Faduma tells us she is fifty four years old. The lines in her face say otherwise. She is very talkative and greets me in English, expressing her joy to meet me. Zanzibari women tend to be more reserved so already Faduma’s behaviour seems out of the ordinary.
This is her first time in the psychiatric clinic and her first interaction with any mental health services. She tells the clinic nurse, Othman, and myself that she is worried people in her neighbourhood are trying to kill her and that the devil is present in her life in her father-in-law. She denies hearing voices but does mention being aware of certain presences that she cannot describe in any more detail. We request that she brings a family member with her next time and so she brings her son, Amar, to her second appointment with us.
During this appointment we are joined by Sarah, a psychologist and another member of the HIPZ mental health team. Faduma’s son describes a gradual change in her mental state over the past few months. She is forgetful and can leave the house for hours at a time, wandering in their area for no apparent reason. Amar stated that his mother only sleeps three hours a night now.
Sarah, Othman and I discuss the presentation. This could be dementia. The WHO’s database in 2016 reported that the average life expectancy of women in Tanzania was 66 years. As dementia is generally a disease seen in later life, it is not a common presentation in Zanzibar. However, Faduma certainly looked closer to seventy than her previously stated fifty four. Dementia incidence is on the rise in Sub-Saharan Africa as life expectancies are increasing. Dementia can present with hallucinations and delusions, causing patients and their families further distress. Faduma appeared to be suffering with such symptoms.
Dementia is the umbrella term used to describe different disease processes affecting the brain that result in the gradual deterioration of a person’s cognitive functioning, impacting on their day to day functioning. There is no cure or reversal agent for dementia but certain medications may be helpful in treating some of the associated symptoms of dementia.
A key feature of care for someone with dementia is psychoeducation. Carers, and patients if possible, need to understand what dementia is and that it is a progressive disease with no cure. They should be offered as much social support as possible. In Zanzibar, patients rarely become isolated thanks to the family and community support present. Sadly, Faduma’s symptoms will progress further and become more severe with time. Our role is to support Faduma and her family what resources we have available.
Unfortunately, there is extremely limited access to allied healthcare professionals in Zanzibar. For example, an occupational therapist would be helpful in making adjustments at home as Faduma may struggle with daily tasks in the years to come. A speech and language therapist may be needed if Faduma’s speech and swallowing deteriorate at the dementia progresses. However, such professionals are not available in this context so Faduma will be seen regularly in psychiatric clinics and we will do our best to manage new symptoms as they arise.
The World Health Organisation (WHO) has recognised dementia as a public health priority, 50 million people worldwide. In 2015, it was estimated that 2.13 million people were living with dementia in sub-Saharan Africa, with this number predicted to nearly double every 20 years, increasing to 3.48 million by 2030 and 7.62 million by 2050. So while dementia has not been a commonly reported burden for countries like Tanzania in the past, it appears to be a pressing issue for the future.