The impact of dementia on women internationally: An integrative review

Women are disproportionately affected by dementia, both in terms of developing dementia and becoming caregivers. We conducted an integrative review of English language literature focusing on the issues affecting women in relation to dementia from an international perspective. The majority of relevant studies were conducted in high-income countries, and none were from low-income countries. The effects of caregiving on health, well-being, and finances are greater for women; issues facing women, particularly in low- and middle-income countries, need to be better understood. Research should focus on building resilience to help people adjust and cope long term.     

Dementia and driving.

Many European countries test cars, but not their drivers, as they age. There is evidence to suggest that human factors are more important than vehicular factors as causes of motor crashes. The elderly also are involved in more accidents per distance travelled than middle-aged drivers. As the UK relies on self-certification of health by drivers over the age of 70 years, we examined the driving practices of patients with dementia attending a Memory Clinic. Nearly one-fifth of 329 patients with documented dementia continued to drive after the onset of dementia, and impaired driving ability was noted in two-thirds of these. Their families experienced great difficulty in persuading patients to stop driving, and had to invoke outside help in many cases. Neuropsychological tests did not help to identify those who drove badly while activity of daily living scores were related to driving ability. These findings suggest that many patients with dementia drive in an unsafe fashion after the onset of the illness. The present system of self-certification of health by the elderly for driver-licensing purposes needs to be reassessed.     

Prevalence of anemia and deficiency of iron, folic acid, and zinc in children younger than 2 years of age who use the health services provided by the Mexican Social Security Institute

Background

Latin America, China and India are experiencing unprecedentedly rapid demographic ageing with an increasing number of people with dementia. The 10/66 Dementia Research Group's title refers to the 66% of people with dementia that live in developing countries and the less than one tenth of population-based research carried out in those settings. This paper describes the protocols for the 10/66 population-based and intervention studies that aim to redress this imbalance.

Methods/design

Cross-sectional comprehensive one phase surveys have been conducted of all residents aged 65 and over of geographically defined catchment areas in ten low and middle income countries (India, China, Nigeria, Cuba, Dominican Republic, Brazil, Venezuela, Mexico, Peru and Argentina), with a sample size of between 1000 and 3000 (generally 2000). Each of the studies uses the same core minimum data set with cross-culturally validated assessments (dementia diagnosis and subtypes, mental disorders, physical health, anthropometry, demographics, extensive non communicable disease risk factor questionnaires, disability/functioning, health service utilisation, care arrangements and caregiver strain). Nested within the population based studies is a randomised controlled trial of a caregiver intervention for people with dementia and their families (ISRCTN41039907; ISRCTN41062011; ISRCTN95135433; ISRCTN66355402; ISRCTN93378627; ISRCTN94921815). A follow up of 2.5 to 3.5 years will be conducted in 7 countries (China, Cuba, Dominican Republic, Venezuela, Mexico, Peru and Argentina) to assess risk factors for incident dementia, stroke and all cause and cause-specific mortality; verbal autopsy will be used to identify causes of death.

Discussion

The 10/66 DRG baseline population-based studies are nearly complete. The incidence phase will be completed in 2009. All investigators are committed to establish an anonymised file sharing archive with monitored public access. Our aim is to create an evidence base to empower advocacy, raise awareness about dementia, and ensure that the health and social care needs of older people are anticipated and met.     

Lack of active follow-up of cancer patients in Chennai, India: implications for population-based survival estimates

OBJECTIVE: To measure the bias in absolute cancer survival estimates in the absence of active follow-up of cancer patients in developing countries. METHODS: Included in the study were all incident cases of the 10 most common cancers and corresponding subtypes plus all tobacco-related cancers not ranked among the top 10 that were registered in the population-based cancer registry in Chennai, India, during 1990-1999 and followed through 2001. Registered incident cases were first matched with those in the all-cause mortality database from the vital statistics division of the Corporation of Chennai. Unmatched incident cancer cases were then actively followed up to determine their survival status. Absolute survival was estimated by using an actuarial method and applying different assumptions regarding the survival status (alive/dead) of cases under passive and active follow-up. FINDINGS: Before active follow-up, matches between cases ranged from 20% to 66%, depending on the site of the primary tumour. Active follow-up of unmatched incident cases revealed that 15% to 43% had died by the end of the follow-up period, while the survival status of 4% to 38% remained unknown. Before active follow-up of cancer patients, 5-year absolute survival was estimated to be between 22% and 47% higher, than when conventional actuarial assumption methods were applied to cases that were lost to follow-up. The smallest survival estimates were obtained when cases lost to follow-up were excluded from the analysis. CONCLUSION: Under the conditions that prevail in India and other developing countries, active follow-up of cancer patients yields the most reliable estimates of cancer survival rates. Passive case follow-up alone or applying standard methods to estimate survival is likely to result in an upward bias.     

