Public Awareness, Knowledge, and Attitude Toward Alzheimer’s Disease in Makkah, Saudi Arabia

Background: Alzheimer's disease is a neurodegenerative disease that slowly deteriorates cognitive function over time. This condition disables the geriatric population worldwide. Knowing its symptoms and presentation could help the general population seek medical attention early. Objective: This study aims to assess the level of awareness, knowledge, and attitude towards Alzheimer’s disease among the general population in Makkah City. Methods: This cross-sectional study employed an online questionnaire distributed randomly in Makkah, Saudi Arabia. A sociodemographic and attitude panel is included under each section of the questionnaire, as well as a knowledge panel based on the Alzheimer's Disease Knowledge Scale (ADKS). The knowledge and awareness level regarding Alzheimer’s disease was determined by adding up discrete scores for each correct knowledge item. A participant's awareness level was categorized as poor if their score was less than 60%. Participants whose scores were 60% or higher were considered to have a high level of awareness Results: A total of 545 participants were investigated; 316 (58%) were females. A range of ages was represented among the participants, from 18 to over 60. Of the study respondents, 68 (12.5%) had an overall good awareness and knowledge of Alzheimer’s disease and its management while 477 (87.5%) had a poor knowledge level. Among divorced/widowed participants, 16.2% had an overall good knowledge level of the disease compared to 8.3% of married respondents with recorded statistical significance (P=.049). Also, 20.4% of those with relatives diagnosed with Alzheimer's disease had good knowledge of the disease versus 10.7% of others without (P=.009). Conclusion: According to the results, there is a lack of awareness and knowledge of Alzheimer’s disease. This study suggests increasing public awareness and knowledge of Alzheimer’s disease through campaigns and public education so that the disease is detected earlier.


Introduction
Alzheimer's disease is the most common form of dementia worldwide.It can be defined as a neurodegenerative disease characterized by slowly progressive loss of cognitive functions such as memory, thinking skills, and behavioral changes [1].There are two main types of Alzheimer's: Early-onset Alzheimer's, which affects those in their 40s to 50s, and late-onset Alzheimer's, which affects those over 65 years of age.The Saudi Alzheimer's Disease Association estimates that 130 thousand people suffer from Alzheimer's disease in Saudi Arabia.The number of patients worldwide will double by 2050 [2].
Alzheimer's disease affects daily living activities such as feeding, toileting, and the simplest tasks.It also affects patients' families and causes an economic burden with estimated costs of US$1 trillion globally [3].
According to studies by Connell et al., perceptions and beliefs about Alzheimer's disease are very important to incorporate the recent cultural changes due to the accelerated prevalence and excess disease burden experienced by people in developed countries [4,5].
Early detection of Alzheimer's disease ensures that affected individuals and their caregivers can make appropriate plans and decisions for their healthcare needs [6].Yet previous studies assessing attitudes and behaviors toward Alzheimer's disease in Europe showed that the general public lacks adequate information regarding the disease or the benefits of early diagnosis and treatment [7].
Despite the lack of proven prevention strategies for Alzheimer's disease, several studies have hypothesized that several protective factors, such as mental activity, regular physical exercise, and a healthy diet, are significantly associated with a decreased risk of Alzheimer's disease [8][9][10][11][12][13].Nevertheless, little information exists about how general public attitudes and knowledge about Alzheimer's disease affect their health behaviors regarding Alzheimer's disease prevention.
According to a previous study conducted in the Aseer region, Saudi Arabia, respondents who are young, females, and have a relative with Alzheimer's disease have good knowledge of the disease [14].However, to date, no previous research has assessed the knowledge, attitudes, and perceptions surrounding Alzheimer's disease among the general public in the Makkah region.Therefore, this study aimed to assess public awareness, knowledge, and attitudes toward Alzheimer's disease.We also assessed socio-demographic factors influencing public knowledge of Alzheimer's disease.

Study designs
The study was conducted on a community-based prospective basis, targeting the general population of Makkah between January 30, 2023, and February 12, 2023.We ensured participants' privacy by avoiding asking for names.Approval was obtained beforehand from the biomedical ethics committee of Umm Al-Qura University (approval number: HAPO-02-K-012-2023-01-1370).

