Cognitive screening for dementia and delirium in sub-Saharan Africa :development and validation of cognitive screening tools for identification of dementia and delirium in older adults by non-specialist health workers in sub-Saharan Africa

PhD ThesisDementia and delirium are recognised to be common inter-related disorders affecting older people worldwide, the majority of whom live in low and middle income countries (LMICs). In sub-Saharan Africa (SSA), research data on dementia and delirium in older adults are currently very few, despite evidence of a growing older population. A major factor limiting research is the lack of appropriately validated cognitive screening instruments. Existing instruments appear educationally biased in SSA, where illiteracy amongst older people remains high. Specialist clinicians are few, and human resources generally limited, resulting in a need for brief tools suitable for use by non-specialists with limited time. The IDEA six-item screen was developed from cognitive screening data collected during a community based door-to-door prevalence study of dementia conducted in Tanzania in 2010. This work aimed to formally validate the IDEA screen for identification of dementia and delirium in older adults in a variety of clinical settings in Tanzania. Additional aims were to identify potential educational bias, consider feasibility of use of the IDEA screen by non-specialist clinicians and consider utility and effectiveness of additional screening items to improve diagnostic accuracy in some settings. Validation studies were conducted in the Kilimanjaro region of Tanzania as follows. 1) Consecutive admissions to medical wards of a Government hospital aged 60 and over (n=97); 2) A randomised sample of individuals aged 60 and over attending a free-of-charge Government outpatient clinic (n=108); 3) A randomised rural community sample aged 60 and over presenting for dementia screening (n=466), and 4) A consecutive sample of 507 individuals aged 60 and over admitted to medical wards of a tertiary referral hospital, supported by detailed informant interview and follow-up where necessary (against blinded consensus DSM-IV dementia and DSM-5 delirium criteria). A culturally appropriate assessment of Instrumental Activities of Daily Living (IDEA-IADL) was developed at a workshop for primary healthcare workers. Validation against DSM-IV dementia criteria took place in a community sample (n=417) of adults aged 60 and over presenting for dementia screening, used alone and in addition to the IDEA six-item screen. Screening was conducted by trained research nurses, occupational therapists and clinical officers in hospital settings, and by nurses and primary health care workers in rural settings. Diagnostic accuracy of the IDEA six-item screen for major cognitive impairment was high in the pilot hospital settings (IP AUC 0.917, OPD AUC 0.919). Accuracy in the lower prevalence community setting was lower (AUC 0.846), but improved by the addition of the IDEA-IADL (AUC 0.896). In the tertiary referral hospital sample AUC was 0.874 for major cognitive impairment (DSM-IV delirium or Identification of dementia in sub-Saharan Africa Doctoral Statement - 3 - DSM-IV dementia) and 0.866 for delirium, but a substantial number of participants were unable to complete the screen (83/507) and the IDEA did not differentiate dementia and delirium. A combined tool developed through modelling outperformed the IDEA (AUC 0.94 95% CI 0.92-0.97) and had the advantage of being much shorter, and being possible in most individuals regardless of illness severity. These studies conclude that the IDEA six-item screen is a brief and culturally appropriate cognitive screening tool with a high degree of diagnostic accuracy for identification of dementia in clinical and community settings in Tanzania. Use of the screen by non-specialist health workers is feasible, and the screen does not appear educationally biased. Diagnostic accuracy is improved by additional use of a functional assessment tool, the IDEA-IADL in the community. In hospital settings with a relatively high prevalence of delirium, the IDEA six item screen is accurate in identification of major cognitive impairment (dementia or delirium) but cannot differentiate these conditions. An alternative screening method for identification of delirium in this setting is presented. Further validation work in other settings in sub-Saharan Africa is needed. Since the proportion of individuals aged 50 and over living with HIV in SSA is projected to increase from one in seven to one in four by 2030, assessment of clinical utility in HIV-associated neurocognitive impairment is also needed, and this is the focus of ongoing work

Social Representation and Practices Related to Dementia in Hai District of Tanzania.

