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BackgroundResearch carried out in high income countries suggests that loneliness may be a common experience among older adults living in these settings. Loneliness is correlated with poor socioeconomic status, living alone, being widowed and is associated with adverse health outcomes, including mortality. There is still a lack of evidence about the epidemiology of loneliness among older adults living in low- and middle-income countries. This study was designed to explore prevalence and correlates of self-reported loneliness and to investigate whether loneliness predicts mortality in Latin America, China and India. MethodsThe study investigated population-based cross-sectional (2003-2007) and longitudinal surveys (follow-up 2007-2010) from the 10/66 Dementia Research Group project carried out among 16685 older adults in urban and rural catchment areas in Cuba, Dominican Republic, Puerto Rico, Venezuela, Peru, Mexico, China and India. Poisson regression and Cox regression analyses were conducted to analyse correlates of loneliness and its association with mortality. ResultsThe standardised prevalence of loneliness varied between 25.3% and 32.4% in Latin America and was 18.3% in India. China showed a low prevalence of loneliness (3.8%). In pooled meta-analyses, there was robust evidence to support an association between loneliness and mortality across Latin America (HR=1.13, 95% CI 1.01-1.26, I2=10.1%) and China (HR=1.58, 95% CI 1.03-2.41), but there were no associations in India. ConclusionsOur findings suggest potential cultural variances may exist in the concept of loneliness in older age. The effect of loneliness upon mortality is consistent across different cultural settings excluding India. Loneliness should therefore be considered as a potential dimension of public health among older populations.

Background There have been few cross-national studies of the prevalence of the frailty phenotype conducted among low or middle income countries. We aimed to study the variation in prevalence and correlates of frailty in rural and urban sites in Latin America, India, and China. Methods Cross-sectional population-based catchment area surveys conducted in 8 urban and 4 rural catchment areas in 8 countries; Cuba, Dominican Republic, Puerto Rico, Venezuela, Peru, Mexico, China, and India. We assessed weight loss, exhaustion, slow walking speed, and low energy consumption, but not hand grip strength. Therefore, frailty phenotype was defined on 2 or more of 4 of the usual 5 criteria. Results We surveyed 17,031 adults aged 65 years and over. Overall frailty prevalence was 15.2% (95% confidence inteval 14.6%–15.7%). Prevalence was low in rural (5.4%) and urban China (9.1%) and varied between 12.6% and 21.5% in other sites. A similar pattern of variation was apparent after direct standardization for age and sex. Cross-site variation in prevalence of frailty indicators varied across the 4 indicators. Controlling for age, sex, and education, frailty was positively associated with older age, female sex, lower socioeconomic status, physical impairments, stroke, depression, dementia, disability and dependence, and high healthcare costs. Discussion There was substantial variation in the prevalence of frailty and its indicators across sites in Latin America, India, and China. Culture and other contextual factors may impact significantly on the assessment of frailty using questionnaire and physical performance-based measures, and achieving cross-cultural measurement invariance remains a challenge. Conclusions A consistent pattern of correlates was identified, suggesting that in all sites, the frailty screen could identify older adults with multiple physical, mental, and cognitive morbidities, disability and needs for care, compounded by socioeconomic disadvantage and catastrophic healthcare spending.

Our aim was to examine relationships between markers of socioeconomic status and chronic disease risks in rural South Asia to understand the etiology of chronic diseases in the region and identify high-risk populations. We examined data from 2271 adults in Chennai, Goa and Matlab sites of the Chronic Disease Risk Factor study in South Asia. We report age–sex adjusted odds ratios for risk factors (tobacco, alcohol, fruit–vegetable use and physical activity) and common chronic conditions (hypertension, diabetes, overweight, depression, impaired lung and vision) by education, occupation and wealth. Respondents with greater wealth and in non-manual professions were more likely to be overweight [OR = 2.48 (95% CI 1.8,3.38)] and have diabetes [OR = 1.88 (95% CI 1.02,3.5)]. Wealth and education were associated with higher fruit and vegetable [OR = 1.89 (95% CI 1.48,2.4)] consumption but lower physical activity [OR = 0.52 (95% CI 0.39,0.69)]. Non-manual workers reported lower tobacco and alcohol use, while wealthier respondents reported better vision and lung function. Ongoing monitoring of inequalities in chronic disease risks is needed for planning and evaluating interventions to address the growing burden of chronic conditions.

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.

