André Tabo

Prevalence of dementia in elderly living in two cities of Central Africa: the EDAC survey.

Background: Data on dementia from low- and middle-income countries are still necessary to quantify the burden of this condition. This multicenter cross-sectional study aimed at estimating the prevalence of dementia in 2 large cities of Central Africa. Methods: General population door-to-door surveys were conducted in the districts of Bangui (Republic of Central Africa) and Brazzaville (Congo) in elderly aged ≧65 years. The subjects were screened with the Community Screening Interview for Dementia and the Five-Words Test. Diagnosis of dementia was made according to the DSM-IV criteria and to the clinical criteria proposed by the NINCDS-ADRDA for Alzheimer’s disease. Results: We enrolled 496 subjects in Bangui and 520 in Brazzaville. The prevalence of dementia was estimated at 8.1% (95% CI = 5.8–10.8) in Bangui and 6.7% (95% CI = 4.7–9.2) in Brazzaville. Conclusion: The prevalence of dementia in urban areas of Central Africa is close to those observed in high-income countries.

Epidemiology of Peripheral Artery Disease in Elder General Population of Two Cities of Central Africa: Bangui and Brazzaville

OBJECTIVES Peripheral artery disease (PAD) is a common condition in Western countries, mostly in the elderly. Little is known about the epidemiology of PAD in Africa. We sought to determine the prevalence of this condition in the elderly in two community-dwelling cohorts in Central Africa. DESIGN Prospective cross-sectional survey in general population over the age of 65 years in Bangui (Central African Republic) and Brazzaville (Congo). METHODS We conducted a systematic door-to-door survey in two representative districts of each city. Demographic, clinical and biological data were collected. The ankle-brachial index (ABI) was used to detect PAD (ABI ≤ 0.90). RESULTS Among the 976 participants, the prevalence of PAD was 15.0% in Bangui and 32.4% in Brazzaville, increasing with age. Adjusted to age, regular alcohol consumption was protective for women in Bangui (OR = 0.50, CI95%:0.25-0.98) and men in Brazzaville (OR = 0.43, CI95%:0.21-0.88). Hypertension was associated with PAD in women (OR = 4.14, CI95%:1.65-10.42 in Bangui and OR = 2.17, CI95%:1.16-4.06 in Brazzaville). Diabetes and smoking showed different associations according to gender and city. CONCLUSIONS This first population study in Central Africa highlights the high prevalence of PAD in the older population, and emphasizes specificities regarding the risk factors, being different from data published in Western countries.

Factors Associated with Dementia Among Elderly People Living in Two Cities in Central Africa: The EDAC Multicenter Study

Risk factors for dementia in American and European countries have been well investigated. However, little research has been carried out in sub-Saharan Africa, where life events as well as environmental, socio-economic, and modifiable risk factors (i.e., cardiovascular risk factors) may differ. Two cross-sectional surveys were conducted in representative samples of the older general population living in Bangui (Central African Republic) and Brazzaville (Congo). Dementia was defined according to the DSM-IV criteria. Multivariate regression analyses were performed in order to identify independent factors associated with dementia. Among the 977 elderly Africans included in this analysis, 75 (7.6%) were diagnosed as having dementia. Increasing age, female gender, hypertension, a body mass index <18.5 kg/m2, depressive symptoms, and the lack of a primary education were significantly associated with dementia. Among life events, the death of one parent during childhood and recently having moved house were also associated with dementia. Beyond the usual risk factors for dementia, this study highlights the role of stressful events in low-income countries. Factors associated with dementia in African countries seem different from established factors in high-income countries and require further investigation.

Socio-Cultural Perceptions and Representations of Dementia in Brazzaville, Republic of Congo: The EDAC Survey

Background: Dementia will concern more and more people in the developing countries, but the perception people have of dementia in these areas has not yet been studied. Method: During a general population survey (EDAC) carried out in Brazzaville (Republic of Congo), 27 elderly persons suspected of having dementia and 31 of their relatives, 90 cognitively impaired elderly persons and 92 of their relatives, as well as 33 hospital workers were interviewed according to the Explanatory Model Interview Catalogue. Results: Item prominence ratings indicate that the attention was mainly on the emotional and socio-economic consequences (scores >1.0 out of 5 points). Ageing and mental stress are the main perceived causes. Hospital workers are more aware of public stigma. Conclusion: The socio-cultural components of the dementia phenomenon have to be taken into account to enforce public health and social measures.

