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

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.

Background: Populations are ageing globally and Low- and Middle-Income Countries (LMICs) are experiencing the fastest rates of demographic change. Few studies have explored the burden of frailty amongst older people in hospital in LMICs, where healthcare services are having to rapidly adapt to align with the needs of older people. This study aimed to measure the prevalence of frailty amongst older people admitted to hospital in Tanzania and to explore their demographic and clinical characteristics., Methods: This study had a prospective observational design. Over a six-month period, all adults ≥ 60 years old admitted to medical wards in four hospitals in northern Tanzania were invited to participate. They were screened for frailty using the Clinical Frailty Scale (CFS) and the Frailty Phenotype (FP). Demographic and clinical characteristics of interest were recorded in a structured questionnaire. These included the Barthel Index, the Identification of Elderly Africans Instrumental Activities of Daily Living (IADEA-IADL) and Cognitive (IDEA-Cog) screens, the EURO-D depression scale and Confusion Assessment Method., Results: 540 adults aged ≥ 60 were admitted, and 308 completed assessment. Frailty was present in 66.6% using the CFS and participants with frailty were significantly older, with lower levels of education and literacy, greater disability, greater comorbidity, poorer cognition and higher levels of delirium. Using the FP, 57.0% of participants were classed as frail though a majority of participants (n = 159, 51.6%) could not be classified due to a high proportion of missing data., Conclusions: This study indicates that the prevalence of frailty on medical wards in northern Tanzania is high according to the CFS. However, the challenges in operationalising the FP in this setting highlight the need for future work to adapt frailty screening tools for an African context. Future investigations should also seek to correlate frailty status with long-term clinical outcomes after admission in this setting., (© 2024. The Author(s).)

Introduction: musculoskeletal (MSK) disorders account for approximately 20% of all years lived with disability worldwide however studies of MSK disorders in Africa are scarce. This pilot study aimed to estimate the community-based prevalence of MSK disorders, identify predictors, and assess the associated disability in a Tanzanian population., Methods: a cross-sectional study was conducted in one village in the Kilimanjaro region from March to June 2019. The Gait, Arms, Legs, Spine (GALS) or paediatric GALS (pGALS) examinations were used during household and school visits. Individuals positive in GALS/pGALS screening were assessed by the regional examination of the musculoskeletal system (REMS) and Modified Health Assessment Questionnaire (MHAQ)., Results: among the 1,172 individuals enrolled in households, 95 (8.1%, 95% CI: 6.6 - 9.8) showed signs of MSK disorders using the GALS/pGALS examination and 37 (3.2%, 95% CI: 2.2 - 4.3) using the REMS. Among 682 schools enrolled children, seven showed signs of MSK disorders using the GALS/pGALS examination (1.0%, 95% CI: 0.4 - 2.1) and three using the REMS (0.4%, 95% CI: 0.0 - 1.3). In the household-enrolled adult population, female gender and increasing age were associated with GALS and REMS-positive findings. Among GALS-positive adults, increasing age was associated with REMS-positive status and increasing MHAQ score., Conclusion: this Tanzanian study demonstrates a prevalence of MSK disorders and identifies predictors of MSK disorders comparable to those seen globally. These findings can inform the development of rheumatology services and interventions in Tanzania and the design of future investigations of the determinants of MSK disorders, and their impacts on health, livelihoods, and well-being., Competing Interests: The authors declare no competing interests., (Copyright: Nateiya Mmeta Yongolo et al.)

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% (χ 2 : 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., (© 2023. The Author(s).)

Objective: The burden of stroke has increased in recent years worldwide, particularly in low-income and middle-income countries. In this study we aim to determine the number of stroke admissions, and associated comorbidities, at a referral hospital in Northern Tanzania., Design: This was a retrospective observational study., Setting: The study was conducted at a tertiary referral hospital, Kilimanjaro Christian Medical Centre (KCMC), in the orthern zone of Tanzania., Participants: The study included adults aged 18 years and above, who were admitted to the medical wards from 2017 to 2019., Outcome: The primary outcome was the proportion of patients who had a stroke admitted in the medical ward at KCMC and the secondary outcome was clinical outcome such as mortality., Methods: We conducted a retrospective audit of medical records from 2017 to 2019 for adult patients admitted to the medical ward at KCMC. Data extracted included demographic characteristics, previous history of stroke and outcome of the admission. Factors associated with stroke were investigated using logistic regression., Results: Among 7976 patients admitted between 2017 and 2019, 972 (12.2%) were patients who had a stroke. Trends show an increase in patients admitted with stroke over the 3 years with 222, 292 and 458 in 2017, 2018 and 2019, respectively. Of the patients who had a stroke, 568 (58.4%) had hypertension while 167 (17.2%) had diabetes mellitus. The proportion of admitted stroke patients aged 18-45 years, increased from 2017 (n=28, 3.4%) to 2019 (n=40, 4.3%). The in-hospital mortality related to stroke was 229 (23.6%) among 972 patients who had a stroke and female patients had 50% higher odds of death as compared with male patients (OR:1.5; CI 1.30 to 1.80)., Conclusion: The burden of stroke on individuals and health services is increasing over time, which reflects a lack of awareness on the cause of stroke and effective preventive measures. Prioritising interventions directed towards the reduction of non-communicable diseases and associated complications, such as stroke, is urgently needed., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Objectives: The burden of dementia is increasing in sub-Saharan Africa (SSA), but there are limited epidemiological data on dementia in SSA. This study investigated the prevalence and associations of dementia in older adults (less than 60 y) attending the outpatient department of Mount Meru Hospital in Tanzania., Methods: This one-phase cross-sectional study screened a sample using the Identification of Dementia in Elderly Africans (IDEA) cognitive screening tool. Those that screened as having possible and probable dementia were further assessed, and diagnosis of dementia was made according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Demographic and risk factor data were collected., Results: Within those screened, 57/1141 (5.0%) (95% CI: 3.7-6.3) had dementia. Female sex [odds ratio (OR)=2.778, 95% CI: 1.074-7.189], having never attended school (OR=6.088, 95% CI: 1.360-27.256), alcohol (U/wk) (OR=1.080, 95% CI: 1.016-1.149), uncorrected visual impairment (OR=4.260, 95% CI: 1.623-11.180), body mass index <18.5 kg/m 2 (OR=6.588, 95% CI: 2.089-20.775), and stroke (OR=15.790, 95% CI: 3.48-74.475) were found to be significantly, independently associated with dementia., Conclusions: The prevalence of dementia in this population is similar to a recent community-based rate in Tanzania and lower than a hospital-based rate in Senegal. This is the first time the association between visual impairment and dementia has been reported in SSA. Other associations are in keeping with previous literature., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: HIV-associated neurocognitive disorders (HANDs) are prevalent in older people living with HIV (PLWH) worldwide. HAND prevalence and incidence studies of the newly emergent population of combination antiretroviral therapy (cART)-treated older PLWH in sub-Saharan Africa are currently lacking. We aimed to estimate HAND prevalence and incidence using robust measures in stable, cART-treated older adults under long-term follow-up in Tanzania and report cognitive comorbidities., Design: Longitudinal study., Participants: A systematic sample of consenting HIV-positive adults aged ≥50 years attending routine clinical care at an HIV Care and Treatment Centre during March-May 2016 and followed up March-May 2017., Measurements: HAND by consensus panel Frascati criteria based on detailed locally normed low-literacy neuropsychological battery, structured neuropsychiatric clinical assessment, and collateral history. Demographic and etiological factors by self-report and clinical records., Results: In this cohort (n = 253, 72.3% female, median age 57), HAND prevalence was 47.0% (95% CI 40.9-53.2, n = 119) despite well-managed HIV disease (Mn CD4 516 (98-1719), 95.5% on cART). Of these, 64 (25.3%) were asymptomatic neurocognitive impairment, 46 (18.2%) mild neurocognitive disorder, and 9 (3.6%) HIV-associated dementia. One-year incidence was high (37.2%, 95% CI 25.9 to 51.8), but some reversibility (17.6%, 95% CI 10.0-28.6 n = 16) was observed., Conclusions: HAND appear highly prevalent in older PLWH in this setting, where demographic profile differs markedly to high-income cohorts, and comorbidities are frequent. Incidence and reversibility also appear high. Future studies should focus on etiologies and potentially reversible factors in this setting.

