Neurological Disorders: Public Health Challenges

Neurological Disorders:Public Health Challenges

Common neurological disorders with great public health impact • Dementia • Epilepsy • Headache disorders • Multiple sclerosis • Neuroinfections • Neurological disorders caused by nutrient deficiency • Pain associated with neurological disorders • Parkinson’s disease • Stroke • Traumatic brain injury

Dementia • Dementia is a syndrome caused by disease of the brain, usually of a chronic or progressive nature, in which there is disturbance of multiple higher cortical functions, including memory, thinking, orientation, comprehension, calculation, learning capacity, language and judgment. • Consciousness is not clouded. • mainly affects older people: only 2% of cases start before the age of 65 years. • After this the prevalence doubles with every five-year increment in age. • Dementia is one of the major causes of disability in later life.

Public Health Framework • Dementia is a disease and not a part of normal ageing. • Dementia affects some 24 million people, most of them elderly, worldwide. Up to two thirds live in low and middle income countries. • Awareness of dementia is very low in all world regions, a problem leading to stigmatization and inefficient help-seeking. • No cure is currently available for the most common causes of dementia, but much can and should be done to improve the quality of life of people with dementia and their carers. • Governments should be urged to take account of the needs of people with dementia, as an integral part of a comprehensive programme of health and welfare services for older people.

Public Health Framework • The priority should be to strengthen primary care services, through training and reorientation from clinic-based acute treatment services to provision of outreach and long-term support. • Governments, nongovernmental organizations working in the area of Alzheimer and other dementias, professionals and carers need to work together to raise awareness, counter stigma and improve the quality and coverage of care services.

Epilepsy • The term is applied to a large group of conditions characterized by common symptoms called “epileptic seizures”, which may occur in the context of a brain insult that can be systemic, toxic or metabolic. • These events (called provoked or acute symptomatic seizures) are presumed to be an acute manifestation of the insult and may not recur when the underlying cause has been removed or the acute phase has elapsed. • Epilepsy is a chronic neurological disorder affecting both sexes and all ages, with worldwide distribution.

Public Health Framework • Epilepsy is one of the most common serious neurological disorders worldwide with no age, racial, social class, national or geographic boundaries. • Worldwide, 50 million people have epilepsy. Around 85% of these live in developing countries.

Public Health Framework • Up to 70% of people with epilepsy could lead normal lives if properly treated, but for an overwhelming majority of patients this is not the case • The worldwide incidence, prevalence and mortality of epilepsy are not uniform and depend on several factors, which include the structure of the local population, the basic knowledge of the disease, the socioeconomic and cultural background, the presence of environmental risk factors, and the distribution of infrastructure, financial, human and material resources.

Public Health Framework • Some forms of epilepsy, particularly those associated with CNS infections and trauma, may be preventable. • As epileptic seizures respond to drug treatment, the outcome of the disease depends on the early initiation and continuity of treatment. Difficulties with availability of or access to treatment (the treatment gap) may seriously impair the prognosis of epilepsy and aggravate the social and medical consequences of the disease.

Public Health Framework • In low income countries the treatment gap needs to be seen in the context of the local situation, with inadequate resources for all forms of health delivery as well as education and sanitation. • The treatment gap is not only a matter of the lack of availability of AEDs, but encompasses the lack of infrastructure, training and public awareness of the condition. All these areas need to be confronted. • Integration of epilepsy care in national health systems needs to be promoted by developing models for epilepsy control worldwide.

Headache disorders • Headache is a painful feature of a relatively small number of primary headache disorders, some of which are widespread and are often life-long conditions. • Headache also occurs as a characteristic symptom of many other conditions; these are termed secondary headache disorders • Headache disorders are among the most common disorders of the nervous system, causing substantial disability in populations throughout the world.

Public Health Framework • Headache disorders are common and ubiquitous. They have a neurological basis, but headache rarely signals serious underlying illness. The huge public health importance of headache disorders arises from their causal association with personal and societal burdens of pain, disability, damaged quality of life and financial cost. • Headache disorders have many types and subtypes, but a very small number of them impose almost all of these burdens. They are diagnosed clinically, requiring no special investigations in most of the cases.

Public Health Framework • Although headache disorders can be treated effectively, globally they are not, because health-care systems fail to make treatment available. • Management of headache disorders everywhere in the world has low priority, which abjectly fails to match headache-related health-care provision and delivery to people’s needs. • Effective management of headache disorders can be provided in primary care for all but a very small minority of patients. Nurses and pharmacists can complement the delivery of health care by primary care physicians.

Public Health Framework • Good management, at whatever level, requires education of doctors and of people affected by headache disorders. Mismanagement, and overuse of medications to treat acute headache, are major risk factors for disease aggravation. • Every government should acknowledge the humanitarian arguments for effective health care for headache disorders.