OBJECTIVES: To estimate the prevalence, social patterning, treatment and control of hypertension among older people in the 10/66 Dementia Research Group developing country sites. METHODS: Cross-sectional surveys of SBP, hypertension, and hypertension awareness, treatment and control among 17?014 people aged 65 years and over in eight urban and four rural sites in Latin America, India and China. RESULTS: Hypertension prevalence was higher in urban (range 52.6-79.8%) than rural sites (range 42.6-56.9%), and lower in men than women [pooled prevalence ratio 0.89, 95% confidence interval (CI) 0.85-0.93]. Educational attainment was positively associated with hypertension in rural and least-developed sites. Age-standardized morbidity ratios, compared to USA (100), were higher in urban sites in Cuba (105), Dominican Republic (109), and Venezuela (107), similar in Puerto Rico (105), urban Mexico (99) and urban India (101), and lower in urban (75) and rural (61) Peru, rural Mexico (81), urban (91) and rural (84) China and rural India (65). In most Latin American centres, and urban China just over one-third of those with hypertension were controlled (BP?140/90). Control was poor in rural China (2%), urban India (12%) and rural India (9%). The proportion controlled, not compositional factors (age, sex, education and obesity), explained most of the between-site variation in SBP. CONCLUSION: Uncontrolled hypertension is common among older people in developing countries, and may rise further during the demographic and health transitions. It is a major determinant of population SBP level. Strengthening primary care to improve hypertension management is necessary for primary prevention.

Introduction The prevalence of dementia according to DSM-IV criteria tends to be very low in less developed settings. The 10/66 Dementia Research Group's cross-culturally validated diagnosis returns a considerably higher prevalence. Assessing the predictive validity of the 10/66 dementia diagnosis will assist in establishing the best criterion for estimating the population burden of dementia. Methods In a population-based study in Chennai, India, we aimed to follow-up after 3 years 75 people with 10/66 dementia and 193 with cognitive impairment but no dementia (CIND), reassessing diagnostic status, clinical severity, cognitive function, disability, and needs for care. Results We traced 54 people with dementia of whom 25 (46.3%) had died, double the mortality rate among those with CIND. Twenty-two of the 24 people with 10/66 dementia that were reexamined still met 10/66 dementia criteria. There was clear evidence of clinical progression and increased needs for care. Only one "case" had unambiguously improved. Cognitive function had deteriorated and disability increased to a much greater extent than among those with CIND. Conclusion The strong predictive validity of the 10/66 dementia diagnosis is consistent with a lack of sensitivity of the DSM-IV criteria to mild-to-moderate cases, which may underestimate prevalence in less developed regions.

BACKGROUND: In countries with high incomes, frailty indicators predict adverse outcomes in older people, despite a lack of consensus on definition or measurement. We tested the predictive validity of physical and multidimensional frailty phenotypes in settings in Latin America, India, and China.METHODS: Population-based cohort studies were conducted in catchment area sites in Cuba, Dominican Republic, Venezuela, Mexico, Peru, India, and China. Seven frailty indicators, namely gait speed, self-reported exhaustion, weight loss, low energy expenditure, undernutrition, cognitive, and sensory impairment were assessed to estimate frailty phenotypes. Mortality and onset of dependence were ascertained after a median of 3.9 years.RESULTS: Overall, 13,924 older people were assessed at baseline, with 47,438 person-years follow-up for mortality and 30,689 for dependence. Both frailty phenotypes predicted the onset of dependence and mortality, even adjusting for chronic diseases and disability, with little heterogeneity of effect among sites. However, population attributable fractions (PAF) summarising etiologic force were highest for the aggregate effect of the individual indicators, as opposed to either the number of indicators or the dichotomised frailty phenotypes. The aggregate of all seven indicators provided the best overall prediction (weighted mean PAF 41.8 % for dependence and 38.3 % for mortality). While weight loss, underactivity, slow walking speed, and cognitive impairment predicted both outcomes, whereas undernutrition predicted only mortality and sensory impairment only dependence. Exhaustion predicted neither outcome.CONCLUSIONS: Simply assessed frailty indicators identify older people at risk of dependence and mortality, beyond information provided by chronic disease diagnoses and disability. Frailty is likely to be multidimensional. A better understanding of the construct and pathways to adverse outcomes could inform multidimensional assessment and intervention to prevent or manage dependence in frail older people, with potential to add life to years, and years to life.

In cross-sectional studies, skull circumference and leg length are often inversely associated with dementia prevalence (Prince et al., in press). Skull circumference and leg length are thought to remain stable across the adult life course, but the associations might yet be explained by reverse causality. Weight loss in dementia could lead to loss of subcutaneous scalp fat. Osteoporosis mainly affects trunk proportions (loss of disc space, vertebral fractures and kyphosis), but limited knee extension could also lead to apparent reductions in leg length. No previous studies have assessed changes in these measurements over time in older people with and without dementia. Only two cohort studies have examined the effect of skull circumference (Borenstein et al., 2001) and knee height (Huang et al., 2008) on incident dementia. Even in cohort studies differential mortality can lead to bias.

