The 2022 symposium on dementia and brain aging in low- and middle-income countries: Highlights on research, diagnosis, care, and impact.

Two of every three persons living with dementia reside in low- and middle-income countries (LMICs). The projected increase in global dementia rates is expected to affect LMICs disproportionately. However, the majority of global dementia care costs occur in high-income countries (HICs), with dementia research predominantly focusing on HICs. This imbalance necessitates LMIC-focused research to ensure that characterization of dementia accurately reflects the involvement and specificities of diverse populations. Development of effective preventive, diagnostic, and therapeutic approaches for dementia in LMICs requires targeted, personalized, and harmonized efforts. Our article represents timely discussions at the 2022 Symposium on Dementia and Brain Aging in LMICs that identified the foremost opportunities to advance dementia research, differential diagnosis, use of neuropsychometric tools, awareness, and treatment options. We highlight key topics discussed at the meeting and provide future recommendations to foster a more equitable landscape for dementia prevention, diagnosis, care, policy, and management in LMICs. HIGHLIGHTS: Two-thirds of persons with dementia live in LMICs, yet research and costs are skewed toward HICs. LMICs expect dementia prevalence to more than double, accompanied by socioeconomic disparities. The 2022 Symposium on Dementia in LMICs addressed advances in research, diagnosis, prevention, and policy. The Nairobi Declaration urges global action to enhance dementia outcomes in LMICs.

Readiness of primary care centres for a community-based intervention to prevent and control noncommunicable diseases in the Caribbean: A participatory, mixed-methods study.

INTRODUCTION: Epidemiological transition to NCDs is a challenge for fragile health systems in the Caribbean. The Congregations Taking Action against NCDs (CONTACT) Study intervention proposes that trained health advocates (HAs) from places of worship (PoWs), supervised by nurses at nearby primary healthcare centres (PHCs), could facilitate access to primary care among vulnerable communities. Drawing on participatory and systems thinking, we explored the capacity of local PHCs in three Caribbean countries to support this intervention. METHODS: Communities in Jamaica (rural, urban), Guyana (rural) and Dominica (Indigenous Kalinago Territory) were selected for CONTACT because of their differing socio-economic, cultural, religious and health system contexts. Through mixed-method concept mapping, we co-developed a list of perceived actionable priorities (possible intervention points ranked highly for feasibility and importance) with 48 policy actors, healthcare practitioners and civic society representatives. Guided in part by the concept mapping findings, we assessed the readiness of 12 purposefully selected PHCs for the intervention, using a staff questionnaire and an observation checklist to identify enablers and constrainers. RESULTS: Concept mapping illustrated stakeholder optimism for the intervention, but revealed perceptions of inadequate primary healthcare service capacity, resources and staff training to support implementation. Readiness assessments of PHCs identified potential enablers and constrainers that were consistent with concept mapping results. Staff support was evident. Constraints included under-staffing, which could hinder supervision of HAs; and inadequate essential NCD medicines, training in NCDs and financial and policy support for embedding community interventions. Despite a history of socio-political disadvantage, the most enabling context was found in the Kalinago Territory, where ongoing community engagement activities could support joint development of programmes between churches and PHCs. CONCLUSION: Multi-sectoral stakeholder consultation and direct PHC assessments revealed viability of the proposed POW-PHC partnership for NCD prevention and control. However, structural and policy support will be key for implementing change.

Walking the talk for dementia: A unique immersive, embodied, and multi-experiential initiative.

Coping with dementia requires an integrated approach encompassing personal, health, research, and community domains. Here we describe "Walking the Talk for Dementia," an immersive initiative aimed at empowering people with dementia, enhancing dementia understanding, and inspiring collaborations. This initiative involved 300 participants from 25 nationalities, including people with dementia, care partners, clinicians, policymakers, researchers, and advocates for a 4-day, 40 km walk through the Camino de Santiago de Compostela, Spain. A 2-day symposium after the journey provided novel transdisciplinary and horizontal structures, deconstructing traditional hierarchies. The innovation of this initiative lies in its ability to merge a physical experience with knowledge exchange for diversifying individuals' understanding of dementia. It showcases the transformative potential of an immersive, embodied, and multi-experiential approach to address the complexities of dementia collaboratively. The initiative offers a scalable model to enhance understanding, decrease stigma, and promote more comprehensive and empathetic dementia care and research.

