Abstract
Background
Neurological disorders constitute major causes of morbidity, and globally, they are the leading causes of death. There is a dearth of neurologists in most African countries and the very few available ones are concentrated in urban areas. The cardiovascular and communicable risk factors responsible for most cases of acute and chronic neurological disorders are also prevalent in rural areas. Although patients from the neighbouring states attend the study centre, the majority are indigent. Therefore, there is a need to observe the pattern of these disorders in Ekiti, to appreciate the disease burden as it would help in the judicious allocation of human and other healthcare resources.
Methodology
We reviewed the case files of patients seen at the neurology clinic and admitted via the emergency department into the Federal Teaching Hospital, Ido-Ekiti, over a period of 6 years (2016 to 2021).
Results
A total of 881patients were seen during the study period, and they were mostly elderly male patients with chronic disorders in which stroke was the most common neurological disorder (44.9%) followed by seizure disorder (13.1%), and neurodegenerative disorders (9.9%). Tumors and myopathies were the least seen disorders.
Conclusion
Health literacy on cardiovascular risk factors and even the distribution of manpower and material resources will help reduce the burden of neurological disorders among the attendees of the Ekiti tertiary health institution.
Keywords: Neurological disorders, Ekiti, Nigeria
Introduction
Neurological disorders constitute major causes of morbidity, and globally, they are the leading causes of death.[3] They are either primary disorders of the nervous system or neurological manifestations of other systemic diseases.[3] Most neurological disorders are viewed as spiritual attacks, therefore, patients and their relations prefer to visit spiritual homes for remedy.[4] This is further compounded by low educational levels, poverty, and inefficient hospital treatment due to the dearth of neurologists in most African countries.[6] In Nigeria, for instance, the few available neurologists are concentrated in urban centers of the country where the adoption of Western lifestyles is believed to contribute more to the increasing incidence of neurovascular and cardiovascular events such as stroke and other cardiovascular diseases.[4] This is no longer the case as there is an increasing level of socialization and urbanization in rural areas as well, predisposing them to cardiovascular risk factors.[1] There is a need to observe the pattern of these disorders in Ekiti, to appreciate the disease burden as it would help in judicious allocation of human and other health care resources.
Methodology
The admission books and case files of patients seen at the emergency department, neurology clinic, and the medical wards of the Federal Teaching Hospital, Ido-Ekiti, Nigeria were retrieved for the extraction of information used for this study. The hospital is a referral centre for the general and specialist hospitals in Ekiti State and neighbouring states: Ondo, Kogi, and Kwara. Records were taken from January 2015 to December 2020. Two reviewers ensured that there was no duplication of records, especially for those patients that were admitted via the emergency department and the neurology clinic to the medical wards. Diagnoses were made by the hospital neurologist and confirmed by the available diagnostic equipment such as MRI, CT machine, EEG machine, and well-equipped medical laboratories. Patients were referred for nerve conduction studies. Cases of stroke were confirmed with brain CT/MRI within a week of admission and for those who were not stable enough to be transferred for neuroimaging, the updated definition of stroke for the 21st century, according to the American Heart Association and American Stroke Association was used.[7] Diagnosis and classification of seizures were based on ictal semiology and EEG. We used the UK Parkinson’s Disease Study Brain Bank criteria for the diagnosis of Parkinson’s disease while other movement disorders were diagnosed clinically based on the pattern. Neuropsychiatric disorders were diagnosed using the ICD-10 criteria[6] in addition to neuroimaging and other biochemical investigations to rule out organic brain disorders. Cord compression syndromes were confirmed with X-ray and MRI.
Results
A total of 881 patients were seen during the study period with males constituting 51.2 percent. Most of the patients were predominantly (69.8%) seen in the clinic with a median age of 58.23 ± 18.33 years.
Table 1:
Age and sex distribution of the patients
| Variable | Frequency | Percent |
|---|---|---|
| Age (years) | ||
| 18 - 44 | 210 | 23.8 |
| 45 - 64 | 333 | 37.8 |
| ≥ 65 | 338 | 38.4 |
| Mean ± SD | 58.23 ± 18.33 | |
| Range | 18 - 105 | |
| Sex | ||
| Male | 451 | 51.2 |
| Female | 430 | 48.8 |
| Place | ||
| Clinic | 615 | 69.8 |
| Ward/Emergency | 266 | 30.2 |
The Years 2016 and 2017 recorded the highest number of patients (27.5 and 26.1% respectively) with a progressive decline to 2020. There were few confirmed neurological cases seen and admitted in 2015 (1.4%). The Year 2020 also recorded a low patient turnout (2.8%).
