Epidemiology, risk determinants, and research trends of dementia in Saudi Arabia: A systematic review

Abstract

Background

Dementia is an emerging public health priority in Saudi Arabia, driven by population aging and a high prevalence of vascular and metabolic disease. Despite increasing research activity, evidence remains fragmented, limiting understanding of the national burden and determinants of dementia.

Objective

To synthesize evidence on dementia epidemiology, risk factors, awareness, comorbidities, caregiving challenges, and research trends in Saudi Arabia.

Methods

A systematic review was conducted following PRISMA 2020 guidelines. PubMed, Scopus, Web of Science, ScienceDirect, and Google Scholar were searched for studies reporting dementia-related outcomes in Saudi populations. Given heterogeneity in study designs, sampling methods, and diagnostic criteria, findings were narratively synthesized.

Results

Fifty-five studies met the inclusion criteria. Alzheimer's disease was the most common dementia subtype. Prevalence estimates among adults aged 60 years and older ranged from 3.8% to 6.3%, reflecting differences in diagnostic approaches and sampling methods. Diabetes and hypertension were the most consistently identified risk factors, while depression and anxiety were also associated with dementia. Public awareness was low, with stigma contributing to delayed recognition and underdiagnosis. Caregiving was family-based and associated with significant burden. Dementia commonly co-occurs with cardiometabolic, neuropsychiatric, and other chronic conditions. Research activity increased after 2020, with over half of the included studies published between 2020 and 2024; however, methodological inconsistencies and limited rural representation remain.

Conclusions

Dementia research in Saudi Arabia has expanded, yet epidemiological estimates remain inconsistent. Standardized diagnostic practices, enhanced surveillance, and public health strategies addressing risk reduction, awareness, and caregiver support are needed to address the dementia burden.

Introduction

Dementia is a leading cause of disability and dependency among older adults worldwide, with global prevalence projected to rise sharply in the coming decades as populations age. ¹ Countries undergoing rapid demographic and epidemiological transition face particular challenges, as increasing life expectancy coincides with a growing burden of vascular and metabolic disorders, key contributors to cognitive decline and dementia risk.^2–4 Understanding country-specific epidemiological patterns is therefore essential for accurate burden estimation, early detection, and the development of contextually appropriate prevention and care strategies.

Saudi Arabia represents a distinctive setting within this global context. Over recent decades, improvements in healthcare access and longevity have been accompanied by a high national prevalence of diabetes, hypertension, obesity, and other cardiometabolic conditions.^2–5 These intersecting trends suggest that dementia burden may rise substantially in parallel with demographic aging. However, available evidence remains fragmented across hospital-based, community-based, and regional studies, with considerable variation in diagnostic criteria, sampling frameworks, and outcome definitions. Such heterogeneity complicates the interpretation of prevalence estimates and limits the ability to generate reliable national projections.

Beyond biological determinants, sociocultural and health-system factors may further influence dementia recognition, reporting, and management. Stigma, limited public awareness, and reliance on informal caregiving structures have been identified as barriers to early diagnosis and structured care pathways in several Middle Eastern contexts.^6–9 These contextual dynamics may contribute to under-detection and delayed presentation, thereby affecting both epidemiological estimates and clinical outcomes.

Although individual studies in Saudi Arabia have examined prevalence, vascular and metabolic risk associations, neuropsychiatric comorbidities, awareness patterns, and caregiving challenges, no comprehensive synthesis integrating these domains has been undertaken. Existing evidence is methodologically heterogeneous, regionally uneven, and often limited by small sample sizes or non-standardized diagnostic practices. This fragmentation restricts cross-study comparability and obscures national trends.

Accordingly, the present systematic review aims to synthesize empirical evidence on dementia in Saudi Arabia, focusing on prevalence estimates, risk determinants, clinical and social dimensions, and evolving research trends. By consolidating these domains within a structured analytical framework, this review seeks to clarify the current epidemiological landscape, highlight methodological and contextual gaps, and identify priorities for future research and policy development.

Methods

Review protocol and search strategy

This systematic review was conducted in accordance with PRISMA 2020 guidelines to ensure methodological rigor, transparency, and reproducibility. ¹⁰ The protocol was not prospectively registered; however, all methodological steps, including the search strategy, eligibility criteria, and analytical framework, were defined a priori and are reported transparently in accordance with PRISMA 2020 guidelines. A structured search strategy was developed to identify empirical studies examining dementia or dementia-related outcomes within the Saudi Arabian context. Five major databases were searched: PubMed, Scopus, ScienceDirect, Web of Science, and Google Scholar. Because Google Scholar returns large volumes of low-precision results, only the first 15 pages (∼300 results) were screened, consistent with established methodological guidance for grey-literature searching, and to maximize relevance while minimizing noise. These databases were selected for their extensive coverage of biomedical, clinical, social, and public health research. PubMed provided depth in biomedical and neurological topics; Scopus and Web of Science enabled multidisciplinary coverage; ScienceDirect ensured access to full-text, peer-reviewed publications; and Google Scholar aided in identifying grey literature and additional academic outputs. The final search was completed on 25 February 2026.

Search strings combined MeSH terms (e.g., “Dementia[MeSH]”, “Prevalence[MeSH]”) with relevant free-text keywords relating to dementia, risk factors, epidemiology, awareness, caregiving, comorbidities, and prevention in Saudi Arabia. Boolean operators (AND/OR), truncation, and field-specific filters were applied as appropriate. All search outputs were imported into a screening database, with duplicates removed before title, abstract, and full-text assessment. This review adhered to the PRISMA 2020 reporting guidelines to ensure transparency and reproducibility.

Inclusion and exclusion criteria

Studies were eligible for inclusion if they met all of the following criteria:

1. Population: Conducted in Saudi Arabia or used samples directly relevant to the Saudi population.

2. Condition: Reported empirical data on dementia, Alzheimer's disease, or dementia-related outcomes, including prevalence, risk factors, public or professional awareness, caregiving experiences, comorbidities, or technological and therapeutic developments.