The dementia severity rating scale: A potential community screening tool for dementia in low- and middle-income countries.

BACKGROUND: The Dementia Severity Rating Scale (DSRS) is an informant report, dementia staging tool that is quick to administer and has previous been shown to differentiate between people with dementia and healthy controls. However, it is not clear how accurate the tool is screening against diagnostic criteria in middle-income settings. METHODS: Embedded within the STRiDE programme, older adults (aged ≥65 years) and their informants were randomly recruited from four sites across Indonesia and South Africa. All informants were asked to complete DSRS. We report the tool's psychometric properties and accuracy against the 10/66 short diagnostic algorithm. RESULTS: Between September and December 2021, data was collected from 2110 older adults in Indonesia and 408 in South Africa. Overall, the DSRS scores significantly differed between those with and without dementia, as identified on the 10/66 short algorithm (p < .05). The difference between groups remained significant after controlling for key factors related to older adult and informant demographics. A score >2 on the DSRS had the greatest agreement with the 10/66 short algorithm and had excellent discriminative properties in both Indonesia (Area Under Curve (AUC) = .75, 95% CIs = .72-.77) and South Africa (AUC = .82, 95% CIs = .76-.88). CONCLUSIONS: The DSRS has potential as a screening tool for dementia in middle-income countries, with high sensitivity and specificity against a standardized diagnostic algorithm.

Exploring English policymakers' attitudes towards dementia risk reduction: A qualitative study.

AIM: A growing evidence-base indicates that dementia occurrence can be changed. This has been linked to potentially modifiable risk factors. Risk reduction and primary prevention strategies are increasingly recognized as needing to include population-level policies to tackle the social and commercial determinants of health. How this knowledge can influence policymaking on dementia prevention is unknown. Understanding attitudes of policymakers is an important step in translating evidence into practice, helping to gauge system readiness for implementation, and potential barriers and enablers for influencing policy. The aim of this qualitative study is to explore the understanding of, and attitudes to, dementia risk reduction and population-level prevention strategies amongst English policymakers at national, regional, and local level. METHODS: Semi-structured interviews were undertaken with a range of dementia and prevention policymakers, with purposive sampling of national and local policymakers, including politicians, government officials, health system leaders, academics, and dementia charity directors. Analysis of interview transcripts was undertaken by thematic analysis. RESULTS: 14 policymakers were interviewed between November 2021 and February 2022. Three main themes were identified (1) Preventability of dementia, (2) Prevention approach, (3) Barriers and facilitators to improving the approach. DISCUSSION: Policymakers generally held dementia to be partially preventable. Policymakers recognised that both individual- and population-level approaches to primary prevention of dementia are required - with some policymakers perceiving that population-level approaches are under-utilised. Key barriers to implementing more population-level approaches were identified as the complexity and co-ordination required to effectively tackle upstream determinants of health.

Sodium and potassium consumption in Jamaica: National estimates and associated factors from the Jamaica Health and Lifestyle Survey 2016-2017.