Figure 1:
Distribution of the patients based on the year
Vascular events (ischemic and hemorrhagic strokes) constituted the highest proportion (44.9%) of neurological disorders seen over the 6-year period. This was followed by seizures and movement disorders, 13.1% and 9.9% respectively. Myopathies (1.0%) and tumors (0.5%) were the least seen. (Figure 2).
Figure 2:
Neurology cases seen from 2015 to 2020
Cases of stroke were commoner in females (50.5% of all cases recorded) and in those above the age of 65 years (59.8% of all cases seen). The highest proportion of seizure disorders was recorded in the youngest age group (18 to 45 years) and commoner in males (13.3% of total cases). Movement disorders were most common (13.3%) among the elderly and commoner in males (14.2% of total cases). The diagnoses and patterns according to age group and sex distribution are shown in Table 2 and Figures 3 and 4 respectively.
Table 2:
Diagnosis based on age and sex distribution of the patients
| Age (years) | Sex | |||||
|---|---|---|---|---|---|---|
| 18 - 44 | 45 - 64 | ≥ 65 | Male | Female | Total | |
| Diagnosis | n=210(%) | n=333(%) | n=338(%) | n=451(%) | n=430(%) | N=881(%) |
| Vascular | 36(17.1) | 158(47.4) | 202(59.8) | 179(39.7) | 217(50.5) | 396(44.9) |
| Infection/inflammatory | 28(13.3) | 31(9.3) | 19(5.6) | 42(9.3) | 36(8.4) | 78(8.9) |
| Seizure/ Epilepsy | 63(30.0) | 27(8.1) | 25(7.4) | 61(13.5) | 54(12.6) | 115(13.1) |
| Movement disorder | 12(5.7) | 29(8.7) | 46(13.6) | 64(14.2) | 23(5.3) | 87(9.9) |
| Neuropsychiatry | 7(3.3) | 16(4.8) | 25(7.4) | 19(4.2) | 29(6.7) | 48(5.4) |
| Neuroimmunology | 5(2.4) | 5(1.5) | 1(0.3) | 8(1.8) | 3(0.7) | 11(1.2) |
| Headache | 17(8.1) | 10(3.0) | 1(0.3) | 10(2.2) | 18(4.2) | 28(3.2) |
| Others | 17(8.1) | 25(7.5) | 9(2.7) | 26(5.8) | 25(5.8) | 51(5.8) |
| Cord compression syndrome | 17(8.1) | 28(8.4) | 9(2.7) | 35(7.8) | 19(4.4) | 54(6.1) |
| Tumor | 2(1.0) | 2(0.6) | 0(0.0) | 2(0.4) | 2(0.5) | 4(0.5) |
| Myopathy | 6(2.9) | 2(0.6) | 1(0.3) | 5(1.1) | 4(0.9) | 9(1.0) |
Figure 3:
Pattern of diagnosis based on the age distribution of the patients
Figure 4:
Pattern of diagnosis based on sex distribution of the patients
All the neurological cases recorded the highest hospital presentation between 2016 and 2017 with a steady decline from 2018 except for cord compression syndrome which peaked that year (11.7%) of cases. In the following year, there was a sharp drop in cases of cord compression syndrome to 3.4%. The diagnoses of the other neurological disorders per year are shown in Table 3.
