Lack of Association of Vascular Risk Factors with HIV-Associated Neurocognitive Disorders in cART-Treated Adults Aged ≥ 50 Years in Tanzania.

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.

Neuropsychological tests associated with symptomatic HIV-associated neurocognitive disorder (HAND) in a cohort of older adults in Tanzania.

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.

Assessing frailty amongst older people admitted to hospital in a low-income setting: a multicentre study in northern Tanzania.

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.

Dementia Prevalence and Risk Factors: Data From Rural Tanzania.

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.

The prevalence and outcomes of depression in older HIV-positive adults in Northern Tanzania: a longitudinal study.

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

Correlates of Gait Speed Among Older Adults From 6 Countries: Findings From the COSMIC Collaboration.

BACKGROUND: Few studies have compared gait speed and its correlates among different ethnogeographic regions. The goals of this study were to describe usual and rapid gait speed, and identify their correlates across Australian, Asian, and African countries. METHODS: We used data from 6 population-based cohorts of adults aged 65+ from 6 countries and 3 continents (N = 6 472), with samples ranging from 231 to 1 913. All cohorts are members of the Cohort Studies of Memory in an International Consortium collaboration. We investigated whether clinical (body mass index [BMI], hypertension, stroke, apolipoprotein status), psychological (cognition, mood, general health), and behavioral factors (smoking, drinking, physical activity) correlated with usual (N = 4 cohorts) and rapid gait speed (N = 3 cohorts) similarly across cohorts. Regression models were controlled for age, sex, and education, and were sex-stratified. RESULTS: Age- and sex-standardized usual gait speed means ranged from 0.61 to 1.06 m/s and rapid gait speed means ranged from 1.16 to 1.64 m/s. Lower BMI and better cognitive function consistently correlated with faster gait speed in all cohorts. Less consistently, not having hypertension and greater physical activity engagement were associated with faster gait speed. Associations with mood, smoking, and drinking were largely nonsignificant. These patterns were not attenuated by demographics. There was limited evidence that the associations differed by sex, except physical activity, where the greater intensity was associated with usual gait among men but not women. CONCLUSIONS: This study is among the first to describe the usual and rapid gait speeds across older adults in Africa, Asia, and Australia.

Prevalence and 1-year incidence of HIV-associated neurocognitive disorder (HAND) in adults aged ≥50 years attending standard HIV clinical care in Kilimanjaro, Tanzania.

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.

Pleural effusion and respiratory compromise from spontaneous migration of a ventriculoperitoneal shunt catheter in a patient with normal-pressure hydrocephalus.

Background: Ventriculoperitoneal shunt (VPS) insertion is one of the most common neurosurgical procedures done around the world to treat hydrocephalus. The occurrence of spontaneous migration of the peritoneal shunt catheter into the thoracic cavity is a very rare complication; we report here case number 27 of respiratory complications of a VPS in a patient with normal-pressure hydrocephalus (NPH). Case Description: A 76-year-old woman with Alzheimer's disease and anosognosia was diagnosed idiopathic NPH treated surgically with a VPS. Pleural effusion and pulmonary complications occurred 4 weeks after the insertion of the shunt due to the spontaneous migration of the peritoneal catheter of the VPS into the thoracic cavity. The hydrothorax of cerebrospinal fluid was drained and the distal catheter was removed and replaced. The patient made an uneventful recovery. Conclusion: Due to the rarity of this complication, there are no standard corrective procedures. Some of the methods used to diagnose and successfully treat this rare complication of the VPS are presented.

Neurological disorders in Northern Tanzania: A 6-year prospective hospital-based case series.

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.

The Cause and Duration of Emergency Admissions to Hospital in People with Idiopathic Parkinson's Disease, Under the Care of a UK Service, During the First Year of the COVID-19 Pandemic.