Public Health Framework • Every government should be aware of the financial cost to the country of headache disorders in its population. Cost-of-illness studies will create awareness of the potential savings that better health care for headache disorders may achieve through mitigated productivity losses. • Partnerships between health policy-makers, health-care providers and people affected by headache disorders and their advocacy groups may be the best vehicle for determining, and bringing about, the changes that people with headache need.

Stroke • Stroke is one of the main noncommunicable diseases of public health importance. After coronary heart disease and cancer, stroke is the most common cause of death in most industrial- ized countries. • In general terms, stroke is a sudden neurological deficit owing to localized brain ischaemia or haemorrhage. • Most strokes are attributed to focal occlusion of the cerebral blood vessel (ischaemic stroke) and the remainder are the result of rupture of a blood vessel (haemorrhagic stroke).

Public Health Framework • Stroke is the second leading cause of mortality worldwide and the major cause of long- term disability in adults. • Further increase of stroke mortality is expected, with the majority of deaths from stroke to occur in less developed countries. • By 2015, over 50 million healthy life years will be lost from stroke, with 90% of this burden in low and middle income countries.

In developed countries, up to 80% of strokes represent ischaemic stroke, while the remaining 20% are attributed to either intracerebral or subarachnoid haemorrhage. In some developing countries the proportion of haemorrhagic strokes is higher. • Non-contrast computerized tomography is a reliable diagnostic tool allowing proper differentiation between ischaemic and haemorrhagic stroke and excluding other causes of brain damage. • Advent of thrombolytic therapy together with development of stroke units leads to a reduction of mortality and disability caused by stroke.

Immediate aspirin treatment of ischaemic stroke is beneficial in terms of reducing early stroke recurrence and increasing disability-free survival. • Effective measures to prevent stroke are lifestyle modification (smoking cessation, increased physical activity and the lowering of body weight), control of hypertension and blood sugar, lowering of plasma cholesterol, carotid endarterectomy in selected cases, and long-term antiplatelet or anticoagulant treatment.

There is a gap between developed and developing countries in terms of stroke prevention, diagnosis, treatment and rehabilitation caused by the lack of trained specialists and expertise, lack of equipment, inadequate diagnostic evaluation and insufficient funds in resource-poor countries. • Stroke research and training are grossly underfunded.

Dementia • Epilepsy • Headache disorders • Multiple sclerosis • Neuroinfections • Neurological disorders caused by nutrient deficiency • Pain associated with neurological disorders • Parkinson’s disease • Stroke • Traumatic brain injury

Neurological Disorders caused by Nutrient Deficiency • In low income countries, inadequate amounts of food (causing conditions such as child malnutrition and retarded growth) and inadequate diversity of food (causing deficiency of vital micronutrients such as vitamins, minerals or trace elements) continue to be priority health problems.

Neurological Disorders caused by Nutrient Deficiency • Malnutrition in all its forms increases the risk of disease and early death. Nearly 800 million people in the world do not have enough to eat. • Malnutrition affects all age groups, but it is especially common among poor people and those with inadequate access to health educa-tion, clean water and good sanitation.

Public Health Framework • Malnutrition, micronutrient deficiencies and ingestion of toxic compounds continue to be priority public health problems. Most of the neurological disorders associated with them are preventable. • Priorities need to be identified for the actions needed to deal with neurological disorders associated with malnutrition, micronutrient deficiencies, or the ingestion of toxic compounds.

Public Health Framework • The strategy of communication should use appropriate and diversified channels for better sensitization and social mobilization. It should target the general population, health professionals and social workers. Schools constitute a favourable environment because they provide access to teachers and pupils who can carry the message home at household level. • The interrelationship between neurological disorders and nutrition must be stressed in the training of general practitioners, paramedical staff and social workers. The capacities of nongovernmental organizations, community organizations and the education sector must be reinforced and developed so as to target the prevention of nutritional problems.

Public Health Framework • Development and review of training manuals, counselling guidelines and training curricula is a necessary part of capacity-strengthening whose contents need to be centered on specific subjects in accordance with needs assessment, the gaps to be filled and the interventions to be implemented in the community. • Educative support to the health services must be elaborated to develop tools of education and counselling for primary and secondary prevention and to develop guidelines and support to facilitate management of the targeted diseases and secondary complications, including disabilities and rehabilitation.

Dementia • Epilepsy • Headache disorders • Multiple sclerosis • Neuroinfections • Neurological disorders caused by nutrient deficiency • Pain associated with neurological disorders • Parkinson’s disease • Stroke • Traumatic brain injury

Neurological Disorders: Public Health Challenges