Study population and sampling methodology
In this study, the Raosoft online sample size calculator was used to calculate a sample size of 385 based on a margin of error of 5%, a confidence level of 95%, and an estimated total population of 2,115,000.A total of 545 participants were included in the study and convenience sampling was used.All adults over the age of 18 who agreed to participate in the questionnaire and successfully completed it were eligible to participate in the study.The participants who could not meet the criteria for participation were excluded from the study.A non-probability snowball sampling technique was used as the sampling method.In order to protect the privacy of the participants, the questionnaires were filled out anonymously.We kept all data confidential and used it only for research purposes.

Data collection
An online Arabic questionnaire was designed using Google Forms.Respondents received electronic links via social media platforms accompanied by the survey objectives, the target population, and a request to participate voluntarily.Survey responses were collected anonymously.No identifying information and no private information was collected from participants.All responses were confidentially maintained.
The Alzheimer's Disease Knowledge Scale (ADKS) was used in this study, which was previously published and reviewed [15].A translation to Arabic was done to assure insurers of an accurate response.According to similar published work conducted in the Aseer region, Saudi Arabia, the questionnaire was edited and validated with three neurology consultants [14].
The questionnaire was divided into three sections.The first section covered socio-demographic data, such as age, gender, and qualification.The second part focused on responders' awareness of the disease.Multiple statements were given, and the survey taker had the choice of agreeing.In the third section, to assess knowledge, survey takers were questioned on risk factors, assessment and diagnosis, course of the disease, caregiving, treatment, and symptoms.The questionnaire is available in the Appendices.

Data analysis
Statistical Package for Social Sciences (SPSS) version 21 (IBM Corp., Armonk, NY) was used to analyze the data.All statistical methods were two-tailed with an alpha level of 0.05, considering significance if the P value is less than or equal to 0.05.Overall knowledge and awareness level regarding Alzheimer's disease was assessed by summing up discrete scores for different correct knowledge items.If the participant's score was less than 60% of the overall score, they were considered poor in awareness.Participants with 60% or higher scores were considered to have a good awareness level.For study variables, a descriptive analysis was conducted using frequency distributions and percentages.These variables included participants' personal data, public perception and attitude toward Alzheimer's disease, knowledge, and awareness items.In addition, the participants' overall awareness level was graphed.Cross tabulation for showing the distribution of participants' overall knowledge and awareness level by their personal data.This is done using the Pearson chi-square test for significance and an exact probability test if there were small frequency distributions.

TABLE 1: Personal data of study participants, Makkah, Saudi Arabia
The public's attitude toward Alzheimer's disease in Makkah, Saudi Arabia is detailed in Table 2. Exactly 63.7% of the study respondents think that with a change in daily plans, the elderly may find it difficult to balance their finances, and 60.6% agree that once an Alzheimer's patient encounters difficulty in performing daily tasks, there is a need to resort to the judiciary to preserve the patient's rights.Likewise, 52.1% of the study respondents prefer not to inform the person, once diagnosed with Alzheimer's disease, and 41.5% think that memory disturbance and forgetting are normal for the elderly and do not require medical advice.About 33.9% of the study participants agree that once they have symptoms of dementia and memory disturbances, they resort to common types of Falk medicine.In addition, 28.3% think it is better for diagnosed patients to avoid going to social events and life activities to avoid embarrassment.Only 12.1% feel embarrassed if a relative was diagnosed with Alzheimer's disease and 19.6% dismiss a diagnosis when a relative has Alzheimer's disease.Overall participants' knowledge and awareness regarding Alzheimer's disease in Makkah, Saudi Arabia is shown in Figure 1.Among the study respondents, 68 (12.5%) had good knowledge and awareness of Alzheimer's disease while 477 (87.5%) had poor knowledge.