Background: Premarital sex is often associated with high risk sexual behavior such as early age of initiation, multiple partners and inconsistent condom use. Evidence shows that such sexual behavior pre-disposes to sexually transmitted diseases including HIV. Objectives: This paper tried to investigate the correlates of premarital sexual behavior among male and female business process outsourcing (BPO) employees to highlight the gender differences that exist in relation to it. Materials and Methods: Data were collected from 526 unmarried BPO employees during behavioral surveillance survey in Chennai, in the year 2009. Results: The results showed that about one-third of respondents (males - 39.6%, females - 26.1%) had experienced premarital sex. Men reported having had their first sexual intercourse at 12 years and women at 16 years of age. While the prevalence of premarital sex was found to be high, the percentage using a condom during last sex was also high, especially, among the female employees (82.4%). Logistic regression showed that monthly individual income, work in shifts, migration, peer influence and friends with previous sexual experience were significant predictors of premarital sex among the male BPO employees. Visit to night clubs was significantly associated with a higher prevalence of premarital sex among the female employees. Conclusions: The study concludes that there is a significant gender dimension in the premarital sexual behavior among the BPO employees and that even as the sexual behavior of the young people is transitioning; their ability to negotiate safe sex behavior is also increasing. It is recommended to enhance efforts to advocate safe sex behavior among young adults employed in the BPO industry.

Background: This is the first study to investigate the associations between chronic health conditions of older people and their impact on co-resident psychological morbidity using population-based samples in low and middle income countries (LAMICs).Methods: Single-phase cross-sectional catchment area surveys were undertaken in urban sites in Cuba, Dominican Republic and Venezuela, and in rural and urban catchment areas in Mexico, Peru, India and China. All residents aged 65 years and over were interviewed with a co-resident key informant. Exposures were structured clinical diagnoses (10/66 and DSM-IV dementia and ICD-10 depression), self-reported diagnosis (stroke) and physical impairments. Mediating variables were dependence and disability (WHODAS 2.0), and the outcome was co-resident psychological morbidity assessed using SRQ-20.Results: Poisson regression analysis was used to estimate the prevalence ratios (PRs) for the associations between health conditions and psychological morbidity in each site, and meta-analysis was used to pool the estimates. 11,988 pairs comprising a participant and a co-resident informant were included in the analysis. After meta-analysis, independent effects were noted for depression (PR2.11; 95% CI 1.82–2.45), dementia (PR 1.98; 95% CI 1.72–2.28), stroke (PR 1.42; 95% CI 1.17–1.71) and physical impairments (PR 1.17; 95% CI 1.13–1.21). The effects were partly mediated through disability and dependence. The mean population attributable fraction of total chronic conditions was 30.1%.Conclusion: The prevalence of co-resident psychological morbidity is higher among co-residents of older people with chronic conditions. This effect was prominent for, but not confined to, depression and dementia. Attention needs to be directed to chronic conditions.

Background: Adult leg length is influenced by nutrition in the first few years of life. Adult head circumference is an indicator of brain growth. There is a limited literature linking short legs and small skulls to an increased risk for cognitive impairment and dementia in late life.Methods: One phase cross-sectional surveys were carried out of all residents aged over 65 years in 11 catchment areas in China, India, Cuba, Dominican Republic, Venezuela, Mexico and Peru (n = 14,960). The cross-culturally validated 10/66 dementia diagnosis, and a sociodemographic and risk factor questionnaire were administered to all participants, and anthropometric measures taken. Poisson regression was used to calculate prevalence ratios for the effect of leg length and skull circumference upon 10/66 dementia, controlling for age, gender, education and family history of dementia.Results: The pooled meta-analyzed fixed effect for leg length (highest vs. lowest quarter) was 0.82 (95% CI, 0.68–0.98) and for skull circumference 0.75 (95% CI, 0.63–0.89). While point estimates varied between sites, the proportion of the variability attributable to heterogeneity between studies as opposed to sampling error (I2) was 0% for leg length and 22% for skull circumference. The effects were independent and not mediated by family history of dementia. The effect of skull circumference was not modified by educational level or gender, and the effect of leg length was not modified by gender.Conclusions: Since leg length and skull circumference are said to remain stable throughout adulthood into old age, reverse causality is an unlikely explanation for the findings. Early life nutritional programming, as well as neurodevelopment may protect against neurodegeneration.

