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Background: Identifying older people who are most vulnerable to adverse outcomes is important. This is particularly so in low-resource settings, such as those in sub-Saharan Africa (SSA), where access to social and healthcare services is often limited. Aim: To validate and further refine a frailty screening tool for SSA. Methods: Phase I screening of people aged 60 years and over was conducted using the Brief Frailty Instrument for Tanzania (B-FIT). In phase II, a stratified, frailty-weighed sample was assessed across a range of variables covering cognition, physical function (including continence, mobility, weakness and exhaustion) nutrition, mood, co-morbidity, sensory impairment, polypharmacy, social support and self-rated health. The frailty-weighted sample was also assessed for frailty according to the comprehensive geriatric assessment (CGA), which we used as our ‘gold standard’ diagnosis. Results: Of 235 people in the frailty-weighted sample, 91 (38.7%) were frail according to CGA, the median age was 73 years and 136 (57.9%) were female. In multivariable modelling, physical disability (Barthel index), cognitive impairment (IDEA cognitive screen), calf circumference, poor distance vision and problems engaging in social activities were found to be associated with frailty. After developing a scoring system, based on regression coefficients, a modified B-FIT screen (B-FIT 2) had an area under the receiver operating characteristic curve of 0.925, a sensitivity of 86.2% and a specificity of 88.8%. Discussion: The inclusion of items assessing nutrition, social support and sensory impairment improved the performance of the B-FIT. Conclusions: The B-FIT 2 should be externally validated.

Mild cognitive impairment (MCI) is recognized as a high-risk condition for conversion to dementia, although data on outcomes of MCI in sub-Saharan Africa are scarce. We investigated outcomes of MCI over a 4-year period in Tanzania and considered risk factors for conversion to dementia.

Cognitive impairment is thought to be a major cause of disability worldwide, though data from sub-Saharan Africa (SSA) are sparse. This study aimed to investigate the association between cognitive impairment and disability in a cohort of community-dwelling older adults living in Tanzania. The study cohort of 296 people aged 70years and over was recruited as part of a dementia prevalence study. Subjects were diagnosed as having dementia or mild cognitive impairment according to the DSM-IV criteria. Disability level was assessed according to the WHO Disability Assessment Schedule, version 2.0 (WHODAS). A higher WHODAS score indicates greater disability. The median WHODAS in the background population was 25.0; in those with dementia and in those with mild cognitive impairment, 72 of 78 (92.3%) and 41 of 46 (89.1%), respectively, had a WHODAS score above this level. The presence of dementia, mild cognitive impairment, hearing impairment, being unable to walk without an aid and not having attended school were independent predictors of having a WHODAS score above 25.0, though age and gender were not. In summary, cognitive impairment is a significant predictor of disability in elderly Tanzanians. Screening for early signs of cognitive decline would allow management strategies to be put in place that may reduce the associated disability burden.

Cognitive impairment is thought to be a major cause of disability worldwide, though data from sub-Saharan Africa (SSA) are sparse. This study aimed to investigate the association between cognitive impairment and disability in a cohort of community-dwelling older adults living in Tanzania. The study cohort of 296 people aged 70 years and over was recruited as part of a dementia prevalence study. Subjects were diagnosed as having dementia or mild cognitive impairment according to the DSM-IV criteria. Disability level was assessed according to the WHO Disability Assessment Schedule, version 2.0 (WHODAS). A higher WHODAS score indicates greater disability. The median WHODAS in the background population was 25.0; in those with dementia and in those with mild cognitive impairment, 72 of 78 (92.3%) and 41 of 46 (89.1%), respectively, had a WHODAS score above this level. The presence of dementia, mild cognitive impairment, hearing impairment, being unable to walk without an aid and not having attended school were independent predictors of having a WHODAS score above 25.0, though age and gender were not. In summary, cognitive impairment is a significant predictor of disability in elderly Tanzanians. Screening for early signs of cognitive decline would allow management strategies to be put in place that may reduce the associated disability burden.

The prevalence of dementia is predicted to increase rapidly in developing countries. Vascular risk factors may contribute to this rise. Our aim was to estimate the proportions of Alzheimer's disease (ADD) and vascular dementia (VAD) in a prevalent cohort of dementia cases in rural Tanzania.