3. Diagnostic Validity: Employed recognized diagnostic criteria or validated cognitive screening tools (e.g., Diagnostic and Statistical Manual of Mental Disorders, International Classification of Diseases, Mini-Mental State Examination, Montreal Cognitive Assessment (MoCA), or equivalent clinical assessments).

4. Study Design: Utilized empirical quantitative or qualitative methodologies, such as cross-sectional, cohort, case-control, retrospective, or mixed-methods designs.

5. Publication Characteristics: Written in English and published in peer-reviewed journals.

6. Methodological Transparency: Provided sufficient methodological detail to permit quality appraisal and synthesis.

Studies were excluded if they:

• did not contain primary empirical data (e.g., reviews, commentaries, editorials)

• focused exclusively on non-dementia cognitive disorders

• employed unclear or unvalidated diagnostic criteria

• were based on very small sample sizes (<30 participants), unless targeting an otherwise underrepresented population

• were published only in Arabic (due to resource constraints, with acknowledgement of potential language bias)

These criteria were designed to ensure that included studies were methodologically sound, clinically relevant, and suitable for high-quality narrative synthesis.

Research dimensions and analytical framework

To capture the multiple dimensions of dementia in Saudi Arabia, the evidence was synthesized using a thematic analytical framework comprising six interconnected dimensions. These dimensions were identified deductively from the review objectives and refined during full-text appraisal to accommodate the heterogeneity of study designs.

The first dimension examined prevalence and risk factors, including sociodemographic, clinical, and lifestyle determinants.

The second addressed public and professional knowledge and awareness, with attention to cultural beliefs and misconceptions that shape recognition, reporting, and help-seeking behavior.

The third dimension explored caregiving challenges within both familial and professional settings, highlighting systemic barriers and emotional, social, and logistical burdens.

The fourth dimension considered comorbidities, particularly metabolic, cardiovascular, neuropsychiatric, and endocrine conditions that intersect with dementia risk and progression.

The fifth provided global and regional context, enabling comparison of Saudi findings with international evidence and situating national trends within broader epidemiological patterns.

Finally, the sixth-dimension synthesized studies on technological and therapeutic advancements, including digital tools, telemedicine, non-pharmacological interventions, and emerging pharmacological therapies. This analytical structure allowed for a coherent integration of diverse evidence and supported the development of an integrated narrative synthesis across all thematic domains.

Study selection process

The literature search identified 771 records across PubMed (n = 402), Scopus (n = 239), Web of Science (n = 88), ScienceDirect (n = 17), and Google Scholar (n = 25). After the removal of 486 duplicate records, 285 unique articles were screened by title and abstract. Of these, 223 were excluded due to the absence of primary empirical data (n = 69), focus on non-dementia cognitive disorders (n = 78), unclear diagnostic criteria (n = 37), small sample size (<30 participants; n = 16), underrepresented populations (n = 17), or non-English language (n = 6). Sixty-two full-text articles were assessed for eligibility, with seven excluded for lack of original data (n = 3), inappropriate outcomes (n = 2), or incomplete reporting (n = 2). A total of 55 studies met the inclusion criteria and were included in the final review. All screening was conducted independently by two reviewers. Disagreements at the title/abstract or full-text stages were resolved through discussion, and a senior reviewer was consulted when consensus could not be reached. Inter-reviewer agreement was assessed qualitatively, as the heterogeneity of study designs and outcomes made formal kappa statistics less informative for this review. All screening, deduplication, and data management were conducted using Microsoft Excel, with manual cross-checking to ensure accuracy and consistency throughout the review process.

Data synthesis and rationale for narrative approach

Quantitative meta-analysis was considered methodologically inappropriate due to substantial clinical and methodological heterogeneity across included studies. Marked variability was observed in study design (cross-sectional, hospital-based, and community-based samples), sampling frameworks, diagnostic criteria, cognitive assessment instruments, and operational definitions of dementia. These differences limit the comparability of both prevalence estimates and risk factor associations and undermine the assumptions required for valid statistical pooling.

In particular, heterogeneity in case ascertainment procedures and population representativeness would compromise the interpretability and external validity of aggregated effect estimates. Accordingly, findings were synthesized narratively, consistent with established methodological principles for the synthesis of heterogeneous observational evidence. This structured approach facilitated the systematic comparison of study characteristics, the identification of recurring patterns, and the critical appraisal of contextual variability, while preserving methodological distinctions across studies. All extracted data were organized and managed in Microsoft Excel, which facilitated a structured comparison of study characteristics, outcomes, and methodological features across the included studies.

Assessment of methodological quality and risk of bias

Given the substantial heterogeneity in study designs, sampling frameworks, and outcome definitions across included studies, application of a single formal risk-of-bias instrument was considered methodologically inappropriate. To ensure systematic and transparent appraisal despite this heterogeneity, we applied a structured checklist adapted from established domains of bias in observational research. This approach assessed sampling strategy and representativeness, diagnostic validity, measurement consistency, reporting completeness, and external validity. Although not a numerical scoring system, this structured appraisal provided a consistent framework for evaluating methodological strengths and limitations across diverse study designs. To ensure accuracy and reproducibility, all extracted data were independently cross-checked by two reviewers. Any discrepancies in extracted variables (e.g., sample characteristics, diagnostic criteria, outcome definitions) were resolved through consensus before synthesis. Instead, methodological quality was appraised using a structured narrative approach, guided by established domains of bias in observational research.

Quality assessment focused on: (i) sampling strategy and representativeness; (ii) clarity and validity of diagnostic criteria; (iii) measurement consistency and outcome ascertainment; (iv) completeness and transparency of reporting; and (v) potential sources of selection, measurement, and publication bias.