Objectives To assess the association between tobacco consumption and dementia using the same methodology in seven developing countries, testing the specific hypotheses that higher exposure to tobacco is associated with a higher prevalence of dementia, that the association is limited to smoked tobacco and is stronger for vascular dementia compared to Alzheimer's disease. Methods Cross-sectional surveys conducted on individuals aged 65+. A total of 15 022 residents in specified catchment areas were assessed face-to-face using a standardised protocol, which included dementia diagnosis and detailed information on past and current tobacco consumption, and on important potential confounders of this association. Results A high proportion of participants were never smokers (52% in Dominican Republic to 83% in Peru), most of those who ever used tobacco in China and India were still smoking at age 65 and above (80% and 84%, respectively). There was a positive association between history of tobacco smoke exposure (pack years up to age 50) and dementia (pooled PR = 1.003; 95%CI 1.001–1.005), Alzheimer's disease (pooled PR = 1.007; 95% CI, 1.003–1.011) and Vascular Dementia (pooled PR = 1.003; 95% CI = 1.001–1.005). These associations were attenuated but remained significant if exposure after the age of 50 was included. In India there was no association between smokeless tobacco and dementia. Conclusions Dementia in developing countries appears to be positively associated with history of tobacco smoking but not smokeless tobacco use. Selective quitting in later life may bias estimation of associations. Copyright © 2011 John Wiley & Sons, Ltd.

Background The number of older people is set to increase dramatically worldwide. Demographic changes are likely to result in the rise of age-related chronic diseases which largely contribute to years lived with a disability and future dependence. However dependence is much less studied although intrinsically linked to disability. We investigated the prevalence and correlates of dependence among older people from middle income countries. Methods A one-phase cross-sectional survey was carried out at 11 sites in seven countries (urban sites in Cuba, Venezuela, and Dominican Republic, urban and rural sites in Peru, Mexico, China and India). All those aged 65 years and over living in geographically defined catchment areas were eligible. In all, 15,022 interviews were completed with an informant interview for each participant. The full 10/66 Dementia Research Group survey protocol was applied, including ascertainment of depression, dementia, physical impairments and self-reported diagnoses. Dependence was interviewer-rated based on a key informant's responses to a set of open-ended questions on the participant's needs for care. We estimated the prevalence of dependence and the independent contribution of underlying health conditions. Site-specific prevalence ratios were meta-analysed, and population attributable prevalence fractions (PAPF) calculated. Results The prevalence of dependence increased with age at all sites, with a tendency for the prevalence to be lower in men than in women. Age-standardised prevalence was lower in all sites than in the USA. Other than in rural China, dementia made the largest independent contribution to dependence, with a median PAPF of 34% (range 23%-59%). Other substantial contributors were limb impairment (9%, 1%-46%), stroke (8%, 2%-17%), and depression (8%, 1%-27%). Conclusion The demographic and health transitions will lead to large and rapid increases in the numbers of dependent older people particularly in middle income countries (MIC). The prevention and control of chronic neurological and neuropsychiatric diseases and the development of long-term care policies and plans should be urgent priorities.

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: Evidence of an association between fish and meat consumption and risk of dementia is inconsistent and nonexistent in populations in developing countries. Objective: The objective was to investigate associations between fish and meat consumption with dementia in low- and middleincome countries. Design: One-phase cross-sectional surveys were conducted in all residents aged 65 y in 11 catchment areas in China, India, Cuba, the Dominican Republic, Venezuela, Mexico, and Peru. A total of 14,960 residents were assessed by using the 10/66 standardized protocol, which includes face-to-face interviews for dietary habits and a cross-culturally validated dementia diagnosis. Results: Dietary intakes and the prevalence of dementia varied between sites. We combined site-specific Poisson regression prevalence ratios (PRs) for the association between fish and meat consumption and dementia in 2 fixed-effect model meta-analyses adjusted for sociodemographic and health characteristics and fish and meat consumption as appropriate. We found a dose-dependent inverse association between fish consumption and dementia (PR: 0.81; 95% CI: 0.72, 0.91) that was consistent across all sites except India and a less-consistent, dose-dependent, direct association between meat consumption and prevalence of dementia (PR: 1.19; 95% CI: 1.07, 1.31). Conclusions: Our results extend findings on the associations of fish and meat consumption with dementia risk to populations in lowand middle-income countries and are consistent with mechanistic data on the neuroprotective actions of omega-3 (n‐3) long-chain polyunsaturated fatty acids commonly found in fish. The inverse association between fish and prevalent dementia is unlikely to result from poorer dietary habits among demented individuals (reverse causality) because meat consumption was higher in those with a diagnosis of dementia. Am J Clin Nutr 2009;90:392‐400.

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.

