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In a Perspective, Cleusa Ferri and K. S. Jacob discuss the assessment, recognition, and care of people living with dementia in low- and middle-income countries.

Objective: Although depression among older people is an important public health problem worldwide, systematic studies evaluating its prevalence and determinants in low and middle income countries (LMICs) are sparse. The biopsychosocial model of depression and prevailing socioeconomic hardships for older people in LMICs have provided the impetus to determine the prevalence of geriatric depression; to study its associations with health, social, and economic variables; and to investigate socioeconomic inequalities in depression prevalence in LMICs., Methods: The authors accessed the World Health Organization Study on Global AGEing and Adult Health Wave 1 data that studied nationally representative samples from six large LMICs (N = 14,877). A computerized algorithm derived depression diagnoses. The authors assessed hypothesized associations using survey multivariate logistic regression models for each LMIC and pooled their risk estimates by meta-analyses and investigated related socioeconomic inequalities using concentration indices., Results: Cross-national prevalence of geriatric depression was 4.7% (95% CI: 1.9%-11.9%). Female gender, illiteracy, poverty, indebtedness, past informal-sector occupation, bereavement, angina, and stroke had significant positive associations, whereas pension support and health insurance showed significant negative associations with geriatric depression. Pro-poor inequality of geriatric depression were documented in five LMICs., Conclusions: Socioeconomic factors and related inequalities may predispose, precipitate, or perpetuate depression amongolder people in LMICs. Relative absence of health safety net places socioeconomically disadvantaged older people in LMICs at risk. The need for population-based public health interventions and policies to prevent and to manage geriatric depression effectively in LMICs cannot be overemphasized., (Copyright © 2016 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

Background: Little is known of the epidemiology of diabetes among older people in low and middle income countries. We aimed to study and compare prevalence, social patterning, correlates, detection, treatment and control of diabetes among older people in Latin America, India, China and Nigeria., Methods: Cross-sectional surveys in 13 catchment area sites in nine countries. Diagnosed diabetes was assessed in all sites through self-reported diagnosis. Undiagnosed diabetes was assessed in seven Latin American sites through fasting blood samples (glucose > = 7 mmol/L)., Results: Total diabetes prevalence in catchment sites in Cuba (prevalence 24.2%, SMR 116), Puerto Rico (43.4%, 197), and urban (27.0%, 125), and rural Mexico (23.7%, 111) already exceeds that in the USA, while that in Venezuela (20.9%, 100) is similar. Diagnosed diabetes prevalence varied very widely, between low prevalences in sites in rural China (0.9%), rural India (6.6%) and Nigeria (6.0%). and 32.1% in Puerto Rico, explained mainly by access to health services. Treatment coverage varied substantially between sites. Diabetes control (40 to 61% of those diagnosed) was modest in the Latin American sites where this was studied. Diabetes was independently associated with less education, but more assets. Hypertension, central obesity and hypertriglyceridaemia, but not hypercholesterolaemia were consistently associated with total diabetes., Conclusions: Diabetes prevalence is already high in most sites. Identifying undiagnosed cases is essential to quantify population burden, particularly in least developed settings where diagnosis is uncommon. Metabolic risk factors and associated lifestyles may play an important part in aetiology, but this requires confirmation with longitudinal data. Given the high prevalence among older people, more population research is indicated to quantify the impact of diabetes, and to monitor the effect of prevention and health system strengthening on prevalence, treatment and control.

