Dementia In sub-Saharan Africa Research Articles

Anti-Oxytotic/Ferroptotic Neuroprotection by Medicinal Plants from Côte d’Ivoire

Dementia in sub-Saharan Africa has been largely underestimated, but the cases are expected to increase substantially as African countries are experiencing highrates of growthin older people. As conventional medicine is expensive and often inaccessible, the majority of the communities in Africa rely on traditional medicine for basic health care. Plants may be a valuable source of neurotherapeutics, particularly of inhibitors of oxytosis/ferroptosis, a neurodegenerative pathway associated with dementia. This study evaluated the anti-oxytotic/ferroptotic activity of different plants used in the traditional medicine of Côte d’Ivoire. Ten plant species (Adenia cissampeloides, Adenia lobata, Entada mannii, Enantia polycarpa, Harungana madagascariensis, Kigelia africana, Terminalia ivorensis, Terminalia mantaly, Terminalia superba and Vernonia amygdalina) were selected based on their traditional use and the respective parts were collected in the Agboville region of South-eastern Côte d’Ivoire. Extracts were prepared by maceration in water and tested for protection in a nerve cell culture model of oxytosis/ferroptosis. The neuroprotective effects of the extracts werefurther evaluated in additional cell-based assays, including intracellular Aβ toxicity, energy loss, inflammation and neurite differentiation. Terminalia ivorensis, Terminalia mantaly and Terminalia superba offered the best protection overall in the assays. They provided strong inhibition of oxytosis/ferroptosis as well as excellent protection against intracellular Aβ toxicity and energy loss. Additional studies are required to confirm the efficacy of these plants as neurotherapeutics, but the findings highlight the potential of plants used in the traditional medicine of Côte d’Ivoire to provide new treatments for dementia.

Poster Symposium: How Well do Western Methods Used to Assess Atypical Aging in Western Countries Generalize to Sub-Saharan African Countries?

Summary Abstract:Risk factors associated with development of neurodegenerative disease has been well-studied in Western and European populations. However, there has been considerably less research in the assessment of such risk factors in developing countries, notably sub-Saharan Africa. There is a paucity of data at the micro level (e.g. neuroimaging and biomarker data) and macro level (e.g. cognitive assessment and psychosocial/environmental risk factors) for development of neurodegenerative conditions in these populations.This symposium examines Western methods of assessment of risk factors and cognitive profiles of older adults at risk for neurodegenerative disorder to determine if they are relevant to sub-Saharan African populations, specifically older Congolese adults. This symposium utilizes an older adult sample that has been comprehensively assessed both at the cellular level (via blood biomarkers and neuroimaging typically used for assessment of dementia in Western populations), to the individual functional level (via cognitive assessment), to finally, psychosocial and environmental risk factors for dementia seen at a community level. First, Dr. Ikanga will present on the association between performance on the African Neuropsychological Battery (ANB) with biomarkers specific to Alzhemer's disease and more general vascular risk factors for cognitive decline. Second, Dr. Hickle will present on structural neuroimaging data of mesial temporal lobe atrophy in comparison with performance on the ANB. Dr. Reyes will then discuss the utility of a cognitive screener developed for use in Sub-Saharan Africa on older adults from the Democratic Republic of Congo, with specific emphasis on educational corrections. Finally, Dr. De Wit will discuss health and psychosocial predictors of depressive symptoms as well as the relation between depressive symptoms and neuropsychological functioning in Congolese older adults, to determine if neurocognitive profiles are similar in Sub-Saharan Africa relative to Western populations. This "micro to macro" approach is unique in providing a comprehensive overview of risks associated with dementia in Congolese adults. This is the first study of its kind to utilize a multi-method approach for older adults at risk for dementia in Sub-Saharan Africa, and results suggest that some approaches are more valid in this population than others. Future areas of research will be discussed, as well as feasibility and validity of Western approaches in assessment of dementia to non-Western populations.