Cleusa Ferri and colleagues studied mortality rates in over 12,000 people aged 65 years and over in Latin America, India, and China and showed that chronic diseases are the main causes of death and that education has an important effect on mortality., Background Even in low and middle income countries most deaths occur in older adults. In Europe, the effects of better education and home ownership upon mortality seem to persist into old age, but these effects may not generalise to LMICs. Reliable data on causes and determinants of mortality are lacking. Methods and Findings The vital status of 12,373 people aged 65 y and over was determined 3–5 y after baseline survey in sites in Latin America, India, and China. We report crude and standardised mortality rates, standardized mortality ratios comparing mortality experience with that in the United States, and estimated associations with socioeconomic factors using Cox's proportional hazards regression. Cause-specific mortality fractions were estimated using the InterVA algorithm. Crude mortality rates varied from 27.3 to 70.0 per 1,000 person-years, a 3-fold variation persisting after standardisation for demographic and economic factors. Compared with the US, mortality was much higher in urban India and rural China, much lower in Peru, Venezuela, and urban Mexico, and similar in other sites. Mortality rates were higher among men, and increased with age. Adjusting for these effects, it was found that education, occupational attainment, assets, and pension receipt were all inversely associated with mortality, and food insecurity positively associated. Mutually adjusted, only education remained protective (pooled hazard ratio 0.93, 95% CI 0.89–0.98). Most deaths occurred at home, but, except in India, most individuals received medical attention during their final illness. Chronic diseases were the main causes of death, together with tuberculosis and liver disease, with stroke the leading cause in nearly all sites. Conclusions Education seems to have an important latent effect on mortality into late life. However, compositional differences in socioeconomic position do not explain differences in mortality between sites. Social protection for older people, and the effectiveness of health systems in preventing and treating chronic disease, may be as important as economic and human development. Please see later in the article for the Editors' Summary, Editors' Summary Background Worldwide, half of all deaths occur in people aged 60 or older. Yet mortality among older people is a neglected topic in global health. In high income countries, where 84% of people do not die until they are aged 65 years or older, the causes of death among older people and the factors (determinants) that affect their risk of dying are well documented. In Europe, for example, the leading causes of death among older people are heart disease, stroke, and other chronic (long-term) diseases. Moreover, as in younger age groups, having a better education and owning a house reduces the risk of death among older people. By contrast, in low and middle income countries (LMICs), where three-quarters of deaths of older people occur, reliable data on the causes and determinants of death among older people are lacking, in part because many LMICs have inadequate vital registration systems—official records of all births and deaths. Why Was This Study Done? In many LMICs, chronic diseases are replacing communicable (infectious) diseases as the leading causes of death and disability—health experts call this the epidemiological transition (epidemiology is the study of the distribution and causes of disease in populations)—and the average age of the population is increasing (the demographic transition). Faced with these changes, which occur when countries move from a pre-industrial to an industrial economy, policy makers in LMICs need to introduce measures to improve health and reduce deaths among older people. However, to do this, they need reliable data on the causes and determinants of death in this section of the population. In this longitudinal population-based cohort study (a type of study that follows a group of people from a defined population over time), researchers from the 10/66 Dementia Research Group, which is carrying out population-based research on dementia, aging, and non-communicable diseases in LMICs, investigate the patterns of mortality among older people living in Latin America, India, and China. What Did the Researchers Do and Find? Between 2003 and 2005, the researchers completed a baseline survey of people aged 65 years or older living in six Latin American LMICs, China, and India. Three to five years later, they determined the vital status of 12,373 of the study participants (that is, they determined whether the individual was alive or dead) and interviewed a key informant (usually a relative) about each death using a standardized “verbal autopsy” questionnaire that includes questions about date and place of death, and about medical help-seeking and signs and symptoms noted during the final illness. Finally, they used a tool called the InterVA algorithm to calculate the most likely causes of death from the verbal autopsies. Crude mortality rates varied from 27.3 per 1,000 person-years in urban Peru to 70.0 per 1,000 person-years in urban India, a three-fold difference in mortality rates that persisted even after allowing for differences in age, sex, education, occupational attainment, and number of assets among the study sites. Compared to the US, mortality rates were much higher in urban India and rural China; much lower in urban and rural Peru, Venezuela, and urban Mexico; but similar elsewhere. Although several socioeconomic factors were associated with mortality, only a higher education status provided consistent independent protection against death in statistical analyses. Finally, chronic diseases were the main causes of death; stroke was the leading cause of death at all the sites except those in rural Peru and Mexico. What Do These Findings Mean? These findings identify the main causes of death among older adults in a range of LMICs and suggest that there is an association of education with mortality that extends into later life. However, these findings may not be generalizable to other LMICs or even to other sites in the LMICs studied, and because some of the information provided by key informants may have been affected by recall error, the accuracy of the findings may be limited. Nevertheless, these findings suggest how health and mortality might be improved in elderly people in LMICs. Specifically, they suggest that efforts to ensure universal access to education should confer substantial health benefits and that interventions that target social and economic vulnerability in later life and promote access to effectively organized health care (particularly for stroke) should be considered. Additional Information Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001179. The World Health Organization provides information on mortality around the world and projections of global mortality up to 2030 The 10/66 Dementia Research Group is building an evidence base to inform the development and implementation of policies for improving the health and social welfare of older people in LMICs, particularly people with dementia; its website includes background information about demographic and epidemiological aging in LMICs Wikipedia has a page on the demographic transition (note: Wikipedia is a free online encyclopedia that anyone can edit; available in several languages) Information about the InterVA tool for interpreting verbal autopsy data is available The US Centers for Disease Control and Prevention has information about healthy aging

