The association between frailty and incidence of dementia in Beijing: findings from 10/66 dementia research group population-based cohort study

BACKGROUND

The relationship between frailty and dementia is unclear and there are very few population-based studies regarding this issue in China. The purpose of this study is to estimate the association between frailty and incident dementia in China, and to explore different effects of frailty established by three definitions of frailty on dementia incidence.

METHODS

A five-year prospective cohort study was carried out in 2022 participants aged 65 years and over in urban and rural sites in Beijing, China. The participants were interviewed by trained community primary health care workers from 2004 to 2009. Frailty was defined using modified Fried frailty phenotype, physical frailty definition, and multidimensional frailty definition. Dementia was diagnosed using the 10/66 dementia criterion for calculating cumulative incidence. Both competing risk regression models and Cox proportional hazards models were applied to examine the associations between frailty at baseline and five-year cumulative incidence of dementia.

RESULTS

At the end of follow-up the five-year cumulative incidence rates of dementia with frailty and without frailty defined by the modified Fried frailty were 21.0% and 9.6%, those defined by the physical frailty were 19.9% and 9.0%, and those defined by the multidimensional frailty were 22.8% and 8.9%, respectively. Compared with non-frail participants, frail people had a higher risk of incident dementia using multidimensional frailty definition after adjusting covariates based on competing risk regression model (HR = 1.47, 95% CI 1.01~2.17) and Cox proportional hazards model (HR = 1.56, 95% CI 1.07~2.26). The association between frailty and incident dementia was statistically significant in participants in the upper three quartiles of age (aged 68 years and over) using the multidimensional frailty definition based on the competing risk regression model (HR = 1.61, 95% CI 1.06~2.43) and Cox proportional hazard model (HR = 1.76, 95% CI 1.19~2.61).

CONCLUSIONS

Multidimensional frailty may play an inherent role in incident dementia, especially in the people aged over 68, which is significant for distinguishing high risk people and determining secondary prevention strategies for dementia patients.

Prediction of dementia risk in low-income and middle-income countries (the 10/66 Study): an independent external validation of existing models

BACKGROUND

To date, dementia prediction models have been exclusively developed and tested in high-income countries (HICs). However, most people with dementia live in low-income and middle-income countries (LMICs), where dementia risk prediction research is almost non-existent and the ability of current models to predict dementia is unknown. This study investigated whether dementia prediction models developed in HICs are applicable to LMICs.

METHODS

Data were from the 10/66 Study. Individuals aged 65 years or older and without dementia at baseline were selected from China, Cuba, the Dominican Republic, Mexico, Peru, Puerto Rico, and Venezuela. Dementia incidence was assessed over 3-5 years, with diagnosis according to the 10/66 Study diagnostic algorithm. Discrimination and calibration were tested for five models: the Cardiovascular Risk Factors, Aging and Dementia risk score (CAIDE); the Study on Aging, Cognition and Dementia (AgeCoDe) model; the Australian National University Alzheimer's Disease Risk Index (ANU-ADRI); the Brief Dementia Screening Indicator (BDSI); and the Rotterdam Study Basic Dementia Risk Model (BDRM). Models were tested with use of Cox regression. The discriminative accuracy of each model was assessed using Harrell's concordance (c)-statistic, with a value of 0·70 or higher considered to indicate acceptable discriminative ability. Calibration (model fit) was assessed statistically using the Grønnesby and Borgan test.

FINDINGS

11 143 individuals without baseline dementia and with available follow-up data were included in the analysis. During follow-up (mean 3·8 years [SD 1·3]), 1069 people progressed to dementia across all sites (incidence rate 24·9 cases per 1000 person-years). Performance of the models varied. Across countries, the discriminative ability of the CAIDE (0·52≤c≤0·63) and AgeCoDe (0·57≤c≤0·74) models was poor. By contrast, the ANU-ADRI (0·66≤c≤0·78), BDSI (0·62≤c≤0·78), and BDRM (0·66≤c≤0·78) models showed similar levels of discriminative ability to those of the development cohorts. All models showed good calibration, especially at low and intermediate levels of predicted risk. The models validated best in Peru and poorest in the Dominican Republic and China.