Dementia Prevalence and Risk Factors: Data From Rural Tanzania.

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 60y) attending the outpatient department of Mount Meru Hospital in Tanzania. 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. 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 <18.5kg/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. 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.

Prevalence of suspected dementia in a sample of adults living in Kinshasa-Democratic Republic of the Congo.

The prevalence of dementia in Sub-Saharan Africa, particularly in French-speaking countries, has received limited attention. This study investigates the prevalence and risk factors of suspected dementia in elderly adults in Kinshasa, Democratic Republic of the Congo (DRC). A community-based sample of 355 individuals over 65 years old was selected using multistage probability sampling in Kinshasa. Participants were screened using the Community Screening Instrument for Dementia, Alzheimer's Questionnaire, Geriatric Depression Scale, Beck Anxiety Inventory, and Individual Fragility Questionnaire, followed by clinical interview and neurological examination. Suspected dementia diagnoses were made based on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria including significant cognitive and functional impairments. Prevalence and odds ratios (ORs) with 95% confidence interval (CI) were calculated using, respectively, regression and logistic regression. Among 355 participants (mean age 74, SD=7; 51% male), the crude prevalence of suspected dementia was 6.2% (9.0% in women and 3.8% in men). Female sex was a significant factor associated with suspected dementia [OR=2.81, 95% CI (1.08-7.41)]. The prevalence of dementia increased with age (14.0% after 75 years and 23.1% after 85 years), with age being significantly associated with suspected dementia [OR=5.42, 95% CI (2.86-10.28)]. Greater education was associated with a lower prevalence of suspected dementia [OR=2.36, 95% CI (2.14-2.94), comparing those with ≥7.3 years of education tothose with <7.3 years of education]. Other factors associated with the prevalence of suspected dementia included being widowed (OR=1.66, 95% CI (1.05-2.61), being retired or semi-retired (OR=3.25, 95% CI (1.50-7.03)], a diagnosis of anxiety [OR=2.56, 95% CI (1.05-6.13)], and death of a spouse or a relative after age 65 [OR=1.73, 95% CI (1.58-1.92)]. In contrast, depression [OR=1.92, 95% CI (0.81-4.57)], hypertension [OR=1.16, 95% CI (0.79-1.71)], body mass index (BMI) [OR=1.06, 95% CI (0.40-2.79)], and alcohol consumption [OR=0.83, 95% CI (0.19-3.58)] were not significantly associated with suspected dementia. This study found a prevalence of suspected dementia in Kinshasa/DRC similar to other developing countries and Central African countries. Reported risk factors provide information to identify high-risk individuals and develop preventive strategies in this setting.

A systematic review and narrative synthesis of the experiences with caring for older people living with dementia in Sub-Saharan Africa

BackgroundIn low- and middle-income countries, including sub-Saharan Africa little is known about the experiences with caring for people living with dementia. The purpose of this systematic review and narrative synthesis was to examine the experiences with caring for older people living with dementia at home.ResultsIn total, 366 abstracts were identified and following screening, 19 studies were included in the synthesis. Six themes were identified: conceptualising dementia, caregiving arrangements, the impact of caregiving, caregiver identity and role, managing caregiving, unmet caregiver needs.ConclusionThere is a dearth of research in relation to caregiving for older people living with dementia in sub-Saharan Africa. There is need for better information campaigns and support programs directed at family and professional caregivers in this context.