A set of cross-sectional surveys carried out in Cuba, Dominican Republic, Peru, Mexico, Venezuela, Puerto Rico, China, and India reveal the prevalence and between-country variation in mild cognitive impairment at a population level., Background Rapid demographic ageing is a growing public health issue in many low- and middle-income countries (LAMICs). Mild cognitive impairment (MCI) is a construct frequently used to define groups of people who may be at risk of developing dementia, crucial for targeting preventative interventions. However, little is known about the prevalence or impact of MCI in LAMIC settings. Methods and Findings Data were analysed from cross-sectional surveys established by the 10/66 Dementia Research Group and carried out in Cuba, Dominican Republic, Peru, Mexico, Venezuela, Puerto Rico, China, and India on 15,376 individuals aged 65+ without dementia. Standardised assessments of mental and physical health, and cognitive function were carried out including informant interviews. An algorithm was developed to define Mayo Clinic amnestic MCI (aMCI). Disability (12-item World Health Organization disability assessment schedule [WHODAS]) and informant-reported neuropsychiatric symptoms (neuropsychiatric inventory [NPI-Q]) were measured. After adjustment, aMCI was associated with disability, anxiety, apathy, and irritability (but not depression); between-country heterogeneity in these associations was only significant for disability. The crude prevalence of aMCI ranged from 0.8% in China to 4.3% in India. Country differences changed little (range 0.6%–4.6%) after standardization for age, gender, and education level. In pooled estimates, aMCI was modestly associated with male gender and fewer assets but was not associated with age or education. There was no significant between-country variation in these demographic associations. Conclusions An algorithm-derived diagnosis of aMCI showed few sociodemographic associations but was consistently associated with higher disability and neuropsychiatric symptoms in addition to showing substantial variation in prevalence across LAMIC populations. Longitudinal data are needed to confirm findings—in particular, to investigate the predictive validity of aMCI in these settings and risk/protective factors for progression to dementia; however, the large number affected has important implications in these rapidly ageing settings. Please see later in the article for the Editors' Summary, Editors' Summary Background Currently, more than 35 million people worldwide have dementia, a group of brain disorders characterized by an irreversible decline in memory, problem solving, communication, and other “cognitive” functions. Dementia, the commonest form of which is Alzheimer's disease, mainly affects older people and, because more people than ever are living to a ripe old age, experts estimate that, by 2050, more than 115 million people will have dementia. At present, there is no cure for dementia although drugs can be used to manage some of the symptoms. Risk factors for dementia include physical inactivity, infrequent participation in mentally or socially stimulating activities, and common vascular risk factors such as high blood pressure, diabetes, and smoking. In addition, some studies have reported that mild cognitive impairment (MCI) is associated with an increased risk of dementia. MCI can be seen as an intermediate state between normal cognitive aging (becoming increasingly forgetful) and dementia although many people with MCI never develop dementia, and some types of MCI can be static or self-limiting. Individuals with MCI have cognitive problems that are more severe than those normally seen in people of a similar age but they have no other symptoms of dementia and are able to look after themselves. The best studied form of MCI—amnestic MCI (aMCI)—is characterized by memory problems such as misplacing things and forgetting appointments. Why Was This Study Done? Much of the expected increase in dementia will occur in low and middle income countries (LAMICs) because these countries have rapidly aging populations. Given that aMCI is frequently used to define groups of people who may be at risk of developing dementia, it would be useful to know what proportion of community-dwelling older adults in LAMICs have aMCI (the prevalence of aMCI). Such information might help governments plan their future health care and social support needs. In this cross-sectional, population-based study, the researchers estimate the prevalence of aMCI in eight LAMICs using data collected by the 10/66 Dementia Research Group. They also investigate the association of aMCI with sociodemographic factors (for example, age, gender, and education), disability, and neuropsychiatric symptoms such as anxiety, apathy, irritability, and depression. A cross-sectional study collects data on a population at a single time point; the 10/66 Dementia Research Group is building an evidence base to inform the development and implementation of policies for improving the health and social welfare of older people in LAMICs, particularly people with dementia. What Did the Researchers Do and Find? In cross-sectional surveys carried out in six Latin American LAMICS, China, and India, more than 15,000 elderly individuals without dementia completed standardized assessments of their mental and physical health and their cognitive function. Interviews with relatives and carers provided further details about the participant's cognitive decline and about neuropsychiatric symptoms. The researchers developed an algorithm (set of formulae) that used the data collected in these surveys to diagnose aMCI in the study participants. Finally, they used statistical methods to analyze the prevalence, distribution, and impact of aMCI in the eight LAMICs. The researchers report that aMCI was associated with disability, anxiety, apathy, and irritability but not with depression and that the prevalence of aMCI ranged from 0.8% in China to 4.3% in India. Other analyses show that, considered across all eight countries, aMCI was modestly associated with being male (men had a slightly higher prevalence of aMCI than women) and with having fewer assets but was not associated with age or education. What Do These Findings Mean? These findings suggest that aMCI, as diagnosed using the algorithm developed by the researchers, is consistently associated with higher disability and with neuropsychiatric symptoms in the LAMICs studied but not with most sociodemographic factors. Because prevalidated and standardized measurements were applied consistently in all the countries and a common algorithm was used to define aMCI, these findings also suggest that the prevalence of aMCI varies markedly among LAMIC populations and is similar to or slightly lower than the prevalence most often reported for European and North American populations. Although longitudinal studies are now needed to investigate the extent to which aMCI can be used as risk marker for further cognitive decline and dementia in these settings, the large absolute numbers of older people with aMCI in LAMICs revealed here potentially has important implications for health care and social service planning in these rapidly aging and populous regions of the world. Additional Information Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001170. Alzheimer's Disease International is the international federation of Alzheimer associations around the world; it provides links to individual associations, information about dementia, and links to three World Alzheimer Reports; information about the 10/66 Dementia Research Group is also available on this web site The Alzheimer's Society provides information for patients and carers about dementia, including information on MCI and personal stories about living with dementia The Alzheimer's Association also provides information for patients and carers about dementia and about MCI, and personal stories about dementia A BBC radio program that includes an interview with a man with MCI is available MedlinePlus provides links to further resources about MCI and dementia (in English and Spanish)