Table 3:
Diagnosis per year
| Year | |||||||
|---|---|---|---|---|---|---|---|
| 2015 | 2016 | 2017 | 2018 | 2019 | 2020 | Total | |
| Diagnosis | n (%) | n (%) | n (%) | n (%) | n (%) | n (%) | N (%) |
| Vascular | 9(75.0) | 101(41.7) | 98(42.6) | 86(43.7) | 81(46.3) | 21(84.0) | 396(44.9) |
| Infection/inflammatory | 2(16.7) | 20(8.3) | 19(8.3) | 12(6.1) | 24(13.7) | 1(4.0) | 78(8.9) |
| Seizure/ Epilepsy | 0(0.0) | 33(13.6) | 36(15.7) | 27(13.7) | 16(9.1) | 3(12.0) | 115(13.1) |
| Movement disorder | 0(0.0) | 24(9.9) | 26(11.3) | 24(12.2) | 13(7.4) | 0(0.0) | 87(9.9) |
| Neuropsychiatry | 0(0.0) | 18(7.4) | 13(5.7) | 3(1.5) | 14(8.0) | 0(0.0) | 48(5.4) |
| Neuroimmunology | 0(0.0) | 2(0.8) | 4(1.7) | 1(0.5) | 4(2.3) | 0(0.0) | 11(1.2) |
| Headache | 0(0.0) | 8(3.3) | 9(3.9) | 4(2.0) | 7(4.0) | 0(0.0) | 28(3.2) |
| Others | 1(8.3) | 22(9.1) | 8(3.5) | 11(5.6) | 9(5.1) | 0(0.0) | 51(5.8) |
| Cord compression syndrome | 0(0.0) | 10(4.1) | 15(6.5) | 23(11.7) | 6(3.4) | 0(0.0) | 54(6.1) |
| Tumor | 0(0.0) | 0(0.0) | 1(0.4) | 3(1.5) | 0(0.0) | 0(0.0) | 4(0.5) |
| Myopathy | 0(0.0) | 4(1.72) | 1(0.4) | 3(1.5) | 1(0.6) | 0(0.0) | 9(1.0) |
| Total | 12(100.0) | 242(100.0) | 230(100.0) | 197(100.0) | 175(100.0) | 25(100.0) | 881(100.0) |
Discussion
They were mostly elderly male patients with chronic disorders similar to the findings at a southeastern teaching hospital by Ekenze et al.[4]There was a sharp increase in the number of cases seen in 2016 as a result of the participation of the institution in research on stroke (Stroke Investigative Research and Education Network, SIREN).[2] As part of the recruitment process, patients were educated on the risk factors for stroke and both the primary and secondary preventive measures. Those with identified risk factors were referred to the hospital immediately for urgent clinical interventions. This might have contributed to the progressive steady decline in the new cases of stroke recorded per year. This emphasizes the role of patient education in health promotion. In the year 2020 where there was a significant drop in admission due to the COVID-19 pandemic. There was total lockdown across the country and only a few patients with emergencies, mainly stroke and seizures, presented to the hospital for admission.
The acute cases were more of stroke, highest in the year 2016 because of increased advocacy on the awareness of symptoms and timely hospital presentation as part of SIREN protocol. The survivors were followed up in the subsequent years with an emphasis on secondary and tertiary stroke prevention strategies.
Stroke had the highest prevalence similar to the findings of Talabi et al[2] in Ibadan and also the experience of Owolabi et al,[3] and Ibrahim et al[2] both in Kano, Nigeria. It was commoner in females, and in those above the age of 65 years as it was found by Desalu et al,[2] six years before this study, in the same geographical area. Ogun et al,[6] in another southwestern tertiary institution in Nigeria, found a similar female preponderance. The reason for the slight female preponderance in this study, as opposed to other studies,[2, 3] is the longer female life span to the age that stroke is most prevalent. Seizure disorders were recorded as the second most prevalent disease in this study similar to findings in some other countries where it is predominant in the young age group, and commoner in males as reported in most African countries.[1] However, a similar study at Ile-Ife, Nigeria, by Komolafe et al[11] found epilepsy as the most common neurological disorder, followed by stroke. This, probably, must have been because their cohorts were outpatients only. Movement disorders ranked third on the list and were most common among elderly men. The commonest seen in our cohort is Parkinson’s disease which is a neurodegenerative disease with a peak incidence of 70-79 years.[6] The order of prevalence observed in this study is the same as that of the neurology clinic of the KomfoAnokye Teaching Hospital in Kumasi, Ghana. The exponential rise in the incidence of cardiovascular risk factors such as diabetes mellitus, obesity, and sedentary lifestyle, hypertension, dyslipidemia in many African countries explains why there are escalating rates of stroke and ischemic heart diseases.[3, 10] It is quite clear why stroke is the most common neurologic disorder in our cohort.
Stroke, movement disorders, and neurodegenerative conditions were seen more in the elderly while seizure/epilepsy was the only disorder most prevalent among young individuals. This observation implies that there is ample time to prevent the development of these disorders. This calls for actions to reduce the burden of stroke by emphasizing primordial and primary prevention of stroke.[1, 10,15,4] Alzheimer’s disease and vascular dementia can also be prevented by adequate and timely control of cardiovascular risk factors.[4] Neuroinfectious conditions (including NeuroAIDs, meningitis, tetanus, and transverse myelitis), and cord compression syndromes, (surprisingly cervical spondylosis) were commoner among the young patients. Presentations were neck pain radiating to the forearms and paresthesia in the hands. There were two cases of lumbar spondylosis that presented with priapism which were subsequently referred to the neurosurgeon for laminectomies. Cord compression cases at the neurology clinic dropped as the hospital got a neurosurgeon in year 2018. Most of the neurological conditions in this cohort were more in males, except for stroke, neuropsychiatric disorders, and headaches.[4] Most of our stroke patients are postmenopausal as stroke rates increase among postmenopausal women compared with age-matched men.[12]
Conclusions
Our experience in Ekiti, Nigeria, shows that stroke is the most common neurological disorder followed by seizures and movement disorders. The observed progressive decline in the cases of stroke may be attributable to health education and timely intervention on detected cardiovascular risk factors which if intensified can also reduce the incidence of Alzheimer’s disease and vascular dementia.