FIGURE 1: Overall participants' knowledge and awareness regarding Alzheimer's disease in Makkah, Saudi Arabia
Factors associated with participants' knowledge and awareness regarding Alzheimer's disease are detailed in Table 5. Exact 16.2% of divorced /widowed participants had an overall good knowledge level of the disease compared to 8.3% of married respondents with recorded statistical significance (P=.049).Also, 20.4% of those with relatives diagnosed with Alzheimer's disease had good knowledge regarding the disease versus 10.7% of others without (P=.009).All other factors were insignificantly associated with participants' knowledge level.

Discussion
This study aims to assess public awareness, knowledge, and attitude toward Alzheimer's disease in Makkah, Saudi Arabia.We found that 87.5% of participants had poor knowledge, and with the rise in the prevalence of dementia and Alzheimer's disease among the continuously aging population, a focus is being placed on early detection and treatment.Difficulties diagnosing and managing mild cognitive impairment, which is usually the first presentation of dementia, are attributed to a triad of hesitant patients, unprepared healthcare providers, and environments of misconceptions and false beliefs [16].However, Alzheimer's remains less known in the community than other chronic diseases among the elderly.There is a lack of factual information regarding Alzheimer's, and even professionals have misconceptions about its differences from normal aging [17].People with Alzheimer's may also experience social stigma that delays their early diagnosis, optimal treatment, and effective delivery of quality care [18].
According to this study, 98 (18%) of the respondents had a relative with Alzheimer's disease, which is lower than a recent study which found 45% of the respondents had a relative diagnosed with Alzheimer's disease [19].It is important to investigate the educational level of participants, particularly those who have a relative diagnosed with the disease.This is because it was reported previously that higher knowledge of patients' caregivers was associated with higher academic qualifications [20].
Regarding knowledge assessment, a number of studies have been conducted on Alzheimer's knowledge.Despite widespread knowledge of Alzheimer's, a systematic review found that most people do not understand the disease well.They think it is just part of the aging process [21].A higher level of knowledge about Alzheimer's was found to be related to younger age, residing in an urban area, and having experience with Alzheimer's contact or care [22].
According to the analysis, the majority of 477 (87.5%) participants in this study had poor knowledge levels.
Similarly, the highest proportion of participants (61%) in a previous study reported a low knowledge score [18].Low knowledge was associated with older age and lower education.This is also compatible with another study where knowledge of Alzheimer's was modest and significantly associated with a family history of Alzheimer's and higher educational levels [23].This gives an insight into the importance of addressing educational levels when investigating variable groups of participants.In this study, 48.3% know that genes are partially responsible for Alzheimer's disease.In contrast, a previous study reported that around 46% of participants believe that the cause of Alzheimer's disease is a brain disease [24].In this study, the number of people who are aware that people with Alzheimer's disease are more likely to suffer from depression is 61.1%, while 27% oppose living in nursing homes.According to a previous study, more than half of the participants (56.2%) believed that nursing homes should not admit people with Alzheimer's disease [24].
Considering attitudes toward Alzheimer's disease patients, only 12.1% of this study feel embarrassed when a relative is diagnosed with the disease.To avoid embarrassing situations, 28.3% of participants believe it is better for diagnosed patients to avoid social events and life activities.This is supported by a previous study that revealed multiple emotional reactions to a person with Alzheimer's, ranging from anxiety and aggressiveness to prosocial reactions and rejection [25].Similarly, a study by Marcinkiewicz and Reid found that a large proportion of the community perceived people with dementia as violent and aggressive [26].In contrast, another study reported that participants believed that people with Alzheimer's disease should not be discriminated against [27].Public interventions should address stigma and increase knowledge while understanding Alzheimer's sociocultural beliefs.
In a systematic review, stigmatizing perceptions and attitudes were mostly associated with modest disease knowledge, lack of contact experience, male gender, and younger age [28].However, the relationship between knowledge and attitudes remains to be investigated.
In a previous study, scientific knowledge of Alzheimer's was not significantly related to personal fear of Alzheimer's, while social comfort was correlated negatively with it [29].Developing a positive attitude and perception for patients with Alzheimer's disease does not necessarily require knowledge of Alzheimer's.