Rheumatic fever: clinical profile of the initial attack in India

The clinical profile of acute rheumatic fever in developing countries is frequently reported to differ from that in developed countries. This probably arose because a distinction was not made between the manifestations of the initial attack and those of a recurrence. Here, we report the patterns of presentation and clinical features of 100 cases of carefully determined initial attacks of rheumatic fever. As many as half the patients had carditis, and, of these, 50% exhibited congestive cardiac failure. This high incidence arises because in developing countries with limited health-care facilities patients continue to be physically active during the long pre-admission period. The study confirms that the clinical profile of the initial attack of rheumatic fever in developing countries is in most respects not unlike that in developed countries.     

Dementing Illnesses in Rural Populations: The Need for Research and Challenges Confronting Investigators

Expansion of the world's elderly populations has increased concerns about aging-related medical disorders like Alzheimer's disease and other dementias. In the United States, one fourth of those older than age 65 and at greatest risk for developing dementia live in rural environments that may influence its manifestation. The objectives of this study were to determine the need for and potential benefits of further epidemiological research concerning dementia and similar disorders in rural U.S. populations and to identify pertinent methodological issues related to rural dementia research. This study employed a National Library of Medicine (MEDLINE) document search based on the key words "cognitive disorders," "dementia," "Alzheimer's disease," and "rural," followed by recovery of literature resources references in the bibliographies of selected articles. Nineteen studies focusing on dementia or related disorders in rural settings have been reported from around the world. While four of these were conducted in the United States, only one rural dementia prevalence study has been undertaken in this country. Because of methodological variability, comparisons of prevalence estimates between these rural studies, as well as with those from urban investigations, is difficult. Nonetheless, there is reason to believe that certain potentially dementing illnesses are more common in rural populations. There is also evidence to suggest that the screening instruments commonly used in such studies tend to misclassify rural elders as "false positive" dementia cases. Information regarding dementing disorders, particularly Alzheimer's disease, in rural populations is scarce. Preliminary observations that dementia may be more common in rural settings and that rural families are more likely to maintain their dementing elders in the community imply that further rural dementia research could yield important insights into the risk factors for these illnesses, the variables influencing their course, and the methods by which they can be more effectively managed. A determination of the reliability and validity of commonly used dementia screening instruments in rural populations would represent an important advancement in this area of research.     

The legal foundation of the production and use of herd-specific vaccines in Europe

In veterinary medicine, herd-specific vaccines are primarily used in farm animals if traditional vaccines are either unavailable or do not perform as expected. As autogenous products, these vaccines are exempt from Directive 2001/82/EC, and therefore the production and use of herd-specific vaccines are regulated differently in each member state of the European Union (EU). This study is an overview of the diverse legal statuses of herd-specific vaccines among European countries. The study was conducted by analyzing legal documents, tailored questionnaires answered by subject-related authorities from sixteen European countries, and related literature. These analyses revealed that tremendous heterogeneity exists with respect to the legal requirements for the production and use of herd-specific vaccines among the countries that were examined. In particular, certain countries have detailed and precise regulations for these vaccines, whereas the legislation regarding these vaccines is vague or even nonexistent in other nations. The implementation of standardized definitions, guidelines for vaccine use in the field, and regulations for vaccine production are essential prerequisites for achieving legal consistency across Europe. These measures would also help countries enact pertinent national legislation with less divergence regarding the production and use of herd-specific vaccines and ensure the existence of comparable safety and quality standards for these vaccines among European countries.     

