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Objective Teleneuropsychology (teleNP) could potentially expand access to services for patients who are confined, have limited personal access to healthcare, or live in remote areas. The emergence of the COVID-19 pandemic has significantly increased the use of teleNP for cognitive assessments. The main objective of these recommendations is to identify which procedures can be potentially best adapted to the practice of teleNP in Latin America, and thereby facilitate professional decision-making in the region. Method Steps taken to develop these recommendations included (1) formation of an international working group with representatives from 12 Latin American countries; (2) assessment of rationale, scope, and objectives; (3) formulation of clinical questions; (4) evidence search and selection; (5) evaluation of existing evidence and summary; and (6) formulation of recommendations. Levels of evidence were graded following the Oxford Centre for Evidence-Based Medicine system. Databases examined included PubMed, WHO-IRIS, WHO and PAHO-IRIS, Índice Bibliográfico Español en Ciencias de la Salud (IBCS), and LILACS. Results Working group members reviewed 18,400 titles and 422 abstracts and identified 19 articles meeting the criteria for level of evidence, categorization, and elaboration of recommendations. The vast majority of the literature included teleNP tests in the English language. The working group proposed a series of recommendations that can be potentially best adapted to the practice of teleNP in Latin America. Conclusions There is currently sufficient evidence to support the use of videoconferencing technology for remote neuropsychological assessments. These recommendations will likely contribute to the advancement of teleNP research and practice in the region.

BackgroundAge and gender specific prevalence rates for parkinsonism and Parkinson's disease (PD) are important to guide research, clinical practice, and public health planning; however, prevalence estimates in Latin America (LatAm) are limited. We aimed to estimate the prevalence of parkinsonism and PD and examine related risk factors in a cohort of elderly individuals from Latin America (LatAm).MethodsData from 11,613 adults (65+ years) who participated in a baseline assessment of the 10/66 study and lived in six LatAm countries were analyzed to estimate parkinsonism and PD prevalence. Crude and age-adjusted prevalence were determined by sex and country. Diagnosis of PD was established using the UK Parkinson's Disease Society Brain Bank's clinical criteria.FindingsIn this cohort, the prevalence of parkinsonism was 8.0% (95% CI 7.6%-8.5%), and the prevalence of PD was 2.0% (95% CI 1.7%-2.3%). PD prevalence increased with age from 1.0 to 3.5 (65-69vs. 80 years or older, p&nbsp

Introduction A growing number of dominantly inherited Alzheimer's disease (DIAD) cases have become known in Latin American (LatAm) in recent years. However, questions regarding mutation distribution and frequency by country remain open. Methods A literature review was completed aimed to provide estimates for DIAD pathogenic variants in the LatAm population. The search strategies were established using a combination of standardized terms for DIAD and LatAm. Results Twenty-four DIAD pathogenic variants have been reported in LatAm countries. Our combined dataset included 3583 individuals at risk; countries with highest DIAD frequencies were Colombia (n = 1905), Puerto Rico (n = 672), and Mexico (n = 463), usually attributable to founder effects. We found relatively few reports with extensive documentation on biomarker profiles and disease progression. Discussion Future DIAD studies will be required in LatAm, albeit with a more systematic approach to include fluid biomarker and imaging studies. Regional efforts are under way to extend the DIAD observational studies and clinical trials to Latin America.

Background The World Health Organization (WHO) has reframed health and healthcare for older people around achieving the goal of healthy ageing. The recent WHO Integrated Care for Older People (ICOPE) guidelines focus on maintaining intrinsic capacity, i.e., addressing declines in neuromusculoskeletal, vitality, sensory, cognitive, psychological, and continence domains, aiming to prevent or delay the onset of dependence. The target group with 1 or more declines in intrinsic capacity (DICs) is broad, and implementation may be challenging in less-resourced settings. We aimed to inform planning by assessing intrinsic capacity prevalence, by characterising the target group, and by validating the general approach—testing hypotheses that DIC was consistently associated with higher risks of incident dependence and death. Methods and findings We conducted population-based cohort studies (baseline, 2003–2007) in urban sites in Cuba, Dominican Republic, Puerto Rico, and Venezuela, and rural and urban sites in Peru, Mexico, India, and China. Door-knocking identified eligible participants, aged 65 years and over and normally resident in each geographically defined catchment area. Sociodemographic, behaviour and lifestyle, health, and healthcare utilisation and cost questionnaires, and physical assessments were administered to all participants, with incident dependence and mortality ascertained 3 to 5 years later (2008–2010). In 12 sites in 8 countries, 17,031 participants were surveyed at baseline. Overall mean age was 74.2 years, range of means by site 71.3–76.3 years; 62.4% were female, range 53.4%–67.3%. At baseline, only 30% retained full capacity across all domains. The proportion retaining capacity fell sharply with increasing age, and declines affecting multiple domains were more common. Poverty, morbidity (particularly dementia, depression, and stroke), and disability were concentrated among those with DIC, although only 10% were frail, and a further 9% had needs for care. Hypertension and lifestyle risk factors for chronic disease, and healthcare utilisation and costs, were more evenly distributed in the population. In total, 15,901 participants were included in the mortality cohort (2,602 deaths/53,911 person-years of follow-up), and 12,939 participants in the dependence cohort (1,896 incident cases/38,320 person-years). One or more DICs strongly and independently predicted incident dependence (pooled adjusted subhazard ratio 1.91, 95% CI 1.69–2.17) and death (pooled adjusted hazard ratio 1.66, 95% CI 1.49–1.85). Relative risks were higher for those who were frail, but were also substantially elevated for the much larger sub-groups yet to become frail. Mortality was mainly concentrated in the frail and dependent sub-groups. The main limitations were potential for DIC exposure misclassification and attrition bias. Conclusions In this study we observed a high prevalence of DICs, particularly in older age groups. Those affected had substantially increased risks of dependence and death. Most needs for care arose in those with DIC yet to become frail. Our findings provide some support for the strategy of optimising intrinsic capacity in pursuit of healthy ageing. Implementation at scale requires community-based screening and assessment, and a stepped-care intervention approach, with redefined roles for community healthcare workers and efforts to engage, train, and support them in these tasks. ICOPE might be usefully integrated into community programmes for detecting and case managing chronic diseases including hypertension and diabetes., In a population-based cohort study, Martin J. Prince and colleagues evaluate intrinsic capacity and its associations with incident dependence and mortality in Latin America, India and China., Author summary Why was this study done? As we grow older, we are affected to different degrees by declines in the working of our organs and body systems, limiting our ability to get around, be well nourished, see, hear, and think clearly, stay continent, and maintain mood and well-being. The World Health Organization has proposed a programme—Integrated Care for Older People (ICOPE)—supported by evidence that simple interventions may slow or reverse these processes, with potential to improve health and functioning and delay needs for care developing among older people. ICOPE targets low- and middle-income countries, but we do not yet know how many older people in these settings are significantly affected by early age-related decline, or whether these changes predict who will go on to deteriorate further, leading to needs for care and earlier death. What did the researchers do and find? We had already completed (between 2003 and 2007) baseline community surveys of 17,031 people aged 65 years and over living in 12 urban and rural sites in 6 Latin American countries, India, and China; we then tried to interview them again 3 to 5 years later (between 2008 and 2010) to identify who had died (in 11 sites, among 15,901 older people) and who had developed needs for care (in 10 sites, among 12,939 older people). Analysing baseline data from these studies, we found that between two-thirds and three-quarters of older people were affected by significant decline in at least 1 of the areas targeted by the ICOPE programme; this proportion was highest among the older old, who were also more likely to have problems in multiple areas. Most (nearly three-quarters) of those with significant decline at baseline had not yet gone on to become physically frail or develop needs for care; they were nevertheless 1.7 to 1.9 times more likely than those without any significant decline to develop needs for care over the follow-up period, and 1.3 to 1.4 times more likely to have died. What do these findings mean? Delivering comprehensive assessment, care planning, and community interventions to up to three-quarters of the older population would be a major challenge for poorly resourced health systems in low- and middle-income countries. Nevertheless, findings from our analyses support the World Health Organization’s strategy to promote health and well-being by targeting a broad group with early decline who do seem to be at increased risk of adverse outcomes. Future research should focus upon feasible, acceptable, and efficient methods of delivering the ICOPE programme (implementation science) and its effectiveness and cost-effectiveness in improving health and social outcomes (controlled trials). The main limitations were that health declines were measured in different ways, some of which may have been imprecise, and those who could not be followed up may have had different characteristics to those who were included in the analysis.