Summary Background Disability in elderly people in countries with low and middle incomes is little studied; according to Global Burden of Disease estimates, visual impairment is the leading contributor to years lived with disability in this population. We aimed to assess the contribution of physical, mental, and cognitive chronic diseases to disability, and the extent to which sociodemographic and health characteristics account for geographical variation in disability. Methods We undertook cross-sectional surveys of residents aged older than 65 years (n=15 022) in 11 sites in seven countries with low and middle incomes (China, India, Cuba, Dominican Republic, Venezuela, Mexico, and Peru). Disability was assessed with the 12-item WHO disability assessment schedule 2.0. Dementia, depression, hypertension, and chronic obstructive pulmonary disease were ascertained by clinical assessment; diabetes, stroke, and heart disease by self-reported diagnosis; and sensory, gastrointestinal, skin, limb, and arthritic disorders by self-reported impairment. Independent contributions to disability scores were assessed by zero-inflated negative binomial regression and Poisson regression to generate population-attributable prevalence fractions (PAPF). Findings In regions other than rural India and Venezuela, dementia made the largest contribution to disability (median PAPF 25·1% [IQR 19·2–43·6]). Other substantial contributors were stroke (11·4% [1·8–21·4]), limb impairment (10·5% [5·7–33·8]), arthritis (9·9% [3·2–34·8]), depression (8·3% [0·5–23·0]), eyesight problems (6·8% [1·7–17·6]), and gastrointestinal impairments (6·5% [0·3–23·1]). Associations with chronic diseases accounted for around two-thirds of prevalent disability. When zero inflation was taken into account, between-site differences in disability scores were largely attributable to compositional differences in health and sociodemographic characteristics. Interpretation On the basis of empirical research, dementia, not blindness, is overwhelmingly the most important independent contributor to disability for elderly people in countries with low and middle incomes. Chronic diseases of the brain and mind deserve increased prioritisation. Besides disability, they lead to dependency and present stressful, complex, long-term challenges to carers. Societal costs are enormous. Funding Wellcome Trust; WHO; US Alzheimer's Association; Fondo Nacional de Ciencia Y Tecnologia, Consejo de Desarrollo Cientifico Y Humanistico, Universidad Central de Venezuela.