With the increasing number of people surviving into old age in Africa, dementia is becoming an important public health problem. Understanding the social dynamics of dementia in resource-poor settings is critical for developing effective interventions. We explored the socio-cultural beliefs surrounding dementia and the life experience of people with dementia (PWD) and their caregivers in the Hai District of Kilimanjaro, Tanzania. Cross-sectional qualitative design. Forty one PWD were purposively sampled from the Hai District of Kilimanjaro. Twenty five paired interviews with PWD and with caregivers, and 16 with caregivers alone, were conducted. Interviews were tape recorded, transcribed verbatim and analyzed using content analysis approach. Forty one PWD (26 females), aged 70 years and older, were recruited but due to speech difficulties only 25 participated in the interviews. Married were 13, widow in 22 and widower 6. The majority, 33/41 were illiterate. PWD and carers perceived memory problems as a normal part of ageing. Dementia was commonly referred as "ugonjwa wa uzeeni" (disease of old people) or memory loss disease. The majority of PWD 13/12 and carers 7/16 did not know what dementia is or what causes it. Dementia was felt to be associated with stroke, high blood pressure, diabetes, old age, curse/witchcraft and life stress. Half of the participants had used modern care and alternative care such as herbs, prayers or traditional healers. Caregivers complained about the burden of caring for PWD and suggested that community organizations should be involved in addressing the problem. Knowledge about dementia is low and the symptoms are accepted as a problem of old age. PWD and carers demonstrate pluralistic behaviour in seeking help from modern care, prayers and traditional healers. The disease adds significant burden to family members. Family and caregivers need more education on early recognition of symptoms and cost effective management of dementia at family level. Faith-based organizations could play an important role in dementia interventions. At a national level effective policy and improvement of the health care system to address the needs of PWD and their families are imperative

Dementia Prevalence Estimates in Sub-Saharan Africa: Comparison of two Diagnostic Criteria.

We have previously reported the prevalence of dementia in older adults living in the rural Hai district of Tanzania according to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria. The aim of this study was to compare prevalence rates using the DSM-IV criteria with those obtained using the 10/66 diagnostic criteria, which is specifically designed for use in low- and middle-income countries. In phase I, 1,198 people aged 70 and older were screened for dementia. A stratified sample of 296 was then clinically assessed for dementia according to the DSM-IV criteria. In addition, data were collected according to the protocol of the 10/66 Dementia Research Group, which allowed a separate diagnosis of dementia according to these criteria to be established. The age-standardised prevalence of clinical DSM-IV dementia was 6.4% (95% confidence interval [CI] 4.9-7.9%) and of '10/66 dementia' was 21.6% (95% CI 17.5-25.7%). Education was a significant predictor of '10/66 dementia', but not of DSM-IV dementia. There are large discrepancies in dementia prevalence rates depending on which diagnostic system is used. In rural sub-Saharan Africa, it is not clear whether the association between education and dementia using the 10/66 criteria is a genuine effect or the result of an educational bias within the diagnostic instrument. Despite its possible flaws, the DSM-IV criteria represent an international standard for dementia diagnosis. The 10/66 diagnostic criteria may be more appropriate when identification of early and mild cognitive impairment is required

Health and socioeconomic resource provision for older people in South Asian countries: Bangladesh, India, Nepal, Pakistan and Sri Lanka evidence from NEESAMA