The Diagnosis of Delirium Superimposed on Dementia: An Emerging Challenge

Delirium occurring in patients with dementia is referred to as delirium superimposed on dementia (DSD). People who are older with dementia and who are institutionalized are at increased risk of developing delirium when hospitalized. In addition, their prior cognitive impairment makes detecting their delirium a challenge. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision are considered the standard reference for the diagnosis of delirium and include criteria of impairments in cognitive processes such as attention, additional cognitive disturbances, or altered level of arousal. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision does not provide guidance regarding specific tests for assessment of the cognitive process impaired in delirium. Importantly, the assessment or inclusion of preexisting cognitive impairment is also not addressed by these standards. The challenge of DSD gets more complex as types of dementia, particularly dementia with Lewy bodies, which has features of both delirium and dementia, are considered. The objective of this article is to critically review key elements for the diagnosis of DSD, including the challenge of neuropsychological assessment in patients with dementia and the influence of particular tests used to diagnose DSD. To address the challenges of DSD diagnosis, we present a framework for guiding the focus of future research efforts to develop a reliable reference standard to diagnose DSD. A key feature of a reliable reference standard will improve the ability to clinically diagnose DSD in facility-based patients and research studies.     

Pilot survey of the prevalence of neurologic disorders in the Parsi community of Bombay

There is a paucity of trained neurologists in developing countries. We designed a questionnaire to rapidly screen a community of 851 people (Parsis living in a colony in Bombay, India) for possible neurologic diseases. This questionnaire was pretested and found to have a sensitivity of 100 percent for detecting epilepsy, febrile seizures (only in children), completed stroke, peripheral neuropathy, movement disorders, cerebral palsy, mental retardation, and severe dementia. The screening questionnaire was administered by trained lay health workers. One hundred and sixty-three people were identified by this questionnaire as possibly having neurologic disease. Neurologists later examined these 163 people and found that 80 of them actually suffered from at least one of the neurologic diseases of interest (positive predictive value = 48 percent). The most common neurologic disorders were peripheral neuropathy (32 cases), essential tremor (13 cases), stroke (12 cases), Parkinson's disease (six cases), and epilepsy (four cases).     

Injury surveillance in developing countries.

In both developed and developing countries, injuries have a substantial effect on the public's health and on quality of life. Although epidemiologic data regarding the occurrence of injuries in developing countries are limited, recent studies have documented substantial injury-related morbidity and mortality in some of these countries. For example, recent studies in rural Papua New Guinea showed that injuries are the leading cause of death for persons ages 15-44 years. Similarly, injuries are the leading cause of hospitalization in Indonesia and Egypt. Surveillance of injuries is necessary in order for public health practitioners and planners in developing countries to direct and allocate scarce resources appropriately.     

Consensus statement on dementia education and training in Europe

Objectives

The aim of the current statement is to agree on: (1) what is the current situation with education and training on dementia in Europe; (2) what are the minimum educational requirements for professionals (neurologists, psychiatrists, primary care providers, nurses, biologists, neuroradiologists, etc.) regarding Alzheimer’s disease and dementia, and (3) how to start a course of action for the future.

Design

In 2005, a simple questionnaire was sent to members of the European Alzheimer’s Disease Consortium (EADC) concerning the education and training on dementia in their countries. Fourteen universities of the respective countries responded to this simple questionnaire. The answers varied, and the conclusion of this effort was that little was done concerning the training of students and health professionals on dementia. In 2008, another more structured and specified questionnaire was sent to professors in different universities of the same countries.

Results

The answers obtained were different from those of the previous questionnaire and demonstrated that it is very difficult to know about training and education in the field of dementia in every European country.

Conclusion

From the data collected, it seems that although in the recent past little had been done concerning training on dementia, nowadays training has been developed in most European countries, and relevant educational projects exist both for medical students and doctors during their specialty training. Our main purpose is to develop training material or develop specific courses to improve the professional knowledge about dementia so that best medical and non-medical practice is implemented.     

Modelling the incidence of congenital rubella syndrome in developing countries

BACKGROUND: As of 1997, less than one-third of developing countries included rubella vaccine in their national immunization programme. In countries that have achieved high coverage of measles vaccine, an ideal opportunity exists to include control of rubella and congenital rubella syndrome (CRS) in enhanced measles control activities. Data on the burden of congenital rubella syndrome are important to guide rubella vaccination policies. METHODS: We reviewed the literature to identify studies of rubella antibody prevalence in developing countries that were conducted on populations with no major selection bias, prior to wide-scale rubella vaccination in the country. We used a simple catalytic model to describe the age-specific prevalence of susceptibility to rubella virus infection in given populations. Estimates of the incidence of infection among pregnant women were calculated using expressions for the average prevalence of susceptibility to infection and the incidence of infection during gestation. To estimate the number of cases of CRS, we assumed an overall risk of 65% after infection in the first 16 weeks of pregnancy and zero risk thereafter. These estimates were derived for each country for which data were available, then for each World Health Organization region, excluding Europe. RESULTS: The estimated mean incidence of CRS per 100,000 live births was lowest in the Eastern Mediterranean region (77.4, range 0-212) and highest in the Americas (175, range 0-598). The mean of the estimates of the total number of cases of CRS in developing countries in 1996 was approximately 110,000. The range was, however, very wide, from as few as 14,000 to as many as 308,000 cases. CONCLUSIONS: Congenital rubella syndrome is an under-recognized public health problem in many developing countries. There is an urgent need for collection of appropriate data to estimate the cost-effectiveness of a potential global rubella control programme.     