INTERPRETATION

Not all dementia prediction models developed in HICs can be simply extrapolated to LMICs. Further work defining what number and which combination of risk variables works best for predicting risk of dementia in LMICs is needed. However, models that transport well could be used immediately for dementia prevention research and targeted risk reduction in LMICs.

FUNDING

National Institute for Health Research, Wellcome Trust, WHO, US Alzheimer's Association, and European Research Council.

The association between, depression, anxiety, and mortality in older people across eight low- and middle-income countries: Results from the 10/66 cohort study

OBJECTIVES

Depression and anxiety are common mental disorders in later life. Few population-based studies have investigated their potential impacts on mortality in low- and middle-income countries (LMICs). The aim of this study is to examine the associations between depression, anxiety, their comorbidity, and mortality in later life using a population-based cohort study across eight LMICs.

METHODS

This analysis was based on the 10/66 cohort study including 15 991 people aged 65 years or above in Cuba, Dominican Republic, Venezuela, Mexico, Peru, Puerto Rico, China, and India, with an average follow-up time of 3.9 years. Subthreshold and clinical levels of depression were determined using EURO-D and ICD-10 criteria, and anxiety was based on Geriatric Mental State (GMS)-Automated Geriatric Examination for Computer Assisted Taxonomy (AGECAT). Cox proportional hazard modelling was used to estimate how having depression, anxiety, or both was associated with mortality adjusting for sociodemographic and health factors.

RESULTS

Participants with clinical depression (hazard ratio [HR]: 1.45; 95% CI, 1.24-1.70) and subthreshold anxiety (HR: 1.26; 95% CI, 1.15-1.38) had higher risk of mortality than those without the conditions after adjusting for sociodemographic factors and health conditions. Comorbidity of depression and anxiety was associated with a 30% increased risk of mortality but the effect sizes varied across countries (Higgins I2  = 58.8%), with the strongest association in India (HR: 1.99; 95% CI, 1.21-3.27).

CONCLUSIONS

Depression and anxiety appear to be associated with mortality in older people living in LMICs. Variation in effect sizes may indicate different barriers to health service access across countries. Future studies may investigate underlying mechanisms and identify potential interventions to reduce the impact of common mental disorders.

Equitable access to mental healthcare integrated in primary care for people with severe mental disorders in rural Ethiopia: a community-based cross-sectional study

Background

Integration of mental healthcare into non-specialist settings is advocated to expand access to care for people with severe mental disorders (SMD) in low-income countries. However, the impact upon equitable access for disenfranchised members of society has not been investigated. The purpose of this study was to (1) estimate contact coverage for SMD of a new service in primary healthcare (PHC) in a rural Ethiopian district, and (2) investigate equity of access for rural residents, women, people with physical impairments and people of low socio-economic status.

Methods

Community key informants were trained to identify and refer people with probable SMD in Sodo district, south-central Ethiopia, using vignettes of typical presentations. Records of those referred to the new PHC-based service were linked to healthcare records to identify people who engaged with care and non-engagers over a 6 month period. Standardised interviews by psychiatric nurses were used to confirm the diagnosis in those attending PHC. Non-engagers were visited in their homes and administered the Psychosis Symptom Questionnaire. Socio-economic status, discrimination, disability, substance use, social support and distance to the nearest health facility were measured.

Results

Contact coverage for the new service was estimated to be 81.3% (300 engaged out of 369 probable cases of SMD identified). Reimbursement for transport and time may have elevated coverage estimates. In the fully adjusted multivariable model, rural residents had 3.81 increased odds (95% CI 1.22, 11.89) of not accessing care, in part due to geographical distance from the health facility (odds ratio 3.37 (1.12, 10.12)) for people living more than 180 min away. There was no association with lower socioeconomic status, female gender or physical impairment. Higher levels of functional impairment were associated with increased odds of engagement. Amongst non-engagers, the most frequently endorsed barriers were thinking the problem would get better by itself and concerns about the cost of treatment.