BACKGROUND: People with Parkinson's disease (PD) have higher rates of hospitalisation and healthcare utilisation compared to the general population. The COVID-19 pandemic caused significant changes in admissions to hospital and access to healthcare. People with PD are some of the most vulnerable to such changes. There is no pre-existing data on the cause and duration of admission to hospital of people with PD during the COVID-19 pandemic. OBJECTIVE: To determine the cause, duration, and outcome of hospital admissions to Northumbria Healthcare NHS Foundation Trust (NHCFT) for people with idiopathic Parkinson's disease (IPD) in 2020. METHODS: All people with IPD who had an emergency admission to NHCFT between 01/01/2020 and 31/12/2020 were identified. Demographic and disease characteristics, the number, duration, cause of admission and the location prior to admission were collected from an audit of medical notes. RESULTS: 271 people with IPD had one or more emergency admissions to NHCFT between 01/01/2020 and 31/12/2020. There was a total of 453 emergency admissions, with a median duration of 5 (IQR 2-13) days. The most common causes of admission to hospital were PD-related motor dysfunction (includes falls with no other underlying cause or associated injury) and injury (includes falls with fracture), at 78 (17.2%) and 70 (15.5%) respectively. CONCLUSIONS: People with IPD had a short duration but high number of emergency admissions to hospital. Our chronological data on number of admissions shows a peak in admissions during August 2020. As a result of these findings and emerging data we suggest that individuals with PD deconditioned during 2020.

The spectrum and burden of in-patient paediatric musculoskeletal diseases in Northern Tanzania.

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.

Screening for delirium and dementia in older hospitalised adults in Zambia.

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.

Social Vulnerability, Frailty, and Their Association With Mortality in Older Adults Living in Rural Tanzania.

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.

HIV-Associated Neurocognitive Disorders: The First Longitudinal Follow-Up of a cART-Treated Cohort of Older People in Sub-Saharan Africa.

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.

Factors affecting family medicine programmes in Sub-Saharan Africa: a narrative review of recent literature.

Objective: To identify the factors enabling and limiting family medicine (FM) programmes in Sub-Saharan Africa (SSA). Design: A narrative review was conducted by searching a variety of databases. Papers focusing on the training, deployment, or contribution to healthcare systems of doctors with postgraduate training in FM in SSA, published in peer-reviewed journals from 2015 onwards and in English language were included. Included papers underwent qualitative analysis. Results: Seventy-one papers were included in the review. 38% focussed on South Africa, while papers focussing on FM in a further 15 countries in SSA were identified. Key factors enabling FM programmes are support from key stakeholders, recognition of family practitioners (FP) as specialists, international collaboration, and dedicated FPs. Key factors limiting FM programmes are a lack of sufficient and well-trained faculty, inappropriate training settings, higher rates of trainee attrition, lack of FM in undergraduate curriculums, lack of career pathways, inappropriate deployment, and a lack of a critical mass. Conclusions: Support from national stakeholders, the recognition of FPs as specialists, and sustainable international collaboration promote FM programmes. The absence of a defined role within the healthcare system, low numbers of FM faculty, a poor presence in undergraduate curriculum, high attrition rate of trainees and the lack of a critical mass limit FM programmes. The standardisation of the role of FM and the implementation of undergraduate and postgraduate FM programmes with national and international collaboration could enable FM to reach a critical mass and realise its full potential in strengthening primary healthcare in SSA. Funding: None declared.

Development of a brief screening method for identification of depression in older adults in 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.

Understanding Caregiver Strain in Parkinsonism-A Mixed Methods Approach.

BACKGROUND: Parkinsonism, including Parkinson's disease (PD) are progressive neurological conditions. As these condition progress, individuals will need more support with their care needs to maintain independent community-living. Care needs are mainly met by unpaid, informal caregivers, usually close family members or friends. Caregiver strain is thought to lead to the need for care home placement when the caregiver can no longer cope. OBJECTIVE: To understand predictors of caregiver strain and its influence on care home placement for people with moderate to advanced Parkinsonism. METHODS: This is a convergent mixed methods study. Quantitative data, following an adapted stress-appraisal model, were collected on caregiver profile, tasks performed and causes of caregiver strain. Semi-structured, in-depth interviews were conducted with caregivers of people with PD (PwP) who went into a care home during the study period, to develop a deeper understanding of the caregiver role and the factors influencing caregiver strain. RESULTS: Quantitative data were collected from 115 patient caregiver dyads. Interviews were conducted with 10 caregivers. A model to predict caregiver strain was developed and predictors of caregiver strain were identified, such as functional disability and poor caregiver sleep. CONCLUSION: Our findings further demonstrate the complexity of carer strain. Particular dimensions are identified that need to be addressed within clinical practice to reduce carer strain and support people with Parkinsonism to remain within their own home for as long as possible.

Driving and Parkinson's Disease: A Survey of the Patient's Perspective.