Background: Current estimates of the prevalence of depression in later life mostly arise from studies carried out in Europe, North America and Asia. In this study we aimed to measure the prevalence of depression using a standardised method in a number of low and middle income countries (LMIC)., Methods: A one-phase cross-sectional survey involving over 17,000 participants aged 65 years and over living in urban and rural catchment areas in 13 sites from 9 countries (Cuba, Dominican Republic, Puerto Rico, Mexico, Venezuela, Peru, China, India and Nigeria). Depression was assessed and compared using ICD-10 and EURO-D criteria., Results: Depression prevalence varied across sites according to diagnostic criteria. The lowest prevalence was observed for ICD-10 depressive episode (0.3 to 13.8%). When using the EURO-D depression scale, the prevalence was higher and ranged from 1.0% to 38.6%. The crude prevalence was particularly high in the Dominican Republic and in rural India. ICD-10 depression was also associated with increased age and being female., Limitations: Generalisability of findings outside of catchment areas is difficult to assess., Conclusions: Late life depression is burdensome, and common in LMIC. However its prevalence varies from culture to culture; its diagnosis poses a significant challenge and requires proper recognition of its expression., (Copyright © 2015 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Evidence on the association between fish consumption and depression is inconsistent and virtually non-existent from low- and middle-income countries. Using a standard protocol, we aim to assess the association of fish consumption and late-life depression in seven low- and middle-income countries., Methodology/findings: We used cross-sectional data from the 10/66 cohort study and applied two diagnostic criteria for late-life depression to assess the association between categories of weekly fish consumption and depression according to ICD-10 and the EURO-D depression symptoms scale scores, adjusting for relevant confounders. All-catchment area surveys were carried out in Cuba, Dominican Republic, Venezuela, Peru, Mexico, China, and India, and over 15,000 community-dwelling older adults (65+) were sampled. Using Poisson models the adjusted association between categories of fish consumption and ICD-10 depression was positive in India (p for trend = 0.001), inverse in Peru (p = 0.025), and not significant in all other countries. We found a linear inverse association between fish consumption categories and EURO-D scores only in Cuba (p for trend = 0.039) and China (p<0.001); associations were not significant in all other countries. Between-country heterogeneity was marked for both ICD-10 (I(2)>61%) and EURO-D criteria (I(2)>66%)., Conclusions: The associations of fish consumption with depression in large samples of older adults varied markedly across countries and by depression diagnosis and were explained by socio-demographic and lifestyle variables. Experimental studies in these settings are needed to confirm our findings.

Objectives: Despite the growing importance of stroke in developing countries, little is known of stroke burden in survivors. The authors investigated the prevalence of self-reported stroke, stroke-related disability, dependence and care-giver strain in Latin America (LA), China and India., Methods: Cross-sectional surveys were conducted on individuals aged 65+ (n=15 022) living in specified catchment areas. Self-reported stroke diagnosis, disability, care needs and care giver burden were assessed using a standardised protocol. For those reporting stroke, the correlates of disability, dependence and care-giver burden were estimated at each site using Poisson or linear regression, and combined meta-analytically., Results: The prevalence of self-reported stroke ranged between 6% and 9% across most LA sites and urban China, but was much lower in urban India (1.9%), and in rural sites in India (1.1%), China (1.6%) and Peru (2.7%). The proportion of stroke survivors needing care varied between 20% and 39% in LA sites but was higher in rural China (44%), urban China (54%) and rural India (73%). Comorbid dementia and depression were the main correlates of disability and dependence., Conclusion: The prevalence of stroke in urban LA and Chinese sites is nearly as high as in industrialised countries. High levels of disability and dependence in the other mainly rural and less-developed sites suggest underascertainment of less severe cases as one likely explanation for the lower prevalence in those settings. As the health transition proceeds, a further increase in numbers of older stroke survivors is to be anticipated. In addition to prevention, stroke rehabilitation and long-term care needs should be addressed.

Background: To describe patterns of recent health service utilisation, and consequent out-of-pocket expenses among older people in countries with low and middle incomes, and to assess the equity with which services are accessed and delivered., Methods: 17,944 people aged 65 years and over were assessed in one-phase population-based cross-sectional surveys in geographically-defined catchment areas in nine countries - urban and rural sites in China, India, Mexico and Peru, urban sites in Cuba, Dominican Republic, Puerto Rico and Venezuela, and a rural site in Nigeria. The main outcome was use of community health care services in the past 3 months. Independent associations were estimated with indicators of need (dementia, depression, physical impairments), predisposing factors (age, sex, and education), and enabling factors (household assets, pension receipt and health insurance) using Poisson regression to generate prevalence ratios and fixed effects meta-analysis to combine them., Results: The proportion using healthcare services varied from 6% to 82% among sites. Number of physical impairments (pooled prevalence ratio 1.37, 95% CI 1.26-1.49) and ICD-10 depressive episode (pooled PR 1.21, 95% CI 1.07-1.38) were associated with service use, but dementia was inversely associated (pooled PR 0.93, 95% CI 0.90-0.97). Other correlates were female sex, higher education, more household assets, receiving a pension, and health insurance. Standardisation for age, sex, physical impairments, depression and dementia did not explain variation in service use. There was a strong borderline significant ecological correlation between the proportion of consultations requiring out-of-pocket costs and the prevalence of health service use (r = -0.50, p = 0.09)., Conclusions: While there was little evidence of ageism, inequity was apparent in the independent enabling effects of education and health insurance cover, the latter particularly in sites where out-of-pocket expenses were common, and private health insurance an important component of healthcare financing. Variation in service use among sites was most plausibly accounted for by stark differences in the extent of out-of-pocket expenses, and the ability of older people and their families to afford them. Health systems that finance medical services through out-of-pocket payments risk excluding the poorest older people, those without a secure regular income, and the uninsured.