Conclusion

Integrating mental healthcare into primary care can achieve high levels of coverage in a rural African setting, which is equitable with respect to gender and socio-economic status. Service outreach into the community may be needed to achieve better contact coverage for rural residents.

Explanatory models of depression in sub-Saharan Africa: Synthesis of qualitative evidence

Debate about the cross-cultural relevance of depression has been central to cross-cultural psychiatry and global mental health. Although there is now a wealth of evidence pertaining to symptoms across different cultural settings, the role of the health system in addressing these problems remains contentious. Depression is undetected among people attending health facilities. We carried out a thematic synthesis of qualitative evidence published in the scientific literature from sub-Saharan Africa to understand how depression is debated, deployed and described. No date limits were set for inclusion of articles. Our results included 23 studies carried out in communities, among people living with HIV, attendees of primary healthcare and with healthcare workers and traditional healers. Included studies were carried out between 1995 and 2018. In most cases, depression was differentiated from 'madness' and seen to have its roots in social adversity, predominantly economic and relationship problems, sometimes entangled with HIV. Participants described the alienation that resulted from depression and a range of self-help and community resources utilised to combat this isolation. Both spiritual and biomedical causes, and treatment, were considered when symptoms were very severe and/or other possibilities had been considered and discarded. Context shaped narratives: people already engaged with the health system for another illness such as HIV were more likely to describe their depression in biomedical terms. Resolution of depression focussed upon remaking the life world, bringing the individual back to familiar rhythms, whether this was through the mechanism of encouraging socialisation, prayer, spiritual healing or biomedical treatment. Our findings suggest that it is essential that practitioners and researchers are fluent in local conceptualisations and aware of local resources to address depression. Design of interventions offered within the health system that are attuned to this are likely to be welcomed as an option among other resources available to people living with depression.

Healthy ageing and the prediction of mortality and incidence dependence in low- and middle- income countries: a 10/66 population-based cohort study

BACKGROUND

In the absence of a consensus on definition and measurement of healthy ageing, we created a healthy ageing index tallying with the functional ability framework provided by the World Health Organization. To create this index, we employed items of functional ability and intrinsic capacity. The current study aims to establish the predictive validity and discrimination properties of this healthy ageing index in settings in Latin American, part of the 10/66 cohort.

METHODS

Population-based cohort studies including 12,865 people ≥65 years old in catchment areas of Cuba, Dominican Republic, Venezuela, Mexico and Peru. We employed latent variable modelling to estimate the healthy ageing scores of each participant. We grouped participants according to the quintiles of the healthy ageing score distribution. Cox's proportional hazard models for mortality and sub-hazard (competing risks) models for incident dependence (i.e. needing care) were calculated per area after a median of 3.9 years and 3.7 years, respectively. Results were pooled together via fixed-effects meta-analysis. Our findings were compared with those obtained from self-rated health.

RESULTS

Participants with lowest levels, compared to participants with highest level of healthy ageing, had increased risk of mortality and incident dependence, even after adjusting for sociodemographic and health conditions (HR: 3.25, 95%CI: 2.63-4.02; sub-HR: 5.21, 95%CI: 4.02-6.75). Healthy ageing scores compared to self-rated health had higher population attributable fractions (PAFs) for mortality (43.6% vs 19.3%) and incident dependence (58.6% vs 17.0%), and better discriminative power (Harrell's c-statistic: mortality 0.74 vs 0.72; incident dependence 0.76 vs 0.70).

CONCLUSION

These results provide evidence that our healthy ageing index could be a valuable tool for prevention strategies as it demonstrated predictive and discriminative properties. Further research in other cultural settings will assist moving from a theoretical conceptualisation of healthy ageing to a more practical one.

Development of a healthy ageing index in Latin American countries - a 10/66 dementia research group population-based study

BACKGROUND

Our population is ageing and in 2050 more than one out of five people will be 60 years or older; 80% of whom will be living in a low-and-middle income country. Living longer does not entail living healthier; however, there is not a widely accepted measure of healthy ageing hampering policy and research. The World Health Organization defines healthy ageing as the process of developing and maintaining functional ability that will enable well-being in older age. We aimed to create a healthy ageing index (HAI) in a subset of six low-and-middle income countries, part of the 10/66 study, by using items of functional ability and intrinsic capacity.