This study aimed to estimate dietary sodium and potassium consumption among Jamaicans and evaluate associations with sociodemographic and clinical characteristics. A cross-sectional study was conducted using data from the Jamaica Health and Lifestyle Survey 2016-2017. Participants were noninstitutionalized Jamaicans aged ≥15 years. Trained staff collected sociodemographic and health data via interviewer-administered questionnaires and spot urine samples. The Pan American Health Organization formula was used to estimate 24-hour urine sodium and potassium excretion. High sodium level was defined as ≥2000 mg/day, and low potassium levels as <3510 mg/day (World Health Organization criteria). Associations between these outcomes and sociodemographic and clinical characteristics were explored using multivariable ANOVA models using log-transformed 24-hour urine sodium and potassium as outcome variables. Analyses included 1009 participants (368 males, 641 females; mean age 48.5 years). The mean sodium excretion was 3582 mg/day (males 3943 mg/day, females 3245 mg/day, P < .001). The mean potassium excretion was 2052 mg/day (males, 2210 mg/day; females, 1904 mg/day; P = .001). The prevalence of high sodium consumption was 66.6% (males 72.8%, females 60.7%, P < .001) and that of low potassium intake was 88.8% (85.1% males, 92.3% females, P < .001). Sodium consumption was inversely associated with older age, higher education, and low glomerular filtration rate but was directly associated with being male, current smoking, and obesity. Overall, males had higher sodium consumption than women, with the effect being larger among hypertensive men. Women with hypertension had lower sodium consumption than nonhypertensive women; however, hypertensive men had higher sodium consumption than nonhypertensive men. Potassium consumption was higher among men, persons with obesity, and those with high total cholesterol but was lower among men with "more than high school" education compared to men with "less than high school" education. We conclude that most Jamaican adults have diets high in sodium and low in potassium. In this study, sodium consumption was directly associated with male sex, obesity, and current smoking but was inversely associated with older age and higher education. High potassium consumption was associated with obesity and high cholesterol levels. These associations should be further explored in longitudinal studies and population-based strategies should be developed to address these cardiovascular risk factors.

Situating commercial determinants of health in their historical context: a qualitative study of sugar-sweetened beverages in Jamaica.

BACKGROUND: Non-communicable diseases (NCDs) are the leading cause of mortality across the Caribbean and similar regions. Structural determinants include a marked increase in the dependency on food imports, and the proliferation of processed foods, including sugar-sweetened beverages (SSBs). We focused on Jamaica as a case study and the health challenge of SSBs, and situated contemporary actions, experiences and policies within their historical context to investigate underlying drivers of commercial determinants of health and attempts to counter them. We asked: how can a historical perspective of the drivers of high level SSB consumption in Jamaica contribute to an enhanced understanding of the context of public health policies aimed at reducing their intake? METHODS: An ethnographic approach with remote data collection included online semi-structured interviews and workshops with 22 local experts and practitioners of health, agriculture and nutrition in Jamaica and attending relevant regional public webinars on SSBs and NCD action in the Caribbean. Our analysis was situated within a review of historical studies of Caribbean food economies with focus on the twentieth century. Jamaican and UK-based researchers collected and ethnographically analysed the data, and discussed findings with the wider transdisciplinary team. RESULTS: We emphasise three key areas in which historical events have shaped contextual factors of SSB consumption. Trade privileged sugar as a cash crop over food production during Jamaica's long colonial history, and trade deregulation since the 1980s through structural adjustment opened markets to transnational companies. These changes increased Jamaican receptiveness to the mass advertisement and marketing of these companies, whilst long-standing power imbalances hampered taxation and regulation in contemporary public health actions. Civil society efforts were important for promoting structural changes to curb overconsumption of SSBs and decentring such entrenched power relations. CONCLUSION: The contemporary challenge of SSBs in Jamaica is a poignant case study of commercial determinants of health and the important context of global market-driven economies and the involvement of private sector interests in public health policies and governance. Historically contextualising these determinants is paramount to making sense of the sugar ecology in Jamaica today and can help elucidate entrenched power dynamics and their key actors.

Comprehensive measurement of the prevalence of dementia in low- and middle-income countries: STRiDE methodology and its application in Indonesia and South Africa.