Attention was given to external validity, as a considerable proportion of studies were conducted in major urban centers (e.g., Riyadh, Jeddah, and the Eastern Province), potentially limiting generalizability to rural or underserved populations. Language bias was also considered, as only English-language publications were included, which may have excluded relevant regionally published data.

Methodological variability in diagnostic instruments and screening procedures across studies was noted as a potential source of heterogeneity, particularly in relation to reported prevalence estimates and associated risk factors. Where possible, greater interpretive weight was assigned to studies employing standardized diagnostic criteria, validated assessment tools, and representative sampling strategies.

Although a quantitative bias scoring system was not implemented, this structured appraisal enabled critical evaluation of internal and external validity and informed cautious interpretation of pooled findings.

Results

Study characteristics and research trends

A total of 55 studies met the inclusion criteria (Figure 1). Collectively, these studies reflect increasing scholarly engagement with dementia in Saudi Arabia over the past decade, although methodological and geographic variability remain substantial. Most investigations were conducted in major urban centers, including Riyadh, Jeddah, and the Eastern Province, with comparatively limited representation from rural or peripheral regions. This uneven distribution may influence the generalizability of reported prevalence estimates and risk associations.

Figure 1.

PRISMA 2020 flow diagram of the study selection process.

In terms of methodological design, the evidence base was dominated by cross-sectional studies, which constituted the majority of included publications. These were primarily hospital-based or community surveys assessing cognitive impairment prevalence, awareness levels, or associated risk factors. A smaller number of case-control studies explored associations between vascular or neuropsychiatric conditions and cognitive decline, while longitudinal or prospective cohort studies were scarce. No large-scale nationally representative cohort studies were identified. The predominance of cross-sectional designs limits causal inference and constrains the interpretation of temporal relationships between risk determinants and cognitive outcomes.

Temporal analysis demonstrates a marked increase in research output after 2020 (Figure 2). Before 2016, only eight studies were identified, and between 2016 and 2019, the annual publication volume remained low. By contrast, 31 of the 55 included studies (56%) were published between 2020 and 2024, indicating a substantial acceleration in research activity. The highest output was observed in 2023 (n = 12), followed by sustained productivity in 2024 (n = 9). Although publication counts declined in 2025 (n = 6) and 2026 (n = 1), these more recent years should be interpreted cautiously due to potential indexing delays.

Figure 2.

Temporal distribution of included studies by year of publication and thematic domain (n = 55). Studies published from 2020 onward account for 56% of the total, with peak output in 2023 (n = 12).

The increase in publication volume was accompanied by thematic diversification. Earlier studies tended to focus on metabolic and cardiovascular comorbidities associated with cognitive impairment, whereas more recent publications expanded to encompass awareness, caregiving burden, diagnostic practices, and technological or therapeutic developments. This shift suggests a broadening research agenda, moving from predominantly risk-factor characterization toward more multidimensional exploration of dementia within clinical and social contexts. The study characteristics reveal a rapidly expanding but methodologically heterogeneous body of literature, characterized by cross-sectional dominance, urban concentration, and evolving thematic scope.

Prevalence and risk determinants

Epidemiology. Available evidence from Saudi Arabia reveals notable regional variability in dementia prevalence, shaped by differences in demographic composition, healthcare utilization patterns, and diagnostic practices. In primary healthcare centers (PHCs) in Riyadh, a cross-sectional study reported a dementia prevalence of 6.3%, with Alzheimer's disease representing 58% of confirmed cases. ¹¹ A retrospective analysis from the Al-Baha region found an increase in documented dementia diagnoses from 3.8% in 2015 to 5.2% in 2020, concurrent with growing multimorbidity among older adults. ¹²

A community-based study similarly reported notable prevalence of both mild cognitive impairment (MCI) and dementia among Saudi adults. ¹³ Further regional evidence reinforces substantial variation in cognitive outcomes. In the Asir region, cognitive impairment was identified in approximately 22% of older adults attending PHCs, with diabetes, hypertension, and low educational attainment emerging as key determinants. ¹⁴ Although cognitive impairment does not equate directly to a clinical dementia diagnosis, the high burden observed suggests substantial unmet diagnostic need and possible under-recognition within routine care pathways. ¹⁵

Despite this evidence, direct regional comparisons remain challenging due to methodological heterogeneity. Most studies relied on non-probability samples, were restricted to single provinces or health-facility settings, and frequently used screening instruments rather than standardized diagnostic interviews. Variations in cognitive assessment tools, screening thresholds, and referral processes may also influence detection rates. Accordingly, existing prevalence estimates likely underestimate the true national burden of dementia in Saudi Arabia. A consolidated summary of prevalence estimates and associated risk factors is presented in Table 1. The principal risk determinants and comorbidities identified across the included studies are summarized in Figure 3.

Table 1.

Studies on dementia prevalence and risk factors in Saudi Arabia.

Focus area	Study population	Key findings	Sources
Prevalence of Dementia	Geriatric patients attending primary healthcare centers (Riyadh)	Dementia prevalence was 6.3%; Alzheimer's disease accounted for 58% of cases.	11
Prevalence of Dementia	General population in Al-Baha region	Prevalence increased from 3.8% to 5.2% between 2015 and 2020; strong association with multimorbidity.	12
Risk Factors	Women residing in Riyadh	Low awareness of modifiable dementia risks: physical inactivity (32%), smoking (41%).	16
Risk Factors	Saudi adults in the Tabuk region	Diabetes (OR = 2.1) and hypertension (OR = 1.8) were identified as significant risk factors.	17
Risk Factors	Older adults with mental health conditions	Anxiety and depression are associated with a 1.5-fold increased risk of dementia.	18
Prevalence & Risk Factors	Older adults attending PHCs (Asir region)	Cognitive impairment ∼22%; associated with diabetes, hypertension, low education	14
International comparison for MCI	Older adults in primary care (Lebanon)	MCI prevalence 18.7%; vascular risk factors were predominant.	19
	Hospital patients in Southern Nigeria	Low education and hearing loss were identified as independent predictors of MCI.	20

Figure 3.