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.

The first case of non-travel related SARS-COV-2 was detected late February 2020 in California, however the delay of diagnostic testing and initial stringent testing criteria made it difficult to identify those who could have acquired it through community spread. There was speculation by many that the virus may have been circulating at least a month earlier [1], and environmental sampling has suggested that versions of this virus were found many months before the first human samples were identified [2]. Here we performed a retrospective study from residual samples collected from a global DoD Respiratory Surveillance Program to establish a tentative timeline by which this virus was circulating in our DoD population. We performed RT-PCR for SARS-COV-2 and compared to the dates of these cases to the first cases identified in respective states and counties using the Johns Hopkins COVID tracker website. Twenty-four positive samples were identified out of approximately 7,000 tested. Although we found some early cases in certain regions, we did not see circulation before late February in samples collected both in the US and outside the USA.SUMMARYWhat is already known about this topic?We know that the first reported case of SARS-COV-2 was mid-January; however, there has been conjecture that the virus was found in the community before this date.What is added by this report?Here we took samples collection from a global respiratory surveillance program and evaluated for the presence of SARS-COV-2 RNA. The first case we found in the surveillance program was approximately 30-60 days before the first case was identified on military installations via diagnostic testing, however was not earlier than the mid-January reported case in California.What are the implications for public health practice?The implementation of new and emerging pathogen detection assays into already established surveillance programs could detect early community spread and possibly reduce spread of pathogen among vulnerable populations.

Background: Age-gender-specific prevalence rates for parkinsonism and Parkinson’s disease (PD) are important to guide research, clinical practice and public health planning; however, prevalence estimates in Latin America (LatAm) are limited. We aimed to estimate the prevalence of parkinsonism and PD and examine its risk factors in a cohort of elderly individuals from LatAm. Methods: Data from 11,613 adults (65+ years) who participated in a baseline assessment of the 10/66 study and who lived in six LatAm countries were analyzed to estimate Parkinsonism and PD prevalence. Crude and age-adjusted prevalence were determined by sex and country. Diagnosis of PD was established using the UK Parkinson’s Disease Society Brain Bank’s clinical criteria. Findings: In this cohort, the prevalence of Parkinsonism was 8.0% (95% CI 7.6%-8.5%), and the prevalence of PD was 2.0% (95% CI 1.7%-2.3%). PD prevalence increased with age from 1.0 to 3.5 (65-69 vs. 80 years or older, p

Background: Rapid technological advances offer a possibility to develop cost-effective digital cognitive assessment tools. However, it is unclear whether these measures are suitable for application in populations from Low and middle-income countries (LMIC). Objective: To examine the accuracy and validity of the Brain Health Assessment (BHA) in detecting cognitive impairment in a Cuban population. Methods: In this cross-sectional study, 146 participants (cognitively healthy = 53, mild cognitive impairment (MCI) = 46, dementia = 47) were recruited at primary care and tertiary clinics. The main outcomes included: accuracy of the BHA and the Montreal Cognitive Assessment (MoCA) in discriminating between controls and cognitively impaired groups (MCI and dementia) and correlations between the BHA subtests of memory, executive functions, and visuospatial skills and criterion-standard paper-and-pencil tests in the same domains. Results: The BHA had an AUC of 0.95 (95% CI: 0.91–0.98) in discriminating between controls and cognitively impaired groups (MCI and dementia, combined) with 0.91 sensitivity at 0.85 specificity. In discriminating between control and MCI groups only, the BHA tests had an AUC of 0.94 (95% CI: 0.90–0.99) with 0.71 sensitivity at 0.85 specificity. Performance was superior to the MoCA across all diagnostic groups. Concurrent and discriminant validity analyses showed moderate to strong correlations between the BHA tests and standard paper-and-pencil measures in the same domain and weak correlations with standard measures in unrelated domains. Conclusion: The BHA has excellent performance characteristics in detecting cognitive impairment including dementia and MCI in a Hispanic population in Cuba and outperformed the MoCA. These results support potential application of digital cognitive assessment for older adults in LMIC.

