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HIV-associated neurocognitive disorders (HAND) are highly prevalent in those ageing with HIV. High-income country data suggest that vascular risk factors (VRFs) may be stronger predictors of HAND than HIV-disease severity, but data from sub-Saharan Africa are lacking. We evaluated relationships of VRFs, vascular end-organ damage and HAND in individuals aged ≥ 50 in Tanzania. c-ART-treated individuals were assessed for HAND using consensus criteria. The prevalence of VRFs and end organ damage markers were measured. The independent associations of VRFs, end organ damage and HAND were examined using multivariable logistic regression. Data were available for 153 individuals (median age 56, 67.3% female). HAND was highly prevalent (66.7%, 25.5% symptomatic) despite well-managed HIV (70.5% virally suppressed). Vascular risk factors included hypertension (34%), obesity (10.5%), hypercholesterolemia (33.3%), diabetes (5.3%) and current smoking (4.6%). End organ damage prevalence ranged from 1.3% (prior myocardial infarction) to 12.5% (left ventricular hypertrophy). Measured VRFs and end organ damage were not independently associated with HAND. The only significant association was lower diastolic BP (p 0.030, OR 0.969 (0.943–0.997). Our results suggest that vascular risk factors are not major drivers of HAND in this setting. Further studies should explore alternative aetiologies such as chronic inflammation. [ABSTRACT FROM AUTHOR]

Studies of depression and its outcomes in older people living with HIV (PLWH) are currently lacking in sub-Saharan Africa. This study aims to investigate the prevalence of psychiatric disorders in PLWH aged ≥ 50 years in Tanzania focussing on prevalence and 2-year outcomes of depression. PLWH aged ≥ 50 were systematically recruited from an outpatient clinic and assessed using the Mini-International Neuropsychiatric Interview (MINI). Neurological and functional impairment was assessed at year 2 follow-up. At baseline, 253 PLWH were recruited (72.3% female, median age 57, 95.5% on cART). DSM-IV depression was highly prevalent (20.9%), whereas other DSM-IV psychiatric disorders were uncommon. At follow-up (n = 162), incident cases of DSM-IV depression decreased from14.2 to 11.1% (χ2: 2.48, p = 0.29); this decline was not significant. Baseline depression was associated with increased functional and neurological impairment. At follow-up, depression was associated with negative life events (p = 0.001), neurological impairment (p < 0.001), and increased functional impairment (p = 0.018), but not with HIV and sociodemographic factors. In this setting, depression appears highly prevalent and associated with poorer neurological and functional outcomes and negative life events. Depression may be a future intervention target. [ABSTRACT FROM AUTHOR]

To develop a brief, culturally appropriate screening tool for identifying late life depression (LLD), for use by non-specialist clinicians in primary and out-patient care settings in sub-Saharan Africa (SSA). Depressive disorders are a leading contributor to the global health burden. LLD is common and cases will increase as populations' age, particularly in low- and middle-income countries (LMICs), such as those in SSA. A chronic mental health workforce shortage and the absence of culturally adapted LLD screening tools to aid non-specialist clinicians have contributed to a significant diagnostic gap. A systematic random sample of older people attending general medical clinics were interviewed using a 30-item LLD questionnaire, developed utilizing a Delphi consensus analysis of items from the Geriatric Depression Scale, Patient Health Questionnaire-2 and questions developed from a study of lay conceptualisations of depression in Tanzania. The items were assessed for validity against blinded DSM 5 diagnosis of depression by a research doctor. Factor and item analysis were then used to refine the questionnaire. The 12-item Maddison Old-age Scale for Identifying Depression (MOSHI-D) was developed. It has good internal consistency (Cronbach's α = 0.820) and construct and criterion validity (AUROC = 0.880). On initial evaluation, the MOSHI-D showed good internal validity. It should be easy for non-specialists to administer. External validation and further refinement will be conducted. A culturally-appropriate LLD screen may improve mental health care integration into existing healthcare settings within SSA and facilitate greater patient access to care, in accordance with current WHO strategy. [ABSTRACT FROM AUTHOR]