Objectives: To characterise mortality and functional outcome and their relationships with socioeconomic deprivation for women and men in Zanzibar., Materials and Methods: Participants in ZanStroke, a prospective observational study of patients admitted to hospital with a diagnosis of acute stroke, were followed up until one year after the stroke. The modified National Institute of Health Stroke Scale was used to assess initial stroke severity, while modified Rankin Scale (mRS) was used to assess disability at 12 months post-stroke. A multidimensional poverty index was created using individual-level data. Kaplan-Meier analysis and Cox regression model were used to examine associations of socioeconomic deprivation and death at 28 days and 12 months after stroke onset, while logistic regression analysis was used to examine associations between deprivation and functional outcome., Results: Overall mortality rate was 38.2% (CI 34.8-41.9) at 28 days, rising to 59.0% (CI 55.2-62.8) at 12 months. When adjusted for other variables, survival was higher among the least deprived (HR 0.60 CI 0.45-0.80), an association that was strongly significant for women (HR 0.46 CI 0.29-0.74). Among 12-month survivors 45.1% (n = 122) had no/low level of disability (mRS 0-2), while 22.9% (n = 62) were unable to walk independently or at all. No difference between socioeconomic deprivation and outcome was seen at one year., Conclusion: Case-fatality rates were high, and socioeconomic disparities were evident even during the acute stroke phase. Policies are needed to reduce significant health disparities, adapt evidence-based interventions, and promote equitable access to stroke care and rehabilitation., Competing Interests: Declaration of Competing Interest KKN is employed at Steno Diabetes Center Copenhagen, a public hospital and research institution under the Capital Region of Denmark, which is partly funded by a grant from the Novo Nordisk Foundation. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Social vulnerability correlates with frailty and is associated with mortality and disability. However, few studies have investigated this relationship outside of high-income country settings. This study aimed to produce and analyze a culturally adapted social vulnerability index (SVI) to investigate the relationship between social vulnerability, frailty, and mortality in older adults in Tanzania., Methods: An SVI was produced using data from a cohort study investigating frailty in older adults in Tanzania. Variables were selected based on previous SVI studies using the categories established by Andrew et al. from the Canadian Study of Health and Aging, and National Population Health Survey. The SVI distribution was examined and compared with a frailty index (FI) produced from the same sample, using mutually exclusive variables. Cox regression survival analysis was used to investigate the association between social vulnerability, frailty, and mortality., Results: A stratified cohort of 235 individuals were included in the study at baseline, with a mean age of 75.2 (SD 11.5). Twenty-six participants died within the follow-up period, with a mean of 503 days (range: 405-568) following the initial assessment. The SVI had a median score of 0.47 (interquartile range: 0.23, range: 0.14-0.86). Social vulnerability significantly predicted mortality when adjusting for age and gender, but not when also adjusting for frailty., Conclusions: Social vulnerability can be successfully operationalized and culturally adapted in Tanzania. Social vulnerability is associated with mortality in Tanzania, but not independently of frailty., (© The Author(s) 2022. Published by Oxford University Press on behalf of The Gerontological Society of America.)

Background: HIV-associated neurocognitive disorders (HAND) are a highly prevalent chronic complication in older people living with HIV (PLWH) in high-income countries. Although sub-Saharan Africa has a newly emergent population of older combination antiretroviral therapy (cART)-treated PLWH, HAND have not been studied longitudinally. We assessed longitudinal prevalence of HAND and have identified possible modifiable factors in a population of PLWH aged 50 years or older, over 3 years of follow-up., Methods: Detailed neuropsychological and clinical assessment was completed annually in the period 2016-2019 in a systematic sample of cART-treated PLWH in Kilimanjaro, Tanzania. A consensus panel defined HAND using American Academy of Neurology criteria for asymptomatic neurocognitive impairment, mild neurocognitive disorder, and HIV-associated dementia. HIV disease severity and other factors associated with HAND progression, improvement, and stability were evaluated in individuals fully assessed at baseline and in 2019., Results: At baseline, 47% of the cohort (n = 253, 72.3% female individuals) met HAND criteria despite good HIV disease control [Y1 59.5% (n = 185), Y2 61.7% (n = 162), and Y3 57.9% (n = 121)]. Of participants fully assessed at baseline and year 3 (n = 121), HAND remained stable in 54% (n = 57), improved in 15% (n = 16), and declined in 31% (n = 33). Older age and lower education level significantly predicted HAND progression, whereas HIV-specific factors did not. Male sex and shorter cART duration were associated with improvement., Conclusions: In this first longitudinal study characterizing clinical course of HAND in older cART-treated PLWH in sub-Saharan Africa, HAND was highly prevalent with variable progression and reversibility. Progression may be more related to cognitive reserve than HIV disease in cART-treated PLWH., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