Background Cuba’s life expectancy at 79 is third highest in Latin America. Many attribute this to social investments in health and education, but comparative research is sparse, thus we compare Cuba with neighboring Dominican Republic, Costa Rica due to its strong social protections, and the U.S. Given high cardiovascular mortality, we focus on cardiovascular risk factor levels. To assess the role of health care, we distinguish medically amenable biomarkers from behavioral risk factors. To assess the role of Cuba’s focus on equity, we compare education gradients in risk factors. Methods We analyze Cuban data from the 10/66 Dementia Research Group baseline survey of urban adults ages 65 plus. Comparison samples are drawn from the Dominican Republic 10/66 survey, the Costa Rican CRELES, and U.S. NHANES. We analyze cross-country levels and education gradients of medically amenable (hypertension, diabetes, hypercholesterolemia, access to health care) and behavioral (smoking, obesity) risk factors,–using sex-stratified weighted means comparisons and age-adjusted logistic regression. Results Neither medically amenable nor behavioral risk factors are uniformly better in Cuba than comparison countries. Obesity is lower in Cuba, but male smoking is higher. Hypertension, diabetes, and hypercholesterolemia levels are high in all countries, though Cuba’s are lower than Costa Rica. Hypertension awareness in Cuba is similar to Costa Rica. Cuba has a higher proportion of hypertensives on treatment than Costa Rica, though lower than the U.S. Comparative gradients by education are similarly mixed. For behavioral factors, Cuba shows the strongest gradients (primarily for men) among the countries compared: smoking improves, but obesity worsens with education. Hypertension awareness also improves with education in Cuba, but Cuba shows no significant differences by education in hypertension treatment. Conclusion Smoking is comparatively high in Cuba, but obesity is low, and the resulting biomarkers show comparatively mixed patterns. Cuba’s social protections have not eliminated strong educational gradients in behavioral risk factors, but the healthcare system appears to have eliminated disparities such as in hypertension treatment.

Introduction Despite high dementia prevalence in Hispanic populations globally, especially Caribbean Hispanics, no study has comparatively examined the association between education and dementia among Hispanics living in the Caribbean Islands and older adults in the United States. Methods We used data on 6107 respondents aged 65 and older in the baseline wave of the population‐based and harmonized 10/66 survey from Cuba, the Dominican Republic, and Puerto Rico, collected between 2003 and 2008, and 11,032 respondents aged 65 and older from the U.S.‐based Health and Retirement Study data in 2014, a total of 17,139 individuals. We estimated multivariable logistic regression models examining the association between education and dementia, adjusted for age, income, assets, and occupation. The models were estimated separately for the Caribbean population (pooled and by setting) and the U.S. population by race/ethnicity (Hispanic, Black, and White), followed by pooled models across all populations Results In the Caribbean population, the relative risk of dementia among low versus high educated adults was 1.45 for women (95% confidence interval [CI] 1.17, 1.74) and 1.92 (95% CI 1.35, 2.49) for men, smaller compared to those in the United States, especially among non‐Hispanic Whites (women: 2.78, 95% CI 1.94, 3.61; men: 5.98, 95% CI 4.02, 7.95). Discussion The differential associations between education and dementia across the Caribbean and US settings may be explained by greater disparities in social conditions in the United States compared to the Caribbean, such as access to health care, healthy behaviors, and social stressors, which serve as potentially important mediators.

Introducción. Son escasos los estudios sobre prevalencia de la fragilidad realizados en países de bajos y medianos ingresos. Objetivo: estimar la prevalencia y asociaciones de riesgo del síndrome de fragilidad en áreas urbanas y rurales de América Latina, India y China. Método. Estudio de corte transversal, puerta a puerta, de base poblacional, fue realizado en ocho áreas urbanas y cuatro áreas rurales de ocho países: Cuba, República Dominicana, Puerto Rico, Venezuela, Perú, México, China y la India. Los indicadores de fragilidad evaluados fueron velocidad de la marcha, agotamiento, pérdida de peso y baja actividad física. El fenotipo de fragilidad se definió por la presencia de dos o más indicadores. Resultados. Fueron visitadas 17 031 personas de 65 años y más. La prevalencia global de fragilidad fue del 15,2 % (IC 95 % 14,6-15,7 %). Controlando el efecto de la edad, el sexo y la educación, la fragilidad se asoció con la edad avanzada, el sexo femenino, bajo nivel socioeconómico, enfermedad física limitante, ictus, depresión, demencia, discapacidad y dependencia, así como a elevados costos en salud. La prevalencia de fragilidad y sus diversos indicadores varía según las diferentes áreas estudiadas en América Latina, India y China. La cultura y otros factores contextuales influyen de manera significativa en la evaluación de la fragilidad incluso utilizando los cuestionarios y las mediciones físicas habituales.

Background Dementia shows sex difference in its epidemiology. Childbirth, a distinctive experience of women, is associated with the risk for various diseases. However, its association with the risk of dementia in women has rarely been studied. Methods We harmonized and pooled baseline data from 11 population-based cohorts from 11 countries over 3 continents, including 14,792 women aged 60 years or older. We investigated the association between parity and the risk of dementia using logistic regression models that adjusted for age, educational level, hypertension, diabetes mellitus, and cohort, with additional analyses by region and dementia subtype. Results Across all cohorts, grand multiparous (5 or more childbirths) women had a 47% greater risk of dementia than primiparous (1 childbirth) women (odds ratio [OR] = 1.47, 95% confidence interval [CI] = 1.10–1.94), while nulliparous (no childbirth) women and women with 2 to 4 childbirths showed a comparable dementia risk to primiparous women. However, there were differences associated with region and dementia subtype. Compared to women with 1 to 4 childbirths, grand multiparous women showed a higher risk of dementia in Europe (OR = 2.99, 95% CI = 1.38–6.47) and Latin America (OR = 1.49, 95% CI = 1.04–2.12), while nulliparous women showed a higher dementia risk in Asia (OR = 2.15, 95% CI = 1.33–3.47). Grand multiparity was associated with 6.9-fold higher risk of vascular dementia in Europe (OR = 6.86, 95% CI = 1.81–26.08), whereas nulliparity was associated with a higher risk of Alzheimer disease (OR = 1.91, 95% CI 1.07–3.39) and non-Alzheimer non-vascular dementia (OR = 3.47, 95% CI = 1.44–8.35) in Asia. Conclusion Parity is associated with women’s risk of dementia, though this is not uniform across regions and dementia subtypes.

We aimed to examine the relationship between Apolipoprotein E ε4 (APOE*4) carriage on cognitive decline, and whether these associations were moderated by sex, baseline age, ethnicity, and vascular risk factors. Participants were 19,225 individuals aged 54–103 years from 15 longitudinal cohort studies with a mean follow-up duration ranging between 1.2 and 10.7 years. Two-step individual participant data meta-analysis was used to pool results of study-wise analyses predicting memory and general cognitive decline from carriage of one or two APOE*4 alleles, and moderation of these associations by age, sex, vascular risk factors, and ethnicity. Separate pooled estimates were calculated in both men and women who were younger (ie, 62 years) and older (ie, 80 years) at baseline. Results showed that APOE*4 carriage was related to faster general cognitive decline in women, and faster memory decline in men. A stronger dose-dependent effect was observed in older men, with faster general cognitive and memory decline in those carrying two versus one APOE*4 allele. Vascular risk factors were related to an increased effect of APOE*4 on memory decline in younger women, but a weaker effect of APOE*4 on general cognitive decline in older men. The relationship between APOE*4 carriage and memory decline was larger in older-aged Asians than Whites. In sum, APOE*4 is related to cognitive decline in men and women, although these effects are enhanced by age and carriage of two APOE*4 alleles in men, a higher numbers of vascular risk factors during the early stages of late adulthood in women, and Asian ethnicity.