References
- 1.Feigin VL, Vos T, Nichols E, Owolabi MO, Carroll WM, Dichgans M, et al. The global burden of neurological disorders: translating evidence into policy. The Lancet Neurology. 2020;19:255-65. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Cojocaru IM, Cojocaru M, Silosi I, Vrabie CD. Peripheral nervous system manifestations in systemic autoimmune diseases. Mædica. 2014;9:289. [PMC free article] [PubMed] [Google Scholar]
- 3.Uwakwe R. The pattern of psychiatric disorders among the aged in a selected community in Nigeria. International Journal of Geriatric Psychiatry. 2000;15:355-62. [DOI] [PubMed] [Google Scholar]
- 4.https://naijagists.com/Yoruba Actress lyabo Oko: Spiritual Attack Caused My Stroke. I'm Not Dead, I'm Recovering In India - NaijaGists.com - Proudly Nigerian DIY Motivation & Information Blog. Assessed 10 August 2023.
- 5.Nweke MC, Eze CK. The place of spiritual and traditional beliefs in stroke rehabilitation in sub-Saharan Africa: A scoping review. Journal of Complementary and Alternative Medical Research. 2019:1-16. [Google Scholar]
- 6.Mateen FJ, Clark SJ, Borzello M, Kabore J, Seidi O. Neurology training in sub-Saharan Africa: A survey of people in training from 19 countries. Annals of Neurology. 2016;79:871-81. [DOI] [PubMed] [Google Scholar]
- 7.Gami AS, Witt BJ, Howard DE, Erwin PJ, Gami LA, Somers VK, et al. Metabolic syndrome and risk of incident cardiovascular events and death: a systematic review and meta-analysis of longitudinal studies. Journal of the American College of Cardiology. 2007;49:403-14. [DOI] [PubMed] [Google Scholar]
- 8.Raimi TH, Odusan O, Fasanmade O. High prevalence of central obesity in rural South-Western Nigeria: Need for targeted prevention. 2015.
- 9.Oladapo O, Salako L, Sodiq O, Shoyinka K, Adedapo K, Falase A. A prevalence of cardiometabolic risk factors among a rural Yoruba south-western Nigerian population: a population-based survey: cardiovascular topics. Cardiovascular Journal of Africa. 2010;21:26-31. [PMC free article] [PubMed] [Google Scholar]
- 10.Sacco RL, Kasner SE, Broderick JP, Caplan LR, Connors J, Culebras A, et al. An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44:2064-89. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Daniel S, Lees A. Parkinson's Disease Society Brain Bank, London: overview and research. Journal of Neural Transmission Supplementum. 1993;39:165-72. [PubMed] [Google Scholar]
- 12.Van Vliet I, De Beurs E. The MINI-International Neuropsychiatric Interview. A brief structured diagnostic psychiatric interview for DSM-IV en ICD-10 psychiatric disorders. Tijdschrift Voor Psychiatrie. 2007;49:393-7. [PubMed] [Google Scholar]
- 13.Ekenze O, Onwuekwe I, Ezeala B. Profile of neurological admissions at the University of Nigeria Teaching Hospital Enugu. Nigerian Journal of Medicine. 2010;19:419-22. [DOI] [PubMed] [Google Scholar]
- 14.Singh A, Jenkins C, Calys-Tagoe B, Arulogun O, Sarfo S, Ovbiagele B, et al. Stroke investigative research and education network: public outreach and engagement. Journal of Community Medicine & Health Education. 2017;7:518. doi: 10.4172/2161-0711.1000518. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Talabi O. A 3-year review of neurologic admissions in University College Hospital Ibadan, Nigeria. West African Journal of Medicine. 2003;22:150-1. [DOI] [PubMed] [Google Scholar]
- 16.Owolabi L, Shehu M, Shehu M, Fadare J. Pattern of neurological admissions in the tropics: Experience at Kano, Northwestern Nigeria. Annals of Indian Academy of Neurology. 2010;13:167. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Ibrahim A, Owolabi LF, Musa BM, Aliyu S, Rabiu M, Yakasai AM. Pattern of in-patient neurologic review: An experience from a Tertiary Hospital North-Western Nigeria. Annals of African medicine. 2016;15:47. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Desalu OO, Wahab KW, Fawale B, Olarenwaju TO, Busari OA, Adekoya AO, et al. A review of stroke admissions at a tertiary hospital in rural Southwestern Nigeria. Annals of African Medicine. 2011;10:80-5. [DOI] [PubMed] [Google Scholar]