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., (Copyright © 2022 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: The burden of neurological disorders is large and altered by the HIV epidemic., Objectives: We describe the pattern of neurological disorders and their association with HIV infection in adult patients attending a consultant hospital in Northern Tanzania., Methods: In this prospective cross-sectional study, we collected data on adult neurological referrals over a 6-year period between 2007-13. The odds of HIV infection, across neurological categories adjusted for age and sex, was calculated., Results: Of 2037 participants, 54.8% were male and 45.2% were female. The median age of participants was 43 years. The results for HIV screening were available for 992/2037 (48.7%) patients, of whom 306 (30.8%) were seropositive. The most frequent neurological disorders were cerebrovascular disease (19.9%), paraplegia (13.6%), and peripheral neuropathies (8%). Taken together CNS infection accounted for 278/2037 (13.6%). The adjusted odds (aOR) of HIV infection was highest amongst infections; brain abscesses (aOR 107, 95% CI 35.1-470.4) and meningitis/encephalitis (aOR 40.1, 95% CI 13.6-172.9), but also raised in cerebrovascular disease, paraplegia, peripheral neuropathies, cranial nerve palsies, seizures, cerebllar disorders, movement disorders, motor neuron disease and headache., Conclusion: The main pattern of neurological disorders in Northern Tanzania is presented. The odds of HIV infection was highest in CNS infections and in a wide range of non-communicable neurological disorders., (© 2022 Howlett WP et al.)

Background: Musculoskeletal diseases (MSD) are a major contributor to the global burden of disease and disability, and disproportionally affect low- and middle-income countries; however, there is a dearth of epidemiological data. Affected children often face increased morbidity, social isolation and economic hardship., Aim: To assess the spectrum and burden of paediatric MSD in children aged 5-18 years admitted to a major referral hospital in Tanzania., Methods: This was a retrospective cohort study of children aged 5-18 years admitted to Kilimanjaro Christian Medical Centre (KCMC) whose initial diagnosis was recognised as a musculoskeletal condition by the International Classification of Diseases-10 between 1 January and 31 December 2017., Results: During 2017, 163 cases of confirmed paediatric MSD were admitted to KCMC, representing 21.2% of all admissions of children aged 5-18 years ( n =  769). Bone disease was the most common diagnosis. They comprised 106 (65.0%) traumatic fractures, 31 (19.0%) osteo-articular infections, 9 (5.5%) malunions and 3 (1.8%) pathological fractures. Congenital defects and rheumatic disease were relatively uncommon, accounting for only 6 (3.7%) and 4 (2.5%) MSD admissions, respectively., Conclusion: The majority of cases of MSD were related to fractures, followed by osteo-articular infections, while recognised cases of rheumatic disease were rare. The study, although small, identified the sizeable burden and spectrum of paediatric MSD admitted to a hospital in Tanzania over a 12-month period and highlights the need for larger studies to inform the optimal allocation of health resources., Abbreviation: CI: confidence interval; HIC: high-income countries; HIV: human immunodeficiency virus; ICD-10: International Classification of Diseases 10; IQR: interquartile range; JIA: juvenile idiopathic arthritis; KCMC: Kilimanjaro Christian Medical Centre; LMIC: low- and middle-income countries; MSD: musculoskeletal diseases: NAI: non-accidental injury; NIHR: National Institute for Health Research; PAFLAR: Paediatric Society of the African League Against Rheumatism; RTA: road traffic accidents; SCD: sickle cell disease; SLE: systemic lupus erythematosus; SSA: sub-Saharan Africa.

Objectives: 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)., Background: 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., Design: 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., Results: 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)., Conclusions: 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.

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.

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., (© 2021 The Authors. International Journal of Geriatric Psychiatry published by John Wiley & Sons Ltd.)

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.

Validated screening tools for HIV-associated neurocognitive disorders (HAND) are lacking for the newly emergent ageing population of people living with HIV (PLWH) in sub-Saharan Africa (SSA). We aimed to validate and compare diagnostic accuracy of two cognitive screening tools, the International HIV dementia scale (IHDS), and the Identification and Interventions for Dementia in Elderly Africans (IDEA) screen, for identification of HAND in older PLWH in Tanzania. A systematic sample of 253 PLWH aged ≥ 50 attending a Government clinic in Tanzania were screened with the IHDS and IDEA. HAND were diagnosed by consensus American Academy of Neurology (AAN) criteria based on detailed clinical neuropsychological assessment. Strict blinding was maintained between screening and clinical evaluation. Both tools had limited diagnostic accuracy for HAND (area under the receiver operating characteristic (AUROC) curve 0.639-0.667 IHDS, 0.647-0.713 IDEA), which was highly-prevalent (47.0%). Accurate HAND screening tools for older PLWH in SSA are needed.

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., (© 2020 The Authors. International Journal of Geriatric Psychiatry published by John Wiley & Sons Ltd.)

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

ABSTRACTObjective:Little is known about the current views and practices of healthcare professionals (HCPs) in Sub-Saharan Africa (SSA) regarding delivery of hospital palliative care. The present qualitative study explored the views of nursing staff and medical professionals on providing palliative and end-of-life care (EoLC) to hospital inpatients in Tanzania., Method: Focus group discussions were conducted with a purposive sample of HCPs working on the medical and pediatric wards of the Kilimanjaro Christian Medical Centre, a tertiary referral hospital in northern Tanzania. Transcriptions were coded using a thematic approach., Results: In total, 32 healthcare workers were interviewed via 7 focus group discussions and 1 semistructured interview. Four major themes were identified. First, HCPs held strong views on what factors were important to enable individuals with a life-limiting diagnosis to live and die well. Arriving at a state of "acceptance" was the ultimate goal; however, they acknowledged that they often fell short of achieving this for inpatients. Thus, the second theme involved identifying the "barriers" to delivering palliative care in hospital. Another important factor identified was difficulty with complex communications, particularly "breaking bad news," the third theme. Fourth, participants were divided about their personal preferences for "place of EoLC," but all emphasized the benefits of the hospital setting so as to enable better symptom control., Significance of Results: Despite the fact that all the HCPs interviewed were regularly involved in providing palliative and EoLC, they had received limited formal training in its provision, although they identified such training as a universal requirement. This training gap is likely to be present across much of SSA. Palliative care training, particularly in terms of communication skills, should be comprehensively integrated within undergraduate and postgraduate education. Research is needed to develop culturally appropriate curricula to equip HCPs to manage the complex communication challenges that occur in caring for a diverse inpatient group with palliative care needs.

