Identifying Frailty and its Outcomes in Older People in Rural Tanzania.

Background/Study Context: Interest in frailty is growing in low- and middle-income countries, due to demographic aging and resource limitations. However, there is a paucity of data on the nature of frailty in Africa. METHODS: The study collected frailty data from people aged 70 years and over living in six villages in the rural Hai District of northern Tanzania. At baseline, a limited data set was collected for 1198 people and a more comprehensive data set for a stratified sample of 296 people. A 40-item frailty index was constructed. Data regarding mortality and dependency were collected at 3-year follow-up. RESULTS: A higher frailty index score was significantly correlated with greater age, never having attended school, falls, mortality, and dependency in activities of daily living. Logistic regression modeling revealed functional disability and cognitive function to be significant independent predictors of the outcome "mortality or dependency." CONCLUSIONS: In resource-poor settings, brief frailty screening assessments may be a useful way of identifying those most in need of support.

Levels of functional disability in elderly people in Tanzania with dementia, stroke and Parkinson's disease.

BACKGROUND: Disability is associated with increasing age and poverty, yet there are few reliable data regarding disability amongst the elderly in low-income countries. The aim of this study was to compare disability levels for three of the most common neurological, non-communicable diseases: dementia, stroke and Parkinson's disease (PD). METHODS: We performed a community-based study of people aged 70 years and over in 12 randomly selected villages in the rural Hai district of Tanzania. Participants underwent disability assessment using the Barthel Index, and clinical assessment for dementia, stroke and PD. RESULTS: In a representative cohort of 2232 people aged 70 years and over, there were 54 cases of stroke, 12 cases of PD and estimated (by extrapolation from a sub-sample of 1198 people) to be 112 cases of dementia. People with stroke were the most disabled, with 62.9% having moderate or severe disability. Levels of moderate or severe disability were 41.2% in people with dementia and 50.0% in people with PD. However, the higher prevalence of dementia meant that, at a population level, it was associated with similar levels of disability as stroke, with 18.5% of 249 people identified as having moderate or severe disability having dementia, compared to 13.7% for stroke and 2.4% for PD. CONCLUSIONS: Levels of disability from these conditions is high and is likely to increase with demographic ageing. Innovative, community-based strategies to reduce disability levels should be investigated.

Electrocardiographic reference values for a population of older adults in sub-Saharan Africa.

BACKGROUND/OBJECTIVES: Older adults in sub-Saharan Africa (SSA) are at greatest risk of an impending noncommunicable diseases epidemic, of which cardiac disease is the most prevalent contributor. Thus, it is essential to establish electrocardiographic reference values for a population that is likely to differ genetically and environmentally from others where reference values are established. METHODS: Two thousand two hundred thirty-two apparently healthy community-based participants without known cardiac disease aged 70+ in rural Tanzania underwent 12-lead electrocardiography. Electrocardiograms were digitally analyzed and gender-specific reference values for P duration (PD), P amplitude (PAMP), P area (PAREA), P terminal negative force (V1) (PTNF), PR interval, QRS duration (QRSD), QT/QTc, R amplitude (II, V5) (RAMP) LVH index (LVHI), R axis and R/S ratio (V1) reported, following univariate analysis of covariance using a multiple linear regression model, adjusting for age, systolic blood pressure (SBP), body mass index (BMI), and RR interval. RESULTS: Data from 1824 subjects were suitable for analysis. Adjusted mean values for men/women were: PD 115/110 ms, PAMP (avg) 123/114 µV, PAMP (II) 203/190 µV, PAREA (avg) 5.3/4.6 mV*s, PAREA (II) 9.3/8.1 mV*s, PTNF 1.7/1.4 mV*s, PR 158/152 ms, QRSD 89/84 ms, QT 370/375 ms, QTc 421/427 ms, RAMP (II) 805/854 µV, (V5) 2022/1742 µV, LVHI 3.0/2.8 mV (Sokolow-Lyon), 1.293/1.146 mV (Cornell), R axis 51/49°, R/S 0.2/0.2. Excluding PTNF , R axis and R/S ratio, all gender differences were significant (P < 0.001 apart from LVHI [Sokolow-Lyon; P < 0.005)] and RAMP (II) [P < 0.05]) following adjustment for age, SBP, BMI, and RR interval. CONCLUSIONS: Our description of comprehensive electrocardiographic parameters establishes reference values in this genetically and environmentally diverse SSA population thereby allowing identification of "outliers" with potential cardiac disease.