Infective dementias

A wide range of infectious diseases can result in dementia, although the identity and nature of these diseases has changed over time. Two of the most significant current groups in terms of scientific complexity are HIV/AIDS and prion diseases. In these disorders, dementia occurs either as a consequence of targeting the brain and selectively damaging neurones, or by an indirect effect of neuroinflammation. In prion diseases, both direct neurotoxicity and neuroinflammation may act to result in neuronal damage. In HIV encephalitis, the progression of the dementia is slower, perhaps reflecting indirect damage that appears to result from neuroinflammation as a main cause of neuronal death. An ever-increasing range of model systems is now available to study the neuronal damage in infectious dementias, ranging from cell culture systems to animal models, some of which, particularly in the case of prion diseases, are very well characterised and amenable to controlled manipulation in terms of both host and agent parameters. As valuable as these experimental models are, they do not allow a direct approach to an understanding of dementia, the complexities of which cannot readily be studied in vitro or in animal models, but they do allow studies of interventions and therapeutic strategies. This review summarises the current state of knowledge regarding the major infective dementias.     

Introduction. Symposium: Obesity in developing countries: biological and ecological factors

Over the past decade there has been an increasing concern about the impact of chronic, noncommunicable diseases on the health of developing world populations. Traditionally, major causes of illness and death in developing countries have been linked to infectious diseases and undernutrition, and these are still major public health problems in several regions of the world. But recent projections indicate that in 20 y noncommunicable diseases will account for over 60% of the disease burden and mortality in the developing world. Obesity is recognized as an underlying risk factor for many of these chronic conditions. As in developed societies, the risk for obesity in developing countries is also strongly influenced by diet and lifestyle, which are changing dramatically as a result of the economic and nutrition transition. This symposium discusses key aspects of the phenomenon of obesity in the developing world and provides some specific examples from countries facing increasing prevalence of that condition.     

Emergency preparedness and public health systems lessons for developing countries

Low- and middle-income countries, where emerging diseases often make their debut, are also likely to bear the harshest consequences of a potential influenza pandemic. Yet public health systems in developing countries are underfunded, understaffed, and in many cases struggling to deal with the existing burden of disease. As a result, developed countries are beginning to expand assistance for emergency preparedness to the developing world. Given developing countries' weak infrastructure and many competing public health priorities, it is not clear how to best direct these resources. Evidence from the U.S. and other developed countries suggests that some investments in bioterror and pandemic emergency preparedness, although initially implemented as vertical programs, have the potential to strengthen the general public health infrastructure. This experience may hold some lessons for how global funds for emergency preparedness could be invested in developing countries to support struggling public health systems in responding to current health priorities as well as potential future public health threats.     

Mortality from dementia in Norway, 1969-83.

From 1969 to the end of 1983 in Norway, dementia was coded as the underlying cause of death from 2058 death certificates, and as a contributory cause from 19,459. This is 3.56% of the total number of deaths. It seems that a considerable proportion of dementia cases are noted on death certificates in Norway. Death rates based on dementia as the underlying cause of death have increased with time, but when including contributory causes, rates have declined. The data may be useful in epidemiological studies, eg, to search for aetiological clues for Alzheimer's disease. Due to the inclusion of contributory causes of death in the registers and to the high number of dementia cases noted on death certificates, Norwegian mortality data on dementia are probably of better quality than in most other countries.     

Prevalence, incidence, prognosis and risk factors of dementia

The epidemiological evidence on the dementing illnesses suggests that dementia poses an important public health problem. Estimates of the prevalence of dementia indicate that in the twelve countries of the European Community 1.5 to 2.5 million people may be suffering of the disease. The available data on the incidence suggest that in these countries 200,000 to 250,000 people are newly hospitalized yearly for dementia. Fruitful epidemiological approaches to identify preventable causes of the dementing illnesses may include incidence studies across populations, family studies, and risk factors studies using Creutzfeldt-Jakob disease as a model for dementia of the Alzheimer type.     