Association Between a Low Ankle-Brachial Index and Dementia in a General Elderly Population in Central Africa (Epidemiology of Dementia in Central Africa Study)

To investigate the association between peripheral arterial disease (PAD) and dementia in native elderly African populations.

Épidémiologie des démences chez les personnes âgées dans le troisième arrondissement de la ville de Bangui (République Centrafricaine)

Given the gradual improvement of living conditions and aging, dementia and related syndromes are becoming serious problems in the developing countries. A cross-sectional door to door type study in neighbourhood, was conducted from October 2008 to January 2009, in the general population in Bangui, order to help get a better understanding of the prevalence and risk factors of dementia among people over 65 living in the Central African capital. Of the 496 elderly respondents, 188 had cognitive disorders. After a neuropsychological examination, 40 of these subjects were diagnosed with dementia. The prevalence of dementia was 8.1% (IC 95% = [5.7-10.5]). The average age of subjects with dementia, ranging from 65 to 90 years, was 76.0 ± 7.1 years. There was a significant risk of developing dementia for an increase of ten years old (OR = 2.6, 95% CI [1.5 to 4.5]). The sex-ratio was 6/34. 82.5% of the demented had never attended school. 70.0% showed a state of malnutrition (BMI ≤ 18,5 kg/m(2)), significantly associated with dementia (OR = 3.3; IC 95% = [1.5-7.3]). The blood pressure was high in 67.5% of demented which is significantly associated with dementia (OR = 2.4; IC 95% = [1.1-5.4]). A recent change in financial status was a factor significantly associated with dementia (OR = 6.4; IC 95% = [1.8-22.5]). These results support the existence of dementia in urban Africa. The observed prevalence is close to those found in high-income countries. Further studies should be conducted which includes both the rural and urban Africa, to better understand the problem and solutions consider to comprehensive care and prevention axes adapted to our context.

Violence and witchcraft accusations against older people in Central and Western Africa: toward a new status for the older individuals?

Social isolation and loss of social status increase the risk of dementia, particularly in Western culture. Prevalence of dementia seems higher in the West than in areas where more traditional culture predominates (Guerchet et al., 2009). However, environmental and social changes mean that this prevalence in traditional societies is likely to increase, particularly in urban regions (Guerchet et al., 2010), where traditional transgenerational family structures tend to disappear and lifestyles are becoming more Westernized. These changes threaten the privileged status of older people, and their relationships with other family members may be subsequently damaged. New diseases that affect young adults, such as AIDS, created a climate of fear and rejection of older people, and suggestions of witchcraft may lead to abuse. Older people had always been held in Africa as belonging to a sacred age group to be treated with reverence and respect and considered as the guardians of tradition and history of the clan (a familial grouping encompassing all the descendants of a unique ancestor). Their closeness to the spirits of the protecting ancestors was thought to enable them to prevent aggression by witchcraft involving harmful spirits. It has long been believed that sorcerers have the power to command harmful spirits and thereby damage health. Illnesses have been always considered to have a supernatural dimension, despite a recent acceptance of more rational explanations. Many revivalist churches (those in the evangelical tradition) are currently being established in Africa. Their leaders are essentially “gurus” who are supplanting the traditional sorcerers and their supposed power to bridge the gap between the real and the hidden (invisible). The quest for a magical/religious explanation for illnesses leads people to look for a culprit. The older people are often suspected to mobilize these ancestors’ spirits to bless individuals and considered as using witchcraft. Consequently, it is common practice to ask the healer about the supernatural origin of serious illness, and older people are easily mentioned as potentially having used witchcraft to do harm. It sometimes happens that an older individual, who is wrongly accused, nevertheless confesses to the accusations in order to relieve the social pressure and, subsequently, develop depressive disorders. Culturally, the older people were expected to be sources of information and training, facilitating the transmission of traditional knowledge and protecting individuals in the clan against invisible forces that can cause illnesses. These valuable qualities of the older people are lost when dementia occurs. In most African cultures, dementia has no name, although the symptoms are recognized and attributed (Faure et al., 2012). Thus, socio-behavioral disorders associated with progressive deterioration of mental functions were not recognized as being pathological. Rather, they are experienced by families as harmful, intentional, and carried out by someone whose role is, by definition, to protect the clan. It is in this context that acts of violence are actually committed against concerned older people, thus running counter to customs and traditions that made them being loved, protected, respected, and even feared because of their supposed powers. Now, the older people are subject to stigma, rejection, and sometimes physical or psychological abuse. It can be suggested that dementia be classified as a mental pathology of the older people and represents failure to compensate for stress imposed by a society in which they feel they have become useless (Sink et al., 2004). Preservation of a traditional culturalmilieu constitutes a defense against the developed culture of Western countries, where individuals who lose their social status immediately become isolated and unappreciated. Dementia can appear to foreshadow death, particularly given the progressive disappearance from modern societies of religious values (Pollitt, 1996). Many workers from voluntary associations report more and more examples of older people being abandoned in villages because they have been rejected. The rural exodus that depopulates the countryside also destroys transgenerational solidarity. Institutions to accommodate the older people—denominational, charitable, and private—are burgeoning in some African countries. Representations of dementia, marked with the projections and rejections of the older persons, run the risk to become worse, while knowledge of the populations