The prevalence of disability in older people in Hai, Tanzania.

BACKGROUND: the World Health Organization estimates that more than one billion of the world's population are disabled. Disability is associated with increasing age and poverty, yet there are few reliable data regarding disability among the elderly in low-income countries. The aim of this study was to accurately document the prevalence of disability in those aged 70 years and over in a community-based setting in sub-Saharan Africa. METHODS: we performed a community-based study of people aged 70 years and over in Hai, Tanzania. Participants underwent disability assessment using the culturally non-specific Barthel index (BI), and also clinical assessment for neurological disorders and memory problems. RESULTS: in 2,232 participants, the age-adjusted prevalence of severe disability (BI<15) was 3.7% (95% CI: 2.9-4.5) and the age-adjusted prevalence of moderate disability (BI: 15-18) was 6.2% [95% confidence interval (CI): 5.2-7.2]. Increasing age, female gender, memory problems and the presence of neurological disorders were all independent predictors of the presence of disability. CONCLUSION: in this study, the average disability level was lower than seen in most high-income countries. This may reflect increased mortality from disabling disease in low-income countries. Disability is likely to increase as the population of low-income countries ages and disease survival improves.

Rates and predictors of three-year mortality in older people in rural Tanzania.

BACKGROUND: There are few data on mortality rates in the general elderly living in sub-Saharan Africa. We aimed to detail three-year mortality rates in a population of rural community-dwelling older adults in northern Tanzania. METHODS: We performed a community-based study of 2232 people aged 70 years and over living in Hai district, Tanzania. At baseline, participants underwent clinical assessment for disability, neurological disorders, hypertension, atrial fibrillation and memory problems. At three-year follow-up mortality data were collected. Mortality rates were compared to UK estimates. RESULTS: At follow-up, data were available for 1873 subjects (83.9%). Of those, 208 (11.1%, 95% CI 9.7-12.5) had died. The age-standardised mortality rate was 10.2% (95% CI 8.8-11.6). Age-standardised mortality rates were lower than estimated for the UK (13.9%). In Cox regression analysis, greater age, higher levels of functional disability, use of a walking aid, subjective report of memory problems, being severely underweight and being normotensive were significant predictors of mortality. CONCLUSIONS: Those who survive to old age in Tanzania appear to have relatively low mortality rates. Physical and cognitive disabilities were strongly associated with mortality risk in this elderly community-dwelling population. The association between blood pressure and mortality merits further study.

The association between disability and cognitive impairment in an elderly Tanzanian population.

Cognitive impairment is thought to be a major cause of disability worldwide, though data from sub-Saharan Africa (SSA) are sparse. This study aimed to investigate the association between cognitive impairment and disability in a cohort of community-dwelling older adults living in Tanzania. The study cohort of 296 people aged 70years and over was recruited as part of a dementia prevalence study. Subjects were diagnosed as having dementia or mild cognitive impairment according to the DSM-IV criteria. Disability level was assessed according to the WHO Disability Assessment Schedule, version 2.0 (WHODAS). A higher WHODAS score indicates greater disability. The median WHODAS in the background population was 25.0; in those with dementia and in those with mild cognitive impairment, 72 of 78 (92.3%) and 41 of 46 (89.1%), respectively, had a WHODAS score above this level. The presence of dementia, mild cognitive impairment, hearing impairment, being unable to walk without an aid and not having attended school were independent predictors of having a WHODAS score above 25.0, though age and gender were not. In summary, cognitive impairment is a significant predictor of disability in elderly Tanzanians. Screening for early signs of cognitive decline would allow management strategies to be put in place that may reduce the associated disability burden.