426 PREVALENCE OF, AND RISK FACTORS FOR, DEMENTIA IN ADULT OUTPATIENT REFERRALS TO A REGIONAL REFERRAL HOSPITAL IN ARUSHA, TANZANIA

Abstract Introduction The global burden of dementia is increasing, with the greatest increase predicted to occur in sub-Saharan Africa (SSA). Despite this there are limited previous data on the prevalence of, and risk factors for, dementia in SSA. This study aimed to estimate the prevalence of dementia, and investigate its associations, in those aged 60 years and older attending the outpatient department of Mount Meru Hospital in northern Tanzania. This is the first hospital-based outpatient dementia prevalence and risk factors study to be conducted in an east African population. Methods This was a one-phase cross-sectional study. Adults aged 60 years and over attending medical outpatients were screened for dementia using The Identification and Intervention for Dementia in Elderly Africans cognitive screening tool. Those who scored ≤9 were clinically assessed using the DSM-IV criteria. Demographic, medical comorbidity and lifestyle information were collected during a clinical assessment. Results Prevalence of dementia was 5.0% (95% confidence interval: 3.7–6.3). Binary logistic regression found female sex (odds ratio (OR) = 2.778), having no formal education (OR = 6.088), quantity of alcohol consumption (units/week) (OR = 1.080), uncorrected visual impairment (OR = 4.260), body mass index &amp;lt;18.5 kg/m2 (OR = 6.588) and stroke (OR = 15.790 with wide 95% confidence interval (3.48–74.475)) to be significantly, independently associated with dementia. Conclusions The prevalence of dementia in this population is lower than previously reported community-based rates in Tanzania, and similar to those in high-income countries. This is the first time the association between uncorrected visual impairment and dementia has been reported in SSA. Other associations identified are in keeping with previous literature. Further research on the management of dementia and its risk factors, and the support and education of carers and patients in east African populations is required.

Prevalence estimates of dementia in older adults in rural Kilimanjaro 2009-2010 and 2018-2019: is there evidence of changing prevalence?

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. 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. 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. 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.

Culturally Tailored Interventions for People Affected by Dementia: A Systematic Review and Conceptual Model About Implementation

Background: Dementia prevalence is higher in low- and middle-income countries (LMICs) and some minority ethnic (ME) groups but these groups are less likely to receive interventions. Methods: In this systematic review, we searched 11 electronic databases from inception to May 26th, 2019. We included non-drug cognitive, psychological or social interventions for people with dementia and their family carers tailored to people in LMICs and ME groups, and provided details of how they were culturally tailored. We assessed study quality and conducted a narrative synthesis of the acceptability, feasibility and effectiveness of culturally tailored interventions, distinguishing between evidence-based interventions, culturally adapted for a new setting and newly developed, culturally tailored interventions with no existing evidence base. This study was registered with PROSPERO: CRD42019133090. Findings: Our searches retrieved 40,558 results of which 23 were eligible for inclusion. Evidence-based, multicomponent interventions adapted for Latino carers were acceptable, feasible and effective in the US and Columbia. Interventions developed for carers in India were effective there but not in other LMICs. Culturally adapted Cognitive Stimulation Therapy was acceptable and feasible to people with dementia in Sub-Saharan Africa. Adaptations were made to peripheral intervention components with core therapeutic components unchanged. Interpretation: We propose a conceptual model based on our findings to aid implementation of culturally appropriate treatments for people affected by dementia in LMICs and ME groups. Evidence-based interventions need to be adapted for culturally different settings with therapeutic components retained, and tested for acceptability, feasibility and evidence that they remain effective. Full effectiveness trials are then unnecessary. Funding Statement: National Institute for Health Research Applied Research Collaboration North Thames and Alzheimer’s Society. Declaration of Interests: None.

Severity of Neuropsychiatric Symptoms and Distress in Dementia among Older People in Central Africa (EPIDEMCA Study).