ABSTRACTBackground:The number of people living with dementia in sub-Saharan Africa (SSA) is expected to increase rapidly in the coming decades. However, our understanding of how best to reduce dementia risk in the population is very limited. As a first step in developing intervention strategies to manage dementia risk in this setting, we investigated rates of cognitive decline in a rural population in Tanzania and attempted to identify associated factors., Methods: The study was conducted in the rural Hai district of northern Tanzania. In 2014, community-dwelling people aged 65 years and over living in six villages were invited to take part in a cognitive screening program. All participants from four of the six villages were followed-up at two years and cognitive function re-tested. At baseline and follow-up, participants were assessed for functional disability, hypertension, and grip strength (as a measure of frailty). At follow-up, additional assessments of visual acuity, hearing impairment, tobacco and alcohol consumption, and clinical assessment for stroke were completed., Results: Baseline and follow-up data were available for 327 people. Fifty people had significant cognitive decline at two-year follow-up. Having no formal education, low grip strength at baseline, being female and having depression at follow-up were independently associated with cognitive decline., Conclusions: This is one of the first studies of cognitive decline conducted in SSA. Rates of decline at two years were relatively high. Future work should focus on identification of specific modifiable risk factors for cognitive decline with a view to developing culturally appropriate interventions.

By 2030, sub-Saharan Africa is forecast to see the steepest rise in the number of people with hypertension of any world region. Hypertensive retinopathy is known to be a common complication of hypertension in developed countries and some studies suggest it is associated with the presence of other hypertension-related end-organ damage (EOD) such as stroke and cardiovascular disease. In Tanzania hypertension is relatively more common than in other parts of sub-Saharan Africa, especially in the older population; however, the prevalence of hypertensive retinopathy and its association with EOD remain unknown. The authors conducted a cross-sectional study of elderly, community-dwelling, rural Tanzanians to determine the prevalence of hypertensive retinopathy and its association with hypertension and other forms of EOD. Hypertensive retinopathy was diagnosed based on retinal imaging. In a cohort of 61 patients with gradable images, the authors found the overall prevalence of hypertensive retinopathy to be 64% (n = 39), which was strongly associated with hypertension (X 2 [1] = 4.207, P = .004), with a significant trend towards more severe retinopathy with more severe hypertension (r = .377, P = .003). The authors did not find hypertensive retinopathy to be associated with other forms of EOD. Hypertensive retinopathy is highly prevalent in this population and is associated in most but not all cases with hypertension. These findings do not suggest that it could be used as a screening tool for EOD, but it is important to identify and educate patients with retinopathy about possible complications of the condition., (©2018 Wiley Periodicals, Inc.)

Background: In sub-Saharan Africa, there are no validated screening tools for delirium in older adults. This study assesses clinical utility of two instruments, the IDEA cognitive screen and the Confusion Assessment Method (CAM) for identification of delirium in older adults admitted to medical wards of a tertiary referral hospital in Tanzania., Method: The IDEA cognitive screen and CAM were administered to a consecutive cohort of older individuals on admission to Kilimanjaro Christian Medical Centre using a blinded protocol. Consensus diagnosis for delirium was established against DSM-5 criteria and dementia by DSM-IV criteria., Results: Of 507 admission assessments, 95 (18.7%) had DSM-5 delirium and 95 (18.7%) had DSM-IV dementia (33 (6.5%) delirium superimposed on dementia). The CAM and IDEA cognitive screen had very good diagnostic accuracy for delirium (AUROC curve 0.94 and 0.87 respectively). However, a number of participants (10.5% and 16.4% respectively) were unable to complete these screening assessments due to reduced consciousness, or other causes of reduced verbal response and were excluded from this analysis; many of whom met DSM-5 criteria for delirium. Secondary analysis suggests that selected cognitive and observational items from the CAM and IDEA cognitive screen may be as effective as the full screening tools in identifying delirium even in unresponsive patients., Conclusion: Both instruments appeared useful for delirium screening in this inpatient setting, but had significant limitations. The combination of assessment items identified may form the basis of a brief, simple delirium screening tool suitable for use by non-specialist clinicians. Further development work is needed., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Few data from sub-Saharan Africa exist on the effects of hypertension on the organs of the human body. We aimed to establish the prevalence of hypertensive end organ damage (EOD) in an elderly cohort of Tanzanians. The population aged 70 years and over of 2 villages in northern Tanzania (n = 246), had blood pressure (BP) data available from 2010 and 2013, and underwent in-depth follow-up for markers of hypertensive EOD in 2016. Assessment included ankle-brachial pressure index, lying-standing BP, electrocardiogram, and mid-stream urine dip. Sustained hypertension (those with hypertension at all 3 assessments) was found in 129 (52.4% subjects). Of the entire cohort, 13.9% had left ventricular hypertrophy and 26.4% had peripheral arterial disease, both of which were associated with sustained hypertension, although orthostatic hypotension, stroke, proteinuria, and arterial stiffening were not. Further investigation, particularly in younger age groups, is merited if hypertension-associated morbidity is to be controlled., (©2018 Wiley Periodicals, Inc.)

Chronic obstructive pulmonary disease (COPD) causes substantial burden of disease in developed countries, but there are limited data from Africa. We aimed to estimate the prevalence of COPD in Tanzania and identify the risk factors associated with it.This was a cross-sectional descriptive survey involving adults aged ≥35 years. We collected data on symptoms and risk factors using the Burden of Obstructive Lung Diseases questionnaire. Spirometry was performed and COPD diagnosed based on post-bronchodilator forced expiratory volume in 1 s/forced vital capacity <70%. We also measured indoor and outdoor carbon monoxide (CO) levels.A total of 869 participants (49.1% females) completed the questionnaires. Of these, 57.1% completed post-bronchodilator spirometry. Of the 25.2% ever-smokers, only 5.4% were current smokers. COPD prevalence was estimated at 17.5% (21.7% in males and 12.9% in females). COPD was associated with a history of cough, phlegm production and wheezing. 51.7% of COPD patients reported cough and 85% had mild to moderate airway limitation. Females had a higher rate of exacerbation. Pulmonary tuberculosis (TB) was reported in 10% of patients. Only 1.7% of patients who were diagnosed as COPD had ever received any medication, with only one female COPD patient having received an inhaler. 99.5% of the population used biomass fuels for cooking. The majority of households had CO levels up to 20 ppm.The prevalence of COPD in Tanzania is high, with a peak at a relatively young age and a preponderance in males. A history of TB, cigarette smoking and male sex are important risk factors. Indoor air pollution coupled with use of biomass fuel for cooking and heating may be an important risk factor for developing COPD in rural Tanzania. However, these factors need to be studied further., Competing Interests: Conflict of interest: None declared., (Copyright ©ERS 2018.)