Objective: Chronic physical comorbidity is common in dementia. However, there is an absence of evidence to support good practice guidelines for attention to these problems. We aimed to study the extent of this comorbidity and its impact on cognitive function and disability in population-based studies in low and middle income countries, where chronic diseases and impairments are likely to be both common and undertreated., Methods: A multicentre cross-sectional survey of all over 65 year old residents (n = 15 022) in 11 catchment areas in China, India, Cuba, Dominican Republic, Venezuela, Mexico and Peru. We estimated the prevalence of pain, incontinence, hearing and visual impairments, mobility impairment and undernutrition according to the presence of dementia and its severity, and, among those with dementia, the independent contribution of these impairments to cognitive function and disability, adjusting for age, gender, education and dementia severity., Results: Incontinence, hearing impairment, mobility impairment and undernutrition were consistently linearly associated with the presence of dementia and its severity across regions. Among people with dementia, incontinence, hearing impairment and mobility impairment were independently associated with disability in all regions while the contributions of pain, visual impairment and undernutrition were inconsistent. Only hearing impairment made a notable independent contribution to cognitive impairment., Conclusions: There is an urgent need for clinical trials of the feasibility, efficacy and cost-effectiveness of regular physical health checks and remediation of identified pathologies, given the considerable comorbidity identified in our population based studies, and the strong evidence for independent impact upon functioning., (Copyright © 2010 John Wiley & Sons, Ltd.)

Background: Post-partum depression, although heterogeneous, is often considered a medical disease when viewed from the biomedical perspective. However, recent reports from the Indian subcontinent have documented psychosocial causal factors., Method: This study employed qualitative methodology in a representative sample of women in rural South India. Women in the post-partum period were assessed using the Tamil versions of the Short Explanatory Model Interview, the Edinburgh Postnatal Depression Scale and a semi-structured interview to diagnose ICD 10 depression. Socio-demographic and clinical details were also recorded., Results: Some 137 women were recruited and assessed, of these, 26.3% were diagnosed to have post-partum depression. The following factors were associated with post-partum depression after adjusting for age and education: age less than 20 or over 30 years, schooling less than five years, thoughts of aborting current pregnancy, unhappy marriage, physical abuse during current pregnancy and after childbirth, husband's use of alcohol, girl child delivered in the absence of living boys and a preference for a boy, low birth weight, and a family history of depression. Post-partum depression was also associated with an increased number of causal models of illness, a number of non-medical models, treatment models and non-medical treatment models., Conclusion: Many social and cultural factors have a major impact on post-partum depression. Post-partum depression, when viewed from a biomedical framework, fails to acknowledge the role of context in the production of emotional distress in the post-partum period.

Background: Depression in the elderly is a common and disabling condition. The aim of the study was to evaluate the sensitivity and specificity of a two-question screen to identify depression and common mental disorders in the elderly., Method: Residents of a ward in the town of Vellore were identified by a door-to-door survey from which 204 subjects aged over 60 years were selected for the study by systematic random sampling. They were screened using the two-question screen. The Revised Clinical Interview Schedule (CIS-R) was employed to confirm the diagnosis., Results: The prevalence of depression and common mental disorder, using the CIS-R standard, was found to be 31.5%. The two-question screen has a sensitivity of 93.8% and specificity of 48.2%., Conclusions: The high sensitivity of the two-question screen makes it a useful screening method which can be employed by health workers in the field.

Background: Depression in old age is an important public health problem causing considerable morbidity and disability worldwide. There is a dearth of community studies from India investigating geriatric depression and its associated risk factors. This study aimed to establish the nature, prevalence and factors associated with geriatric depression in a rural south Indian community., Methods: We recruited 1000 participants aged over 65 years from Kaniyambadi block, Vellore, India. We assessed their socio-demographic profile, psychiatric morbidity, cognitive functioning, anthropometrics and disability status using the following structured assessment tools: Geriatric Mental State, Community Screening Instrument for Dementia, Modified CERAD 10 word list learning task, History and Aetiology Schedule Dementia Diagnosis and Subtype, WHO Disability Assessment Scale II, and Neuropsychiatric Inventory. We adopted a case control framework to study the factors associated with geriatric depression., Results: Prevalence of geriatric depression (ICD-10) within the previous one month was 12.7% (95% CI 10.64-14.76%). Low income (OR 1.78; 95% CI 1.08-2.91), experiencing hunger (OR 2.58; 95% CI 1.56-4.26), history of cardiac illnesses (OR 4.75; 95% CI 1.96-11.52), transient ischemic attack (OR 2.43; 95% CI 1.17-5.05), past head injury (OR 2.70; 95% CI 1.36-5.36) and diabetes (OR 2.33; 95% CI 1.15-4.72) increased the risk for geriatric depression after adjusting for other determinants using conditional logistic regression. Having more confidants (OR 0.13; 95% CI 0.06-0.26) was the significant protective factor. Age, female gender, cognitive impairment and disability status were not significantly associated with geriatric depression. DSM-IV diagnosis of major depression was significantly correlated with experiencing hunger, diabetes, transient ischemic attack, past head injury, more disability and less nourishment; having more friends was protective., Conclusions: Geriatric depression is prevalent in rural south India. Poverty and physical ill health are risk factors for depression among elderly while good social support is protective.