Neuropsychiatric symptoms are common in dementia. Limited data are available concerning their association with dementia in developing countries. Our aim was to describe the severity of neuropsychiatric symptoms among older people, evaluate the distress experienced by caregivers, and assess which neuropsychiatric symptoms were specifically associated with dementia among older adults in Central Africa. This study is part of the EPIDEMCA program, a cross-sectional multicenter population-based study. The EPIDEMCA program was conducted from November 2011 to December 2012 in urban and rural areas of the Central African Republic and the Republic of the Congo. Participants were older people (≥65 y) included in the EPIDEMCA program who underwent a neuropsychiatric evaluation. The sample included overall 532 participants, of whom 130 participants had dementia. Neuropsychiatric symptoms were assessed with the brief version of the Neuropsychiatric Inventory including the evaluation of severity and associated distress. Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision, criteria were followed to diagnose dementia. A logistic regression model was used to identify associated neuropsychiatric symptoms. The prevalence of neuropsychiatric symptoms was 89.9% (95% confidence interval = 84.6-95.1) among people living with dementia. The overall median severity score for neuropsychiatric symptoms was 9 [interquartile range [IQR] = 6-12], and the overall median distress score was 7 [IQR = 4-10]. Overall median scores of both severity and distress were significantly increased with the number of neuropsychiatric symptoms, the presence of dementia, and dementia severity. Depression, delusions, apathy, disinhibition, and aberrant motor behavior were associated with dementia after multivariate analysis. This report is one of the few population-based studies on neuropsychiatric symptoms among older people with dementia in Sub-Saharan Africa and the first one evaluating the severity of those symptoms and distress experienced by caregivers. Individual neuropsychiatric symptoms were strongly associated with dementia in older people and require great attention considering their burden on populations. J Am Geriatr Soc 68:180-185, 2019.

Factors Affecting Caregivers' Acceptance of the Use of Wearable Devices by Patients With Dementia: An Extension of the Unified Theory of Acceptance and Use of Technology Model.

This study aims to examine the factors affecting caregivers' acceptance of the use of wearable devices by patients with dementia by extending the Unified Theory of Acceptance and Use of Technology (UTAUT) model with 2 additional constructs: resistance to change (RC) and technology anxiety (TA). A structured online questionnaire was developed and distributed to caregivers who have either dealt previously with or were currently taking care of patients with dementia in sub-Saharan Africa. The selection of countries for the study was purely based on the availability of caregivers of patients with dementia and their readiness to take part in the survey. Questionnaire data from 350 respondents were analyzed and the hypothesis tested using partial least squares based on structural equation modeling. The results of the extended model show that social influence, effort expectancy, facilitating conditions, and behavioral intention (BI) all had P < .05, thus were statistically significant in explaining the perceived BI and actual use of health-care wearable devices among patients with dementia as reported by caregivers. However, P value for RC and TA was greater than .05, hence were insignificant.

Clinical characteristics and treatment outcomes among stroke patients hospitalized to Nekemte referral hospital, western Ethiopia

ObjectivesStroke is the brain equivalent of a heart attack. It is one of the most common causes of morbidity and mortality worldwide and is a prominent cause of death, disability and dementia in sub-Saharan Africa (SSA). Hence, the purpose of this study was to assess the clinical characteristics and treatment outcomes among hospitalized stroke patients at Nekemte referral hospital (NRH). Patients and methodsRetrospective cross sectional study design was conducted on randomly selected stroke patients admitted to medical wards of NRH from 2013 to 2017. ResultsAmong 364 patients included in the study, 208 (57.1%) were males and the mean age of the patients was 59.66 ± 13.4 years. Regarding types of stroke, 192 (52.7%) were diagnosed as having ischemic stroke. During admission 132 (36.3%) patients complained left side body weakness (hemiparesis) and the major risk factor identified was hypertension 230 (63.2%). Overall, 65.4% of patients had poor outcome while 34.6% of patients had good out comes (improved). Being illiterate /unable to read and write (AOR = 3.94, 95% CI: 1.31–11.76, P = 0.01), attending secondary school (AOR = 3.6, 95% CI: 1.4–9.17, P = 0.007) and length of hospital stay >5 days (AOR = 2, 95% CI: 1.04–3.86, P = 0.037) were independent predictors of poor treatment outcome. ConclusionAbout two third of the patients had poor treatment outcome. Educational status and mean length of hospital stays were independent predictors of poor treatment out-comes. An emergency care setup capable of early patient evaluation, identification and management of stroke complications is crucial to overcome early stroke related mortality.