Dementia risk determinants and associated comorbidities were reported across the included Saudi Arabian studies. Panel A shows adjusted odds ratios (95% confidence intervals) for the principal risk determinants: type 2 diabetes (OR 2.1, 1.4–3.0^22,23;), hypertension (OR 1.8, 1.2–2.5^24,25;), and depression (1.5-fold, no 95% CI reported^26,27;). Panel B shows the reported prevalence of associated comorbidities and markers among older or cognitively impaired adults: vitamin D deficiency (68% ²⁸ ;), polypharmacy (58% ²⁹ ;), rheumatoid arthritis (41% ²⁵ ;), geriatric anxiety (29% ²⁷ ;), stroke recurrence (23% ³⁰ ;), and APOE ε4 carrier frequency (8–12% ²¹ ;). All values are drawn from studies included in this review (Tables 1 and 4).

Vascular and metabolic risk factors: Across studies conducted in Saudi Arabia, vascular and metabolic comorbidities consistently emerged as dominant risk determinants. In a large community-based sample from Tabuk, both diabetes (OR = 2.1) and hypertension (OR = 1.8) were significantly associated with increased dementia risk. ¹⁷ These findings align with national epidemiological patterns, as Saudi Arabia exhibits among the highest regional rates of cardiometabolic disease. Consequently, vascular risk profiles are likely to play a major role in shaping future dementia trends within the Kingdom.

Awareness of these modifiable risk factors remains limited. Among women residing in Riyadh, only 32% recognized physical inactivity and 41% identified smoking as contributors to dementia. ¹⁶ Although awareness alone does not guarantee behavior change, low recognition of vascular determinants may reduce engagement in primary prevention and delay help-seeking.

Genetic susceptibility has also been explored. The APOE ε4 allele, one of the strongest genetic risk markers for Alzheimer's disease, has been reported in 8-12% of Saudi adults, ²¹ a prevalence lower than that observed in many Western populations. While this difference may partly influence observed epidemiological patterns, existing data are too limited to determine its population-level contribution to dementia risk.

Neuropsychiatric and contextual risk associations: Neuropsychiatric comorbidity appears to amplify dementia vulnerability further. A Saudi study demonstrated that depression and anxiety were associated with an approximately 1.5-fold increase in dementia risk after adjustment for vascular factors. ¹⁸ A similar pattern has been documented in international literature on the bidirectional relationship between affective disorders and cognitive decline, wherein chronic stress, inflammation, and reduced cognitive reserve may contribute to accelerated neurodegeneration.

Regional comparisons offer additional insight into contextual determinants. Lebanon and Nigeria were selected as comparators because they share with Saudi Arabia a comparable stage of demographic and epidemiological transition and a reliance on primary-care-based cognitive research, allowing cautious contextualization of Saudi findings within similar health-system settings rather than against high-income countries with mature dementia surveillance. In Lebanon, MCI prevalence reached 18.7% among older adults in primary care, where vascular risk factors predominated. ¹⁹ In Southern Nigeria, low educational attainment and hearing loss were identified as independent predictors of MCI. ²⁰ Although these studies fall outside Saudi Arabia, they highlight shared patterns across Middle Eastern and African populations, particularly the convergence of vascular and sociodemographic risk factors.

Synthesis and interpretation: The available evidence suggests that dementia risk in Saudi Arabia reflects the interplay of multiple biological, behavioral, and social determinants. Vascular and metabolic disorders, which are highly prevalent nationally, appear to exert a substantial influence on cognitive decline and may underpin much of the observed burden. Neuropsychiatric comorbidities, including depression and anxiety, further compound vulnerability and may interact with vascular pathways to accelerate cognitive deterioration. Low awareness of modifiable risk factors and educational disparities may also shape care-seeking behavior, recognition of early symptoms, and access to timely diagnostic assessment.

Interpretation of these findings should be cautious, as most studies rely on cross-sectional designs conducted within limited geographical areas and frequently use screening tools rather than comprehensive diagnostic evaluations. These methodological constraints limit inferences about temporality, causation, and national representativeness.

Clinical, social, and care context

Dementia recognition and care in Saudi Arabia are shaped not only by epidemiological risk but also by clinical knowledge, public perceptions, and caregiver and system-level challenges. Evidence across multiple studies highlights substantial variability in professional preparedness, public understanding, and support structures, each influencing diagnostic timing and care quality. Table 2 summarizes all studies assessing knowledge and awareness among healthcare professionals, the general public, and at-risk groups, while Table 3 presents findings related to caregiving and system-level challenges.

Table 2.

Studies on dementia knowledge and awareness in Saudi Arabia.

Population group	Knowledge/Awareness focus	Geographic region	Key findings	Sources
Healthcare Professionals	General Knowledge	Riyadh	58–72% correct responses on dementia assessments; gaps in early symptom recognition	31
	Attitudes & Perceptions	Jazan	41% of medical students are unable to identify Alzheimer's as the most common type	32
	Educational Gaps	Jazan	Nursing students had 78% knowledge accuracy, but 55% discomfort with agitation management	33
General Public	Awareness Levels	Mecca Region	38% could define Alzheimer's; 62% associated dementia only with memory loss	34,35
	Knowledge Assessment	Jazan Province	29% attributed dementia to supernatural causes or normal aging	36
	Disease Perception	Nationwide	Low recognition of non-memory symptoms (23%) and modifiable risk factors (31%)	37,38
International comparison (at-risk group)	Early Recognition	Malaysia (university clinic)	92.8% of older adults at elevated MCI risk had low dementia awareness	39
International Comparison	Knowledge Gaps	Bulgaria	Similar misconceptions observed in non-Arabic contexts	40

Table 3.

Dementia care challenges in Saudi Arabia.