Background: The majority of people with dementia live in low-and middle-income countries (LMICs). In sub-Saharan Africa (SSA) human-resource shortages in mental health and geriatric medicine are well recognized. Use of technological solutions may improve access to diagnosis. We aimed to assess the diagnostic accuracy of a brief dementia screening mobile application (app) for non-specialist workers in rural Tanzania against blinded gold-standard diagnosis of DSM-5 dementia. The app includes 2 previously-validated culturally appropriate low-literacy screening tools for cognitive (IDEA cognitive screen) and functional impairment (abbreviated IDEA-IADL questionnaire). Methods: This was a 2-stage community-based door-to-door study. In Stage1, rural primary health workers approached all individuals aged ≥60 years for app-based dementia screening in 12 villages in Hai district, Kilimanjaro Tanzania. In Stage 2, a stratified sub-sample were clinically-assessed for dementia blind to app screening score. Assessment included clinical history, neurological and bedside cognitive assessment and collateral history. Results: 3011 (of 3122 eligible) older people consented to screening. Of these, 610 were evaluated in Stage 2. For the IDEA cognitive screen, the area under the receiver operating characteristic (AUROC) curve was 0.79 (95% CI 0.74-0.83) for DSM-5 dementia diagnosis (sensitivity 84.8%, specificity 58.4%). For those 358 (44%) completing the full app, AUROC was 0.78 for combined cognitive and informant-reported functional assessment. Conclusions: The pilot dementia screening app had good sensitivity but lacked specificity for dementia when administered by non-specialist rural community workers. This technological approach may be a promising way forward in low-resource settings, specialist onward referral may be prioritized. [ABSTRACT FROM AUTHOR]

Objectives: Depression is the commonest mental disorder in older adults worldwide, affecting 7% of the world's older population and accounting for 5.7% of years lived with disability among adults aged over 60 years. We conducted a secondary data analysis to determine the point prevalence, associated risk factors and treatment gap for DSM‐IV depression among older adults in the Hai District, rural Tanzania. Methods: The primary data source was a cross‐sectional two‐stage community‐based dementia study where older adults aged ≥70 years (n = 296) were fully‐assessed for dementia and depression in the second stage. Age‐adjusted prevalence of depression was determined based on the WHO standard population using the Direct Method. Univariate and multivariate logistic regression models were performed. Results: Of the 296 older adults assessed for depression, 48 were diagnosed with depression based on Diagnostic and Statistical Manual of Mental Disorders‐IV criteria. The median (Inter Quartile Range; QR) age was 80 (75–88) years. Age‐adjusted point prevalence of depression was 21.2% (95% CI: 16.6–21.9) and the treatment gap for depression was 100%. There was reduced odds of depression in older adults who rated their physical health as good or very good (adjusted odds ratio [AOR] = 0.22; 95%CI: 0.10–0.46; p < 0.001), or moderate (AOR 0.26; 95%CI: 0.10–0.66; p = 0.005). Conclusions: Depression in older adults is associated with physical health status and there is an alarmingly high treatment gap. Future research on depression in older adults should focus on effective interventions to address physical morbidity, psychosocial factors and the treatment gap. Key Points: Despite depression being the commonest mental disorder in older adults reported worldwide, in Sub‐Saharan Africa, the epidemiological data on depression in this population group are limited.We found point prevalence estimates of depression in older adults similar to those reported in community‐based studies in high income countries.Self‐rated overall physical health status was associated with depression in older adults.Future research on depression in older adults should focus on the physical morbidity, psychosocial factors and the treatment gap. [ABSTRACT FROM AUTHOR]

Introduction: Although limited, existing epidemiological data on dementia in sub‐Saharan Africa indicate that prevalence may be increasing; contrasting with recent decreases observed in high‐income countries. We have previously reported the age‐adjusted prevalence of dementia in rural Tanzania in 2009–2010 as 6.4% (95% confidence interval [CI] 4.9–7.9) in individuals aged ≥70 years. We aimed to repeat a community‐based dementia prevalence study in the same setting to assess whether prevalence has changed. Methods: This was a two‐phase door‐to‐door community‐based cross‐sectional survey in Kilimanjaro, Tanzania. In Phase I, trained primary health workers screened all consenting individuals aged ≥60 years from 12 villages using previously validated, locally developed, tools (IDEA cognitive screen and IDEA‐Instrumental Activities of Daily Living questionnaire). Screening was conducted using a mobile digital application (app) on a hand‐held tablet. In Phase II, a stratified sample of those identified in Phase I were clinically assessed using the DSM‐5 criteria and diagnoses subsequently confirmed by consensus panel. Results: Of 3011 people who consented, 424 screened positive for probable dementia and 227 for possible dementia. During clinical assessment in Phase II, 105 individuals met DSM‐5 dementia criteria. The age‐adjusted prevalence of dementia was 4.6% (95% CI 2.9–6.4) in those aged ≥60 years and 8.9% (95% CI 6.1–11.8) in those aged ≥70 years. Prevalence rates increased significantly with age. Conclusions: The prevalence of dementia in this rural Tanzanian population appears to have increased since 2010, although not significantly. Dementia is likely to become a significant health burden in this population as demographic transition continues. Key Points: Using similar methodology, 9 years later, the prevalence of dementia appears to be increasing in Tanzania rather than decreasing, as observed in high‐income countries. [ABSTRACT FROM AUTHOR]

