Ennapadam S. Krishnamoorthy

Prevalence of dementia in Latin America, India, and China: a population-based cross-sectional survey

Summary Background Studies have suggested that the prevalence of dementia is lower in developing than in developed regions. We investigated the prevalence and severity of dementia in sites in low-income and middle-income countries according to two definitions of dementia diagnosis. Methods We undertook one-phase cross-sectional surveys of all residents aged 65 years and older (n=14 960) in 11 sites in seven low-income and middle-income countries (China, India, Cuba, Dominican Republic, Venezuela, Mexico, and Peru). Dementia diagnosis was made according to the culturally and educationally sensitive 10/66 dementia diagnostic algorithm, which had been prevalidated in 25 Latin American, Asian, and African centres; and by computerised application of the dementia criterion from the Diagnostic and Statistical Manual of Mental Disorders (DSM IV). We also compared prevalence of DSM-IV dementia in each of the study sites with that from estimates in European studies. Findings The prevalence of DSM-IV dementia varied widely, from 0·3% (95% CI 0·1–0·5) in rural India to 6·3% (5·0–7·7) in Cuba. After standardisation for age and sex, DSM-IV prevalence in urban Latin American sites was four-fifths of that in Europe (standardised morbidity ratio 80 [95% CI 70–91]), but in China the prevalence was only half (56 [32–91] in rural China), and in India and rural Latin America a quarter or less of the European prevalence (18 [5–34] in rural India). 10/66 dementia prevalence was higher than that of DSM-IV dementia, and more consistent across sites, varying between 5·6% (95% CI 4·2–7·0) in rural China and 11·7% (10·3–13·1) in the Dominican Republic. The validity of the 847 of 1345 cases of 10/66 dementia not confirmed by DSM-IV was supported by high levels of associated disability (mean WHO Disability Assessment Schedule II score 33·7 [SD 28·6]). Interpretation As compared with the 10/66 dementia algorithm, the DSM-IV dementia criterion might underestimate dementia prevalence, especially in regions with low awareness of this emerging public-health problem. Funding Wellcome Trust (UK); WHO; the US Alzheimers Association; and Fondo Nacional De Ciencia Y Tecnologia, Consejo De Desarrollo Cientifico Y Humanistico, and Universidad Central De Venezuela (Venezuela).

The protocols for the 10/66 dementia research group population-based research programme

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

The 10/66 Dementia Research Group's fully operationalised DSM-IV dementia computerized diagnostic algorithm, compared with the 10/66 dementia algorithm and a clinician diagnosis: a population validation study

BackgroundThe criterion for dementia implicit in DSM-IV is widely used in research but not fully operationalised. The 10/66 Dementia Research Group sought to do this using assessments from their one phase dementia diagnostic research interview, and to validate the resulting algorithm in a population-based study in Cuba.MethodsThe criterion was operationalised as a computerised algorithm, applying clinical principles, based upon the 10/66 cognitive tests, clinical interview and informant reports; the Community Screening Instrument for Dementia, the CERAD 10 word list learning and animal naming tests, the Geriatric Mental State, and the History and Aetiology Schedule – Dementia Diagnosis and Subtype. This was validated in Cuba against a local clinician DSM-IV diagnosis and the 10/66 dementia diagnosis (originally calibrated probabilistically against clinician DSM-IV diagnoses in the 10/66 pilot study).ResultsThe DSM-IV sub-criteria were plausibly distributed among clinically diagnosed dementia cases and controls. The clinician diagnoses agreed better with 10/66 dementia diagnosis than with the more conservative computerized DSM-IV algorithm. The DSM-IV algorithm was particularly likely to miss less severe dementia cases. Those with a 10/66 dementia diagnosis who did not meet the DSM-IV criterion were less cognitively and functionally impaired compared with the DSMIV confirmed cases, but still grossly impaired compared with those free of dementia.ConclusionThe DSM-IV criterion, strictly applied, defines a narrow category of unambiguous dementia characterized by marked impairment. It may be specific but incompletely sensitive to clinically relevant cases. The 10/66 dementia diagnosis defines a broader category that may be more sensitive, identifying genuine cases beyond those defined by our DSM-IV algorithm, with relevance to the estimation of the population burden of this disorder.

Dementia: A global approach

Preface 1. The aging brain and mind: cultural and anthropological perspectives Kua Ee Heok 2. Mild cognitive impairment: current concepts and cross cultural issues Seethalakshmi Ramanathan and Ennapadam S. Krishnamoorthy 3. Alzheimers Disease: the African American story Hugh Hendrie 4. Vascular cognitive impairment: 4A. The syndrome of vascular cognitive impairment: current concepts J. V. Bowler 4B. Debate: is vascular dementia more common in some parts of the world? Yes Suvarna Alladi No R. Stewart 5. Cross cultural issues of global significance: 5A. Infections and dementia - the view from a developing nation P. Satishchandra and Vijayan Joy 5B. Nutrition and dementia - where is the nexus? Alan D. Dangour and Ricardo Uauy 6. Assessment: 6A. The experience of assessing cognition across cultures Kathleen S. Hall 6B. Assessing behavior in dementia across cultures Vorapun Senanarong and Jeffrey L. Cummings 7. Psychosocial factors: 7A. Quality of life in dementia: global perspective and transcultural issues Caroline Selai, Demetris Pillas and Annabel Dodds 7B. Caregiving for dementia: global perspectives and transcultural issues T. Alphons, E. S. Krishnamoorthy and K. Gomez 7C. Care arrangements for patients with dementia: China Helen Chiu, Joshua Tsoh and Xin Yu 8. Service delivery and management: 8A. Dementia services: developing rural and remote services Sadanand Rajkumar and Julia Lane 8B. Non-pharmacological approachs: patient centred approaches S. Kalyanasundaram 9. The clinical approach to the person with dementia: 9A. Peru (South America) Mariella Guerra 9B. Nigeria Richard Uwakwe 9C. Australia David Ames and Eleanor Flynn 9D. The United States of America Jeffrey L. Cummings 9E. Japan Akira Homma 9F. China Joshua Tsoh, Helen Chiu and Xin Yu 10. Raising global awareness: the role of non-governmental organisations: 10A. The role of NGOs in raising awareness: Alzheimers Disease International Marc Wortmann 10B. Perspectives from a developing nation Jacob Roy Kuriakose 11. The contribution of cross-cultural research to dementia care and policy - an overview, focusing on the work of the 10/66 Dementia Research Group Martin J. Prince Index.

Caregiver Burden and Quality of Life of Older Persons With Stroke A Community Hospital Study in South India

This article reports a preliminary investigation in India of the association between caregiver burden and quality of life (QOL) in older persons with stroke after controlling for disability, depression, and sociodemographic factors. A cross-sectional analysis was carried out with 46 stroke patients attending a community hospital in India. The primary outcome variable was patient QOL assessed using the World Health Organization Quality of Life questionnaire–short form (WHOQOL-Bref). The primary explanatory variable was caregiver burden, assessed using the Zarit Inventory. Patient economic dissatisfaction (F = 6.12, p = .04), patient depression (F = 20.8, p < .001), and caregiver burden (F = 7.36, p = .009) were found to be associated with lower patient QOL. Caregiver burden was independently associated with lower patient QOL after controlling for patient depression, disability, and economic dissatisfaction (standardized B coefficient = −0.28, p = .03). The level of caregiver burden was a significant correlate of QOL after stroke. Implications for future studies and practice are discussed.