METHODS

The study sample included residents 65-years old and over (n = 12,865) from catchment area sites in Cuba, Dominican Republic, Peru, Venezuela, Mexico and Puerto Rico. Items were collected by interviewing participants or key informants between 2003 and 2010. Two-stage factor analysis was employed and we compared one-factor, second-order and bifactor models. The psychometric properties of the index, including reliability, replicability, unidimensionality and concurrent convergent validity as well as measurement invariance per ethnic group and gender were further examined in the best fit model.

RESULTS

The bifactor model displayed superior model fit statistics supporting that a general factor underlies the various items but other subdomain factors are also needed. The HAI indicated excellent reliability (ω = 0.96, ωΗ = 0.84), replicability (H = 0.96), some support for unidimensionality (Explained Common Variance = 0.65) and some concurrent convergent validity with self-rated health. Scalar measurement invariance per ethnic group and gender was supported.

CONCLUSIONS

A HAI with excellent psychometric properties was created by using items of functional ability and intrinsic capacity in a subset of six low-and-middle income countries. Further research is needed to explore sub-population differences and to validate this index to other cultural settings.

AN INTRODUCTION TO THE ATHLOS PROJECT: AGEING TRAJECTORIES OF HEALTH: LONGITUDINAL OPPORTUNITIES AND SYNERGIES

ATHLOS is a 5-year project, funded by the European Union’s Horizon 2020 Research and Innovation Program. Its aim is to achieve a better understanding of healthy ageing, utilising longitudinal data from existing cohort studies. The measure of healthy ageing used within ATHLOS is based on the definition used by the World Health Organization as the ongoing process of developing and maintaining functional ability to enable well-being in older age. The first step of the project was to harmonise 17 community based cohort studies of ageing, covering 38 countries over the world and over 411,000 individuals. In this talk we will discuss the work of the different work packages of the project, including a description of the existing evidence on risk factors of healthy ageing.

THE IMPACT OF LIFESTYLE BEHAVIORS ON HEALTHY AGING TRAJECTORIES: THE ATHLOS PROJECT

The number of people above 60 years old will double by 2050. There is a considerate variability in the health status of older people. The identification of the different trajectories that people follow as they grow older constitutes one of the aims of the ATHLOS project. In the current study, we created a metric of health in the four available waves (2001, 2003, 2012, 2015) of the Mexican Health and Aging Study (MHAS) by employing Bayesian multilevel Item Response Theory. Growth mixture modelling indicated that older Mexicans (n=14,143) age by following four distinct pathways (i.e. high-stable, moderate-stable, low-stable, decliners). Adherence to healthy lifestyle behaviours (i.e. physical activity, non-smoking, limited alcohol consumption) was associated with better health trajectories. Preliminary analyses in the ATHLOS harmonised dataset also suggest that older people age by following four distinct pathways. The impact of lifestyle behaviours within the harmonised dataset will be investigated and also presented.

INEQUALITIES IN HEALTHY AGING: THE DIFFERENTIAL IMPACT OF EDUCATION AND WEALTH ACROSS COHORT STUDIES

Several studies have investigated longitudinal changes in health status and functional ability but few have examined whether inequalities in healthy ageing varied across different countries. The aim of this study is to investigate trajectories of health metric scores (generated in previous symposium abstract) over the ageing process and examine the impact of education and wealth on the trajectories across eight cohorts in the ATHLOS consortium (N=135,828) using multilevel regression modelling. After adjusting for age, gender and study, higher levels of education (9.52; 95% CI: 9.30, 9.74) and wealth (8.06; 95% CI: 7.84, 8.28) were associated with higher baseline scores but had minimal impacts on decline rates. These effect sizes varied across different cohort studies and the inequality gradient was found to be strongest in the Health Retirement Study from US. Future research may investigate potential mechanisms which might explain the differential impact of education and wealth in different societies.