Objective: This study aimed to assess the feasibility of a low-literacy adaptation of the Alzheimer's Disease Assessment Scale - Cognitive (ADAS-Cog) for use in rural sub-Saharan Africa (SSA) for interventional studies in dementia. No such adaptations currently exist., Methods: Tanzanian and Nigerian health professionals adapted the ADAS-Cog by consensus. Validation took place in a cross-sectional sample of 34 rural-dwelling older adults with mild/moderate dementia alongside 32 non-demented controls in Tanzania. Participants were oversampled for lower educational level. Inter-rater reliability was conducted by two trained raters in 22 older adults (13 with dementia) from the same population. Assessors were blind to diagnostic group., Results: Median ADAS-Cog scores were 28.75 (interquartile range (IQR), 22.96-35.54) in mild/moderate dementia and 12.75 (IQR 9.08-16.16) in controls. The area under the receiver operating characteristic curve (AUC) was 0.973 (95% confidence interval (CI) 0.936-1.00) for dementia. Internal consistency was high (Cronbach's α 0.884) and inter-rater reliability was excellent (intra-class correlation coefficient 0.905, 95% CI 0.804-0.964)., Conclusion: The low-literacy adaptation of the ADAS-Cog had good psychometric properties in this setting. Further evaluation in similar settings is required.

Objectives: The dementia diagnosis gap in sub-Saharan Africa (SSA) is large, partly because of difficulties in screening for cognitive impairment in the community. As part of the Identification and Intervention for Dementia in Elderly Africans (IDEA) study, we aimed to validate the IDEA cognitive screen in a community-based sample in rural Tanzania METHODS: Study participants were recruited from people who attended screening days held in villages within the rural Hai district of Tanzania. Criterion validity was assessed against the gold standard clinical dementia diagnosis using DSM-IV criteria. Construct validity was assessed against, age, education, sex and grip strength and instrumental activities of daily living (IADLs). Internal consistency and floor and ceiling effects were also examined., Results: During community screening, the IDEA cognitive screen had high criterion validity, with an area under the receiver operating characteristic curve of 0.855 (95% CI 0.794 to 0.915). Higher scores on the screen were significantly correlated with lower age, male sex, having attended school, better grip strength and improved performance in activities of daily living. Factor analysis revealed a single factor with an eigenvalue greater than one, although internal consistency was only moderate (Cronbach's alpha = 0.534)., Conclusions: The IDEA cognitive screen had high criterion and construct validity and is suitable for use as a cognitive screening instrument in a community setting in SSA. Only moderate internal consistency may partly reflect the multi-domain nature of dementia as diagnosed clinically. Copyright © 2016 John Wiley & Sons, Ltd., (Copyright © 2016 John Wiley & Sons, Ltd.)

Aims: The aim of this study was to record stroke admissions to a tertiary referral hospital in Tanzania over four decades., Methods: We audited the medical records held at a large teaching and tertiary referral hospital in northern Tanzania over four decades. We collected records for the years 1974-1976, 1984-1986, 1994-1995 and 2008. All patients admitted as inpatients with a primary diagnosis of stroke were included in the study. Data collected included age, sex, stroke subtype, predominant side of symptoms and survival to discharge., Results: The number of stroke admissions rose from just four in the three-year period 1974-1976 (mean 1.3 cases annually) to 153 cases annually in 2008. The mean age of those admitted rose steadily during this period, as did the proportion of females admitted., Conclusions: The burden of stroke on health services in Tanzania appears to have increased rapidly. If this increase is to be slowed, then sustainable primary preventative measures to target known stroke risk factors will be required., (© 2015 John Wiley & Sons Ltd.)

Background: Disability is associated with increasing age and poverty, yet there are few reliable data regarding disability amongst the elderly in low-income countries. The aim of this study was to compare disability levels for three of the most common neurological, non-communicable diseases: dementia, stroke and Parkinson's disease (PD)., Methods: We performed a community-based study of people aged 70 years and over in 12 randomly selected villages in the rural Hai district of Tanzania. Participants underwent disability assessment using the Barthel Index, and clinical assessment for dementia, stroke and PD., Results: In a representative cohort of 2232 people aged 70 years and over, there were 54 cases of stroke, 12 cases of PD and estimated (by extrapolation from a sub-sample of 1198 people) to be 112 cases of dementia. People with stroke were the most disabled, with 62.9% having moderate or severe disability. Levels of moderate or severe disability were 41.2% in people with dementia and 50.0% in people with PD. However, the higher prevalence of dementia meant that, at a population level, it was associated with similar levels of disability as stroke, with 18.5% of 249 people identified as having moderate or severe disability having dementia, compared to 13.7% for stroke and 2.4% for PD., Conclusions: Levels of disability from these conditions is high and is likely to increase with demographic ageing. Innovative, community-based strategies to reduce disability levels should be investigated.

The authors hypothesized that published hypertension rates in Tanzania were influenced by the physiological response of individuals to blood pressure (BP) testing, known as the white-coat effect (WCE). To test this, a representative sample of 79 participants from a baseline cohort of 2322 people aged 70 years and older were followed to assess BP using conventional BP measurement (CBPM) and ambulatory BP monitoring (ABPM). There was a significant difference between daytime ABPM and CBPM for both systolic BP (mean difference 29.7 mm Hg) and diastolic BP (mean difference 7.4 mm Hg). Rates of hypertension were significantly lower when measured by 24-hour ABPM (55.7%) than by CBPM (78.4%). The WCE was observed in 54 participants (68.4%). The WCE was responsible for an increase in recorded BP. Accurate identification of individuals in need of antihypertensive medication is important if resources are to be used efficiently, especially in resource-poor settings., (©2015 Wiley Periodicals, Inc.)