Background Population aging will lead to a dramatic increase in dementia prevalence, which will disproportionally affect racial minorities. The presence of racial differences in dementia prevalence has been widely reported in United States, but there are no relevant studies on this topic in low- and middle-income countries. Methods In a cross-sectional survey, 2944 older Cubans were recruited at a community-based level aimed to identify the effects of self-identified race and genetic admixture on cognitive performance. Dementia diagnosis was established using 10/66 Dementia and DSM-IV criteria. APOE-ε4 genotype was determined in 2511 (85%) and genetic admixture was completed for all dementia cases and in a randomly selected sample of cognitive healthy participants (218 dementia cases and 367 participants without dementia). Results The overall prevalence of dementia was 8.7%, without large or statistically significant differences on dementia prevalence (p = .12) by self-identified race. Mean cognitive scores were similar across racial groups (p = .46). After controlling for age, sex, and education, greater proportion of African ancestry was not associated with cognitive performance (p = .17). Conclusions We found no evidence of an independent effect of self-identified race and/or population ancestry on dementia prevalence or cognitive performance. This suggests that observed differences in dementia prevalence among diverse populations may be driven primarily by social determinants of health.

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.

BackgroundResearch carried out in high income countries suggests that loneliness may be a common experience among older adults living in these settings. Loneliness is correlated with poor socioeconomic status, living alone, being widowed and is associated with adverse health outcomes, including mortality. There is still a lack of evidence about the epidemiology of loneliness among older adults living in low- and middle-income countries. This study was designed to explore prevalence and correlates of self-reported loneliness and to investigate whether loneliness predicts mortality in Latin America, China and India. MethodsThe study investigated population-based cross-sectional (2003-2007) and longitudinal surveys (follow-up 2007-2010) from the 10/66 Dementia Research Group project carried out among 16685 older adults in urban and rural catchment areas in Cuba, Dominican Republic, Puerto Rico, Venezuela, Peru, Mexico, China and India. Poisson regression and Cox regression analyses were conducted to analyse correlates of loneliness and its association with mortality. ResultsThe standardised prevalence of loneliness varied between 25.3% and 32.4% in Latin America and was 18.3% in India. China showed a low prevalence of loneliness (3.8%). In pooled meta-analyses, there was robust evidence to support an association between loneliness and mortality across Latin America (HR=1.13, 95% CI 1.01-1.26, I2=10.1%) and China (HR=1.58, 95% CI 1.03-2.41), but there were no associations in India. ConclusionsOur findings suggest potential cultural variances may exist in the concept of loneliness in older age. The effect of loneliness upon mortality is consistent across different cultural settings excluding India. Loneliness should therefore be considered as a potential dimension of public health among older populations.

Cuba, the Dominican Republic, and Puerto Rico, otherwise known as the Spanish Insular Caribbean, comprise a subgroup of insular territories that have similar cultural, historical, and colonial backgrounds. The Spanish Insular Caribbean population faces a particularly high risk for dementia, and only steadily emerging, albeit unique behavioral and psychological approaches for treatment. Comprehensive efforts to provide adequate and culturally congruent treatment are complex and characterized by social, economic, political, and public health influences. This chapter begins contextualizing the treatment of dementia by describing the cultural and historical landscape of the Spanish-speaking islands in the Caribbean. Prevalence rates of dementia in these regions are also discussed along with the current strategic, national guidelines for comprehensive care and the systems of healthcare provision in each country. Furthermore, cultural considerations for dementia management are discussed, including a summary of the psychological strengths exemplified within the Cuban, Dominican, and Puerto Rican communities. The chapter concludes with a review of treatment practices and interventions for individuals with dementia and their caregivers.