Violence and witchcraft accusations against older people in Central and Western Africa

Social isolation and loss of social status increase the risk of dementia, particularly in Western culture. Prevalence of dementia seems higher in the West than in areas where more traditional culture predominates (Guerchet et al., 2009). However, environmental and social changes mean that this prevalence in traditional societies is likely to increase, particularly in urban regions (Guerchet et al., 2010), where traditional transgenerational family structures tend to disappear and lifestyles are becoming more Westernized. These changes threaten the privileged status of older people, and their relationships with other family members may be subsequently damaged. New diseases that affect young adults, such as AIDS, created a climate of fear and rejection of older people, and suggestions of witchcraft may lead to abuse. Older people had always been held in Africa as belonging to a sacred age group to be treated with reverence and respect and considered as the guardians of tradition and history of the clan (a familial grouping encompassing all the descendants of a unique ancestor). Their closeness to the spirits of the protecting ancestors was thought to enable them to prevent aggression by witchcraft involving harmful spirits. It has long been believed that sorcerers have the power to command harmful spirits and thereby damage health. Illnesses have been always considered to have a supernatural dimension, despite a recent acceptance of more rational explanations. Many revivalist churches (those in the evangelical tradition) are currently being established in Africa. Their leaders are essentially “gurus” who are supplanting the traditional sorcerers and their supposed power to bridge the gap between the real and the hidden (invisible). The quest for a magical/religious explanation for illnesses leads people to look for a culprit. The older people are often suspected to mobilize these ancestors’ spirits to bless individuals and considered as using witchcraft. Consequently, it is common practice to ask the healer about the supernatural origin of serious illness, and older people are easily mentioned as potentially having used witchcraft to do harm. It sometimes happens that an older individual, who is wrongly accused, nevertheless confesses to the accusations in order to relieve the social pressure and, subsequently, develop depressive disorders. Culturally, the older people were expected to be sources of information and training, facilitating the transmission of traditional knowledge and protecting individuals in the clan against invisible forces that can cause illnesses. These valuable qualities of the older people are lost when dementia occurs. In most African cultures, dementia has no name, although the symptoms are recognized and attributed (Faure et al., 2012). Thus, socio-behavioral disorders associated with progressive deterioration of mental functions were not recognized as being pathological. Rather, they are experienced by families as harmful, intentional, and carried out by someone whose role is, by definition, to protect the clan. It is in this context that acts of violence are actually committed against concerned older people, thus running counter to customs and traditions that made them being loved, protected, respected, and even feared because of their supposed powers. Now, the older people are subject to stigma, rejection, and sometimes physical or psychological abuse. It can be suggested that dementia be classified as a mental pathology of the older people and represents failure to compensate for stress imposed by a society in which they feel they have become useless (Sink et al., 2004). Preservation of a traditional culturalmilieu constitutes a defense against the developed culture of Western countries, where individuals who lose their social status immediately become isolated and unappreciated. Dementia can appear to foreshadow death, particularly given the progressive disappearance from modern societies of religious values (Pollitt, 1996). Many workers from voluntary associations report more and more examples of older people being abandoned in villages because they have been rejected. The rural exodus that depopulates the countryside also destroys transgenerational solidarity. Institutions to accommodate the older people—denominational, charitable, and private—are burgeoning in some African countries. Representations of dementia, marked with the projections and rejections of the older persons, run the risk to become worse, while knowledge of the populations