Care setting	Focus area	Key challenges	Sources
Professional Caregivers	Nurses’ Perspectives	High workload, inadequate training, and emotional burden	42,43
	Mental Health Nurses’ Experiences	Managing neurocognitive symptoms and communication difficulties	43
Social Work Context	Gerontological Social Work	Policy deficiencies, cultural stigma, and changing family structures	44

Professional knowledge and early detection. Several studies indicate significant gaps in healthcare professionals’ understanding of dementia. In Riyadh, general knowledge scores among healthcare workers ranged from 58–72%, with notable deficiencies in recognizing early symptoms and distinguishing them from normal aging processes. ³¹ Further evidence from Jazan demonstrates that foundational training may be insufficient: 41% of medical students could not identify Alzheimer's disease as the most prevalent dementia subtype. ³²

Nursing students in Jazan also demonstrated mixed preparedness. Although overall knowledge accuracy was relatively high (78%), more than half (55%) reported discomfort managing behavioral symptoms such as agitation, indicating limited practical training despite theoretical competence. ³³ Collectively, these studies suggest that limited confidence in cognitive assessment and uncertainty regarding diagnostic criteria in frontline settings may delay referral, early recognition, and optimal care initiation. Table 2 presents the full set of studies assessing knowledge and awareness.

Public awareness and sociocultural perceptions: Findings from public-awareness studies similarly point to widespread misconceptions about dementia across Saudi Arabia. In the Mecca region, only 38% of respondents could define Alzheimer's disease accurately, and 62% believed dementia to be solely a memory-loss condition, demonstrating a narrow understanding of its broader cognitive, behavioral, and functional impacts.^34,35 In the Jazan Province, cultural beliefs exerted a stronger influence, with 29% of participants attributing dementia to supernatural causes or considering it a normal part of aging. ³⁶

Nationally, dementia literacy remains limited: only 23% of respondents recognized non-memory symptoms (e.g., visuospatial or executive changes), and just 31% were aware of modifiable risk factors such as physical inactivity, smoking, or hypertension.^37,38 Awareness is particularly concerning among at-risk groups. A comparable pattern is seen among at-risk groups elsewhere: in a Malaysian university-based primary care clinic, 92.8% of older adults with chronic disease, a group at elevated risk of MCI, demonstrated low dementia awareness. ³⁹

Complementary international evidence provides useful context. Bulgaria, an upper-middle-income and non-Arabic-speaking country, was included as a contrasting comparator to test whether dementia-related misconceptions are culturally specific; the finding of similarly high rates of misconceptions about dementia causes and symptomatology there ⁴⁰ illustrates that these knowledge gaps are not unique to Saudi Arabia or to Arabic-speaking populations but reflect a broader global pattern.

Caregiving burden and system-level challenges: Care provision in Saudi Arabia remains largely family-centered, and studies show that informal caregivers often experience significant emotional and psychological strain. ⁴¹ Healthcare professionals providing dementia care also report substantial challenges. Nurses describe high workloads, inadequate dementia-specific training, and emotional stress when supporting individuals with cognitive impairment.^42,43 Mental-health nurses further highlight difficulties managing neurocognitive symptoms, communication impairments, and behavioral disturbances, reflecting a need for more specialized dementia-care competencies. ⁴³

From a social-work perspective, dementia care is influenced by policy limitations, cultural stigma, and rapid shifts in family structures, all of which may affect access to care and the sustainability of informal support systems. ⁴⁴ Although the healthcare system has made strides in dementia-care planning, few studies have rigorously evaluated continuity of care, multidisciplinary integration, or availability of long-term support services. The studies summarized in Table 3 indicate a care environment in which both professional and family caregivers face considerable pressures, compounded by structural and societal constraints.

Interpretation: Taken together, the findings from Tables 2 and 3 reveal that gaps in clinical knowledge, public understanding, and system-level resources intersect to shape the dementia-care environment in Saudi Arabia. Although these studies cover diverse populations and settings, most are cross-sectional and regionally constrained, limiting causal inference and generalizability. Nonetheless, the consistency of themes, insufficient professional preparedness, pervasive public misconceptions, caregiver burden, and structural limitations highlight critical areas for strengthening dementia recognition, care pathways, and support systems.

Comorbidity profile and systemic disease burden

Dementia in Saudi Arabia frequently presents within a broader constellation of chronic systemic disease. Across all included studies, multimorbidity, not isolated pathology, emerged as a defining clinical feature (Table 4). The most consistently documented comorbidities included metabolic disorders, cardiovascular disease, neuropsychiatric conditions, and additional chronic illnesses that collectively influence cognitive trajectories, diagnostic complexity, and care outcomes.

Table 4.

Comorbid conditions associated with dementia in Saudi Arabia.

Comorbidity category	Specific conditions	Association strength	Clinical implications	Sources
Metabolic Disorders	Type 2 Diabetes	OR 2.1 (1.4–3.0)	Accelerated cognitive decline; poorer glycemic control correlates with impairment	22,23
	Vitamin D Deficiency	Prevalence 68% in the elderly	Potential role in neuroprotection and calcium homeostasis	28
Cardiovascular Diseases	Hypertension	OR 1.8 (1.2–2.5)	Shared vascular pathology with vascular dementia	24,25
	Cerebrovascular Stroke	23% recurrence rate	Post-stroke cognitive impairment is common in survivors	30
Mental Health Conditions	Depression	1.5-fold increased risk	May represent a prodromal symptom or an independent risk factor	26,27
	Geriatric Anxiety	Prevalence 29%	Exacerbates cognitive symptoms and functional decline	27
Other Chronic Conditions	Rheumatoid Arthritis	Comorbidity rate 41%	Chronic inflammation potentially contributes to neurodegeneration	25
	Polypharmacy	58% in elderly outpatients	Medication burden may worsen cognitive function	29

Metabolic disorders: Metabolic disease was highly prevalent among individuals with cognitive impairment. Type 2 diabetes, one of the most pervasive chronic conditions in Saudi Arabia, showed a strong association with dementia, with odds ratios of OR 2.1 (1.4–3.0) reported across multiple studies.^22,23 Beyond its statistical association, poorer glycemic control was linked to more pronounced cognitive decline, reinforcing the role of metabolic dysregulation in neurodegeneration. ²² Vitamin D deficiency, reported in 68% of older adults in one study, ²⁸ also appeared frequently among cognitively impaired individuals. While causal pathways remain unclear, potential roles in calcium homeostasis, neuroinflammation, and neuroprotection have been proposed, suggesting biological plausibility even in the absence of longitudinal confirmation.