There are over 3 million people in sub-Saharan Africa (SSA) aged 50 and over living with HIV. HIV and combined antiretroviral therapy (cART) exposure may accelerate the ageing in this population, and thus increase the prevalence of premature frailty. There is a paucity of data on the prevalence of frailty in an older HIV + population in SSA and screening and diagnostic tools to identify frailty in SSA. Patients aged ≥ 50 were recruited from a free Government HIV clinic in Tanzania. Frailty assessments were completed, using 3 diagnostic and screening tools: the Fried frailty phenotype (FFP), Clinical Frailty Scale (CFS) and Brief Frailty Instrument for Tanzania (B-FIT 2). The 145 patients recruited had a mean CD4 + of 494.84 cells/µL, 99.3% were receiving cART and 72.6% were virally suppressed. The prevalence of frailty by FFP was 2.758%. FFP frailty was significantly associated with female gender (p = 0.006), marital status (p = 0.007) and age (p = 0.038). Weight loss was the most common FFP domain failure. The prevalence of frailty using the B-FIT 2 and the CFS was 0.68%. The B-FIT 2 correlated with BMI (r = − 0.467, p = 0.0001) and CD4 count in females (r = − 0.244, p = 0.02). There is an absence of frailty in this population, as compared to other clinical studies. This may be due to the high standard of HIV care at this Government clinic. Undernutrition may be an important contributor to frailty. It is unclear which tool is most accurate for detecting the prevalence of frailty in this setting as levels of correlation are low. [ABSTRACT FROM AUTHOR]

Objectives: HIV-associated neurocognitive disorder (HAND), although prevalent, remains a poorly researched cause of morbidity particularly in sub-Saharan Africa (SSA). We aimed to explore the risk factors for HAND in people aged 50 and over under regular follow-up at a government HIV clinic in Tanzania.Methods: HIV-positive adults aged 50 years and over were approached for recruitment at a routine HIV clinic appointment over a 4-month period. A diagnostic assessment for HAND was implemented, including a full medical/neurological assessment and a collateral history from a relative. We investigated potential risk factors using a structured questionnaire and by examination of clinic records.Results: Of the cohort (n = 253), 183 (72.3%) were female and the median age was 57 years. Fifty-five individuals (21.7%) met the criteria for symptomatic HAND. Participants were at a greater risk of having symptomatic HAND if they lived alone [odds ratio (OR) = 2.566, P = .015], were illiterate (OR 3.171, P = .003) or older at the time of HIV diagnosis (OR = 1.057, P = .015). Age was correlated with symptomatic HAND in univariate, but not multivariate analysis.Conclusions: In this setting, HIV-specific factors, such as nadir CD4 count, were not related to symptomatic HAND. The "legacy theory" of early central nervous system damage prior to initiation of anti-retroviral therapy initiation may contribute, only in part, to a multifactorial aetiology of HAND in older people. Social isolation and illiteracy were associated with symptomatic HAND, suggesting greater cognitive reserve might be protective. [ABSTRACT FROM AUTHOR]

Background There is a dearth of knowledge about the availability and affordability of the different drug treatments for Parkinson's disease (PD) across sub-Saharan Africa (SSA). We aimed to determine the availability and affordability of drugs for treating PD in Kenya. Methods A facility-based survey was conducted in selected medicine outlets (pharmacies) in what were formerly the headquarter towns of the eight provinces of Kenya. We used the World Health Organization/Health Action International methodology to obtain data for drugs used to treat PD. Unit price for each drug was obtained. Results Forty-eight outlets were visited in total, six in each of Kenya's eight provinces. Levodopa (L-dopa) was available in only 24 (50.0%) outlets. Only one public pharmacy sold l-dopa (14 were private and nine were other types of outlet). Ergot-derived dopamine agonists (DAs) and anticholinergics were available in 37 and 35 outlets, respectively. Monoamine-oxidase inhibitors, non-ergot-derived DAs, and catechol- O-methyl transferase inhibitors were available in four, two and zero outlets, respectively. Mean cost of 100 l-dopa tablets was $48.2, though costs varied widely (range, $28.2-$82.4). Only five outlets considered l-dopa affordable, all of which sold 100 tablets for less than $31. Conclusion There is a lack of availability of PD drugs in Kenya, particularly in public pharmacies, where costs are generally lower. Few pharmacists consider the drugs available to be affordable. If PD is to be effectively managed in Kenya, then strategies are needed to increase the availability and affordability of medication. [ABSTRACT FROM AUTHOR]