Background: We have previously described the development of the Identification and Intervention for Dementia in Elderly Africans (IDEA) cognitive screen for use in populations with low levels of formal education. The IDEA cognitive screen was developed and field-tested in an elderly, community-based population in rural Tanzania with a relatively high prevalence of cognitive impairment. The aim of this study was to validate the IDEA cognitive screen as an assessment of major cognitive impairment in hospital settings in Nigeria and Tanzania., Methods: In Nigeria, 121 consecutive elderly medical clinic outpatients reviewed at the University College Hospital, Ibadan were screened using the IDEA cognitive screen. In Tanzania, 97 consecutive inpatients admitted to Mawenzi Regional Hospital (MRH), Moshi, and 108 consecutive medical clinic outpatients attending the geriatric medicine clinic at MRH were screened. Inter-rater reliability was assessed in Tanzanian outpatients attending St Joseph's Hospital in Moshi using three raters. A diagnosis of dementia or delirium (DSM-IV criteria) was classified as major cognitive impairment and was provided independently by a physician blinded to the results of the screening assessment., Results: The area under the receiver operating characteristic (AUROC) curve in Nigerian outpatients, Tanzanian outpatients and Tanzanian inpatients was 0.990, 0.919 and 0.917 respectively. Inter-rater reliability was good (intra-class correlation coefficient 0.742 to 0.791). In regression models, the cognitive screen did not appear to be educationally biased., Conclusions: The IDEA cognitive screen performed well in these populations and should prove useful in screening for dementia and delirium in other areas of sub-Saharan Africa.

Cognitive impairment is thought to be a major cause of disability worldwide, though data from sub-Saharan Africa (SSA) are sparse. This study aimed to investigate the association between cognitive impairment and disability in a cohort of community-dwelling older adults living in Tanzania. The study cohort of 296 people aged 70years and over was recruited as part of a dementia prevalence study. Subjects were diagnosed as having dementia or mild cognitive impairment according to the DSM-IV criteria. Disability level was assessed according to the WHO Disability Assessment Schedule, version 2.0 (WHODAS). A higher WHODAS score indicates greater disability. The median WHODAS in the background population was 25.0; in those with dementia and in those with mild cognitive impairment, 72 of 78 (92.3%) and 41 of 46 (89.1%), respectively, had a WHODAS score above this level. The presence of dementia, mild cognitive impairment, hearing impairment, being unable to walk without an aid and not having attended school were independent predictors of having a WHODAS score above 25.0, though age and gender were not. In summary, cognitive impairment is a significant predictor of disability in elderly Tanzanians. Screening for early signs of cognitive decline would allow management strategies to be put in place that may reduce the associated disability burden., (Copyright © 2014 Ministry of Health, Saudi Arabia. Published by Elsevier Ltd. All rights reserved.)

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

Objectives: The prevalence of dementia is predicted to increase rapidly in developing countries. Vascular risk factors may contribute to this rise. Our aim was to estimate the proportions of Alzheimer's disease (ADD) and vascular dementia (VAD) in a prevalent cohort of dementia cases in rural Tanzania., Design: A two-stage door-to-door dementia prevalence study., Setting: Hai district, Tanzania, Participants: In Phase I, the Community Screening Instrument for Dementia (CSI-D) was used to screen 1198 community-dwelling people for dementia. In Phase II, 168/184 (91.3%) of those with poor performance, 56/104 (53.8%) of those with intermediate performance and 72/910 (7.9%) of those with good performance on CSI-D were interviewed and diagnoses were made using the DSM-IV criteria., Measurements: For subtype diagnosis, DSM-IV dementia criteria plus NINCDS-ADRDA criteria were used for ADD and NINDS-AIREN criteria for VAD. Other dementias were diagnosed by international consensus criteria. Diagnoses were confirmed or excluded by computerised tomography where clinically appropriate., Results: Of 78 dementia cases, 38 (48.7%) were ADD and 32 (41.0%) were VAD. The crude prevalence of ADD was 3.7% (95% CI 2.5 to 4.9) and of VAD was 2.9% (95% CI 1.9 to 3.9). The age-adjusted prevalence was 3.0% (95% CI 1.8 to 4.2) for ADD and 2.6% (95% CI 1.6 to 3.6) for VAD. A previous diagnosis of diabetes mellitus was independently associated with greater odds of having VAD than ADD., Conclusions: VAD accounted for a greater proportion of dementia cases than expected. Further investigation and treatment of risk factors is required in this setting., (Copyright © 2014. Published by Elsevier Inc.)

Aim: The aim of this project was to develop a dementia screening instrument for use in the hospital or community in populations with low levels of formal education., Methods: A screening instrument was developed from retrospective data collected in a rural area of Tanzania in 2010. The community screening instrument for dementia was administered to over 95% of the population aged 70 years and older of 6 villages (n = 1198) in Hai district, Tanzania. Factor analysis, regression modeling, and Mokken scale analysis (MSA) were used to develop screening instruments from these data, which were then tested and refined during prospective fieldwork., Results: A 5-item screening instrument with an area under the receiver-operating characteristic (AUROC) curve of 0.871, sensitivity of 91.7%, and specificity of 61.7% was developed using a combination of factor analysis and logistic regression modeling and had a higher AUROC (0.786) than a 7-item screening instrument developed using MSA. During prospective testing and refinement (n = 60), the 5-item instrument performed well (AUROC 0.867) and took an average of less than 10 minutes to administer. Its performance was improved by including a matchstick design item added to measure praxis, AUROC 0.888., Conclusions: The 6-item brief dementia screening instrument has acceptable properties and will be further tested and validated during future fieldwork. Although developed for use in sub-Saharan Africa, it may be of use in other world regions where the use of other cognitive screening instruments may result in bias due to low levels of formal education., (© The Author(s) 2014.)

Background: Caregiver burden includes the many physical, mental and socio-economic problems arising from caring for individuals with chronic and disabling diseases. Being a carer in sub-Saharan Africa (SSA), where little is known about chronic neurological conditions, may be extremely demanding. Conversely, multigenerational living may allow sharing of care among many caregivers. We wished to determine the relative burden of caring for two chronic neurodegenerative conditions (Parkinson's disease (PD) and dementia) in rural Tanzania., Methods: All surviving patients from a PD prevalence study, newly identified people with PD from a neurological disorders study and all people with dementia from a dementia prevalence study in Hai, rural Tanzania, were invited to participate. The Zarit Burden Interview (ZBI) was used to determine level of caregiver strain (higher score reflects more strain)., Results: Of 25 PD patients ZBI was recorded in 20 (14 male). Five had no identifiable carer as they were largely independent. Three had PD dementia (PDD). Of 75 people with dementia (excluding 3 PDD), 43 (32 female) completed the ZBI. For the other 32, the caregivers felt the care they provided was a normal intergenerational expectation. Median ages were 78.5 and 85 years for PD and dementia, respectively. Median ZBI was 30.5 for PD and 14 for dementia (U = 166.0, z = -3.913, p < 0.001). Disease duration and disease type (PD or dementia) were univariate predictor of ZBI score, although only disease type was predictive by multivariable linear regression., Conclusions: Caring for an individual with PD may be more burdensome than caring for an individual with dementia in SSA. People with more advanced PD had higher caregiver burden.