Cardiovascular diseases: Vascular pathology was another prominent component of the multimorbidity profile. Hypertension, with reported associations of OR 1.8 (1.2–2.5),^24,25 and cerebrovascular stroke, including a documented 23% recurrence rate among affected individuals, ³⁰ both appeared frequently in patients with dementia. Evidence indicates that post-stroke cognitive impairment is common, underscoring the shared vascular mechanisms that link cerebrovascular injury with subsequent neurocognitive decline. The pattern aligns with international models of vascular-neurodegenerative interplay, highlighting the importance of integrated cardiovascular risk management.

Neuropsychiatric conditions: Neuropsychiatric comorbidity was similarly pronounced. Depression was associated with a 1.5-fold increase in dementia risk,^26,27 consistent with evidence suggesting that affective symptoms may constitute either early manifestations of cognitive decline or independent risk factors mediated by inflammatory, neuroendocrine, or behavioral pathways.

Geriatric anxiety, reported at a prevalence of 29% among older adults, ²⁷ was shown to exacerbate cognitive symptoms and accelerate functional decline. Together, the data illustrate the bidirectional and mutually reinforcing relationship between mental health and cognitive vulnerability.

Other chronic conditions: Additional systemic conditions were also reported. Rheumatoid arthritis, with a comorbidity rate of 41% among older adults with cognitive impairment, ²⁵ raises questions about the role of chronic systemic inflammation in dementia pathogenesis. Polypharmacy, affecting 58% of elderly outpatients in one study, ²⁹ represents another clinically relevant burden; both as a proxy for multimorbidity and as a potential contributor to cognitive impairment through drug interactions, sedative load, and anticholinergic effects.

Global context and emerging directions

Saudi Arabia's dementia burden must be understood within the wider global context of demographic aging and evolving chronic-disease patterns. International estimates indicate that dementia affected approximately 57.4 million people worldwide in 2021,^45,46 with incidence driven primarily by population aging and increased survival following vascular events. ⁴⁷ Major global risk factors include hypertension, low educational attainment, and air-pollution exposure.^45,46 These international figures and comparative epidemiological profiles are summarized in Table 5.

Table 5.

Comparative burden of dementia across global regions.

Region	Key epidemiological features	Risk factor profile	Economic impact	Sources
Global	57.4 million cases (2021)	Hypertension, low education, and air pollution	23 billion regional cost (2021)	45,46
Saudi Arabia	6.3% prevalence (age ≥ 60)	Metabolic syndrome, APOE ε4 (8–12%)	Understudied healthcare costs	11,17,21
China	Urban-rural disparities	PM2.5 exposure, stroke prevalence	248 billion (2021)	48,49

Comparative burden across global regions: When placed alongside global estimates, Saudi Arabia appears to be in an earlier phase of demographic aging relative to regions such as East Asia and Western Europe. Nevertheless, national data show a dementia prevalence of 6.3% among adults aged ≥ 60, ¹¹ alongside a distinctive risk-factor profile characterized by high rates of metabolic syndrome and APOE ε4 carrier frequencies of 8–12%.^17,21 Although these figures are lower than those reported in some high-income countries, differences in diagnostic criteria, sampling strategies, and surveillance infrastructure limit direct comparison.

Regional comparisons to rapidly transitioning countries provide further context. In China, dementia burden is shaped by marked urban-rural disparities, widespread exposure to fine particulate matter (PM2.5; airborne particles with an aerodynamic diameter of 2.5 micrometers or less), and high stroke prevalence, contributing to substantial variability in cognitive outcomes.^48,49 The economic costs associated with dementia in China were estimated at 248 billion USD in 2021,^48,49 illustrating the anticipated financial pressures as populations grow older and chronic disease patterns intensify.

Globally, dementia imposes economic costs exceeding 23 billion USD as of 2021,^45,46 driven by healthcare utilization, long-term care needs, and indirect costs linked to caregiving and lost productivity. In contrast, economic estimates for Saudi Arabia remain understudied, and few investigations have quantified national-level financial impacts. ⁵⁰ Given the country's aging trajectory and high cardiometabolic burden, the absence of robust cost data represents a critical evidence gap for national health-system planning.

Emerging diagnostic and therapeutic directions: Growing interest in diagnostic innovation has led to the exploration of several technology-assisted approaches within the Saudi context. One line of research has examined AI-based ensemble models designed for explainable predictions and multimodal data integration, showing potential for enhancing early detection in primary-care settings.⁵¹Parallel work has evaluated digital cognitive-testing platforms and telemedicine-supported consultation frameworks, reflecting a broader move toward scalable technologies to support regions with limited specialist access. These developments are summarized in Table 6.

Table 6.

Technological and therapeutic advancements for dementia.

Advancement category	Specific approach	Key features	Clinical relevance	Sources
Diagnostic Technologies	AI Ensemble Models	Explainable predictions, multimodal data integration	Enhances early detection in primary care	51
Therapeutic Interventions	Multidomain Lifestyle Programs	Diet, exercise, cognitive training, vascular monitoring	Addresses multiple modifiable risk factors	52,53
Pharmacological Developments	Latest Treatment Protocols	Targeted mechanisms, combination therapies	Updates clinical guidelines for Saudi practitioners	54

Therapeutic research has followed international trends. Lifestyle-based multidomain interventions that include dietary modification, structured physical activity, cognitive training, and vascular-risk monitoring have been highlighted as promising strategies for addressing multiple modifiable risk pathways simultaneously.^52,53 In addition, recent pharmacological updates reflecting global advances in targeted mechanisms and combination therapies have informed evolving clinical guidelines relevant to Saudi practitioners. ⁵⁴ However, most pharmacological evidence derives from international data, as locally generated clinical-trial evidence remains limited.

