10]. groups [53]. In a recent study in Singapore, age-adjusted dementia
On the other hand, the use of more sensitive neuroimaging methods prevalence was significantly higher among Indians compared to Malays
for the identification of vascular lesions may lead to higher estimates of and Chinese [27], which may reflect underlying influence of genetics
CVD and hence VaD. In the same Japanese community study referred to and lifestyle factors. Specifically, the APOEε2 allele was observed to be
above, which identified a 47% frequency of VaD with brain CT scan [10] least common among Indians in Singapore and significantly different
a study using magnetic resonance imaging (MRI), diagnosed 42% of de- from Malays and Chinese [54]. Furthermore, ethnic differences in de-
mented patients as AD + CVD and a further 19% were diagnosed with mentia etiologies have also been reported in Singapore [55] where In-
VaD [7]. Therefore, the type of neuroimaging modality used can affect dians had a higher frequency of AD compared to Malays and Chinese.
the prevalence and differentiation of the subtypes of dementia. More studies in multi-ethnic populations living in a common geograph-
ical location are needed to understand these interactions.
4.3. Vascular cognitive impairment (VCI) and modifiable vascular risk Nutritional factors may also have an important influence on cognition
factors in Asia. This is exemplified by an association between cognitive status, al-
bumin, and anemia and body mass index among Chinese Singaporean el-
Stroke is a global disease with the great majority (87%) of morbid- derly [56]. Moreover, nutritional deficiencies such as low vitamin B12
ity and mortality occur in low and middle-income countries including and folate have been reported to affect cognition [57,58]. Among high
those in Asia [38]. Stroke increases the risk of developing dementia functioning Chinese elderly, elevated homocysteine was associated
[13,39]. However, the conventional definition of vascular dementia with deficits in constructional ability and processing speed whilst epi-
is deficient as stroke may produce a spectrum of cognitive changes sodic memory and language were associated with low folate levels
not necessarily a prominent memory loss as what is seen among AD [58]. Raised homocysteine levels may also be an independent risk factor
patients. The term vascular cognitive impairment (VCI) has been pro- for mild cognitive impairment in Koreans [59]. Such nutritional deficien-
posed so as to recognize the broad spectrum of cognitive problems re- cies associated with cognitive decline are potentially reversible and early
lated to CVD. Studies have shown that VCI is common and presents an identification may lead to possible treatments.
important target for therapy, as it may be preventable [40].
Several modifiable vascular risk factors are increasingly frequent
among Asians, which may contribute to an increased incidence of de- 5. Conclusion
mentia. Atherosclerosis is associated with an increased risk of demen-
tia [41] and it may be pertinent that the frequency of intracranial The impact of dementia in Asia on health, society and economics re-
large artery disease is high among Asian AD (18%) and VaD (53%) pa- quires more attention. As this review is limited only to studies pub-
tients [42]. Identification of this high-risk population and timely in- lished in English, significant epidemiologic data written in local Asian
tervention may prevent strokes and associated cognitive impairment. languages may have been excluded. However, there remains a paucity
Hypertension is another vascular risk factor associated with demen- of studies from several regions and countries with large populations
tia [43,44]. Of the estimated 972 million people with hypertension in such as Indonesia and South Asia. Moreover, more studies using stan-
the year 2000, 639 (66%) million were in developing countries with dardized cross-culturally sensitive cognitive instruments and ascertain-
the majority from China and India [43] where detection and control ment of functional and social decline are needed to better understand
may be less ideal than in developed countries. In a community-based the burden and causes of early dementia.
study from Korea, 44% of AD cases and 35% of mild cognitive impair- The changing profile of dementia subtypes in Asia may be attributed
ment patients had hypertension as a vascular risk factor [20]. to changing demographic profile, urbanization, environmental interac-
More than 60% of the world's population with diabetes will be from tions, ethnicity and advances in the use of neuroimaging modalities. The
Asia, the majority coming from China and India [45]. Longitudinal stud- use of more advanced and sensitive neuroimaging modalities may alter
ies have showed an association between diabetes and AD [46,47] as well our understanding of the prevalence of the brain pathologies underly-
as a strong relationship between diabetes and stroke-related dementias ing dementia. Already MRI can detect sub-clinical cerebrovascular dis-
[48]. Data from the Honolulu Asian Aging study showed that diabetic ease and the effect of such “silent strokes” on dementia requires
subjects had a relative risk (RR) of 1.6 (95% CI 1.0–2.3) for dementia, further investigation so as to enhance early diagnosis and timely medi-
2.0 (1.0–3.5) for VaD, 1.5 (1.0–2.4) for AD, and 1.5 (0.8–2.7) for AD cal intervention [40]. Furthermore, the use of amyloid-beta positron
without CVD [49]. emission tomography (PET) ligands can discriminate between AD and
Moreover, the presence of metabolic syndrome doubles the risk healthy controls [60], hence allowing pre-clinical AD patients to be
for dementia and also showed significant association with functional identified early in the course of the disease.
decline, depression and low quality of life [50,51]. The prevalence of Asian epidemiological studies may also contribute towards the
metabolic syndrome is rapidly increasing in Asia especially in South understanding of how inter-ethnic differences in dementia risk and
Asian countries such as India [52]. In East Asian countries such as subtypes may arise. This is because potentially modifiable risk factors
Korea, metabolic syndrome has been shown to affect 40% of AD pa- only apparent in low and middle-income countries as well as interac-
tients and 23% of patients with mild cognitive impairment [20]. tions between genetic predisposition and environment may trigger
these differences. Identification of these factors may lead to the devel-
4.4. Novel risk factors for dementia opment of more effective and accessible treatments.

Changes in societal perception of aging, protective family atti-


tudes, the validity of assessment tools especially in terms of lan- Conflict of interest
guage, effect of literacy and the expertise of medical practitioners
in recognizing dementia are some of the methodological factors The authors have no relevant conflicts of interest.
16 J.-A.S. Catindig et al. / Journal of the Neurological Sciences 321 (2012) 11–16

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