BACKGROUND: A core element of the Strengthening Responses to Dementia in Developing Countries (STRiDE) programme was to generate novel data on the prevalence, cost and impact of dementia in low- and middle-income countries, to build better health policy. Indonesia and South Africa are two middle-income countries in need of such data. AIMS: To present the STRiDE methodology and generate estimates of dementia prevalence in Indonesia and South Africa. METHOD: We conducted community-based, single-phase, cross-sectional studies in Indonesia and South Africa, randomly sampling participants aged 65 years or older in each country. Dementia prevalence rates for each country were generated by using the 10/66 short schedule and applying its diagnostic algorithm. Weighted estimates were calculated with national sociodemographic data. RESULTS: Data were collected between September and December 2021 in 2110 people in Indonesia and 408 people in South Africa. The adjusted weighted dementia prevalence was 27.9% (95% CI 25.2-28.9) in Indonesia and 12.5% (95% CI 9.5-16.0) in South Africa. Our results indicate that there could be >4.2 million people in Indonesia and >450 000 people in South Africa who have dementia. Only five participants (0.2%) in Indonesia and two (0.5%) in South Africa had been previously diagnosed with dementia. CONCLUSIONS: Despite prevalence estimates being high, formal diagnosis rates of dementia were very low across both countries (<1%). Further STRiDE investigations will provide indications of the impact and costs of dementia in these countries, but our results provide evidence that dementia needs to be prioritised within national health and social care policy agendas.

Community stressors (violence, victimization, and neighborhood disorder) with cardiometabolic outcomes in urban Jamaica.

Background: Despite limited data on neighborhood factors and health risk in Caribbean populations, previous analyses from Jamaica have shown that neighborhood and home disorder were associated with lower physical activity and higher cumulative biological risk among women, while poorer neighborhood infrastructure was associated with higher overweight/obesity among men. Design: Cross-sectional survey design. Objectives: In this study, we explored whether community stressors, as measured by community violence, victimization and neighborhood disorder scores, were associated with cardiometabolic outcomes (obesity, diabetes, hypertension and high cholesterol) in urban Jamaican communities. Sex-specific Poisson regression models were used to estimate prevalence ratios (PR) for these associations, adjusting for age, education, diet, physical activity and smoking. Participants: Of the 849 participants (M = 282; F = 567), mean age was 48 ± 18.5 years and most had at least a high school education. Men were more likely to be current smokers (29.4 vs. 10.6%) and adequately physically active (53.2 vs. 42.0%); more women were obese (46.0 vs. 19.0%), more likely to have hypertension (52.9 vs. 45.4%) and had high cholesterol (34.2 vs. 21.6%) (all p < 0.05). Results: We observed significant associations only for those in the middle tertile of neighborhood disorder with prevalence of higher cholesterol [PR:1.72 (1.20 to 2.47)] in women and lower prevalence of obesity [PR:0.24 (0.10 to 0.53)] in men. Conclusion: Results suggest that higher, but not the highest level of neighborhood disorder was associated with higher cholesterol levels in women and lower obesity in men. Future work will explore additional approaches to measuring neighborhood characteristics in Jamaica and the mechanisms that may underlie any relationships that are identified.

Transforming dementia research into policy change: A case study of the multi-country STRiDE project.

STRiDE was an ambitious four-year project in seven countries aiming to build capacity around generating and using research to support the development of policies to improve quality of life of people with dementia and their carers. The project's innovative approach combined rigorous academic research and hands-on civil society advocacy. This paper explores the project's unique strategy for policy change and compiles case-studies from several of the STRiDE countries. Finally, we share lessons learned and next steps to keep momentum for policy change going in each of these countries - and beyond.

What would a population-level approach to dementia risk reduction look like, and how would it work?

Dementia is a leading global public health challenge. Prevention approaches have traditionally focused on individual-level strategies. However, such approaches have limited potential, particularly for resource-constrained populations in which exposure to risk factors is greatest, and exposure to protective factors is lowest. A population-level approach to dementia risk reduction is therefore essential to meet the scale of the challenge and to tackle global inequalities in risk and incidence of disease. Such approaches can be highly cost effective. In this viewpoint article, we describe what such an approach should look like, barriers and facilitators to success, and how we should go about achieving it. We include 10 strategic goals to achieve population-level dementia risk reduction and protection enhancement, targeted at researchers, professionals, funders, science communicators, governments, businesses, and policy makers. If we are to significantly reduce the prevalence of dementia there must be increased emphasis on population-level approaches. HIGHLIGHTS: Dementia risk reduction is a global public health priority Population-level approaches change societal conditions to make them less conducive to dementia's modifiable risk factors, and increase exposure to protective factors. Urgent development of population-level approaches is required to reduce the prevalence of, and inequalities in, dementia Action is required from researchers, governments and business, funders, public health professionals, and science communicators.