Epidemiology of dementia in elderly living in the 3rd borough of Bangui (Central African Republic)

Given the gradual improvement of living conditions and aging, dementia and related syndromes are becoming serious problems in the developing countries. A cross-sectional door to door type study in neighbourhood, was conducted from October 2008 to January 2009, in the general population in Bangui, order to help get a better understanding of the prevalence and risk factors of dementia among people over 65 living in the Central African capital. Of the 496 elderly respondents, 188 had cognitive disorders. After a neuropsychological examination, 40 of these subjects were diagnosed with dementia. The prevalence of dementia was 8.1% (IC 95% = [5.7-10.5]). The average age of subjects with dementia, ranging from 65 to 90 years, was 76.0 ± 7.1 years. There was a significant risk of developing dementia for an increase of ten years old (OR = 2.6, 95% CI [1.5 to 4.5]). The sex-ratio was 6/34. 82.5% of the demented had never attended school. 70.0% showed a state of malnutrition (BMI ≤ 18,5 kg/m(2)), significantly associated with dementia (OR = 3.3; IC 95% = [1.5-7.3]). The blood pressure was high in 67.5% of demented which is significantly associated with dementia (OR = 2.4; IC 95% = [1.1-5.4]). A recent change in financial status was a factor significantly associated with dementia (OR = 6.4; IC 95% = [1.8-22.5]). These results support the existence of dementia in urban Africa. The observed prevalence is close to those found in high-income countries. Further studies should be conducted which includes both the rural and urban Africa, to better understand the problem and solutions consider to comprehensive care and prevention axes adapted to our context.

Dépression post accident vasculaire cérébral en Afrique : mythe ou réalité ?

Depression is a complication occurring frequently after a stroke. It negatively affects the physical, cognitive and social recovery. Authors report the results of a casecontrol study section was performed in neurology of the friendship hospital and psychiatry of the general hospital in Bangui, from January to August 2012 to ascertain the existence of a link between stroke and depression in hospitalized patients and to identify factors limiting taken into efficient load. On one hundred five subjects included, thirty five were stroke victims matched with seventy witnesses. The prevalence of post stroke depression was 88.6% (31/35) versus (20/70) 28.5% in controls (p <0.001). This post stroke depression occurred in 58% of men with a sex ratio of 1.4. The mean age of subjects with post stroke depression was 49.1 years, with extremes ranging from 33 to 76 years of age. Most (64.5%) subjects with post stroke depression was no occupation; 71.5% of them had a stroke dating back more than six weeks, and 92% had a motor deficit with a Barthel Index <100. Subjects with stroke suffered mostly moderate depression (48.1%) whereas the controls usually had mild depression (80.4%). This depression was not correlated with motor deficit, or the laterality of the lesion, or cognitive disorder. But, some Central African specificities could explain this phenomenon. These results demonstrate the reality of post stroke depression in Africa, hence the need to think in support of any subject with stroke topic. Moreover, questions about the tools used to evaluate the post stroke depression and the time interval between stroke onset and the onset of depressive symptoms remain and require further consideration.