In sub-Saharan Africa (SSA), a rapidly aging population is presenting challenges to health care systems. Doctors need specialized knowledge to be prepared for the increase in age-related medical conditions. This study aims to investigate the current provision of geriatrics education (GE) in SSA medical schools and discover some of the barriers faced in its implementation. Questionnaires were sent to a list of medical schools in SSA, supplied by the sub-Saharan African Medical Schools Study. Responses were received from 25/135 institutions (19%), representing 11 countries in SSA. Of these institutions, 4% taught geriatrics and 40% had no geriatrics teaching. The largest perceived barriers to GE were a lack of staff expertise (72%), lack of funding (52%), and absence of geriatrics in the national curricula (48%). There are still a large number of medical schools in SSA who do not teach geriatrics. Improvements in GE should be implemented through local approaches and national policy, while appreciating the cultural context and economic constraints of each country to prepare future doctors for the increasing challenges of an aging population. [ABSTRACT FROM PUBLISHER]

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

It was previously thought that the prevalence of Parkinson's disease (PD) in developing countries, and in particular sub-Saharan Africa (SSA), was lower than the rest of the world. The Hai PD prevalence project [] diagnosed 32 patients (the majority previously undiagnosed and untreated) with PD from a population of 161,000, giving age standardised prevalence rates of 64 (men) and 20 (women)/100,000, respectively. Subsequently, drug treatment has been commenced for all surviving patients with annual follow up. The aim of the study was to document response to treatment, development of side effects, progression of disease and feasibility and sustainability of supplying medication to patients in rural Tanzania. Eleven patients died before the start of medication, and a further four during follow up. One patient moved away from the study area. At the end of 3 years of treatment, 16 patients were surviving. Only one stopped medication due to side effects (dyskinesia). At 3 years, 9/16 experienced wearing off and a further three had dyskinesias. Non motor symptoms were a problem at initial assessment [] and continued to be a problem for many of the patients. We have shown that it is possible to find, treat and follow up patients with PD in a rural sub-Saharan African setting. Availability of affordable medication locally is a major issue. Acknowledging that movement disorders and neurological diseases in general are an issue in this setting is important to drive education and training, and for allocation of funding from health care providers in SSA. [ABSTRACT FROM AUTHOR]

Delirium prevalence and aetiology in older people in hospital or community settings in sub-Saharan Africa (SSA) is largely unknown. Cognitive screening tools designed for high-income countries (HICs) may be inappropriate due to cultural and educational differences, and delirium-specific measures lack validation in this context. The 'Identification and Intervention for Dementia in Elderly Africans' (IDEA) screen is a low-literacy tool developed and validated for dementia and delirium screening in Tanzania and Nigeria. This study aims to determine the prevalence and aetiology of delirium and dementia in older hospitalised patients in Zambia and to assess the utility of the IDEA screen for identification of major cognitive impairment in this setting. This was a blinded 4-month validation study which took place February–June 2015. Consecutive inpatient admissions of a rural mission hospital aged ≥60 years were administered the IDEA screen onadmission. Individuals were evaluated for dementia or delirium based on clinical examination, notes review and the Confusion Assessment Method. Delirium aetiological factors were recorded and classified (infectious/non-infectious). Of 136 patients recruited, dementia, delirium and major cognitive impairment were identified in 37 (27.2%), 45 (33.1%) and 62 (45.6%) respectively. Diagnostic accuracy of the IDEA screen for dementia and delirium was 0.661–0.795 (AUROC). Of those with delirium, 18 (40%) were classified infectious and 26 (57.8%) were classified non-infectious aetiologies. Dementia and delirium prevalence in older Zambian inpatients is comparable tohigh-income countries. The IDEA screen ispotentially clinically useful in this setting though diagnostic accuracy was lower than in initial validation studies. Non-infectious diseases are more highly represented amongst delirium precipitants than anticipated. • Dementia/delirium prevalence in older Zambian inpatients is comparable to high-income country rates. • The IDEA is potentially useful for screening major cognitive impairment and delirium in this setting. • Non-infectious diseases are more prevalent delirium precipitants than anticipated. • The prevalence of dementia in low and middle income countries is rapidly increasing. • Accurate prevalence and aetiological data are necessary to aid development of SSA-specific delirium guidelines. [ABSTRACT FROM AUTHOR]