People with Dementia in Sub-Saharan Africa: From Support to Abuse by Caregivers: Results of EPIDEMCA-FU Program in Congo

Background/Aims: Dementia is an emerging public health problem in sub-Saharan Africa (SSA). In SSA, the stigma suffered by people with dementia (PWD) can be strongly linked to pejorative social representations, interfering in social relationships with informal caregivers. The objective of the study was to analyze the consequences of social representations of PWD in social interactions with informal caregivers. Methods: A qualitative study was conducted in Republic of Congo among 93 interviewees. Nondirectional interviews were conducted in local languages and complemented by participating observations. The collected data were transcribed literally, synthesized, and then coded to allow extraction and organization of text segments. Results: Informal caregivers, daughters-in-laws, were considered as abusers and granddaughters as benevolent. The leaders of syncretic churches and traditional healers were the first therapeutic itineraries of PWD, due to pejorative social representations of disease. Of these, some PWD have appeared at front of a customary jurisdiction for accusations of witchcraft. Dementia, perceived as a mysterious disease by informal caregivers, wasn’t medicalized by leaders of syncretic churches, traditional healers, nurses, or general practitioners. Conclusion: Stigma, generated by social representations, can change the patient’s behavior and the one of informal caregivers, leading to time delay in the search for appropriate help.

Knowledge, attitudes and practices related to stroke in Ghana and Nigeria: A SIREN call to action.

IntroductionStroke is a prominent cause of death, disability, and dementia in sub-Saharan Africa (SSA). The Stroke Investigative Research and Education Network works collaboratively with stroke survivors and individuals serving as community controls to comprehensively characterize the genomic, sociocultural, economic and behavioral risk factors for stroke in SSA.PurposeIn this paper, we aim to: i) explore the attitudes, beliefs, and practices related to stroke in Ghana and Nigeria using the process of qualitative description; and ii) propose actions for future research and community-based participation and education.MethodsStroke survivors, their caregivers, health care professionals, and community representatives and faith-based leaders participated in one of twenty-six focus groups, which qualitatively explored community beliefs, attitudes and practices related to stroke in Ghana and Nigeria. Arthur Kleinman’s Explanatory Model of Illness and the Social Ecological Model guided the questions and/or thematic analysis of the qualitative data. We hereby describe our focus group methods and analyses of qualitative data, as well as the findings and suggestions for improving stroke outcomes.Results and discussionThe major findings illustrate the fears, causes, chief problems, treatment, and recommendations related to stroke through the views of the participants, as well as recommendations for working effectively with the SIREN communities. Findings are compared to SIREN quantitative data and other qualitative studies in Africa. As far as we are aware, this is the first paper to qualitatively explore and contrast community beliefs, attitudes, and practices among stroke survivors and their caregivers, community and faith-based leaders, and health professionals in multiple communities within Nigeria and Ghana.

Screening for Instrumental Activities of Daily Living in Sub-Saharan Africa: A Balance Between Task Shifting, Simplicity, Brevity, and Training.

Task shifting has been suggested as one way to help manage the increasing burden of dementia in sub-Saharan Africa (SSA). However, brief, easy-to-use and valid screening tools are needed to support this approach. Our team has developed an 11-item questionnaire to assess instrumental activities of daily living (IADLs) in SSA, the Identification and Intervention for Dementia in Elderly Africans (IDEA)-IADL questionnaire. We aimed to externally validate the questionnaire and develop a shorter, more efficient version. A community-based sample of 329 older adults in 4 rural villages was screened for dementia using the validated IDEA cognitive screen and the 11-item IDEA-IADL questionnaire. A stratified sample was assessed for Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) dementia by a United Kingdom-based doctor, who was blinded to the results of screening. Area under the receiver operating characteristic (AUROC) curve analysis was used to assess validity, and factor analysis and regression modeling were used to develop a shorter version of the questionnaire. A 3-item IDEA-IADL questionnaire was developed and externally validated in the study sample. The questionnaire was deemed to be valid and enhanced screening performance in 2 villages (AUROC: 0.857 and 0.895) but detracted from the accuracy of the IDEA cognitive screen in the other 2 villages (AUROC: 0.591 and 0.639). These differences appeared to be due to differences in interpretation of responses to questions by the assessors. A brief IDEA-IADLs scale was developed and worked well in some villages. However, our study highlights a training need if brief screening tools to assess IADLs are to be effectively used by nonspecialists in low-resource settings.