Interpretation: The findings presented in Tables 5 and 6 position Saudi Arabia within a global dementia context characterized by rising prevalence, vascular-linked risk accumulation, and emerging technological and therapeutic innovations. Yet, national research infrastructure remains developing: surveillance systems are fragmented, longitudinal epidemiological data are sparse, and economic assessments remain largely absent.

Discussion

The findings of this systematic review demonstrate that dementia research in Saudi Arabia has expanded substantially over the past decade, yet the evidence base remains methodologically heterogeneous and regionally uneven. Prevalence estimates ranged from 3.8% to 6.3%, but these figures must be interpreted cautiously due to variation in diagnostic criteria, sampling frameworks, and case ascertainment procedures. The predominance of cross-sectional and hospital-based studies limits the ability to infer national burden or temporal trends. Nonetheless, the convergence of findings across multiple studies suggests that dementia is an increasingly significant public health concern in the Kingdom. When placed alongside regional evidence, these estimates are broadly consistent with, though at the lower end of, figures for the Middle East and North Africa, where recent Global Burden of Disease analyses report a rising age-standardized dementia burden, ⁴⁶ and with syntheses of dementia prevalence across the Arab world. ⁵⁰ The comparatively lower Saudi estimates most plausibly reflect the younger age structure of the population and reliance on screening instruments rather than standardized diagnostic interviews, rather than a genuinely lower underlying risk. ⁴⁵

Vascular and metabolic determinants, particularly diabetes and hypertension, emerged as the most consistent risk factors. This pattern aligns with global evidence linking cardiometabolic disease to cognitive decline, but the exceptionally high national prevalence of these conditions in Saudi Arabia may amplify future dementia burden. Neuropsychiatric comorbidities, including depression and anxiety, were also frequently associated with cognitive impairment, reflecting the complex interplay between mental health and neurodegeneration. Taken together, the data point to a need for integrated chronic-disease management strategies that address both metabolic and psychological determinants of cognitive health.

Smoking warrants particular attention as a modifiable determinant of dementia risk in the Saudi context. The 2024 Lancet Commission identifies smoking among the fourteen modifiable risk factors that together account for up to 45% of potentially preventable dementia, acting through vascular injury, oxidative stress, and systemic inflammation. ⁵⁵ A recent multinational analysis attributed a substantial and rising share of the Alzheimer's disease and related dementia burden to smoking across transitioning economies. ⁴⁹ These mechanisms are directly relevant to Saudi Arabia, where public recognition of smoking as a dementia risk factor remains low: only 41% of women surveyed in Riyadh identified smoking as a contributor to cognitive decline. ¹⁶ Embedding structured tobacco cessation within the vascular-risk and chronic-disease services delivered through primary healthcare centers, therefore, represents a pragmatic, evidence-based opportunity to reduce future dementia burden alongside diabetes and hypertension control.

From a primary care standpoint, these barriers carry practical weight. In Saudi Arabia, primary healthcare centers serve as the first and often sole point of contact for older adults managing diabetes, hypertension, and other chronic conditions. ⁵⁶ Average consultation times in these settings are short, physician workloads are high, and the clinical focus tends to center on glycemic and blood pressure targets rather than cognitive assessment. ⁵⁷ Adding routine cognitive screening to an already strained chronic disease visit requires not only protected time and trained staff but also a clear referral pathway once impairment is detected. At present, such pathways remain underdeveloped in most Saudi health regions.

A related and underappreciated problem concerns the instruments themselves. The Mini-Mental State Examination and the MoCA, both widely used in the studies reviewed here, were developed and normed in English-speaking Western populations. While Arabic translations of the MoCA exist and community-based normative data have been generated for Saudi adults, ⁵⁸ important psychometric questions persist. Item content, scoring thresholds, and educational adjustment formulas do not transfer seamlessly across languages and cultures, and two Saudi studies conducted in Riyadh using different screening instruments have produced discrepant prevalence estimates.^11,15 A recent scoping review of cognitive assessment among Arabic speakers found that most available tools lack rigorous cross-cultural validation and that dialectal, educational, and sociocultural variation introduces systematic measurement error. ⁵⁹ Until locally validated instruments with Saudi-specific norms are established and widely adopted, prevalence figures from screening-based studies should be interpreted with particular caution.

Saudi Arabia's Health Sector Transformation Program, a central pillar of Vision 2030, provides an institutional framework within which these gaps could be addressed. ⁶⁰ The program emphasizes preventive care, strengthened primary healthcare infrastructure, digital health solutions, and value-based models of care delivery. ⁶¹ Cognitive health has not yet been explicitly embedded within these transformation goals, but the program's emphasis on chronic disease prevention and early detection creates a natural entry point. Integrating brief cognitive screening into routine follow-up for diabetes and hypertension, two conditions that affect millions of Saudi adults and that the present review identifies as dominant dementia risk determinants, would represent a pragmatic and scalable first step. The 2024 Lancet Commission on dementia estimated that up to 45% of dementia cases globally could be prevented or delayed by addressing 14 modifiable risk factors, many of which, including diabetes, hypertension, physical inactivity, obesity, and depression, are highly prevalent globally, including in the Saudi population. ⁵⁵ Aligning national chronic disease programs with this evidence base offers a realistic avenue for reducing future dementia burden.

Awareness studies revealed substantial gaps in public and professional knowledge, with misconceptions, stigma, and limited recognition of non-memory symptoms contributing to delayed diagnosis and underreporting. These sociocultural dynamics mirror patterns observed in other Middle Eastern and low-awareness contexts, suggesting that public-health messaging and primary-care training remain underdeveloped components of dementia preparedness. Caregiving research further highlighted the predominance of family-based care and the significant emotional and psychological burden experienced by caregivers, consistent with international literature on informal care in collectivist societies.

