NEUROLOGICAL DISEASES AMONG GERIATRIC POPULATION OF ARAR CITY, KINGDOM OF SAUDI ARABIA: A CROSS SECTIONAL STUDY

1. Associate Prof. of Public Health and Community Medicine, Faculty of Medicine, Northern Border University, KSA. 2. Intern, Faculty of Medicine, Alfaisal University, Riyadh, KSA. 3. Final year student, Faculty of Medicine, Northern Border University, KSA. 4. Medical Student, Sohag University, Egypt. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History

Neurological disorders are common and represent a major public health problem. For example, 50 million people have epilepsy. Neurological disorders and some of the other conditions with neurological impairments and sequelae constitute over 6% of the global burden of disease. This burden is especially high in many low and middle income countries. Public health challenges describes and discusses the increasing global public health importance of common neurological disorders such as dementia, epilepsy, headache disorders, multiple sclerosis, neuroinfections, neurological disorders associated with malnutrition, pain associated with neurological disorders, Parkinson's disease, stroke and traumatic brain injuries [2]. Neurology has an especially close relationship with psychology and psychiatry, as all three disciplines focus on the functions and disorders of a single organ, the brain. The main targets of the traditional British "neurological examination" may be elementary motor and sensory processes, but any adequate assessment of "brain function" must take account of cognition and behavior. Cognitive and behavioral involvement is the rule, not the exception, among patients with disorders of the central nervous system (CNS) [4]. Thus far, no nationwide, if any, research has been conducted recently on the incidence and prevalence of strokes in Saudi Arabia. However, over the past decade there was one study which reported that the crude incidence rate for first-ever incidence of stroke in Saudi Arabia was 29.8/100,000/year [5]. In addition, they reported that, the important risk factors were: systemic hypertension (38%), diabetes mellitus (37%), heart disease (27%), smoking (19%) and family history of stroke (14%) [5]. In 10 years of work on stroke in Saudi Arabia, the incidence and prevalence of strokes were low when compared to those reported from Western countries. However, the high prevalence of diabetes mellitus as a risk factor were quite distinctive. Undetected and untreated hypertension and a low frequency of cigarette smoking in the stroke-prone age group could be one explanation of these findings [6]. Parkinson's Disease (PD) is a common neurodegenerative disorder. Epidemiological studies of PD from 1985 to 2010, worldwide data showed a rising prevalence of PD with age (all per 100,000): 173 in 55 to 64 years; 428 in 60 to 69 years; 425 in 65 to 74 years; 1087 in 70 to 79 years; and 1903 in older than age 80. A significant difference was seen in prevalence by geographic location with 646 in individuals from Asia (P < 0.05). A significant difference in prevalence by sex was found (P < 0.05) [7]. Among the urban and rural population of Al Kharga District, New Valley, Egypt, the results revealed that the total prevalence rate of neurological disorders in Al Kharga District, New Valley was 2.4% with no significant difference among both sexes. The highest prevalence rate was recorded among elderly people (60+ years; 9.25%) [8].
In a study conducted in in Fayoum, Egypt, stroke was found in 2.8% of the studied elderly; 2.0% of males and 0.8% of females, headache was found in 58.4%; 31% of males and 27.4% of females [9]. In in Southern Saudi Arabia, Al-Modeer study, stroke was found in 34.9% of elderly, more in males than females (39.4% of males and 27.1% of females), parkinsonism was 4.3% (5.4% in males and 3.5% in females [10]. Between 1982 and 1992, in a study conducted by Al Rajeh et al., in a hospital that exclusively treated the Saudi Arabian National Guard community rated the crude annual incidence rate at 43.8 per 100,000 Males predominated in all types of stroke. In both male and female groups the most likely stroke-prone age was 60 to 70 years. Hypertension (56%), diabetes mellitus (42%), and cardiopathy (33%) were common risk factors [11]. In Thugbah community in the Eastern Province of Saudi Arabia to determine its point prevalence of neurological diseases. only 1.5% were more than 60 years old. The overall crude prevalence ratio for all forms of neurological disease was 131/1,000 population. Headache syndromes were the most prevalent disorder ( 20.7). Stroke, Parkinson's disease, and Alzheimer's disease were uncommon with respective PRs of 1.8, 0.27 and 0.22. The major medical diseases that may be neurologically relevant were diabetes mellitus, hypertension, and connective tissue disorders [12]. As very few studies have focused on the elderly population, there is a lacuna in data of neurological disorders in elderly in Northern region of Saudi Arabia.

Objectives:
To study some of the demographic characteristics of the elderly population and to estimate the prevalence of neurological diseases, its types and determinants among the elderly population of Arar city, Kingdom of Saudi Arabia.

Study design and setting:
The present cross sectional community based study was conducted in Arar city, the capital of Northern Borders Governorate

Study period and target population:
This study was conducted during the period from 1 June to 30 September 2016, on elderly people of age 60 years and more.

Sampling:
The sample size was calculated using the sample size equation: n=z2p(1-p)/e2, considering target population more than 1000, and study power 95%. Data was collected from 138 elderly participant aged 60 years and above. Systematic random sampling technique was followed. After identifying the first house randomly in the selected area, every 9th house was visited to include all the elderly subjects residing in those selected houses till the required sample is covered.