The psychosis treatment gap and its consequences in rural Ethiopia

BACKGROUND

The "treatment gap" (TG) for mental disorders, widely advocated by the WHO in low-and middle-income countries, is an important indicator of the extent to which a health system fails to meet the care needs of people with mental disorder at the population level. While there is limited research on the TG in these countries, there is even a greater paucity of studies looking at TG beyond a unidimensional understanding. This study explores several dimensions of the TG construct for people with psychosis in Sodo, a rural district in Ethiopia, and its implications for building a more holistic capacity for mental health services.

METHOD

The study was a cross-sectional survey of 300 adult participants with psychosis identified through community-based case detection and confirmed through subsequent structured clinical evaluations. The Butajira Treatment Gap Questionnaire (TGQ), a new customised tool with 83 items developed by the Ethiopia research team, was administered to evaluate several TG dimensions (access, adequacy and effectiveness of treatment, and impact/consequence of the treatment gap) across a range of provider types corresponding with the WHO pyramid service framework.

RESULTS

Lifetime and current access gap for biomedical care were 41.8 and 59.9% respectively while the corresponding figures for faith and traditional healing (FTH) were 15.1 and 45.2%. Of those who had received biomedical care for their current episode, 71.7% did not receive minimally adequate care. Support from the community and non-governmental organisations (NGOs) were negligible. Those with education (Adj. OR: 2.1; 95% CI: 1.2, 3.8) and history of use of FTH (Adj. OR: 3.2; 95% CI: 1.9-5.4) were more likely to use biomedical care. Inadequate biomedical care was associated with increased lifetime risk of adverse experiences, such as history of restraint, homelessness, accidents and assaults.

CONCLUSION

This is the first study of its kind. Viewing TG not as a unidimensional, but as a complex, multi-dimensional construct, offers a more realistic and holistic understanding of health beliefs, help-seeking behaviors, and need for care. The reconceptualized multidimensional TG construct could assist mental health services capacity building advocacy and policy efforts and allow community and NGOs play a larger role in supporting mental healthcare.

Impact of perinatal and repeated maternal common mental disorders on educational outcomes of primary school children in rural Ethiopia: population-based cohort study

BACKGROUND

There have been no studies from low- or middle-income countries to investigate the long-term impact of perinatal common mental disorders (CMD) on child educational outcomes.

AIMS

To test the hypothesis that exposure to antenatal and postnatal maternal CMD would be associated independently with adverse child educational outcomes in a rural Ethiopian.

METHOD

A population-based birth cohort was established in 2005/2006. Inclusion criteria were: age between 15 and 49 years, ability to speak Amharic, in the third trimester of pregnancy and resident of the health demographic surveillance site. One antenatal and nine postnatal maternal CMD assessments were conducted using a self-reporting questionnaire, validated for the local use. Child educational outcomes were obtained from the mother at T1 (2013/2014 academic year; mean age 8.5 years) and from school records at T2 (2014/2015 academic year; mean age 9.3 years).

RESULTS

Antenatal CMD (risk ratio (RR) = 1.06, 95% CI 1.05-1.07) and postnatal CMD (RR = 1.07, 95% CI 1.06-1.09) were significantly associated with child absenteeism at T2. Exposure to repeatedly high maternal CMD scores in the preschool period was not associated with absenteeism after adjusting for antenatal and postnatal CMD. Non-enrolment at T1 (odds ratio 0.75, 95% CI 0.62-0.92) was significantly but inversely associated with postnatal maternal CMD. There was no association between maternal CMD and child academic achievement or drop-out.

CONCLUSIONS

Our findings support the hypothesis of a critical period for exposure to maternal CMD for adverse child outcomes and indicate that programmes to enhance regular school attendance in low-income countries need to address perinatal maternal CMD.

DECLARATION OF INTEREST

None.

Redesigning care for older people to preserve physical and mental capacity: WHO guidelines on community-level interventions in integrated care

Islene Araujo de Carvalho and coauthors discuss the WHO guidelines on integrated care for older people.