Strengths of the study
This study provides valuable evidence since there are a limited number of Saudi studies in this field.This study also included participants from a wide range of demographic and socio-economic backgrounds, making it easier for the Ministry of Health to focus on the targeted population to raise awareness about Alzheimer's disease.Furthermore, this study paved the way as the base for further studies in this aspect.

Limitations of the study
Limitations were present in the study.It may have been a highly selective group of cases because it was done in a specific setting.That the questionnaire was not culturally adopted.Therefore, generalizing the findings to Saudi Arabia's population may prove difficult.Statistical significance would also improve with a larger number of respondents.

Conclusions
The results of this study revealed that the majority of 477 (87.5%) respondents had a poor knowledge level of awareness and knowledge of Alzheimer's disease among the general population in Makkah.A significant association was reported between those with relatives diagnosed with Alzheimer's disease and good knowledge regarding the disease (P=.009).The general population should receive more attention since there is an increasing prevalence of Alzheimer's disease.Based on this study's findings and conclusions, we recommend (for the Ministry of Health) this topic be investigated serially and frequently to generate more evidence and data; (for the Ministry of Education and Health) convoys, medical missions, and conferences be held to increase the medical community's awareness of this topic; (for the Ministry of Media) media platforms and broadcasts are exploited in raising public awareness towards the significance and impact of Alzheimer's disease.

TABLE 2 : Public's attitude toward Alzheimer's disease in Makkah, Saudi Arabia
The public's knowledge and awareness regarding Alzheimer's disease in Makkah, Saudi Arabia is detailed in Table3.Regarding Alzheimer's risk factor knowledge, only 12.3% correctly report that mindfulness exercises cannot prevent a person from developing Alzheimer's disease, while 48.3% are aware that genes can only be partially responsible for causing Alzheimer's disease, 34.1% know that people at the age of 30 can develop Alzheimer's disease, and 25.3% correctly say that high blood pressure may increase a person's risk of getting Alzheimer's disease.As for Alzheimer's effect on patients' lives, 61.1% know patients with Alzheimer's disease are more likely to suffer from depression, 48.6% of respondents say it is safe for Alzheimer's patients to drive, as long as they have a companion in their car at all times, and 27% reject nursing homes for people with Alzheimer's disease.Regarding evaluation and diagnosis, 64.4% of the respondents know that Alzheimer's disease is a type of dementia, 56.7% report that when a person with Alzheimer's disease becomes agitated, a medical evaluation may reveal health problems that caused the disorder, 39.6% are aware that symptoms of severe depression can be mistaken for Alzheimer's disease, and 24.6% do not believe that if memory and confusion problems start suddenly, they are likely caused by Alzheimer's disease.Regarding Alzheimer's disease progression, 61.7% of participants know that Alzheimer's patients will require 24 hours of supervision.In addition, 49.9% of respondents reported that people with Alzheimer's will fall more often as the disease progresses.However, 16.5% say the average lifespan after Alzheimer's symptoms appear is 6 to 12 years.

TABLE 3 : Public knowledge and awareness regarding Alzheimer's disease in Makkah, Saudi ArabiaTable 4 .
Public knowledge and awareness regarding Alzheimer's disease in Makkah, Saudi Arabia, continued.For patient care, 49.9% are aware that simple instructions are best for people with Alzheimer's disease, and 49.4% correctly report that if a person with Alzheimer's disease becomes alert and restless at night, a good strategy is to make sure that they get plenty of exercise during the day, but 8.1% deny that when Alzheimer's patients have difficulty taking care of themselves, caregivers must take matters into their own hands immediately.Regarding management, 56.7% of the study respondents know that malnutrition can exacerbate Alzheimer's symptoms, 51.8% of respondents say that people with early Alzheimer's disease can receive therapy for anxiety and depression, while 36.5% deny that reminder notes can lead to deterioration in Alzheimer's patients.As for disease signs, 40.6% know that one of the symptoms that can occur with Alzheimer's disease is the belief that other people steal things, 39.4% believe that difficulty handling money or paying bills is one of the earliest symptoms of Alzheimer's, while 21.8% know that tremor, or shaking of the hands or arms, is not a common symptom in people with Alzheimer's disease.