- 19.Ogun S, Ojini F, Ogungbo B, Kolapo K, Danesi M. Stroke in south west Nigeria: a 10-year review. Stroke. 2005;36:1120-2. [DOI] [PubMed] [Google Scholar]
- 20.Njoku C, Aduloju A. Stroke in Sokoto, Nigeria: A five year retrospective study. Annals of African Medicine. 2004;3:73-6. [Google Scholar]
- 21.Onwuchewa A, BellGam H, Asekomeh Gs. Stroke at the university of port harcourt teaching hospital, rivers state, Nigeria. Tropical Doctor. 2009;39:150-2. [DOI] [PubMed] [Google Scholar]
- 22.Tegueu CK, Nguefack S, Doumbe J, Fogang YF, Mbonda PC, Mbonda E. The spectrum of neurological disorders presenting at a neurology clinic in Yaounde, Cameroon. The Pan African Medical Journal. 2013;14:148.doi: 10.11604/pamj.2013.14.148.2330 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Olubunmi A. Epilepsy in Nigeria-a review of etiology, epidemiology and management. Benin Journal of Postgraduate Medicine. 2006;8: 27-51. [Google Scholar]
- 24.Komolafe M, Owagbemi O, Alimi T. The distribution and pattern of neurological disease in a neurology clinic in Ile-Ife, Nigeria. Nigerian Journal of Clinical Practice. 2018;21:1520-4. [DOI] [PubMed] [Google Scholar]
- 25.Muangpaisan W, Mathews A, Hori H, Seidel D. A systematic review of the worldwide prevalence and incidence of Parkinson’s disease. Journal of the Medical Association of Thailand. 2011;94:749-55. [PubMed] [Google Scholar]
- 26.Sarfo FS, Akassi J, Badu E, Okorozo A, Ovbiagele B, Akpalu A. Profile of neurological disorders in an adult neurology clinic in Kumasi, Ghana. Eneurologicalsci. 2016;3:69-74. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Owolabi MO, Adu D, Ramsay M, Ovbiagele B. Understanding the rise in cardiovascular diseases in Africa: harmonising H3Africa genomic epidemiological teams and tools: cardiovascular topic. Cardiovascular Journal of Africa. 2014;25:134-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Akinyemi RO, Ovbiagele B, Adeniji OA, Sarfo FS, Abd-Allah F, Adoukonou T, et al. Stroke in Africa: profile, progress, prospects and priorities. Nature Reviews Neurology. 2021;17:634-56. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.De Freitas G, Bogousslavsky J. Primary stroke prevention. European Journal of Neurology. 2001;8:1-15. [DOI] [PubMed] [Google Scholar]
- 30.Pandian JD, Gall SL, Kate MP, Silva GS, Akinyemi RO, Ovbiagele BI, et al. Prevention of stroke: a global perspective. The Lancet. 2018;392:1269-78. [DOI] [PubMed] [Google Scholar]
- 31.Luchsinger JA, Mayeux R. Cardiovascular risk factors and Alzheimer’s disease. Current Atherosclerosis Reports. 2004;6:261-6. [DOI] [PubMed] [Google Scholar]
- 32.Wang C, Tian F, Zhou Y, He W, Cai Z. The incidence of cervical spondylosis decreases with aging in the elderly, and increases with aging in the young and adult population: a hospital-based clinical analysis. Clinical Interventions in Aging. 2016;11:47. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Thakur K. The Global Burden of Neuroinfectious Diseases. 2017. American Academy of Nuerology Institute 2017. Available at: http://www.upandrunningnetworks.com/files/C222_2.pdf Assessed 10 August 2023. [Google Scholar]
- 34.Clayton JA. Sex influences in neurological disorders: case studies and perspectives. Dialogues in Clinical Neuroscience. 2016;18:357. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Haast RA, Gustafson DR, Kiliaan AJ. Sex differences in stroke. Journal of Cerebral Blood Flow & Metabolism. 2012;32:2100-7. [DOI] [PMC free article] [PubMed] [Google Scholar]