Summary Background Results of the few cohort studies from countries with low incomes or middle incomes suggest a lower incidence of dementia than in high-income countries. We assessed incidence of dementia according to criteria from the 10/66 Dementia Research Group and Diagnostic and Statistical Manual of Mental Disorders (DSM) IV, the effect of dementia at baseline on mortality, and the independent effects of age, sex, socioeconomic position, and indicators of cognitive reserve. Methods We did a population-based cohort study of all people aged 65 years and older living in urban sites in Cuba, the Dominican Republic, and Venezuela, and rural and urban sites in Peru, Mexico, and China, with ascertainment of incident 10/66 and DSM-IV dementia 3–5 years after cohort inception. We used questionnaires to obtain information about age in years, sex, educational level, literacy, occupational attainment, and number of household assets. We obtained information about mortality from all sites. For participants who had died, we interviewed a friend or relative to ascertain the likelihood that they had dementia before death. Findings 12 887 participants were interviewed at baseline. 11 718 were free of dementia, of whom 8137 (69%) were reinterviewed, contributing 34 718 person-years of follow-up. Incidence for 10/66 dementia varied between 18·2 and 30·4 per 1000 person-years, and were 1·4–2·7 times higher than were those for DSM-IV dementia (9·9–15·7 per 1000 person-years). Mortality hazards were 1·56–5·69 times higher in individuals with dementia at baseline than in those who were dementia-free. Informant reports suggested a high incidence of dementia before death; overall incidence might be 4–19% higher if these data were included. 10/66 dementia incidence was independently associated with increased age (HR 1·67; 95% CI 1·56–1·79), female sex (0·72; 0·61–0·84), and low education (0·89; 0·81–0·97), but not with occupational attainment (1·04; 0·95–1·13). Interpretation Our results provide supportive evidence for the cognitive reserve hypothesis, showing that in middle-income countries as in high-income countries, education, literacy, verbal fluency, and motor sequencing confer substantial protection against the onset of dementia. Funding Wellcome Trust Health Consequences of Population Change Programme, WHO, US Alzheimer's Association, FONACIT/ CDCH/ UCV

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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.

BACKGROUND: Harmful effects of alcohol abuse are well documented for drinkers, and adverse effects are also reported for the physical and emotional well-being of family members, with evidence often originating from either drinkers or their families in clinic-based settings. This study evaluates intra-household associations between alcohol abuse in men, and depression and suicidal attempts in women, in community-based settings of Chennai, India. METHODS: This community-based cross-sectional study of chronic disease risk factors and outcomes was conducted in n = 259 households and n = 1053 adults (aged 15 years and above) in rural and urban Chennai. The Alcohol Use Disorder Identification Test (AUDIT) score was used to classify alcohol consumption into 'low-risk', 'harmful', 'hazardous' and 'alcohol dependence' drinking and the Patient Health Questionnaire (PHQ-9) score to classify depression as 'mild', 'moderate', 'moderate-severe' and 'severe'. Multivariate logistic regression models estimated the association of depression in women with men's drinking patterns in the same household. RESULTS: A significant 2.5-fold increase in any depression (PHQ-9 ≥ 5) was observed in men who were 'alcohol-dependent' compared to non-drinkers (OR = 2.53; 95% CI: 1.26, 5.09). However, there was no association between men's drinking behavior and depression in women of the same household, although suicidal attempts approached a significant dose-response relationship with increasing hazard-level of men's drinking (p = 0.08). CONCLUSION: No significant intra-household association was observed between men's alcohol consumption and women's depression, though an increasing (non-significant) trend was associated with suicidal attempts. Complex relationships between suicidal attempts and depression in women and male abusive drinking require further exploration, with an emphasis on intra-household mechanisms and pathways.

Background 1) To report site-specific normative values by age, sex and educational level for four components of the 10/66 Dementia Research Group cognitive test battery; 2) to estimate the main and interactive effects of age, sex, and educational level by site; and 3) to investigate the effect of site by region and by rural or urban location. Methods Population-based cross-sectional one phase catchment area surveys were conducted in Cuba, Dominican Republic, Venezuela, Peru, Mexico, China and India. The protocol included the administration of the Community Screening Instrument for Dementia (CSI 'D', generating the COGSCORE measure of global function), and the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) verbal fluency (VF), word list memory (WLM, immediate recall) and recall (WLR, delayed recall) tests. Only those free of dementia were included in the analysis. Results Older people, and those with less education performed worse on all four tests. The effect of sex was much smaller and less consistent. There was a considerable effect of site after accounting for compositional differences in age, education and sex. Much of this was accounted for by the effect of region with Chinese participants performing better, and Indian participants worse, than those from Latin America. The effect of region was more prominent for VF and WLM than for COGSCORE and WLR. Conclusion Cognitive assessment is a basic element for dementia diagnosis. Age- and education-specific norms are required for this purpose, while the effect of gender can probably be ignored. The basis of cultural effects is poorly understood, but our findings serve to emphasise that normative data may not be safely generalised from one population to another with quite different characteristics. The minimal effects of region on COGSCORE and WLR are reassuring with respect to the cross-cultural validity of the 10/66 dementia diagnosis, which uses only these elements of the 10/66 battery.