Background: Although the association between cerebrovascular and coronary artery disease (CAD) is well known in high-income countries, this association is not well documented in black Africans., Aims: The aim of this study was to document electrocardiographic (ECG) evidence of CAD in stroke cases and controls and to identify other common ECG abnormalities related to known stroke risk factors in a community-based population of incident stroke cases in Tanzania, East Africa., Methods: This was a case-control study. Incident stroke cases were identified by the Tanzanian Stroke Incidence Project. Age- and sex-matched controls were randomly selected from the background population. Electrocardiograms were manually analyzed using the Minnesota Coding System, looking for evidence of previous myocardial infarction (MI), atrial fibrillation (AF) or atrial flutter (AFl), and left ventricular hypertrophy (LVH)., Results: In Hai, there were 93 cases and 241 controls with codable electrocardiograms, and in Dar-es-Salaam, there were 39 cases and 72 controls with codable electrocardiograms. Comparing cases and controls, there was a higher prevalence of MI and AF or AFl (but not LVH) in cases compared with controls., Conclusions: This is the first published study of ECG assessment of CAD and other stroke risk factors in an incident population of stroke cases in sub-Saharan Africa. It suggests that concomitant CAD in black African stroke cases is more common than previously suggested., (Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Objectives: This study was carried out to quantify the degree of cognitive impairment and the extent of speech, language, and swallowing problems in a representative cohort of Swahili-speaking people with stroke in Tanzania., Methods: A case-control design was used, comparing people with and without stroke on a screening test for aphasia (spoken comprehension and expression), a water swallow test, and the Community Screening Instrument for Dementia (CSI-D)., Results: Fifty-eight persons between 6 and 60 months (median 36) post stroke and 58 age- and gender-matched control subjects were assessed. Twenty-eight strokes were left hemisphere; 25, right; 2, posterior circulation; and 3, undetermined. Forty-nine of 58 (84%) control subjects scored 19 to 20 (maximum) on the language screen compared with 26 of 56 (46%) persons with stroke who completed the assessment. Higher age and lower educational attainment, but not gender or time since stroke, were associated with poorer performance on language and swallow assessments. Poorer CSI-D score was significantly correlated with all items. Greater disability (Barthel Index score) was significantly correlated with poorer performance in all items except rate of drinking water. Those with a left hemisphere stroke performed less well on understanding and expression items but better than other subjects with stroke on the water swallow task., Conclusions: This is the first attempt to describe aphasia incidence in a sub-Saharan African language. Further work on the psychometric properties of the screening instrument is warranted. Given that it delivers a relatively coarse indication of language disturbance, it is likely that incidence of aphasia in the current cohort is underestimated.

Background/objectives: Older adults in sub-Saharan Africa (SSA) are at greatest risk of an impending noncommunicable diseases epidemic, of which cardiac disease is the most prevalent contributor. Thus, it is essential to establish electrocardiographic reference values for a population that is likely to differ genetically and environmentally from others where reference values are established., Methods: Two thousand two hundred thirty-two apparently healthy community-based participants without known cardiac disease aged 70+ in rural Tanzania underwent 12-lead electrocardiography. Electrocardiograms were digitally analyzed and gender-specific reference values for P duration (PD), P amplitude (PAMP), P area (PAREA), P terminal negative force (V1) (PTNF), PR interval, QRS duration (QRSD), QT/QTc, R amplitude (II, V5) (RAMP) LVH index (LVHI), R axis and R/S ratio (V1) reported, following univariate analysis of covariance using a multiple linear regression model, adjusting for age, systolic blood pressure (SBP), body mass index (BMI), and RR interval., Results: Data from 1824 subjects were suitable for analysis. Adjusted mean values for men/women were: PD 115/110 ms, PAMP (avg) 123/114 μV, PAMP (II) 203/190 μV, PAREA (avg) 5.3/4.6 mV*s, PAREA (II) 9.3/8.1 mV*s, PTNF 1.7/1.4 mV*s, PR 158/152 ms, QRSD 89/84 ms, QT 370/375 ms, QTc 421/427 ms, RAMP (II) 805/854 μV, (V5) 2022/1742 μV, LVHI 3.0/2.8 mV (Sokolow-Lyon), 1.293/1.146 mV (Cornell), R axis 51/49°, R/S 0.2/0.2. Excluding PTNF , R axis and R/S ratio, all gender differences were significant (P < 0.001 apart from LVHI [Sokolow-Lyon; P < 0.005)] and RAMP (II) [P < 0.05]) following adjustment for age, SBP, BMI, and RR interval., Conclusions: Our description of comprehensive electrocardiographic parameters establishes reference values in this genetically and environmentally diverse SSA population thereby allowing identification of "outliers" with potential cardiac disease., (©2013 Wiley Periodicals, Inc.)

Background: Autonomic dysfunction is common in patients with Parkinson's disease (PD). We report autonomic function test results in a prevalent, largely untreated, Tanzanian population of PD patients, at different disease stages and investigate the relationship between autonomic dysfunction and mortality., Methods: Ewing's battery of autonomic tests was carried out on a prevalent population of PD patients living in the rural Hai district of Tanzania. Where possible, all four tests were performed in the patient's home. The main outcome of interest was the presence of abnormalities of sympathetic or parasympathetic function. Information on medications used and other co-morbidities was recorded., Results: Autonomic function tests were recorded for 29 subjects, of whom 3 were on medication at the time of assessment. Of the 26 unmedicated patients, 14 (53.8%) had at least one abnormal test result for autonomic function, of whom only 3 (21.4%) were in late stage disease (Hoehn and Yahr stage IV or V), compared to 7 (58.3%) of 12 with normal autonomic function tests in late stage disease. Ten subjects had died at 5-year follow-up, but there was no association between mortality and autonomic function test abnormalities., Conclusions: In unmedicated subjects, many patients in late stage disease had relatively preserved autonomic function, compared to those in early stage disease. In people with PD who are taking medication, it may be that when autonomic dysfunction presents in late stage disease it is often due to side effects of medication rather than the disease itself.