When viewed in a global context, the Saudi evidence base resembles the early-stage dementia evidence base observed in countries prior to the establishment of national dementia strategies. The rapid increase in publications after 2020 indicates growing academic engagement, yet the absence of nationally representative epidemiological studies, standardized diagnostic protocols, and longitudinal cohorts continues to limit precision and comparability. Strengthening these foundational elements will be essential for accurate burden estimation and effective policy development.

Collectively, the findings highlight an urgent need for coordinated national efforts to improve dementia surveillance, enhance public and professional awareness, and integrate cognitive health into chronic-disease prevention frameworks. The review also identifies opportunities for research expansion, including longitudinal studies, rural and underserved population sampling, and evaluation of culturally adapted interventions. These priorities align with global recommendations for strengthening dementia preparedness in rapidly aging populations.

Implications for research and clinical practice

Several priorities emerge from this synthesis. First, nationally representative cohort studies are urgently needed. Saudi Arabia lacks even one population-based longitudinal study of dementia incidence and progression. Establishing such a cohort, ideally stratified by region, age group, and urban-rural residence, would generate the incidence data required for credible national burden estimates and would enable investigation of how Saudi-specific risk profiles, particularly the co-occurrence of early-onset diabetes, obesity, and physical inactivity, interact to shape cognitive trajectories over time.

Second, the case for embedding cognitive assessment into existing chronic disease care pathways is strong. Given that diabetes and hypertension are managed at scale through Saudi primary healthcare centers, incorporating a brief, validated cognitive screen into routine follow-up visits for patients aged 60 and above would be both practical and low-cost. For this to succeed, primary care physicians need structured training in cognitive assessment and clear referral algorithms connecting them to specialist memory services. The current evidence suggests that most primary care providers in Saudi Arabia lack confidence in early dementia recognition, ³¹ a gap that targeted continuing medical education and clinical decision support tools could help close.

Third, investment in culturally validated screening instruments is overdue. The Arabic MoCA has been adapted and tested in Saudi community samples, ⁵⁸ but normative data remain limited and no consensus exists on optimal cutoff scores for the Saudi population. Development and validation of locally normed cognitive screening tools, calibrated for the educational and linguistic diversity of Saudi older adults, should be a research priority. Without such instruments, screening programs risk both overdiagnosis among less educated individuals and underdetection in those with higher educational attainment.

Fourth, structured evaluation of emerging care models warrants attention. Memory clinics, multidisciplinary assessment teams, and telemedicine-supported cognitive consultations have shown promise in other health systems, but their feasibility and cost-effectiveness in the Saudi context remain untested. The Health Sector Transformation Program's emphasis on digital solutions and value-based care ⁶⁰ provides institutional support for piloting and evaluating these models across diverse Saudi health regions.

Finally, the development of a coordinated national framework for dementia research and care deserves serious consideration. Such a framework could support the creation of a national dementia registry, harmonize diagnostic criteria across institutions, coordinate multicenter studies, and align research priorities with the goals of the Health Sector Transformation Program. Saudi academic medical centers, several of which already host geriatric medicine and neurology programs, are well-positioned to anchor this effort. However, moving from fragmented institutional initiatives to a national strategy will require sustained commitment from both the academic and policy sectors.

Limitations

This review has several limitations that should be considered when interpreting the findings. First, the evidence base is dominated by cross-sectional and hospital-based studies, which limit causal inference and may underestimate community-level prevalence. Second, substantial methodological heterogeneity, particularly in diagnostic criteria, cognitive assessment tools, and sampling strategies, restricted comparability across studies and precluded meta-analysis. Third, most included studies were conducted in major urban centers, resulting in limited representation of rural or underserved populations and potentially biasing national estimates. Fourth, only English-language publications were included, which may have excluded relevant Arabic-language studies and introduced language bias. Finally, although a structured narrative appraisal was applied, the absence of a unified risk-of-bias tool for diverse study designs may limit the consistency of methodological assessment.

An additional methodological concern relates to the cognitive screening instruments employed across studies. Most investigations relied on the Mini-Mental State Examination or MoCA, yet few reported whether the specific version used had been formally validated for Arabic-speaking Saudi populations. Community-based normative data for the Arabic MoCA have been published for Saudi adults, ⁵⁸ but significant variability persists across Arabic adaptations, and scoring thresholds derived from Western populations may not perform equivalently in Saudi clinical settings. ⁵⁹ This lack of standardized, locally validated instruments introduces potential measurement error that may have contributed to the heterogeneity of prevalence estimates observed across studies.

Despite these limitations, the review provides the most detailed synthesis to date of dementia epidemiology, risk determinants, awareness patterns, comorbidities, and research trends in Saudi Arabia.

Conclusion

Dementia research in Saudi Arabia has grown rapidly in recent years, reflecting increasing recognition of the condition's clinical and public-health significance. However, epidemiological estimates remain inconsistent, nationally representative data are lacking, and awareness and diagnostic capacity require substantial strengthening. The convergence of high cardiometabolic disease prevalence, demographic aging, and limited public awareness suggests that dementia burden is likely to rise in the coming decades.

To prepare for this trajectory, national efforts should prioritize standardization of diagnostic practices, development of longitudinal surveillance systems, integration of cognitive health into chronic-disease management, and expansion of public and professional education. Strengthening research infrastructure, particularly through representative sampling, rural inclusion, and longitudinal cohort development, will be essential for improving epidemiological precision and informing policy. By consolidating fragmented evidence into a coherent synthesis, the present synthesis provides a foundation for future research, clinical planning, and national dementia strategy development in Saudi Arabia.

Data availability statement

All data analyzed in this review are derived from the published studies cited in the reference list. No new datasets were generated or analyzed.