Data collection:
Data were collected by means of personal interview with the sampled elderly using a predesigned questionnaire covering the following items: (1) Socio-demographic characteristics including age, sex, educational and marital status.
(2) Smoking status and certain types of diseases that may be prevalent among elderlies suggested to affect neurological diseases such as diabetes millets and obesity. (3) The questionnaire included also questions regarding the already previously diagnosed neurological diseases, its types and its determinants, after ensuring the diagnosis by reviewing the accompanied health records and prescriptions and asking the caregivers about the case.

Ethical considerations:
Data collector gave a brief introduction to the participants by explaining the aims and benefits of the study. Informed written consent was obtained from all participants. Anonymity and confidentiality of data were maintained throughout the study. There was no conflict of interest.

Statistical analysis:
We utilized the statistical package for social sciences, version 16 (SPSS Inc., Chicago, Illinois, USA) to analyze the study data. The results were displayed as counts and percentages. The X2 test was used as a test of significance, and differences were considered significant at P value less than 0.05.  Table (2) illustrates the percentage distribution of neurological diseases among the studied elderly population. The overall prevalence rate of neurological diseases observed in this study was 20.9%; the prevalence of stroke was 4.3%, parkinsonism was 3.6%, facial palsy 4.3%, headache syndrome was 6.5% and 2.1% previous nervous system surgery. Table (3) illustrates the relationship between neurological diseases and socio-demographic characteristics in the studied elderly population. Headache, parkinsonism are more common in females bur stroke is more in males.

Results:
Headache is common in 60-69 years age group but parkinsonism and stroke are more common in 70-79 years age group. There is specificdistribution with marital status. Table (4) illustrates the relationship between neurological diseases and DM, obesity, hypertension and smoking history in the studied elderly population. Headache, parkinsonism and stroke are more in non diabetics than diabetics, in non obese than obese, non smokers and in non hypertensive studied elderly population. Table ( 5) illustrates the relationship between neurological diseases and psychiatric diseases in the studied elderly population. Alzheimer's disease is not associated with neurological diseases, depression is associated with Stroke.
No psychiatric diseases was associated with headache or parkinsonism in the studied elderly population.

Discussion:
Ageing is inevitable and it is a concern of every one. Elderly life is full of problems-physical, social and economic. Older people are helpless and a disability is more likely to occur in the old age [13]. Neurological diseases considered a major concern because of its increasing frequency and serious consequences and related disability and dependency. The present study is a descriptive cross sectional survey, conducted to estimate the prevalence of neurological diseases, its types and determinants among the elderly population of Arar city, Kingdom of Saudi Arabia. In the Northern Province of Saudi Arabia, well-known cultural barriers to discussing sensitive issues, especially with strangers, exist. the information provided by the elderly would form a basis for more in-depth and large scale studies concerning neurological diseases in this vulnerable group in our region.
The present study showed that, the age of elderly ranges from 60-92 years with a mean age (± SD) was 70 (±9.25) years, male to female ratio was 47.8 to 52.2. in southwest Saudi Arabia by Al-Modeer et al, the age of elderly ranges from 60-104 years with a mean of 77.2 ± 8.9. Most of the studied elderly (55.9%) were females [10]. In Al Rajeh et al., in a hospital that exclusively treated the Saudi Arabian National Guard hospital, the mean age of the patients was 63 (±17) years [11]. In a study conducted on elderly in Dubai, United Arab Emirates, the gender ratio of the elderly patients in the study was 2.1 female: 1.0 male. the age of elderly ranges from 60-113 years with mean (SD) age was 78.77 (9.50) years [16].
In the present study, married were 62.3% while 33.3 were widow, illiteracy constitutes 48.6%, primary school literates were 19.6% and total of 76.2% had less than secondary education. In Ibrahim et al in Jeddah, widowed elderly represented about one-fifth (21.8 %) of the sample which is less than our figure. The majority of elderly (78.4 %) had less than secondary education which is consistent with our figure [14]. Khadervalli et al [15] in their study reported only 27% as illiterate and 31% as primary school literates, which is better than our figures.
The overall prevalence rate of neurological diseases observed in this study was 20.9% with no significant difference among both sexes. This results are comparable to other studies. For example, in Thugbah community in the Eastern Province of Saudi Arabia, Al Rajeh et al., reported overall prevalence rate of neurological diseases 13.1% which is more than our figure [12]. In Al Kharga District, New Valley, Egypt, the results revealed that the total prevalence rate of neurological disorders among elderly people (60+ years) was 9.25% with no significant difference among both sexes [8].
In our study the prevalence of stroke (4.3%) were more in males than females . In Fayoum, Egypt study, the prevalence of stroke (2.8%) were more in males than females, this less than our finding [9]. In Al-Modeer study, Stroke was found in 34.9% of elderly, more in males than females (39.4% of males and 27.1% of females), which is far higher than our figure [10]. A stroke registry revealed 0.04% (0.03% males, 0.017% females) of first-ever strokes affecting Saudi nationals [5] which is far less than our figure. Al Rajeh et al., reported overall prevalence rate of stroke 1.8% which is also less than our figure [12].In a study conducted in Dubai,