Background: The global population is ageing rapidly, with low- and middle-income countries (LMICs) undergoing a fast demographic transition. As the number of older adults in LMICs increases, services able to effectively address their physical and mental health needs will be increasingly important. Objective: We review the health and socioeconomic resources currently available for older people in South Asian countries, Bangladesh, India, Nepal, Pakistan and Sri Lanka, to identify gaps in available resources and assess areas for improvement. Methods: We conducted a search of grey and published literature via Google Search, Compendex, EBSCO, JSTOR, Medline, Ovid, ProQuest databases, Scopus and Web of Science. Data on population demographics, human resources, health funding and social protection for older people were extracted. Local informants were consulted to supplement and verify the data. Results: In the study countries, the number of health professionals with expertise in elderly care was largely unknown, with minimal postgraduate training programmes available in elderly medicine or psychiatry. Older adults are therefore cared for by general physicians, nurses and community health workers, all of whom are present in insufficient numbers per capita. Total average healthcare expenditure was 2.5–5.5% of GDP, with 48.1–72.0% of healthcare costs covered by out-of-pocket payments. Pakistan did not have a social pension; only India and Nepal offered financial assistance to people with dementia; and all countries had disproportionately low numbers of care elderly homes. Conclusions: Inadequate healthcare funding, a shortage of healthcare professionals and insufficient government pension and social security schemes are significant barriers to achieving universal health coverage in LMICs. Governing bodies must expand training pro-grammes for healthcare providers for older adults, alongside increasing social protection to improve access to those in need and to prevent catastrophic health expenditure

Mediterranean diet adherence and cognitive function in older, UK adults: The EPIC-Norfolk study

Background In Mediterranean countries, adherence to a traditional Mediterranean dietary pattern (MedDiet) is associated with better cognitive function and reduced dementia risk. It is unclear if similar benefits exist in non-Mediterranean regions. Objective To examine associations between MedDiet adherence and cognitive function in an older, UK population. To investigate whether associations differed between individuals with high versus low cardiovascular disease (CVD) risk. Design We conducted an analysis in 8009 older individuals with dietary data at Health Check 1 (1993-1997) and cognitive function data at Health Check 3 (2006-2011) of the European Prospective Investigation of Cancer, Norfolk (EPIC-Norfolk). Associations were explored between MedDiet adherence and global and domain specific cognitive test scores and risk of poor cognitive performance in the entire cohort, and when stratified according to CVD risk status. Results Higher MedDiet adherence defined by the Pyramid MedDiet score was associated with better global cognition (β±SE=-0.012±0.002; P<0.001), verbal episodic memory (β±SE=-0.009±0.002; P<0.001), and simple processing speed (β±SE=-0.002±0.001; P=0.013). Lower risk of poor verbal episodic memory (OR(95%CI)=0.784 (0.641,0.959); P=0.018), complex processing speed (OR(95%CI)=0.739 (0.601,0.907); P=0.004), and prospective memory (OR(95%CI)=0.841 (0.724,0.977); P=0.023) was also observed for the highest versus lowest Pyramid MedDiet tertiles. The effect of a one-point increase in Pyramid score on global cognitive function was equivalent to 1.7 fewer years of cognitive ageing. MedDiet adherence defined by the MEDAS score (mapped using both binary and continuous scoring) showed similar, albeit less consistent, associations. In stratified analyses, associations were evident in individuals at higher CVD risk only (P<0.05). Conclusions Higher adherence to the MedDiet is associated with better cognitive function and lower risk of poor cognition in older, UK adults. This evidence underpins the development of interventions to enhance MedDiet adherence, particularly in individuals at higher CVD risk, aiming to reduce the risk of age-related cognitive decline in non-Mediterranean populations

A new approach for developing “implementation plans” for cognitive stimulation therapy (CST) in low and middle-income countries: Results from the CST-International study

Background: Even with a strong evidence base, many healthcare interventions fail to be translated to clinical practice due to the absence of robust implementation strategies. For disorders such as Alzheimer's disease and other dementias, access to evidence-based interventions beyond research settings is of great importance. Cognitive Stimulation Therapy (CST) is a brief, group-based intervention, with consistent evidence of effectiveness. Methods: An implementation focused, three-phase methodology was developed using extensive stakeholder engagement. The methods resulted in a standardized Implementation Plan for the successful translation of CST from research to practice. The methodology was developed using the Consolidated Framework for Implementation Research (CFIR) and refined in three countries that vary in levels of economic development and healthcare systems (Brazil, India and Tanzania. Results: Five Implemention Plans for CST were produced. Each plan contained implementation strategies and action plans devised in conjunction with policy professionals, healthcare professionals, people with dementia and family carers, and an international team of researchers and clinicians. Conclusion: This novel methodology can act as a template for implementation studies in diverse healthcare systems across the world. It is an effective means of devising socio-culturally informed Implementation Plans that account for economic realities, health equity and healthcare access