The SARS-CoV-2 global pandemic will disproportionately impact countries with weak economies and vulnerable populations including people with dementia. Latin American and Caribbean countries (LACs) are burdened with unstable economic development, fragile health systems, massive economic disparities, and a high prevalence of dementia. Here, we underscore the selective impact of SARS-CoV-2 on dementia among LACs, the specific strain on health systems devoted to dementia, and the subsequent effect of increasing inequalities among those with dementia in the region. Implementation of best practices for mitigation and containment faces particularly steep challenges in LACs. Based upon our consideration of these issues, we urgently call for a coordinated action plan, including the development of inexpensive mass testing and multilevel regional coordination for dementia care and related actions. Brain health diplomacy should lead to a shared and escalated response across the region, coordinating leadership, and triangulation between governments and international multilateral networks. Fil: Ibañez, Agustin Mariano. Universidad Adolfo Ibáñez; Chile. Universidad de San Andrés; Argentina. Universidad Autónoma del Caribe; Colombia. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina Fil: Santamaria Garcia, Hernando. Pontificia Universidad Javeriana; Colombia. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina Fil: Guerrero Barragan, Alejandra. University of California; Estados Unidos Fil: Kornhuber, Alexander. University of California; Estados Unidos Fil: Mendonca Marques Ton, Alyne. Universidade Vila Velha; Brasil Fil: Slachevsky, Andrea. Universidad de Chile; Chile Fil: Teixeira, Antonio Lucio. No especifíca; Fil: Mar Meza, Beatriz Marcela. University of California; Estados Unidos Fil: Serrano, Cecilia Mariela. Unidad Asistencial "Dr. César Milstein"; Argentina Fil: Cano, Carlos. Pontificia Universidad Javeriana; Colombia Fil: Arias Gonzalez, Carolina. University of California; Estados Unidos Fil: González Billault, Christian. Universidad de Chile; Chile Fil: Butler, Christopher. University of Oxford; Reino Unido. Pontificia Universidad Católica de Chile; Chile Fil: Bustin, Julian. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Houssay. Instituto de Neurociencia Cognitiva y Traslacional. Fundación Ineco Rosario Sede del Incyt | Instituto de Neurología Cognitiva. Instituto de Neurociencia Cognitiva y Traslacional. Fundación Ineco Rosario Sede del Incyt | Fundación Favaloro. Instituto de Neurociencia Cognitiva y Traslacional. Fundación Ineco Rosario Sede del Incyt; Argentina Fil: Duran Aniotz, Claudia. Universidad Adolfo Ibañez; Chile Fil: Acosta, Daisy. Universidad Nacional Pedro Henríquez Ureña; República Dominicana Fil: Matallana, Diana L.. Pontificia Universidad Javeriana; Colombia Fil: Acosta Alvear, Diego. University of California; Estados Unidos Fil: Trépel, Dominic. No especifíca; Fil: De Paula França Resende, Elisa. University of California; Estados Unidos. Universidade Federal do Rio de Janeiro; Brasil Fil: Ferreira de Oliveira, Fabricio. Universidade Federal de Sao Paulo; Brasil Fil: Ibanez, Francisco. Universidad Nacional de San Juan; Argentina Fil: De Felice, Fernanda G.. Universidade Federal do Rio de Janeiro; Brasil Fil: Navarrete, Gorka. Universidad Adolfo Ibañez; Chile Fil: Tarnanas, Ioannis. No especifíca; Fil: Meier, Irene B.. No especifíca; Fil: Smid, Jerusa. No especifíca; Fil: Llibre-Guerra, Jorge. University of California; Estados Unidos Fil: Llibre Rodriguez, Juan J.. Universidad de Ciencias Médicas; Cuba Fil: Fajersztajn, Laís. University of California; Estados Unidos. Universidade de Sao Paulo; Brasil Fil: Tadao Takada, Leonel. Universidade de Sao Paulo; Brasil Fil: Duque, Lissette. National Commission In Bioethics; Ecuador Fil: Okada de Oliveira, Maira. Universidade de Sao Paulo; Brasil Fil: Aparecida Camargos Bicalho, Maria. Universidade Federal de Minas Gerais; Brasil Fil: Behrens, María Isabel. Universidad Nacional de San Juan; Argentina. Universidad de Chile; Chile Fil: Pintado Caipa, Maritza. University of California; Estados Unidos Fil: Parra, Mario. University of Strathclyde; Reino Unido Fil: Wilson, Maxwell Z.. University of California; Estados Unidos Fil: De La Cruz Puebla, Myriam. Universidad de Barcelona; España. University of California; Estados Unidos Fil: Custodio, Nilton. Peruvian National Institute Of Health; Perú Fil: Santibanez, Rodrigo. Pontificia Universidad Católica de Chile; Chile. Universidad Católica de Chile; Chile Fil: Serafim, Rodrigo Bernardo. No especifíca; Fil: Melo Tavares, Ronnielly. Universidade Federal do Rio de Janeiro; Brasil Fil: Piña Escudero, Stefanie Danielle. University of California; Estados Unidos Fil: Rodriguez, Tomas Leon. Universidad de Chile; Chile Fil: Dawson, Walter. University of California; Estados Unidos Fil: Miller, Bruce L.. University of California; Estados Unidos Fil: Kosik, Kenneth. University of California; Estados Unidos

Alzheimer’s disease (AD) and dementia has emerged as a significant societal issue and a global priority. The prevalence of dementia is rising more rapidly in low and middle income countries (LMIC) than in high income countries. A growing body of evidence shows that prevention through risk factor management is the key to reducing the burden of dementia in the society, especially in LMIC. However, a one-size-fits all approach to health promotion is neither efficient nor effective. Latin American countries (LAC) have unique challenges related to dementia, including rapid aging population, high admixture degree and risk factors profile, which influence the prevalence and presentation of dementia. During this session, we will present findings and tools that will help tailor and personalize risk factor management in Hispanics populations. Participants will be first introduced to genetics of Alzheimer disease in Hispanic populations relative to non-Hispanics and the influence of gene by environment interactions. The second presentation will report on the epidemiology and risk factors of AD using cross countries/society comparisons (Non-Hispanics whites vs Hispanics living in US vs Hispanics living in Latin America.) The third presenter will discuss the development of a tool that visualizes how each risk factor contributes to the risk of dementia and how one may lower their risk by addressing the risk factors. The tool can be used in primary care settings in Cuba, Dominican Republic and Puerto Rico. Finally, the fourth presenter uses state-of-the-art digital assessment tools (brain health assessment), for low-cost monitoring of cognitive functioning, MCI and dementia. Such instruments are important for future evaluation of the impact of preventive strategies. At the end of the presentations, attendees will be able to identify the unique genetic and social determinants that drive AD in LAC. Recommendations will be given for preventive strategies tailored to LMIC. The findings to be shared will be essential for building evidence-based interventions tailored to reducing the burden of dementia in the Hispanic populations.Session Chair:Juan Llibre RodriguezAlzheimer Disease and genetics in Hispanic PopulationsJorge J Llibre-GuerraAlzheimer disease epidemiology and risk factors in Caribbean and non-Caribbean Hispanics populations.Ivonne Z. Jiménez VelázquezDevelopment of a tool to motivate for healthy behaviors to prevent dementia in the Caribbean.Daisy AcostaA brief digital cognitive assessment for detection of cognitive impairment in Hispanics populations.Ana Rodriguez-Salgado

BackgroundThe World Health Organization has reframed health and healthcare for older people around achieving the goal of healthy ageing. Recent evidence-based guidelines on Integrated Care for Older People focus on maintaining intrinsic capacity, addressing declines in mobility, nutrition, vision and hearing, cognition, mood and continence aiming to prevent or delay the onset of care dependence. The target group (with one or more declines in intrinsic capacity) is broad, and implementation at scale may be challenging in less-resourced settings.Planning can be informed by assessing the prevalence of intrinsic capacity, characterising the target group, and validating the general approach by evaluating risk prediction for incident dependence and mortality.MethodsPopulation-based cohort studies in urban sites in Cuba, Dominican Republic, Puerto Rico, Venezuela, and rural and urban sites in Peru, Mexico, India and China. Sociodemographic, behaviour and lifestyle, health, healthcare utilisation and cost questionnaires, and physical assessments were administered to all participants, with ascertainment of incident dependence, and mortality, three to five years later.ResultsIn the 12 sites in eight countries, 17,031 participants were surveyed at baseline. Intrinsic capacity was least likely to be retained for locomotion (71.2%), vision (71.3%), cognition (73.5%), and mood (74.1%). Only 30% retained full capacity across all domains, varying between one quarter and two-fifths in most sites. The proportion retaining capacity fell sharply with increasing age, and declines affecting multiple domains were more common. Poverty, morbidity (particularly dementia, depression and stroke), and disability were concentrated among those with DIC, although only 10% were frail, and a further 9% had needs for care. Hypertension and lifestyle risk factors for chronic disease, healthcare utilization and costs were more evenly distributed in the general older population. 15,901 participants were included in the mortality cohort (2,602 deaths/ 53,911 person years of follow-up), and 12,965 participants in the dependence cohort (1900 incident cases/ 38,377 person-years). DIC (any decline, and number of domains affected) strongly and independently predicted incident dependence and death. Relative risks were higher for those who were frail, but were also substantially elevated for the much larger sub-groups yet to become frail. Mortality was mainly concentrated in the frail and dependent sub-groups.ConclusionsOur findings support the strategy to optimize intrinsic capacity in pursuit of healthy ageing. Most needs for care arise in those with declines in intrinsic capacity who are yet to become frail. Implementation at scale requires community-based screening and assessment, and a stepped-care approach to intervention. Community healthcare workers’ roles would need redefinition to engage, train and support them in these tasks. ICOPE could be usefully integrated into community programmes orientated to the detection and case management of chronic diseases including hypertension and diabetes.