Background: Studies have suggested that the prevalence of dementia is lower in developing than in developed regions. We investigated the prevalence and severity of dementia in sites in low-income and middle-income countries according to two definitions of dementia diagnosis., Methods: We undertook one-phase cross-sectional surveys of all residents aged 65 years and older (n=14 960) in 11 sites in seven low-income and middle-income countries (China, India, Cuba, Dominican Republic, Venezuela, Mexico, and Peru). Dementia diagnosis was made according to the culturally and educationally sensitive 10/66 dementia diagnostic algorithm, which had been prevalidated in 25 Latin American, Asian, and African centres; and by computerised application of the dementia criterion from the Diagnostic and Statistical Manual of Mental Disorders (DSM IV). We also compared prevalence of DSM-IV dementia in each of the study sites with that from estimates in European studies., Findings: The prevalence of DSM-IV dementia varied widely, from 0.3% (95% CI 0.1-0.5) in rural India to 6.3% (5.0-7.7) in Cuba. After standardisation for age and sex, DSM-IV prevalence in urban Latin American sites was four-fifths of that in Europe (standardised morbidity ratio 80 [95% CI 70-91]), but in China the prevalence was only half (56 [32-91] in rural China), and in India and rural Latin America a quarter or less of the European prevalence (18 [5-34] in rural India). 10/66 dementia prevalence was higher than that of DSM-IV dementia, and more consistent across sites, varying between 5.6% (95% CI 4.2-7.0) in rural China and 11.7% (10.3-13.1) in the Dominican Republic. The validity of the 847 of 1345 cases of 10/66 dementia not confirmed by DSM-IV was supported by high levels of associated disability (mean WHO Disability Assessment Schedule II score 33.7 [SD 28.6])., Interpretation: As compared with the 10/66 dementia algorithm, the DSM-IV dementia criterion might underestimate dementia prevalence, especially in regions with low awareness of this emerging public-health problem.

While two thirds of the 24 million people with dementia worldwide live in low and middle income countries, very little research has been conducted to support policy making in these regions. Among the non-communicable diseases, dementia (in common with other chronic NCDs linked more to long-term disability than to mortality) has been relatively under-prioritized. International agreements, plans and policy guidelines have called for an end to ageist discrimination and a focus upon reducing disadvantage arising from poverty and the consequences of ill health. Social protection, access to good quality age-appropriate healthcare and addressing the problem of disability are all key issues. However, as yet, little progress has been made in addressing these concerns. In this review we outline the current international policy agenda for older individuals, and its specific relevance to those with dementia and other disabling non-communicable diseases. We consider the potential for epidemiological research to raise awareness, refine the policy agenda, and promote action, using the example of the dissemination strategy developed by the 10/66 Dementia Research Group.

Very high rates of suicide have been reported from India and the developing world. However, much of the debate on suicide prevention focuses on individuals, methods, site-specific solutions, or particular suicide prevention strategies. This article argues for population based approaches that focus on improving the general health of populations (e.g., macroeconomic policies that aim for social justice, schemes to meet basic human needs, organizing local support groups within vulnerable sections of society, developing and implementing an essential pesticide list, addressing gender issues, and increasing public awareness through the mass media) rather than medical, psychiatric, and other strategies that target individuals (e.g., treatment of mental illness, counseling, etc.) in order to reduce high suicide rates in India and developing countries. Individual approaches will help people in distress and prevent individuals from committing suicide, but will not reduce population suicide rates.