BACKGROUND: Parkinson's disease (PD) is a multi-system disorder that can impact on driving ability. Little is known about how these changes in driving ability affect people with PD, making it difficult for clinicians and carers to offer appropriate support. OBJECTIVE: To assess patient views concerning the effect of PD on their driving ability, the impact of these changes and how they manage them. METHOD: An online survey was created by a team of clinicians, people with PD, their carers, and representatives from Parkinson's UK. People with PD throughout the United Kingdom were invited to participate through Parkinson's UK's website, newsletter and Parkinson's Excellence Network email list. RESULTS: 805 people with PD took part in the survey. We found that the loss of a driving licence had an adverse impact on employment, socialisation, travel costs and spontaneous lifestyle choices. Multiple changes in driving ability related to PD were described, including that impulse control disorders can have an adverse impact on driving. Changes in driving ability caused people to change their driving practices including taking shorter journeys and being less likely to drive at night. Participants advised managing changes in driving ability through planning, vehicle adaptions, maintaining skills and self-assessment. CONCLUSION: This study demonstrates the impact that changes in driving ability can have on the lifestyle of people with PD and reveals the strategies that individuals adopt to manage these changes.

Factors affecting family medicine programmes in Sub-Saharan Africa: a narrative review of recent literature

Objectives: This study sought to assess the level of anti-glycaemic medication-taking and its predictors among adults living with diabetes receiving treatment at Cape Coast Teaching Hospital (CCTH). Design: This was a cross-sectional study carried out among adults living with diabetes and receiving care at CCTH. Data on socio-demographic characteristics and anti-glycaemic medication-taking were gathered using a structured questionnaire. A scale consisting of 4 domains (filling prescribed medication; taking medications appropriately ac-cording to the instructions of healthcare professionals; practising behavioural modifications, and showing up for fol-low-up appointments) and eight items was used to measure the level of anti-glycaemic medication-taking. Descriptive statistics, chi-square test (and Fisher's exact test where appropriate), bivariate and multivariate logistic regression models were used in analysing the data. Setting: The study was carried out in the diabetes clinic in Cape Coast Teaching Hospital. Participants: The total enumerative sampling technique was used to select 250 adults living with diabetes and receiv-ing care at CCTH.Main outcome measures: Anti-glycaemic medication-taking Results: Out of 250 participants studied, 42% had high anti-glycaemic medication-taking. Predictors of anti-glycae-mic medication-taking included; forgetfulness (aOR=0.02, 95% CI: 0.00-0.64, p<0.001), patient's involvement in treatment plan (aOR=0.12, 95% CI: 0.02-0.64, p=0.014) and having good knowledge about one's medication (aOR=2.34, 95% CI: 1.10-4.98, p=0.028). Conclusion: Less than half of the sample population (42%) had high anti-glycaemic medication-taking, with forget-fulness, involvement in the treatment plan and good knowledge about anti-glycaemic medications, predicting medi-cation-taking

Stroke in Africa: profile, progress, prospects and priorities.

Stroke is a leading cause of disability, dementia and death worldwide. Approximately 70% of deaths from stroke and 87% of stroke-related disability occur in low-income and middle-income countries. At the turn of the century, the most common diseases in Africa were communicable diseases, whereas non-communicable diseases, including stroke, were considered rare, particularly in sub-Saharan Africa. However, evidence indicates that, today, Africa could have up to 2-3-fold greater rates of stroke incidence and higher stroke prevalence than western Europe and the USA. In Africa, data published within the past decade show that stroke has an annual incidence rate of up to 316 per 100,000, a prevalence of up to 1,460 per 100,000 and a 3-year fatality rate greater than 80%. Moreover, many Africans have a stroke within the fourth to sixth decades of life, with serious implications for the individual, their family and society. This age profile is particularly important as strokes in younger people tend to result in a greater loss of self-worth and socioeconomic productivity than in older individuals. Emerging insights from research into stroke epidemiology, genetics, prevention, care and outcomes offer great prospects for tackling the growing burden of stroke on the continent. In this article, we review the unique profile of stroke in Africa and summarize current knowledge on stroke epidemiology, genetics, prevention, acute care, rehabilitation, outcomes, cost of care and awareness. We also discuss knowledge gaps, emerging priorities and future directions of stroke medicine for the more than 1 billion people who live in Africa.