Risk of conversion from mild cognitive impairment to dementia in low- and middle-income countries: A systematic review and meta-analysis

Daniel Reidpath - ORCID: 0000-0002-8796-0420 https://orcid.org/0000-0002-8796-0420Introduction With no treatment for dementia, there is a need to identify high risk cases to focus preventive strategies, particularly in low- and middle-income countries (LMICs) where the burden of dementia is greatest. We evaluated the risk of conversion from mild cognitive ompairment (MCI) to dementia in LMICs. Methods Medline, Embase, PsycINFO, and Scopus were searched from inception until June 30, 2020. The search was restricted to observational studies, conducted in population-based samples, with at least 1 year follow-up. There was no restriction on the definition of MCI used as long as it was clearly defined. PROSPERO registration: CRD42019130958. Results Ten thousand six hundred forty-seven articles were screened; n = 11 retained. Of the 11 studies, most were conducted in China (n = 7 studies), with only two studies from countries classified as low income. A qualitative analysis of n = 11 studies showed that similar to high-income countries the conversion rate to dementia from MCI was variable (range 6 0%–44 8%; average follow-up 3 7 years [standard deviation = 1 2]). A meta-analysis of studies using Petersen criteria (n = 6 studies), found a pooled conversion rate to Alzheimer's disease (AD) of 23 8% (95% confidence interval = 15 4%–33.4%); approximately one in four people with MCI were at risk of AD in LMICs (over 3 0–5 8 years follow-up). Risk factors for conversion from MCI to dementia included demographic (e.g., age) and health (e.g., cardio-metabolic disease) variables. Conclusions MCI is associated with high, but variable, conversion to dementia in LMICs and may be influenced by demographic and health factors. There is a notable absence of data from low-income settings and countries outside of China. This highlights the urgent need for research investment into aging and dementia in LMIC settings. Being able to identify those individuals with cognitive impairment who are at highest risk of dementia in LMICs is necessary for the development of risk reduction strategies that are contextualized to these unique settings.National Institute for Health Research (NIHR) Global Group. Grant Number: DePEC 16/137/62https://doi.org/10.1002/trc2.122678pubpub

Risk of conversion from mild cognitive impairment to dementia in low‐ and middle‐income countries: A systematic review and meta‐analysis

Abstract: Introduction: With no treatment for dementia, there is a need to identify high risk cases to focus preventive strategies, particularly in low‐ and middle‐income countries (LMICs) where the burden of dementia is greatest. We evaluated the risk of conversion from mild cognitive ompairment (MCI) to dementia in LMICs. Methods: Medline, Embase, PsycINFO, and Scopus were searched from inception until June 30, 2020. The search was restricted to observational studies, conducted in population‐based samples, with at least 1 year follow‐up. There was no restriction on the definition of MCI used as long as it was clearly defined. PROSPERO registration: CRD42019130958. Results: Ten thousand six hundred forty‐seven articles were screened; n = 11 retained. Of the 11 studies, most were conducted in China (n = 7 studies), with only two studies from countries classified as low income. A qualitative analysis of n = 11 studies showed that similar to high‐income countries the conversion rate to dementia from MCI was variable (range 6 . $.$ 0%–44 . $.$ 8%; average follow‐up 3 . $.$ 7 years [standard deviation = 1 . $.$ 2]). A meta‐analysis of studies using Petersen criteria (n = 6 studies), found a pooled conversion rate to Alzheimer's disease (AD) of 23 . $.$ 8% (95% confidence interval = 15 . $.$ 4%–33.4%); approximately one in four people with MCI were at risk of AD in LMICs (over 3 . $.$ 0–5 . $.$ 8 years follow‐up). Risk factors for conversion from MCI to dementia included demographic (e.g., age) and health (e.g., cardio‐metabolic disease) variables. Conclusions: MCI is associated with high, but variable, conversion to dementia in LMICs and may be influenced by demographic and health factors. There is a notable absence of data from low‐income settings and countries outside of China. This highlights the urgent need for research investment into aging and dementia in LMIC settings. Being able to identify those individuals with cognitive impairment who are at highest risk of dementia in LMICs is necessary for the development of risk reduction strategies that are contextualized to these unique settings