Acceptability and use of waist-worn physical activity monitors in Jamaican adolescents: lessons from the field.

OBJECTIVE: We report our experience with a validated waist-worn activity monitor in Jamaican adolescents attending urban high schools. Seventy-nine adolescents from the Global Diet and Activity Research (GDAR) study, recruited from 5 urban Jamaican high schools (two coeducational (n = 37), two all-female schools (n = 32) and one all-boys school (n = 10)) were asked to wear Actigraph wGT3X-BT accelerometers for 7 days (24-h), removing the device only when bathing or swimming. They also logged wake up and bed times in an activity diary. Accelerometry was considered valid if at least 4 days with ≥ 10-h monitor wear were recorded. Validity was compared by adolescent demographic and school characteristics. We also reviewed the students' written feedback on objective physical activity measurement. RESULTS: Participants, 80.5% female, had a mean age of 15.5 ± 0.8 years with 60% attending schools in low-income communities. Accelerometer return rates were > 98% with 84% providing valid data. Validity did not vary by age group, sex and school setting. While participants were excited about participating in the accelerometer sub-study, commonly reported challenges included monitor discomfort during sleep and maintaining the study diary. Objective measurement of physical activity using 24-h waist-worn accelerometers is feasible and acceptable in Jamaican adolescents.

A systematic review of the cost-effectiveness of community and population interventions to reduce the modifiable risk factors for dementia.

Dementia is a leading global cause of morbidity and mortality. Evidence suggests that tackling modifiable lifecourse risk factors could prevent or delay a significant proportion of cases. Population- and community-based approaches change societal conditions such that everyone across a given community is more likely to live more healthily. We systematically reviewed economic studies of population- and community-based interventions to reduce modifiable lifecourse risk factors for dementia. We searched Medline, EMBASE, Web of Science, CINAHL, PsycInfo, Scopus, Econlit, ERIC, the British Education Index, and Google, on 03/03/2022. We included cost-effectiveness, cost-benefit, and cost-utility studies, provided that the direct outcome of the intervention was a modifiable risk factor for dementia, and was measured empirically. Quality appraisal was completed using the Consensus on Health Economic Criteria checklist. A narrative synthesis was performed. We included 45 studies, from 22,749 records identified. Included studies targeted smoking (n = 15), education (n = 10), physical inactivity (n = 9), obesity (n = 5), air pollution (n = 2), traumatic brain injury (n = 1), and multiple risk factors (n = 3). Intervention designs included changing the physical/food environment (n = 13), mass media programmes (n = 11), reducing financial barriers or increasing resources (n = 10), whole-community approaches (n = 6), and legislative change (n = 3). Overall, interventions were highly cost-effective and/or cost-saving, particularly those targeting smoking, educational attainment, and physical inactivity. Effects were observed in high- (e.g. USA and UK) and low- and middle-income (e.g. Mexico, Tanzania, Thailand) countries. Further research into the direct effects of targeting these risk factors on future dementia prevalence will have important economic, social and policy implications.

Reducing Sugar Intake in South Africa: Learnings from a Multilevel Policy Analysis on Diet and Noncommunicable Disease Prevention.

High sugar intake contributes to diet-related excess weight and obesity and is a key determinant for noncommunicable diseases (NCDs) in low- and middle-income countries (LMICs). The World Health Organization (WHO) gives specific advice on limiting sugar intake in adults and children. Yet, to what extent have policy ideas on sugar intake reduction originating at the global level found expression at lower levels of policymaking? A systematic policy document analysis identified policies issued at the African regional, South African national and Western Cape provincial levels between 2000 and 2020 using search terms related to sugar, sugar-sweetened beverages (SSBs), and NCDs. Forty-eight policy documents were included in the review, most were global and national policies and thus the focus of analysis. A policy transfer conceptual framework was applied. Global recommendations for effectively tackling unhealthy diets and NCDs advise implementing a mix of cost-effective policy options that employ a multisectoral approach. South African country-level policy action has followed the explicit global guidance, and ideas on reducing sugar intake have found expression in sectors outside of health, to a limited extent. As proposed in this paper, with the adoption of the SSB health tax and other policy measures, South Africa's experience offers several learnings for other LMICs.

