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.

Effectiveness of App-Based Cognitive Screening for Dementia by Lay Health Workers in Low Resource Settings. A Validation and Feasibility Study in Rural Tanzania.

BACKGROUND: The majority of people with dementia live in low-and middle-income countries (LMICs). In sub-Saharan Africa (SSA) human-resource shortages in mental health and geriatric medicine are well recognized. Use of technological solutions may improve access to diagnosis. We aimed to assess the diagnostic accuracy of a brief dementia screening mobile application (app) for non-specialist workers in rural Tanzania against blinded gold-standard diagnosis of DSM-5 dementia. The app includes 2 previously-validated culturally appropriate low-literacy screening tools for cognitive (IDEA cognitive screen) and functional impairment (abbreviated IDEA-IADL questionnaire). METHODS: This was a 2-stage community-based door-to-door study. In Stage1, rural primary health workers approached all individuals aged ≥60 years for app-based dementia screening in 12 villages in Hai district, Kilimanjaro Tanzania.In Stage 2, a stratified sub-sample were clinically-assessed for dementia blind to app screening score. Assessment included clinical history, neurological and bedside cognitive assessment and collateral history. RESULTS: 3011 (of 3122 eligible) older people consented to screening. Of these, 610 were evaluated in Stage 2. For the IDEA cognitive screen, the area under the receiver operating characteristic (AUROC) curve was 0.79 (95% CI 0.74-0.83) for DSM-5 dementia diagnosis (sensitivity 84.8%, specificity 58.4%). For those 358 (44%) completing the full app, AUROC was 0.78 for combined cognitive and informant-reported functional assessment. CONCLUSIONS: The pilot dementia screening app had good sensitivity but lacked specificity for dementia when administered by non-specialist rural community workers. This technological approach may be a promising way forward in low-resource settings, specialist onward referral may be prioritized.

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

INTRODUCTION: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Conceptualization of depression amongst older adults in rural Tanzania: a qualitative study.

BACKGROUND: Depression in older people is likely to become a growing global health problem with aging populations. Significant cultural variation exists in beliefs about depression (terminology, symptomatology, and treatments) but data from sub-Saharan Africa are minimal. Low-resource interventions for depression have been effective in low-income settings but cannot be utilized without accurate diagnosis. This study aimed to achieve a shared understanding of depression in Tanzania in older people. METHODS: Using a qualitative design, focus groups were conducted with participants aged 60 and over. Participants from rural villages of Kilimanjaro, Tanzania, were selected via randomized sampling using census data. Topic guides were developed including locally developed case vignettes. Transcripts were translated into English from Swahili and thematic analysis conducted. FINDINGS: Ten focus groups were held with 81 participants. Three main themes were developed: a) conceptualization of depression by older people and differentiation from other related conditions ("too many thoughts," cognitive symptoms, affective and biological symptoms, wish to die, somatic symptoms, and its difference to other concepts); b) the causes of depression (inability to work, loss of physical strength and independence, lack of resources, family difficulties, chronic disease); c) management of depression (love and comfort, advice, spiritual support, providing help, medical help). CONCLUSIONS: This research expands our understanding of how depression presents in older Tanzanians and provides information about lay beliefs regarding causes and management options. This may allow development of culturally specific screening tools for depression that, in turn, increase diagnosis rates, support accurate diagnosis, improve service use, and reduce stigma.

The functional architecture of the stomatognathic system and orofacial aesthetic repositioning during the aging process

Introduction: Facial aging implies special care and personalized treatment. Thus,the new strand of Neomodern Dentistry seeks, through Orofacial Harmonization,the functional and aesthetic balance between the stomatognathic system and thefacial aspect. Objective: This article seeks to disclose, through a literature review, the aesthetical consequences of the stomatognatic system repositioning andorofacial aging. Data source: The present literature review consisted in researchesup to May 2019 using PubMed and Google Academic electronic databases. A 10-year publication limit was applied in the research. No language restriction wasapplied. Inclusion criteria were clinical investigations, books, dissertations, thesisor literature reviews that addressed the topics of interest. Data synthesis: A totalof 231 articles were retrieved from databases. After applying a 10-year publicationlimit, 111 remained and, based on the inclusion and exclusion criteria, 20 articleswere selected and included in this review. Conclusion: Considering the limitationsof the present study, it can be concluded that the aging process is natural andpredictable and can be changeable and malleable through procedures that restorethe support nutrients that were lost. The aesthetics can be achieved as a functionalconsequence of the stomatognathic system repositioning due to orofacial aging.

Introdução: O envelhecimento facial implica em cuidados especiais e um tratamento diferenciado. Desse modo, a nova vertente da Odontologia Neomoderna busca, por meio da Harmonização Orofacial, o equilíbrio funcional e estético entre o aparelho estomatognático e a face. Objetivo: Esse artigo busca compreender, por meio de uma revisão de literatura, as consequências estéticas do reposicionamento do aparelho estomatognático e envelhecimento orofacial. Fonte dos dados: A presente revisão de literatura consistiu em um viés qualitativo nas plataformas PubMed e Google Acadêmico, nos últimos 10 anos, sem restrição de idiomas. Os critérios de inclusão consistiram em estudos clínicos, livros, dissertações, teses ou revisões de literatura que abordavam os tópicos de interesse. Síntese dos dados: Foram recuperados nas bases de dados 231 artigos. Após a aplicação de um limite de publicação de 10 anos, 111 permaneceram e, com base nos critérios de inclusão e exclusão, 20 artigos foram selecionados e incluídos nesta revisão. Conclusão: Com as limitações do presente estudo, pode-se concluir que o processo de envelhecimento é natural e previsível e pode ser mutável e maleável por meio de procedimentos que restauram os nutrientes de suporte perdidos. A estética pode ser alcançada como uma consequência funcional do reposicionamento do sistema estomatognático e do envelhecimento orofacial.

Técnica mediata para clareamento de dentes desvitalizados: uma comparação clínica entre agentes clareadores: relato de caso clínico / Non-vital bleaching: a comparison between bleaching agents: case report

Neste relato foram descritos os passos clínicos empregados durante a técnica mediata para clareamento de dentes desvitalizados, sem aplicação de calor. O objetivo foi comparar clinicamente o resultado obtido no clareamento dos dentes 11 e 21, utilizando como agentes clareadores pasta de perborato de sódio + água destilada e peróxido de carbamida a 37 por cento, respectivamente. Concluiu-se que a técnica mediata utilizando o peróxido de carbamida a 37 por cento em cinco sessões, com intervalos de uma semana, mostrou-se mais eficaz para o clareamento de dentes desvitalizados que a mesma técnica utilizando a pasta de perborato de sódio + água destilada