There are limited, reliable data on the prevalence of hypertension in East African populations. The aim of this study was to document the prevalence of hypertension in the rural Hai district of Tanzania. All consenting individuals aged 70 years and over who were living in 12 randomly-selected villages in the district underwent three consecutive sitting blood pressure (BP) measurements. An average of the last two measurements was taken. Prior diagnosis of, and treatment for, hypertension was recorded. Of the 2223 subjects, 1553 (69.9%, 95% CI 68.0-71.8) had hypertension (BP ≥140/90). Of those with hypertension 733 (47.2%) had isolated systolic hypertension. Only 586 (37.7%) hypertensives had been previously diagnosed, 94 (6.1%) were currently treated and 14 (0.9%) were adequately controlled. This is the first large-scale prevalence study of hypertension in the elderly in sub-Saharan Africa (SSA). Our results approximate to a 'rule of sixths'; 2/6 of hypertensives were previously detected, 1/6 of those previously detected were on treatment and 1/6 of those on treatment were adequately controlled. Hypertension is a large problem in the elderly population in SSA, and there are a growing number of elderly who are at risk of hypertensive sequelae owing to lack of detection and treatment.

Objectives: There are few data on neurological disorders prevalence from low- and middle-income countries, particularly sub-Saharan Africa (SSA) and none specific to the African elderly. We aimed to determined the prevalence of neurological disorders in those aged 70 years and over in a rural African community., Materials and Methods: This study was a cross-sectional two-phased community epidemiological survey set in the rural Hai district of Tanzania. Screening was performed with a validated screening questionnaire with high sensitivity and specificity. Positive responders to screening underwent full neurological history and examination to confirm or refute the presence of neurological disorders and to classify the disorder using the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10)., Results: Of 2232 participants, there were 384 neurological diagnoses amongst 349 people. The age-adjusted prevalence of people with neurological diagnoses was 154.1 per 1000 (95% CI 139.2-169.1). The age-adjusted prevalence per 1000 of the most common neurological disorders were tremor (48.2), headache (41.8), stroke (23.0), peripheral polyneuropathy (18.6), upper limb mononeuropathy (6.5) and parkinsonism (5.9)., Conclusions: This is the first published community-based neurological disorders prevalence study specifically in the elderly in SSA. It reveals a high prevalence of neurological morbidity and demonstrates the contribution neurological disorders make to the non-communicable disease epidemic. This is likely to increase as the population of low-income countries ages constituting a public health dilemma., (© 2012 John Wiley & Sons A/S.)

Introduction: Fluorosis is endemic throughout the East African Rift valley, including parts of Tanzania. The aim of the study was to identify all cases of deforming juvenile skeletal fluorosis (JSF) in a northern Tanzanian village and to document the extent of dental fluorosis (DF)., Methods: Door-to-door prevalence survey of all residents of the village. Residents were assessed for the presence of DF and JSF. Those with JSF and randomly selected controls from the same age range were further assessed for possible JSF risk factors., Results: The village had a population of 1435. DF was endemic within the population, being present in 911 (75.5%; 95% CI, 73.0-77.9) of dentate individuals who were examined (n = 1207). JSF was present in 56 of 1263 people examined, giving a prevalence of 4.4% (95% CI, 3.3-5.6) and was more common in males. Low body mass index, drinking predominantly well water 3 years previously, not being weaned on bananas, the use of fluoride salts in cooking during childhood and drinking more cups of tea per day were independent predictors of JSF., Conclusions: Juvenile skeletal fluorosis is a common and preventable public health problem. Providing clean, low-fluoride, piped water to affected communities is of obvious health benefit., (© 2012 Blackwell Publishing Ltd.)

Background: This study aimed to identify correlates of case fatality within an incident stroke population in rural Tanzania., Methods: Stroke patients, identified by the Tanzanian Stroke Incidence Project, underwent a full examination and assessment around the time of incident stroke. Records were made of demographic data, blood pressure, pulse rate and rhythm, physical function (Barthel index), neurological status (communication, swallowing, vision, muscle activity, sensation), echocardiogram, chest X-ray and computed tomography (CT) head scan. Cases were followed up over the next 3 - 6 years., Results: In 130 incident cases included in this study, speech, language and swallowing problems, reduced muscle power, and reduced physical function were all significantly correlated with case fatality at 28 days and 3 years. Age was significantly correlated with case fatality at 3 years, but not at 28 days post-stroke. Smoking history was the only significant correlate of case fatality at 28 days that pre-dated the incident stroke. All other significant correlates were measures of neurological recovery from stroke., Conclusions: This is the first published study of the correlates of post-stroke case fatality in sub-Saharan Africa (SSA) from an incident stroke population. Case fatality was correlated with the various motor impairments resulting from the incident stroke. Improving poststroke care may help to reduce stroke case fatality in SSA.

There are few data on neurological disorder prevalence from developing countries, particularly in the elderly in sub-Saharan Africa (SSA). This is in part due to the lack of a feasible and valid screening instrument. We aimed to develop (and pilot) a brief screening instrument for neurological disorders in an elderly population in SSA. Our study population of 2,232 was selected at random from the entire 70 years and over population of a demographic surveillance site in rural Tanzania. One village, with a population of 277, was randomly selected as a pilot site prior to screening the rest of the study population. We designed a screening questionnaire based on the neurological section of the WHO International Statistical Classification of Diseases and Related Health Problems 10th Revision for use by non-medical interviewers (NMI). Of the 277 participants aged 70 years and over in the pilot village, 82 had neurological disorders, with a further 267 identified as having neurological disorders during the study extension to the remaining study population of 1955. The questionnaire was practical, acceptable to recipients, and easily performed by an NMI. The sensitivity and specificity of the questionnaire were 87.8 and 94.9 %, respectively, in the pilot and 97.0 and 90.4 %, respectively, in the extension. This is the first published screening instrument for measuring the prevalence of neurological disorders in a developing country, which is dedicated to the elderly population. It is feasible to use and has high sensitivity and specificity.

Background: the World Health Organization estimates that more than one billion of the world's population are disabled. Disability is associated with increasing age and poverty, yet there are few reliable data regarding disability among the elderly in low-income countries. The aim of this study was to accurately document the prevalence of disability in those aged 70 years and over in a community-based setting in sub-Saharan Africa., Methods: we performed a community-based study of people aged 70 years and over in Hai, Tanzania. Participants underwent disability assessment using the culturally non-specific Barthel index (BI), and also clinical assessment for neurological disorders and memory problems., Results: in 2,232 participants, the age-adjusted prevalence of severe disability (BI<15) was 3.7% (95% CI: 2.9-4.5) and the age-adjusted prevalence of moderate disability (BI: 15-18) was 6.2% [95% confidence interval (CI): 5.2-7.2]. Increasing age, female gender, memory problems and the presence of neurological disorders were all independent predictors of the presence of disability., Conclusion: in this study, the average disability level was lower than seen in most high-income countries. This may reflect increased mortality from disabling disease in low-income countries. Disability is likely to increase as the population of low-income countries ages and disease survival improves.