Background With no effective treatments for cognitive decline or dementia, improving the evidence base for modifiable risk factors is a research priority. This study investigated associations between risk factors and late-life cognitive decline on a global scale, including comparisons between ethno-regional groups. Methods and findings We harmonized longitudinal data from 20 population-based cohorts from 15 countries over 5 continents, including 48,522 individuals (58.4% women) aged 54–105 (mean = 72.7) years and without dementia at baseline. Studies had 2–15 years of follow-up. The risk factors investigated were age, sex, education, alcohol consumption, anxiety, apolipoprotein E ε4 allele (APOE*4) status, atrial fibrillation, blood pressure and pulse pressure, body mass index, cardiovascular disease, depression, diabetes, self-rated health, high cholesterol, hypertension, peripheral vascular disease, physical activity, smoking, and history of stroke. Associations with risk factors were determined for a global cognitive composite outcome (memory, language, processing speed, and executive functioning tests) and Mini-Mental State Examination score. Individual participant data meta-analyses of multivariable linear mixed model results pooled across cohorts revealed that for at least 1 cognitive outcome, age (B = −0.1, SE = 0.01), APOE*4 carriage (B = −0.31, SE = 0.11), depression (B = −0.11, SE = 0.06), diabetes (B = −0.23, SE = 0.10), current smoking (B = −0.20, SE = 0.08), and history of stroke (B = −0.22, SE = 0.09) were independently associated with poorer cognitive performance (p < 0.05 for all), and higher levels of education (B = 0.12, SE = 0.02) and vigorous physical activity (B = 0.17, SE = 0.06) were associated with better performance (p < 0.01 for both). Age (B = −0.07, SE = 0.01), APOE*4 carriage (B = −0.41, SE = 0.18), and diabetes (B = −0.18, SE = 0.10) were independently associated with faster cognitive decline (p < 0.05 for all). Different effects between Asian people and white people included stronger associations for Asian people between ever smoking and poorer cognition (group by risk factor interaction: B = −0.24, SE = 0.12), and between diabetes and cognitive decline (B = −0.66, SE = 0.27; p < 0.05 for both). Limitations of our study include a loss or distortion of risk factor data with harmonization, and not investigating factors at midlife. Conclusions These results suggest that education, smoking, physical activity, diabetes, and stroke are all modifiable factors associated with cognitive decline. If these factors are determined to be causal, controlling them could minimize worldwide levels of cognitive decline. However, any global prevention strategy may need to consider ethno-regional differences., Darren Lipnicki and the Sydney COSMIC team analysed cognitive performance and risk factor data from older people from 15 countries to assess associations between risk factors and late-life cognition, Author summary Why was this study done? There is a growing global burden associated with cognitive decline and dementia. Evidence for modifiable risk factors that could be targeted to reduce this burden needs to be improved. Risk factors for cognitive decline and dementia might differ between ethno-regional groups. What did the researchers do and find? We analyzed cognitive performance and risk factor data from 48,522 older individuals, provided by 20 studies of aging representing 15 countries (Australia, Brazil, Cuba, France, Germany, Greece, Hong Kong, Italy, Japan, Singapore, Spain, South Korea, The Netherlands, the United Kingdom, and the United States). Cognitive performance was measured as Mini-Mental State Examination (MMSE) and global cognition scores. When controlling for confounding risk factors, the apolipoprotein E ε4 allele (APOE*4), depression, diabetes, current smoking, and history of stroke were associated with poorer cognitive performance, and higher levels of education and vigorous physical activity were associated with better performance. Age, APOE*4, and diabetes were associated with faster cognitive decline. Compared to white people, Asian people showed stronger associations between having ever smoked and cognitive performance, and between diabetes and cognitive decline. What do these findings mean? Modifiable risk factors associated with cognitive decline include education, smoking, physical activity, diabetes, and stroke. If these associations are determined to be causal, interventions targeting these factors may help reduce the global burden of cognitive decline and dementia. Interventions may require tailoring to particular ethno-regional groups.

OBJECTIVES: Growing evidence shows that cardiovascular health (CVH) is associated with brain health. Little is known about this topic among older adults in Latin America, where the number of people living with dementia is rising. This study aimed to assess the longitudinal association between cardiovascular health and dementia in six Latin American countries. METHODS: We analyzed longitudinal data from the 10/66 study which included non-demented residents at baseline aged 65+ in six Latin American countries (n=6447) and were followed up for three years. An index of modifiable CVH factors (ranging from 0 to 14) was calculated. Incident dementia was modeled using competing risks regression to adjust for risk of death. RESULTS: The sample included 6.2% participants with poor (0–5), 81.0% with moderate (6–10) and 12.8% with ideal CVH (11–14). At follow-up, 9.4% had developed dementia and 13.1% had died. Compared to poor CVH, participants with moderate and ideal levels of CVH had a significantly lower risk of dementia both in the unadjusted (subhazard ratio for moderate: 0.77; ideal: 0.59) and adjusted models (moderate: 0.73; ideal: 0.66). CONCLUSION: Moderate and ideal levels of CVH in old age may protect against dementia incidence. These findings may inform health promotion efforts within dementia national plans adopted recently in some Latin American countries.

Objective: The objective of this study was to estimate healthy life expectancies in eight low- and middle-income countries (LMICs), using two indicators: disability-free life expectancy (DFLE) and dependence-free life expectancy (DepFLE). Method: Using the Sullivan method, healthy life expectancy was calculated based on the prevalence of dependence and disability from the 10/66 cohort study, which included 16,990 people aged 65 or above in China, Cuba, Dominican Republic, India, Mexico, Peru, Puerto Rico, and Venezuela, and country-specific life tables from the World Population Prospects 2017. Results: DFLE and DepFLE declined with older age across all sites and were higher in women than men. Mexico reported the highest DFLE at age 65 for men (15.4, SE = 0.5) and women (16.5, SE = 0.4), whereas India had the lowest with (11.5, SE = 0.3) in men and women (11.7, SE = 0.4). Discussion: Healthy life expectancy based on disability and dependency can be a critical indicator for aging research and policy planning in LMICs.