ObjectivesThe global burden of dementia is increasing, with the greatest increase predicted to occur in sub-Saharan Africa (SSA). Despite this there are limited previous data on the prevalence of, and risk factors for, dementia in SSA. This study aimed to estimate the prevalence of dementia, and investigate its associations, in those aged 60 years and older attending the outpatient department of Mount Meru Hospital in northern Tanzania. This is the first hospital-based outpatient dementia prevalence and risk factors study to be conducted in an east African population.MethodsThis was a one-phase cross-sectional study. Adults aged 60 years and over attending medical outpatients were screened for dementia using The Identification and Intervention for Dementia in Elderly Africans cognitive screening tool. Those who scored ≤9 were clinically assessed using the DSM-IV criteria. Demographic, medical comorbidity and lifestyle information were collected during a clinical assessment.ResultsPrevalence of dementia was 5.0% (95% confidence interval: 3.7-6.3). Binary logistic regression found female sex (odds ratio (OR)=2.778), having no formal education(OR=6.088), quantity of alcohol consumption (units/week) (OR=1.080), uncorrected visual impairment (OR=4.260), body mass index <18.5kg/m2 (OR=6.588) and stroke (OR=15.790with wide 95% confidence interval (3.48-74.475)) to be significantly, independently associated with dementia.ConclusionsThe prevalence of dementia in this population is lower than previously reported community-based rates in Tanzania, and similar to those in high-income countries.This is the first time the association between uncorrected visual impairment and dementia has been reported in SSA. Other associations identified are in keeping with previous literature. Further research on the management of dementia and its risk factors, and the support and education of carers and patients in east African populations is required to advise future policy.

ObjectiveHIV infection is a major cause of disease burden and disability across sub-Saharan Africa (SSA). HIV-associated neurocognitive impairment (HAND) is estimated to affect 8 million people with HIV infection across the continent and is associated with increased mortality and morbidity. As a result of demographic transition and increased coverage of combination antiretroviral therapy (cART) the proportion of people aged 50 and over living with HIV infection in SSA is predicted to triple (to over 9 million people by 2040). Despite this, few published data exist on the prevalence of, or risk factors for, HAND in older individuals in SSA. We aimed to estimate prevalence and risk factors for HAND in a stable population of HIV positive individuals under long term follow up at a government clinic in Northern Tanzania, one of the pioneer sites for cART in SSA.MethodA systematic sample of individuals aged 50 and over attending a HIV care and treatment centre for routine follow up were assessed for HAND using a locally normed neuropsychological battery adapted to a low literacy setting. All participants subsequently underwent a clinical interview, neurological examination, informant history for functional impairment and standardised psychiatric screening questionnaire. HAND was defined according the American Academy of Neurology (AAN) 2007 criteria for Asymptomatic Neurocognitive Impairment, Minor Neurocognitive Disorder (MND) and HIV-associated Dementia (HAD). General and HIV-specific risk factors for symptomatic HAND were examined using univariable and multivariable logistic regression.ResultsComplete data were available for 227 participants (162 (71%) female, median age 57.9 years) of whom 35% had 4 years formal education or fewer. Median Cd4 count was 500/µl and 95.5% of participants were on cART. Preliminary data indicate that the overall prevalence of HAND was 61.2% (ANI 35.2%, MND 23.8%, HAD 2.2%) and of symptomatic HAND (MND and HAD) 25%. Presence of symptomatic HAND was not related to current or nadir Cd4 count, or time since HIV diagnosis, but was independently associated with older age, illiteracy, living alone and greater number of depression symptoms.ConclusionHAND was very prevalent in this stable outpatient cohort of older adults most of whom were on cART. Initial results suggest that in this cohort of older adults in SSA, risk factors for symptomatic neurocognitive impairment appeared to be less related to HIV infection and more similar to factors commonly associated with neurodegenerative dementias in both high income and low income country settings.

BackgroundThe dementia diagnosis gap in sub-Saharan Africa (SSA) is large, partly due to difficulties in assessing function, an essential step in diagnosis.ObjectivesAs part of the Identification and Intervention for Dementia in Elderly Africans (IDEA) study, to develop, pilot, and validate an Instrumental Activities of Daily Living (IADL) questionnaire for use in a rural Tanzanian population to assist in the identification of people with dementia alongside cognitive screening.DesignThe questionnaire was developed at a workshop for rural primary healthcare workers, based on culturally appropriate roles and usual activities of elderly people in this community. It was piloted in 52 individuals under follow-up from a dementia prevalence study. Validation subsequently took place during a community dementia-screening programme. Construct validation against gold standard clinical dementia diagnosis using DSM-IV criteria was carried out on a stratified sample of the cohort and validity assessed using area under the receiver operating characteristic (AUROC) curve analysis.ResultsAn 11-item questionnaire (IDEA-IADL) was developed after pilot testing. During formal validation on 130 community-dwelling elderly people who presented for screening, the AUROC curve was 0.896 for DSM-IV dementia when used in isolation and 0.937 when used in conjunction with the IDEA cognitive screen, previously validated in Tanzania. The internal consistency was 0.959. Performance on the IDEA-IADL was not biased with regard to age, gender or education level.ConclusionsThe IDEA-IADL questionnaire appears to be a useful aid to dementia screening in this setting. Further validation in other healthcare settings in SSA is required.

BackgroundWe 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.MethodsIn 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.ResultsThe 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.ConclusionsThere 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.