Objective: This study attempted to evaluate sensitivity, specificity and predictive values of the diagnosis of dementia made by trained community health workers., Method: A total of 1,000 subjects over the age of 65 years were recruited for the study. The community health workers identified nine subjects as having dementia. This was compared against an education adjusted diagnosis of dementia made in accordance with the 10/66 dementia research group protocol., Results: The sensitivity and specificity of the community health worker diagnosis was 3.8% and 99.4% respectively. The false positive rate and positive predictive values were 55.6% and 44.4%, respectively. The false negative rate and negative predictive value were 10.3% and 89.7% respectively. Similar values were obtained against a DSM IV diagnosis. Subjects with dementia who were correctly diagnosed by the community health workers and those whose condition was missed did not differ significantly on socio-demographic and clinical variables., Conclusion: Informal screening by community health workers resulted in low sensitivity and positive predictive values. Screening strategies in situations of low prevalence are not effective.

Background: Latin America, China and India are experiencing unprecedentedly rapid demographic ageing with an increasing number of people with dementia. The 10/66 Dementia Research Group's title refers to the 66% of people with dementia that live in developing countries and the less than one tenth of population-based research carried out in those settings. This paper describes the protocols for the 10/66 population-based and intervention studies that aim to redress this imbalance., Methods/design: Cross-sectional comprehensive one phase surveys have been conducted of all residents aged 65 and over of geographically defined catchment areas in ten low and middle income countries (India, China, Nigeria, Cuba, Dominican Republic, Brazil, Venezuela, Mexico, Peru and Argentina), with a sample size of between 1000 and 3000 (generally 2000). Each of the studies uses the same core minimum data set with cross-culturally validated assessments (dementia diagnosis and subtypes, mental disorders, physical health, anthropometry, demographics, extensive non communicable disease risk factor questionnaires, disability/functioning, health service utilisation, care arrangements and caregiver strain). Nested within the population based studies is a randomised controlled trial of a caregiver intervention for people with dementia and their families (ISRCTN41039907; ISRCTN41062011; ISRCTN95135433; ISRCTN66355402; ISRCTN93378627; ISRCTN94921815). A follow up of 2.5 to 3.5 years will be conducted in 7 countries (China, Cuba, Dominican Republic, Venezuela, Mexico, Peru and Argentina) to assess risk factors for incident dementia, stroke and all cause and cause-specific mortality; verbal autopsy will be used to identify causes of death., Discussion: The 10/66 DRG baseline population-based studies are nearly complete. The incidence phase will be completed in 2009. All investigators are committed to establish an anonymised file sharing archive with monitored public access. Our aim is to create an evidence base to empower advocacy, raise awareness about dementia, and ensure that the health and social care needs of older people are anticipated and met.

Background: Sustainable cost-effective interventions to improve psychiatric morbidity and quality of life among the elderly have not been systematically evaluated in developing countries., Method: The most vulnerable elderly living in Pennathur, Vellore district, India, in terms of socioeconomic status and social supports, were invited to participate in a day-care program. Baseline assessments were done using the Mini Mental Status Examination, the Revised Clinical Interview Schedule and the World Health Organisation Quality of Life- Bref. Follow-up assessment was done at 3 months on subjects who took part and those who refused., Results and Conclusions: Forty-one (16.4%) were invited to take part. Twenty subjects took part in the program while 21 refused. There was a significant reduction in psychiatric morbidity and improvement in quality of life scores at 3 months for subjects who attended the program. The improvement in quality of life persisted after adjusting for gender, socioeconomic status and baseline scores. Costing of the program suggests sustainability., (Copyright (c) 2006 John Wiley & Sons, Ltd.)

Objectives In a multi-site population-based study in several middle-income countries, we aimed to investigate relative contributions of care arrangements and characteristics of carers and care recipients to strain among carers of people with dementia. Based on previous research, hypotheses focused on carer sex, care inputs, behavioural and psychological symptoms (BPSD) and socioeconomic status, together with potential buffering effects of informal support and employing paid carers. Methods In population-based catchment area surveys in 11 sites in Latin America, India and China, we analysed data collected from people with dementia and care needs, and their carers. Carer strain was assessed with the Zarit Burden Interview. Results With 673 care recipient/carer dyads interviewed (99% of those eligible), mean Zarit Burden Interview scores ranged between 17.1 and 27.9 by site. Women carers reported more strain than men. The most substantial correlates of carer strain were primary stressors BPSD, dementia severity, needs for care and time spent caring. Socioeconomic status was not associated with carer strain. Those cutting back on work experienced higher strain. There was tentative evidence for a protective effect of having additional informal or paid support. Conclusions Our findings underline the global impact of caring for a person with dementia and support the need for scaling up carer support, education and training. That giving up work to care was prevalent and associated with substantial increased strain emphasizes the economic impact of caring on the household. Carer benefits, disability benefits for people with dementia and respite care should all be considered. Copyright © 2012 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]