Neuropsychological tests associated with symptomatic HIV-associated neurocognitive disorder (HAND) in a cohort of older adults in Tanzania

Objective: Human immunodeficiency virus (HIV)-associated neurocognitive disorder (HAND) prevalence is expected to increase in East Africa as treatment coverage increases, survival improves, and this population ages. This study aimed to better understand the current cognitive phenotype of this newly emergent population of older combination antiretroviral therapy (cART)-treated people living with HIV (PLWH), in which current screening measures lack accuracy. This will facilitate the refinement of HAND cognitive screening tools for this setting. Method: This is a secondary analysis of 253 PLWH aged ≥50 years receiving standard government HIV clinic follow-up in Kilimanjaro, Tanzania. They were evaluated with a detailed locally normed low-literacy neuropsychological battery annually on three occasions and a consensus panel diagnosis of HAND by Frascati criteria based on clinical evaluation and collateral history. Results: Tests of verbal learning and memory, categorical verbal fluency, visual memory, and visuoconstruction had an area under the receiver operating characteristic curve &gt;0.7 for symptomatic HAND (s-HAND) (0.70–0.72; p &lt; 0.001 for all tests). Tests of visual memory, verbal learning with delayed recall and recognition memory, psychomotor speed, language comprehension, and categorical verbal fluency were independently associated with s-HAND in a logistic mixed effects model (p &lt; 0.01 for all). Neuropsychological impairments varied by educational background. Conclusions: A broad range of cognitive domains are affected in older, well-controlled, East African PLWH, including those not captured in widely used screening measures. It is possible that educational background affects the observed cognitive impairments in this setting. Future screening measures for similar populations should consider assessment of visual memory, verbal learning, language comprehension, and executive and motor function

Feasibility and acceptability of a multi-domain intervention to increase Mediterranean diet adherence and physical activity in older UK adults at risk of dementia: Protocol for the MedEx-UK randomised controlled trial

Introduction Dementia prevalence continues to increase, and effective interventions are needed to prevent, delay or slow its progression. Higher adherence to the Mediterranean diet (MedDiet) and increased physical activity (PA) have been proposed as strategies to facilitate healthy brain ageing and reduce dementia risk. However, to date, there have been no dementia prevention trials in the UK focussed on combined dietary and PA interventions. This study aims to: (1) assess feasibility and acceptability of a theory-underpinned digital and group-based intervention for dementia risk reduction in an 'at risk' UK cohort; (2) evaluate behaviour change responses to the intervention; and, (3) provide information on cognitive, neurological, vascular and physiological outcomes to inform the design of a follow-on, full-scale efficacy trial. Methods One hundred and eight participants aged 55 to 74 years with a QRISK2 score of ≥10% will be recruited to take part in this 24-week multi-site study. Participants will be randomised into three parallel arms: (1) Control; (2) MedDiet; and, (3) MedDiet+PA. The study will evaluate a personalised website, group session and food delivery intervention to increase MedDiet adherence and PA in older adults at risk of dementia. Diet and PA will be monitored prior to, during and following the intervention. Feasibility, acceptability and hypothesised mediators will be assessed in addition to measures of cognitive function, brain structure/perfusion (MRI), vascular function and metabolic markers (blood, urine and faecal) prior to, and following, the intervention. Discussion This trial will provide insights into the feasibility, acceptability and mechanism of effect of a multi-domain intervention focussed on the MedDiet alone and PA for dementia risk reduction in an 'at risk' UK cohort. Ethics and dissemination The study has received NHS REC and HRA approval (18/NI/0191). Findings will be disseminated via conference presentations, public lectures, and peer-reviewed publications. Trial registration details ClinicalTrials.gov NCT03673722