Rates of diagnosis and treatment of neurological disorders within a prevalent population of community-dwelling elderly people in sub-Saharan Africa.

BACKGROUND: The prevalence of neurological disorders in those aged 70years and over in the Hai district of Tanzania has been previously reported. The following research reports rates of patient's: treatment seeking, diagnosis and treatment within this prevalent population. METHODS: All people identified as having at least one neurological disorder in the prevalence study were questioned regarding whether they had sought treatment for their disorder, whether they had had a previous correct diagnosis and whether they were being currently treated. RESULTS: From a background population of 2232 people, 349 people had neurological disorders, of whom 225 (64.5%) had sought treatment for their symptoms. Of the 384 disorders identified in these 349 people, only 14.6% had been diagnosed and only 9.9% were receiving appropriate treatment. Males were significantly more likely to have been diagnosed and were more likely to have been treated appropriately. CONCLUSIONS: Levels of diagnosis and treatment were low, with some gender inequality. Reasons for this may include a lack of recognition of the condition within the local population and lack of access to appropriate services. In the absence of effective primary and secondary preventative measures, and effective treatment, the burden of neurological disorders is likely to increase with further demographic ageing.

Strikingly low prevalence of atrial fibrillation in elderly Tanzanians.

OBJECTIVES: To determine the prevalence of atrial fibrillation (AF) in individuals aged 70 and older in a rural African community. DESIGN: Community-based cross-sectional survey. SETTING: A demographic surveillance site (DSS) within the rural Hai district of northern Tanzania. PARTICIPANTS: Approximately one-quarter (N = 2,232) of the population aged 70 and older of the DSS. MEASUREMENTS: Participants were screened for AF using 12-lead electrocardiography; demographic and 1-year mortality data were collected; and functional status, body mass index, and blood pressure were recorded. The sex-specific prevalence of AF in each 5-year age band was determined. RESULTS: Fifteen of 2,232 participants (12 women, 3 men) had AF, giving a crude prevalence rate of 0.67% (95% confidence interval (CI) = 0.33-1.01) and an age-adjusted prevalence of 0.64% (95% CI = 0.31-0.97). Prevalence was 0.96% (95% CI = 0.42-1.49) in women and 0.31% (95% CI = -0.04 to 1.24) in men. Prevalence increased with age, from 0.46% (95% CI = 0.01-0.90) in those aged 70-74-1.30% (95% CI = 0.17-2.42) in those aged 85 and older. One-year mortality was 50% in women and 66.6% in men. CONCLUSIONS: This is the first published community-based AF prevalence study from sub-Saharan Africa. The prevalence rate of AF is strikingly lower than in other elderly populations studied, yet the 1-year mortality rate was exceedingly high.

Neurological disorder screening in the elderly in low-income countries.

There are few data on neurological disorder prevalence from developing countries, particularly in the elderly in sub-Saharan Africa (SSA). This is in part due to the lack of a feasible and valid screening instrument. We aimed to develop (and pilot) a brief screening instrument for neurological disorders in an elderly population in SSA. Our study population of 2,232 was selected at random from the entire 70 years and over population of a demographic surveillance site in rural Tanzania. One village, with a population of 277, was randomly selected as a pilot site prior to screening the rest of the study population. We designed a screening questionnaire based on the neurological section of the WHO International Statistical Classification of Diseases and Related Health Problems 10th Revision for use by non-medical interviewers (NMI). Of the 277 participants aged 70 years and over in the pilot village, 82 had neurological disorders, with a further 267 identified as having neurological disorders during the study extension to the remaining study population of 1955. The questionnaire was practical, acceptable to recipients, and easily performed by an NMI. The sensitivity and specificity of the questionnaire were 87.8 and 94.9 %, respectively, in the pilot and 97.0 and 90.4 %, respectively, in the extension. This is the first published screening instrument for measuring the prevalence of neurological disorders in a developing country, which is dedicated to the elderly population. It is feasible to use and has high sensitivity and specificity.