Partnerships in a Global Mental Health Research Programme-the Example of PRIME

Collaborative research partnerships are necessary to answer key questions in global mental health, to share expertise, access funding and influence policy. However, partnerships between low- and middle-income countries (LMIC) and high-income countries have often been inequitable with the provision of technical knowledge flowing unilaterally from high to lower income countries. We present the experience of the Programme for Improving Mental Health Care (PRIME), a LMIC-led partnership which provides research evidence for the development, implementation and scaling up of integrated district mental healthcare plans in Ethiopia, India, Nepal, South Africa and Uganda. We use Tuckman's first four stages of forming, storming, norming and performing to reflect on the history, formation and challenges of the PRIME Consortium. We show how this resulted in successful partnerships in relation to management, research, research uptake and capacity building and reflect on the key lessons for future partnerships.

Impact of integrated district level mental health care on clinical and social outcomes of people with severe mental illness in rural Ethiopia: an intervention cohort study

AIM

There is limited evidence of the safety and impact of task-shared care for people with severe mental illnesses (SMI; psychotic disorders and bipolar disorder) in low-income countries. The aim of this study was to evaluate the safety and impact of a district-level plan for task-shared mental health care on 6 and 12-month clinical and social outcomes of people with SMI in rural southern Ethiopia.

METHODS

In the Programme for Improving Mental health carE, we conducted an intervention cohort study. Trained primary healthcare (PHC) workers assessed community referrals, diagnosed SMI and initiated treatment, with independent research diagnostic assessments by psychiatric nurses. Primary outcomes were symptom severity and disability. Secondary outcomes included discrimination and restraint.

RESULTS

Almost all (94.5%) PHC worker diagnoses of SMI were verified by psychiatric nurses. All prescribing was within recommended dose limits. A total of 245 (81.7%) people with SMI were re-assessed at 12 months. Minimally adequate treatment was received by 29.8%. All clinical and social outcomes improved significantly. The impact on disability (standardised mean difference 0.50; 95% confidence interval (CI) 0.35-0.65) was greater than impact on symptom severity (standardised mean difference 0.28; 95% CI 0.13-0.44). Being restrained in the previous 12 months reduced from 25.3 to 10.6%, and discrimination scores reduced significantly.

CONCLUSIONS

An integrated district level mental health care plan employing task-sharing safely addressed the large treatment gap for people with SMI in a rural, low-income country setting. Randomised controlled trials of differing models of task-shared care for people with SMI are warranted.

Cohort Differences in Cognitive Aging in the Longitudinal Aging Study Amsterdam

Objectives

This study aims to examine cohort differences in cognitive performance and rates of change in episodic memory, processing speed, inductive reasoning, and general cognitive performance and to investigate whether these cohort effects may be accounted for by education attainment.

Method

The first cohort (N = 705) was born between 1920 and 1930, whereas the second cohort (N = 646) was born between 1931 and 1941. Both birth cohorts were aged 65 to 75 years at baseline and were followed up 3 and 6 years later. Data were analyzed using linear mixed models.

Results

The later born cohort had better general cognitive performance, inductive reasoning, and processing speed at baseline, but cohort differences in inductive reasoning and general cognitive performance disappeared after adjusting for education. The later born cohort showed steeper decline in processing speed. Memory decline was steeper in the earlier born cohort but only from Time 1 to Time 3 when the same memory test was administered. Education did not account for cohort differences in cognitive decline.

Discussion

The later born cohort showed better initial performance in certain cognitive abilities, but no better preservation of cognitive abilities overtime compared with the earlier born cohort. These findings carry implications for healthy cognitive aging.