Lead poisoning in South African children: the hazard is at home

Lead is a toxic heavy metal that has been used extensively in modern society, causing widespread environmental contamination even in isolated parts of the world. Irrefutable evidence associates lead at different exposure levels with a wide spectrum of health and social effects, including mild intellectual impairment, hyperactivity, shortened concentration span, poor school performance, violent/aggressive behavior, and hearing loss. Lead has an impact on virtually all organ systems, including the heart, brain, liver, kidneys, and circulatory system, resulting in coma and death in severe cases. In recent years, a consensus was reached regarding the absence of a threshold for the key health effects associated with lead exposure and the permanent and irreversible nature of many health and social consequences of lead exposure. The public health problem of environmental lead exposure has been widely investigated in developed countries like the United States of America, where actions taken have led to significant reductions in children's blood lead concentrations. In contrast, there is a relative dearth of information and action regarding lead poisoning in developing countries, particularly in African countries, despite evidence of widespread and excessive childhood lead exposure. In this paper, we will review the information from available published papers, the 'grey literature', and unpublished reports to give an overview of lead exposure in South African children over the past two decades, with particular emphasis on sources of exposure in the home environment.     

Progress toward introduction of Haemophilus influenzae type b vaccine in low-income countries--worldwide, 2004-2007

Haemophilus influenzae type b (Hib) disease is estimated to cause 3 million cases of meningitis and severe pneumonia and approximately 386,000 deaths worldwide per year in children aged <5 years. Safe and effective Hib conjugate vaccines have been widely used in industrialized countries for nearly 20 years. However, primarily because of financial constraints and lack of awareness among both public health officials and the public regarding Hib disease burden and benefits of the vaccine, use of these vaccines has been low in developing countries, where most Hib disease and deaths occur. In 2000, the GAVI Alliance (formerly known as the Global Alliance for Vaccines and Immunizations) began providing financial support for Hib vaccine in 72 countries that had a gross national income of < or =$1,000 (USD) per capita. Despite this support, before 2005, adoption of Hib vaccine by these countries remained low. In response, in June 2005, the GAVI Alliance established the Hib Initiative to accelerate evidence-informed decision making regarding use of Hib vaccine in GAVI-eligible countries. During 2004-2007, the number of GAVI-eligible countries using Hib vaccine or approved to use the vaccine increased from 13 (18%) to 47 (65%).     

Patient-Held Maternal and/or Child Health Records: Meeting the Information Needs of Patients and Healthcare Providers in Developing Countries?

Though improvements in infant and maternal mortality rates have occurred over time, women and children still die every hour from preventable causes. Various regional, social and economic factors are involved in the ability of women and children to receive adequate care and prevention services. Patient-held maternal and/or child health records have been used for a number of years in many countries to help track health risks, vaccinations and other preventative health measures performed. Though these records are primarily designed to record patient histories and healthcare information and guide healthcare workers providing care, because the records are patient-held, they also allow families a greater ability to track their own health and prevention strategies.A literature search was performed to answer these questions: (1) What are maternal information needs regarding pregnancy, post-natal and infant healthcare, especially in developing countries? (2) What is known about maternal information seeking behavior in developing countries? (3) What is the history and current state of maternal and/or child patient-held healthcare records, do they provide for the information needs of the healthcare provider and what are the effects and outcomes of patient-held records in general and for maternal and/or child health in particular?Specific information needs of pregnant women and mothers are rarely studied. The small numbers of maternal information behavior results available indicate that mothers, in general, prefer to receive health information directly from their healthcare provider as opposed to from other sources (written, etc.) Overall, in developing countries, patient-held maternal and/or child healthcare records have a mostly positive effect for both patient and care provider. Mothers and children with records tend to have better outcomes in healthcare and preventative measures. Further research into the information behaviors of pregnant women and mothers to determine the extent of reliance on interpersonal information seeking is recommended before expending significant resources on enhanced patient-held maternal and/or child healthcare records including storage on mobile devices. In particular, research is needed to explore the utility of providing targeted health messages to mothers regarding their own health and that of their children; this might best be accomplished through mobile technologies.