Alzheimer’s disease (AD) and dementia has emerged as a significant societal issue and a global priority. The prevalence of dementia is rising more rapidly in low and middle income countries (LMIC) than in high income countries. Yet, knowledge of dementia risk factors is dominated by research from high income countries (HIC), which cannot be readily translated to LMIC. Latin American countries (LAC) have unique challenges related to dementia, including rapid aging population, high admixture degree and risk factors profile, which influence the prevalence and presentation of dementia. Several epidemiological studies during the past decade have shown a rapid increase of dementia in LAC, but the impact of genetic, protective and risk factors remain poorly understood. This research session will feature a series of short and engaging talks about new trends of dementia in the region and will answer key questions regarding dementia determinants and consequences in Hispanic populations. Participants will be first introduced to the aging process in LAC, prevalence and incidence of dementia within the region. The second presentation will report on genetics of Alzheimer disease in Hispanic populations. The third presenter will discuss the complexities of dementia multimorbidity and the impact of neuropsychiatric symptoms. The fourth presenter will discuss about Nationals and Regional Strategies to address dementia and reflects on recommendations and future directions for the region. All presentations will be based on findings from multiple research projects across the region. Furthermore, presenters will extended comparison to Non-Hispanics whites and Hispanics populations living in US, which allows cross countries/society comparisons. Overall, new information about dementia will be shared with the audience. Attendees will be able to identify the unique genetic and social determinants that drive AD in LAC. Recommendations will be given for preventive strategies tailored to LMIC. The findings to be shared will be essential for building evidence-based interventions that achieve the goals of the National Plan to Address Alzheimer’s Disease.

BackgroundAdult leg length is influenced by nutrition in the first few years of life. Adult head circumference is an indicator of brain growth. Cross-sectional studies indicate inverse associations with dementia risk, but there have been few prospective studies.MethodsPopulation-based cohort studies in urban sites in Cuba, Dominican Republic Puerto Rico and Venezuela, and rural and urban sites in Peru, Mexico and China. Sociodemographic and risk factor questionnaires were administered to all participants, and anthropometric measures taken, with ascertainment of incident 10/66 dementia, and mortality, three to five years later.ResultsOf the original at risk cohort of 13,587 persons aged 65 years and over, 2,443 (18.0%) were lost to follow-up; 10,540 persons with skull circumference assessments were followed up for 40,466 person years, and 10,400 with leg length assessments were followed up for 39,954 person years. There were 1,009 cases of incident dementia, and 1,605 dementia free deaths. The fixed effect pooled meta-analysed adjusted subhazard ratio (ASHR) for leg length (highest vs. lowest quarter) was 0.80 (95% CI, 0.66-0.97) and for skull circumference was 1.02 (95% CI, 0.84-1.25), with no heterogeneity of effect between sites (I2=0%). Leg length measurements tended to be shorter at follow-up, particularly for those with baseline cognitive impairment and dementia. However, leg length change was not associated with dementia incidence (ASHR, per cm 1.006, 95% CI 0.992-1.020), and the effect of leg length was little altered after adjusting for baseline frailty (ASHT 0.82, 95% CI 0.67-0.99). A priori hypotheses regarding effect modification by gender or educational level were not supported.ConclusionsConsistent findings across settings provide quite strong support for an association between adult leg length and dementia incidence in late-life. Leg length is a relatively stable marker of early life nutritional programming, which may confer brain reserve and protect against neurodegeneration in later life through mitigation of cardiometabolic risk. Further clarification of these associations could inform predictive models for future dementia incidence in the context of secular trends in adult height, and invigorate global efforts to improve childhood nutrition, growth and development.

OBJECTIVE: In an admixed population of older Cubans, the incidence and association of APOE and socio demographic risk factors with dementia incidence was estimated. METHODS: A single-phase survey (baseline) of all over 65-year-olds residing in seven catchment areas in Cuba (n=2944) was conducted between 2003 and 2007. Dementia diagnosis was established according to DSM-IV and 10/66 criteria. APOE genotype was determined in 2520 participants. An incidence wave was conducted 4.5 years after cohort inception in order to estimate incidence and associations with sociodemographic risk factors of the APOE ε4 genotype. RESULTS: The incidence rate of DSM IV dementia was 9.0 per 1000 person-years (95% CI 7.2-11.3) and of 10/66 dementia was 20.5 per 1000 person-years (95% CI, 17.6-23.5). Older age, a family history of dementia and APOE ε4 genotype were independent risk factors for incident 10/66 dementia. APOE genotype was associated cross-sectionally with dementia prevalence, but the effect on the incidence of dementia was attenuated, and only apparent among those in the youngest age group. CONCLUSION: The incidence of dementia in the older Cuban population is relatively high and similar to levels reported in Europe and North-America. The study showed that the relationship between APOE ε4 and incident dementia is stronger in the younger-old than the older-old and that this change must be taken into account in models of dementia. OBJETIVO: Em uma população miscigenada de cubanos idosos, estimamos a incidência de demência e a associação entre o genótipo da APOE e os fatores de risco sociodemográficos na incidência de demência. MÉTODOS: Realizamos uma pesquisa de uma fase (linha de base) de todos os idosos com mais de 65 anos residentes em sete áreas de Cuba (n=2944), de 2003 a 2007. O diagnóstico de demência foi estabelecido de acordo com os critérios do DSM-IV e do 10/66. O genótipo APOE foi determinado em 2520 participantes. Avaliação da incidência foi conduzida 4,5 anos após a linha de base, a fim de estimar a incidência e associações com fatores de risco sociodemográficos e o genótipo APOE ε4. RESULTADOS: A taxa de incidência de demência foi de 9,0 por 1000 pessoas-ano (IC 95% 7,2-11,3) de acordo com o DSM-IV e de 20,5 por 1000 pessoas-ano (IC 95%, 17,6-23,5) de acordo com o 10/66. Idade avançada, história familiar de demência e genótipo APOE ε4 foram fatores de risco independentes para a incidência de demência de acordo com os critérios do 10/66. O genótipo APOE foi associado com a prevalência de demência em estudo transversal, mas o efeito sobre a incidência de demência foi atenuado, e apenas aparente entre aqueles na faixa etária mais jovem. CONCLUSÃO: A incidência de demência na população cubana mais velha é relativamente alta, semelhante às relatadas na Europa e América do Norte. O estudo mostra que a relação entre APOE ε4 incidente e demência é mais forte entre os idosos mais jovens e que esta alteração deve de ser considerada em modelos de demência.