A longitudinal study of cognitive decline in rural Tanzania: rates and potentially modifiable risk factors.

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. 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. 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.

EARLY LIFE AND COGNITIVE RESERVE: ASSOCIATIONS WITH DEMENTIA AMONG OLDER PEOPLE IN CENTRAL AFRICA IN THE EPIDEMCA POPULATION-BASED STUDY

Some evidence suggests that early life experiences, during the brain development and maturation period, influence the risk of developing dementia in late life. Indicators of brain development, early life nutrition, stressful life events as well as education and occupational attainment have shown associations with the prevalence or the incidence of dementia. However the evidence was mainly established in high-income settings. The aim of this study is to investigate the association between early life and cognitive reserve indicators with dementia in sub-Saharan African countries. A multicentre population-based study was carried out in Central African Republic and Republic of Congo between 2011 and 2012 including both urban and rural sites. Participants aged ≥65 years old were interviewed using a structured questionnaire and underwent a physical examination. Leg length (index of brain development), skull circumference (index of early life nutrition), early life events (residence, stressful life events), education, and occupational attainment data were collected. Participants in Congo were followed up for 2 years. DSM-IV and NINCDS-ADRDA criteria were required for dementia and Alzheimer's disease diagnoses at baseline and follow-up. The effect of covariates on dementia prevalence and incidence were modelled using Poisson and competing-risk regression models. At baseline, 2002 participants were included in both countries. Overall, mean age was 73.3 ± 6.7 years, sex-ratio M/F was 0.62 and 135 were diagnosed with dementia. Over 68% of the participants had no formal education, half were farmer/breeder (49.2%) and 11.6% reported a full-time occupation. Regarding early life, only 18.9% had never lived a stressful event during their childhood and 20.0% were born in the countryside. After adjustment on site, age, and sex, only a smaller skull circumference was significantly associated with dementia prevalence (PR=2.2 (95%CI:1.1–4.4). Interactions between early life and cognitive reserve indicators and sex or study area, as well as the effects on dementia incidence within the Congolese participants will be presented in details. Preliminary results support the effect of early life nutrition on dementia prevalence in late-life in Central Africa. These results will add to the scarce evidence on early life, cognitive reserve and dementia in sub-Saharan Africa.

Cognitive stimulation therapy as a sustainable intervention for dementia in sub-Saharan Africa: Feasibility and clinical efficacy using a stepped-wedge design - ERRATUM.

In the above article (Paddick, 2017) The corresponding author's details were previously listed incorrectly. The correct details are; contact number +44 191 293 2709 and email address William.gray@nhct.nhs.uk. The original article has been updated with the correct contact details. The publishers apologise for any inconvenience and confusion this error has caused.

Cognitive stimulation therapy as a sustainable intervention for dementia in sub-Saharan Africa: feasibility and clinical efficacy using a stepped-wedge design.