Evaluating measurement properties of subjective cognitive decline self-reported outcome measures: a systematic review.

BACKGROUND: Subjective cognitive decline (SCD) is present in the early stage of preclinical Alzheimer's disease (AD) and is associated with an increased risk of further cognitive decline and AD dementia later in life. Early detection of at-risk groups with subjective complaints is critical for targeted dementia prevention at the earliest. Accurate assessment of SCD is crucial. However, current measures lack important psychometric evaluations and or reporting. OBJECTIVES: To systematically evaluate measurement properties of self-reported outcome measures (PROMs) used to assess SCD in the older adult population with or at risk of AD. METHODS AND ANALYSIS: We used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols 2015 Checklist for reporting. We conducted a literature search, screened, and included validation studies of SCD based on self-reported questionnaires from both population-based and clinical studies, conducted in older adults (≥ 55). We critically appraised the included primary studies using the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidelines. RESULTS: Sixteen studies met the inclusion criteria. The included studies reported psychometric properties of 17 SCD self-reported questionnaires. We extracted data on the structural validity, internal consistency, test-retest reliability, and cross-cultural validity and found a widespread proneness to bias across studies, and a marked heterogeneity is assessed and reported measurement properties that prevented the consolidation of results. CONCLUSION: Our findings suggest that available SCD questionnaires lack content validity evaluation. Currently available measurements of SCD lack development and validation standards. Further work is needed to develop and validate SCD self-reported measurement with good quality measurement properties.

Three Growth Spurts in Global Physical Activity Policies between 2000 and 2019: A Policy Document Analysis.

Non-communicable diseases (NCDs) contribute significantly to global mortality and are of particular concern in growing urban populations of low- and-middle income countries (LMICs). Physical inactivity is a key NCD determinant and requires urgent addressing. Laudable global and regional efforts to promote physical activity are being made, but the links between physical activity (PA), NCD reduction, and integrated intersectoral approaches to reducing obesogenic environments are not consistently made. This study applied a document analysis approach to global PA and NCD policies to better understand the current global policy environment and how this may facilitate integrated PA promotion. A total of 34 global policies related to PA, from different sectors, were analyzed. PA policy in mitigation of NCDs has evolved exponentially, with a progression towards addressing structural determinants alongside individual behavior change. The global PA agenda is primarily driven by the World Health Organization. Intersectoral collaboration is importantly regarded, but the contributions of other sectors, outside of health, education, transport, and urban planning, are less clear. Improving PA among key sub-populations-women, girls, and adolescents-requires greater policy consideration. It is imperative for PA-relevant sectors at all levels to recognize the links with NCDs and work towards integrated policy and practice in mitigation of the rising NCD pandemic.

Description of the cross-cultural process adopted in the STRiDE (STrengthening Responses to dementia in DEveloping countries) program: A methodological overview.

Cross-cultural adaptation is an important part of using validated questionnaires across countries and settings. Here we describe the cross-cultural process adopted in the STRiDE (STrengthening Responses to dementia in DEveloping countries) program. We adopted a cross-cultural adaptation process including forward translation, back translations, and cognitive interviews of the STRiDE toolkit. In total, 50 older adults and 41 carers across sites in Indonesia and South Africa participated in cognitive interviews; field notes and verbatim quotes are reported. We describe the cross-cultural adaptation process of the STRiDE toolkit. During the process, issues were identified with the translated toolkit, including aspects related to cultural appropriateness, terminology equivalence, and timings. The data demonstrate that a rigorous, yet pragmatic, cross-cultural adaptation process can be achieved even with limited resources. Our process should help the design and conduct of future dementia research in various contexts.