Background There have been few cross-national studies of the prevalence of the frailty phenotype conducted among low or middle income countries. We aimed to study the variation in prevalence and correlates of frailty in rural and urban sites in Latin America, India, and China. Methods Cross-sectional population-based catchment area surveys conducted in 8 urban and 4 rural catchment areas in 8 countries; Cuba, Dominican Republic, Puerto Rico, Venezuela, Peru, Mexico, China, and India. We assessed weight loss, exhaustion, slow walking speed, and low energy consumption, but not hand grip strength. Therefore, frailty phenotype was defined on 2 or more of 4 of the usual 5 criteria. Results We surveyed 17,031 adults aged 65 years and over. Overall frailty prevalence was 15.2% (95% confidence inteval 14.6%–15.7%). Prevalence was low in rural (5.4%) and urban China (9.1%) and varied between 12.6% and 21.5% in other sites. A similar pattern of variation was apparent after direct standardization for age and sex. Cross-site variation in prevalence of frailty indicators varied across the 4 indicators. Controlling for age, sex, and education, frailty was positively associated with older age, female sex, lower socioeconomic status, physical impairments, stroke, depression, dementia, disability and dependence, and high healthcare costs. Discussion There was substantial variation in the prevalence of frailty and its indicators across sites in Latin America, India, and China. Culture and other contextual factors may impact significantly on the assessment of frailty using questionnaire and physical performance-based measures, and achieving cross-cultural measurement invariance remains a challenge. Conclusions A consistent pattern of correlates was identified, suggesting that in all sites, the frailty screen could identify older adults with multiple physical, mental, and cognitive morbidities, disability and needs for care, compounded by socioeconomic disadvantage and catastrophic healthcare spending.

BackgroundDiabetes prevalence is already high in middle income countries, particularly among older people. Current evidence on diabetes as a risk factor for dementia is limited to cohort studies in high income countries. Few studies carried out fasting glucose assessments to identify undiagnosed cases, and assess diabetes control. We aimed to determine the association between both diagnosed diabetes and total diabetes (including undiagnosed cases) and incident dementia, examining also the impact of glycaemic control on dementia risk.MethodsPopulation-based cohort studies of those aged 65 years and over in sites in Cuba, Dominican Republic, Puerto Rico, Peru, Venezuela, and Mexico. Diagnosed diabetes was assessed through self-reported diagnosis, and undiagnosed diabetes through fasting blood samples (glucose >= 7mmol/L). Blood pressure, smoking, underactivity and waist circumference were assessed from questionnaires and physical examination. Incident 10/66 dementia (and subtypes), and mortality, were ascertained three to five years later.Results12,297 interviews were completed at baseline, with 80-95% responding by site. The ‘at risk’ cohort comprised 10,945 dementia-free individuals, of whom 8,171 (75%) provided blood samples. Mean age varied from 72.0 to 75.1 years by site. Total diabetes prevalence was 43.5% in Puerto Rico, ranging from 11.5% to 27.0% in other sites. Most diabetes cases (50.2% to 68.4%) were not controlled (fasting glucose >7.0 mmol/L). 7,000 participants were followed up for 26,423 person-years with 659 incident dementia cases, and 905 dementia free deaths. Total diabetes was associated with incident 10/66 dementia (pooled meta-analysed adjusted sub-hazard ratio [pASHR] 1.25, 95% CI, 1.05-1.49, I2=48.6%), with a stronger association for uncontrolled (pASHR 1.47, 95% CI 1.19-1.81, I2=49.6%) than controlled cases (pASHR 1.29, 95% CI 0.95-1.74, I2=13.3%). Total diabetes was strongly associated with the incidence of vascular dementia (pASHR 2.25, 95% CI 1.24-4.08, I2=23.7%), but not Alzheimer’s Disease (pASHR 0.99, 95% CI 0.70-1.42, I2=49.0%).ConclusionsDiabetes, particularly when poorly controlled, may increase dementia risk. There is considerable scope for improved detection and control of diabetes among older people in these settings, and hence an opportunity to carry out proof of concept prevention trials. Overlapping epidemics of these age dependent disorders will challenge poorly-resourced health systems in the future.

BackgroundExposure to endogenous estrogen may protect against dementia, but evidence remains equivocal. Such effects may be assessed more precisely in settings where exogenous estrogen administration is rare. We aimed to determine whether reproductive period (menarche to menopause), and other indicators of endogenous estrogen exposure are inversely associated with dementia incidenceMethodsPopulation-based cohort studies, of women aged 65 years and over in urban sites in Cuba, Dominican Republic Puerto Rico and Venezuela, and rural and urban sites in Peru, Mexico and China. Sociodemographic and risk factor questionnaires were administered to all participants, including ages at menarche, birth of first child, and menopause, and parity, with ascertainment of incident 10/66 dementia, and mortality, three to five years later.Results9,428 women participated in the baseline phase, with response rates of 72–98% by site. The ‘at risk’ cohort comprised 8,466 dementia-free women. Mean age at baseline varied from 72.0 to 75.4 years, lower in rural than urban sites and in China than in Latin America. Mean parity was 4.1, generally higher in rural than urban sites and ranging from 2.4-7.2 by site. 6,854 women with baseline reproductive period data were followed up for 26,463 person years. There were 692 cases of incident dementia, and 895 dementia free deaths. Pooled meta-analysed fixed effects, per year, for reproductive period (Adjusted Sub-Hazard Ratio [ASHR] 1.001, 95% CI 0.988-1.015) did not support any association with dementia incidence, with no evidence also for any interaction between APOE genotype and reproductive period (ASHR 0.993, 95% CI 0.947-1.041, I2=39.3%). Similarly no association was observed between incident dementia and; ages at menarche, birth of first child, and menopause: nulliparity; or index of cumulative endogenous estrogen exposure. Greater parity was positively associated with incident dementia (ASHR 1.030, 95% CI 1.002-1.059, I2=0.0%).ConclusionsWe found no evidence to support the theory that natural variation in cumulative exposure to endogenous oestrogens across the reproductive period influences the incidence of dementia in late life.

The Cuban Twin Registry is a nation-wide, prospective, population-based twin registry comprising all zygosity types and ages. It was initiated in 2004 to study genetic and environmental contributions to complex diseases with high morbidity and mortality in the Cuban population. The database contains extensive information from 55,400 twin pairs enrolled in the period 2004–2006. Additionally, 2,600 new multiple births have been included from 2007 to date. In the past 4 years, more than 130 studies have been carried out using the registry with a classical genetic epidemiological approach in which concordance rates for monozygotic and dizygotic twins and heritability of various disease traits were estimated. This article summarizes the history, registry's methodology, recent research findings, and future directions of work.