Cognitive stimulation therapy (CST) is a psychosocial group-based intervention for dementia shown to improve cognition and quality of life with a similar efficacy to cholinesterase inhibitors. Since CST can be delivered by non-specialist healthcare workers, it has potential for use in low-resource environments, such as sub-Saharan Africa (SSA). We aimed to assess the feasibility and clinical effectiveness of CST in rural Tanzania using a stepped-wedge design. Participants and their carers were recruited through a community dementia screening program. Inclusion criteria were DSM-IV diagnosis of dementia of mild/moderate severity following detailed assessment. No participant had a previous diagnosis of dementia and none were taking a cholinesterase inhibitor. Primary outcomes related to the feasibility of conducting CST in this setting. Key clinical outcomes were changes in quality of life and cognition. The assessing team was blind to treatment group membership. Thirty four participants with mild/moderate dementia were allocated to four CST groups. Attendance rates were high (85%) and we were able to complete all 14 sessions for each group within the seven week timeframe. Substantial improvements in cognition, anxiety, and behavioral symptoms were noted following CST, with smaller improvements in quality of life measures. The number needed to treat was two for a four-point cognitive (adapted Alzheimer's Disease Assessment Scale-Cognitive) improvement. This intervention has the potential to be low-cost, sustainable, and adaptable to other settings across SSA, particularly if it can be delivered by non-specialist health workers.

The role of traditional and faith healers in the treatment of dementia in Tanzania and the potential for collaboration with allopathic healthcare services.

Low diagnostic rates are a barrier to improving care for the growing number of people with dementia in sub-Saharan Africa. Many people with dementia are thought to visit traditional healers (THs) and Christian faith healers (FHs) and these groups may have a role in identifying people with dementia. We aimed to explore the practice and attitudes of these healers regarding dementia in rural Tanzania and investigate attitudes of their patients and their patients’ carers. This was a qualitative study conducted in Hai district, Tanzania. Semi-structured interviews were conducted with a convenience sample of THs and FHs and a purposive-stratified sample of people with dementia and their carers. Interview guides were devised which included case vignettes. Transcripts of interviews were subject to thematic analysis. Eleven THs, 10 FHs, 18 people with dementia and 17 carers were recruited. Three themes emerged: (i) conceptualisation of dementia by healers as a normal part of the ageing process and no recognition of dementia as a specific condition; (ii) people with dementia and carer reasons for seeking help and experiences of treatment and the role of prayers, plants and witchcraft in diagnosis and treatment; (iii) willingness to collaborate with allopathic healthcare services. FHs and people with dementia expressed concerns about any collaboration with THs. Although THs and FHs do not appear to view dementia as a specific disease, they may provide a means of identifying people with dementia in this setting.

Cognitive stimulation therapy as a low-resource intervention for dementia in sub-Saharan Africa (CST-SSA): Adaptation for rural Tanzania and Nigeria.

Cognitive stimulation therapy is a non-pharmacological intervention for people with dementia. Its use has been associated with substantial improvements in cognition and quality of life in studies from high-income countries, equivalent to those achieved by pharmacological treatments. Cognitive stimulation therapy may be particularly suited to low resource settings, such as sub-Saharan Africa, because it requires little specialist equipment and can be delivered by non-specialist health workers. The aim of this study was to adapt cognitive stimulation therapy for use in sub-Saharan Africa taking into account socio-cultural differences and resource implications. Cognitive stimulation therapy is a structured programme, originally developed in the United Kingdom. Substantial adaptations were required for use in sub-Saharan Africa. The formative method for adapting psychotherapy was used as a framework for the adaption process. The feasibility of using the adapted cognitive stimulation therapy programme to manage dementia was assessed in Tanzania and Nigeria in November 2013. Further adaptations were made following critical appraisal of feasibility. The adapted cognitive stimulation therapy intervention appeared feasible and acceptable to participants and carers. Key adaptations included identification of suitable treatment settings, task adaptation to accommodate illiteracy and uncorrected sensory impairment, awareness of cultural differences and usage of locally available materials and equipment to ensure sustainability. Cognitive stimulation therapy was successfully adapted for use in sub-Saharan Africa. Future work will focus on a trial of cognitive stimulation therapy in each setting.