Healthy ageing trajectories and lifestyle behaviour: the Mexican Health and Aging Study

Projections show that the number of people above 60 years old will triple by 2050 in Mexico. Nevertheless, ageing is characterised by great variability in the health status. In this study, we aimed to identify trajectories of health and their associations with lifestyle factors in a national representative cohort study of older Mexicans. We used secondary data of 14,143 adults from the Mexican Health and Aging Study (MHAS). A metric of health, based on the conceptual framework of functional ability, was mapped onto four waves (2001, 2003, 2012, 2015) and created by applying Bayesian multilevel Item Response Theory (IRT). Conditional Growth Mixture Modelling (GMM) was used to identify latent classes of individuals with similar trajectories and examine the impact of physical activity, smoking and alcohol on those. Conditional on sociodemographic and lifestyle behaviour four latent classes were suggested: high-stable, moderate-stable, low-stable and decliners. Participants who did not engage in physical activity, were current or previous smokers and did not consume alcohol at baseline were more likely to be in the trajectory with the highest deterioration (i.e. decliners). This study confirms ageing heterogeneity and the positive influence of a healthy lifestyle. These results provide the ground for new policies.

Health-related quality-of-life assessment in dementia: Evidence of cross-cultural validity in Latin America

All health-related quality-of-life (HRQL) measures for dementia have been developed in high-income countries and none were validated for cross-cultural use. Yet, the global majority of people living with dementia reside in low- and middle-income countries. We therefore investigated the measurement invariance of a set of self- and informant-report HRQL measures developed in the United Kingdom when used in Latin America. Self-reported HRQL was obtained using (DEMQOL) at a memory assessment service in the United Kingdom (n = 868) and a population cohort study in Latin America (n = 417). Informant reports were collected using DEMQOL-Proxy at both sites (n = 909 and n = 495). Multiple-group confirmatory bifactor models for ordered categorical item responses were estimated to evaluate measurement invariance. Results support configural, metric, and scalar invariance for the concept of general HRQL in DEMQOL and DEMQOL-Proxy. The dominant impact of general HRQL on item responses was evident across U.K. English and Ibero American Spanish versions of DEMQOL (ω_h = 0.87–0.90) and DEMQOL-Proxy (ω_h = 0.88–0.89). Ratings of “positive emotion” did not show a major impact on general HRQL appraisal, particularly for Latin American respondents. Item information curves show that self- and informant-reports were highly informative about the presence rather than the absence of HRQL impairment. We found no major difference in conceptual meaning, sensitivity, and relevance of DEMQOL and DEMQOL-Proxy for older adults in the United Kingdom and Latin America. Further replication is needed for consensus over which HRQL measures are appropriate for making cross-national comparisons in global dementia research.

Measuring health-related quality-of-life (HRQL) in older adults living with dementia is important to quantify their burden of disease. Globally more than half of these adults live in low- and middle-income countries, but all HRQL measures for dementia originate from high-income countries. Our study is the first to show for a self- and informant-report HRQL instrument (DEMQOL) that the appraisals are comparable across U.K. (English) and Latin American (Spanish) community samples.

Homelessness and severe mental illness in low- and middle-income countries: scoping review

BACKGROUND

Despite being a global problem, little is known about the relationship between severe mental illness (SMI) and homelessness in low- and middle-income countries (LMICs). Homeless people with SMI are an especially vulnerable population and face myriad health and social problems. In LMICs, low rates of treatment for mental illness, as well as differing family support systems and cultural responses to mental illness, may affect the causes and consequences of homelessness in people with SMI.

AIMS

To conduct a systematic, scoping review addressing the question: what is known about the co-occurrence of homelessness and SMI among adults living in LMICs?

METHOD

We conducted an electronic search, a manual search and we consulted with experts. Two reviewers screened titles and abstracts, assessed publications for eligibility and appraised study quality.

RESULTS

Of the 49 included publications, quality was generally low: they were characterised by poor or unclear methodology and reporting of results. A total of 7 publications presented the prevalence of SMI among homeless people; 12 presented the prevalence of homelessness among those with SMI. Only five publications described interventions for this population; only one included an evaluation component.

CONCLUSIONS

Evidence shows an association between homelessness and SMI in LMICs, however there is little information on the complex relationship and direction of causality between the phenomena. Existing programmes should undergo rigorous evaluation to identify key aspects required for individuals to achieve sustainable recovery. Respect for human rights should be paramount when conducting research with this population.

DECLARATION OF INTEREST

None.