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Background: There is rapid growth of older people in Low- and Middle- Income Countries (LMICs). The aim of this review was to assess the literature on prevalence of anxiety and depression in this demographic, which to our knowledge, has not yet been conducted., Methods: Databases including Medline, PsychInfo, Embase, Scielo and African Journals Online were searched for terms including "mental disorders", "neurotic disorders", "mood disorders" and "anxiety disorders". Studies published between 1990 and 2020 providing data on older people (≥50 years) in LMICs (defined by World Bank Criteria) were included and quality-assessed. Meta-analysis was conducted on a subset of higher-quality studies to derive pooled prevalence estimates of depression., Results: One hundred and forty relevant studies were identified, of which thirty-two were included in meta-analysis. One hundred and fifteen studies reported depression prevalence only, 19 reported both depression and anxiety, and six reported anxiety only. In all studies identified, depression prevalence ranged from 0.5 % to 62.7 %, and Generalised Anxiety Disorder prevalence ranged from 0.2 % to 32.2 %. The pooled prevalence of depression on meta-analysis was 10.5 % (95 % CI, 8.9 % - 11.2 %). Reported prevalence rates of depression were significantly different in studies using ICD-10 compared with DSM criteria, and between community and clinical settings., Limitations: The search strategy contained bias towards English language papers and high income country (HIC) publications. There is significant heterogeneity within the meta-analysis., Discussion: A wide range of methodologies and clinical criteria are used in prevalence studies of depression and anxiety in older people. Studies using screening tools found higher prevalence rates; clinicians and researchers should ensure diagnosis is made with gold-standard clinical criteria. Meta-analysis data suggest that rates of depression are similar in older people in LMICs compared to HICs but mental healthcare resources are limited, suggesting a large potential treatment gap., Competing Interests: Conflict of interest None of the authors declare a conflict of interest., (Crown Copyright © 2023. Published by Elsevier B.V. All rights reserved.)

Objectives: To assess the prevalence and factors associated with multimorbidity in a community-dwelling general adult population on a large Health and Demographic Surveillance System (HDSS) scale., Design: Population-based cross-sectional study., Setting: South East Asia Community Observatory HDSS site in Malaysia., Participants: Of 45 246 participants recruited from 13 431 households, 18 101 eligible adults aged 18-97 years (mean age 47 years, 55.6% female) were included., Main Outcome Measures: The main outcome was prevalence of multimorbidity. Multimorbidity was defined as the coexistence of two or more chronic conditions per individual. A total of 13 chronic diseases were selected and were further classified into 11 medical conditions to account for multimorbidity. The conditions were heart disease, stroke, diabetes mellitus, hypertension, chronic kidney disease, musculoskeletal disorder, obesity, asthma, vision problem, hearing problem and physical mobility problem. Risk factors for multimorbidity were also analysed., Results: Of the study cohort, 28.5% people lived with multimorbidity. The individual prevalence of the chronic conditions ranged from 1.0% to 24.7%, with musculoskeletal disorder (24.7%), obesity (20.7%) and hypertension (18.4%) as the most prevalent chronic conditions. The number of chronic conditions increased linearly with age (p<0.001). In the logistic regression model, multimorbidity is associated with female sex (adjusted OR 1.28, 95% CI 1.17 to 1.40, p<0.001), education levels (primary education compared with no education: adjusted OR 0.63, 95% CI 0.53 to 0.74; secondary education: adjusted OR 0.60, 95% CI 0.51 to 0.70; tertiary education: adjusted OR 0.65, 95% CI 0.54 to 0.80; p<0.001) and employment status (working adults compared with retirees: adjusted OR 0.70, 95% CI 0.60 to 0.82, p<0.001), in addition to age (adjusted OR 1.05, 95% CI 1.05 to 1.05, p<0.001)., Conclusions: The current single-disease services in primary and secondary care should be accompanied by strategies to address complexities associated with multimorbidity, taking into account the factors associated with multimorbidity identified. Future research is needed to identify the most commonly occurring clusters of chronic diseases and their risk factors to develop more efficient and effective multimorbidity prevention and treatment strategies., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The objective of this research was to systematically review and synthesize quantitative studies that assessed the association between socioeconomic inequalities and primary health care (PHC) utilization among older people living in low- and middle- income countries (LMICs). Six databases were searched, including Embase, Medline, Psych Info, Global Health, Latin American and Caribbean Health Sciences Literature (LILACS), and China National Knowledge Infrastructure, CNKI, to identify eligible studies. A narrative synthesis approach was used for evidence synthesis. A total of 20 eligible cross-sectional studies were included in this systematic review. The indicators of socioeconomic status (SES) identified included income level, education, employment/occupation, and health insurance. Most studies reported that higher income, higher educational levels and enrollment in health insurance plans were associated with increased PHC utilization. Several studies suggested that people who were unemployed and economically inactive in older age or who had worked in formal sectors were more likely to use PHC. Our findings suggest a pro-rich phenomenon of PHC utilization in older people living in LMICs, with results varying by indicators of SES and study settings.

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., Competing Interests: The authors have declared that no competing interests exist.

Objectives: In this study we aimed to 1) describe healthy ageing trajectory patterns, 2) examine the association between multimorbidity and patterns of healthy ageing trajectories, and 3) evaluate how different groups of diseases might affect the projection of healthy ageing trajectories over time., Setting and Participants: Our study was based on 130880 individuals from the Ageing Trajectories of Health: Longitudinal Opportunities and Synergies (ATHLOS) harmonised dataset, as well as 9171 individuals from Waves 2-7 of the English Longitudinal Study of Ageing (ELSA)., Methods: Using a healthy ageing index score, which comprised 41 items, covering various domains of health and ageing, as outcome, we employed the growth mixture model approach to identify the latent classes of individuals with different healthy ageing trajectories. A multinomial logistic regression was conducted to assess if and how multimorbidity status and multimorbidity patterns were associated with changes in healthy ageing, controlled for sociodemographic and lifestyle risk factors., Results: Three similar patterns of healthy ageing trajectories were identified in the ATHLOS and ELSA datasets: 1) a 'high stable' group (76% in ATHLOS, 61% in ELSA), 2) a 'low stable' group (22% in ATHLOS, 36% in ELSA) and 3) a 'rapid decline' group (2% in ATHLOS, 3% in ELSA). Those with multimorbidity were 1.7 times (OR = 1.7, 95% CI: 1.4-2.1) more likely to be in the 'rapid decline' group and 11.7 times (OR = 11.7 95% CI: 10.9-12.6) more likely to be in the 'low stable' group, compared with people without multimorbidity. The cardiorespiratory/arthritis/cataracts group was associated with both the 'rapid decline' and the 'low stable' groups (OR = 2.1, 95% CI: 1.2-3.8 and OR = 9.8, 95% CI: 7.5-12.7 respectively)., Conclusion: Healthy ageing is heterogeneous. While multimorbidity was associated with higher odds of having poorer healthy ageing trajectories, the extent to which healthy ageing trajectories were projected to decline depended on the specific patterns of multimorbidity., Competing Interests: The authors have declared that no competing interests exist.

Objectives: This study was designed to explore prevalence and correlates of self-reported loneliness and to investigate whether loneliness predicts mortality among older adults (aged 65 or above) in Latin America, China and India. Methods: The study investigated population-based cross-sectional (2003-2007) and longitudinal surveys (follow-up 2007-2010) from the 10/66 Dementia Research Group project. Poisson regression and Cox regression analyses were conducted to analyse correlates of loneliness and its association with mortality. Results: The 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 American countries (HR = 1.13, 95% CI 1.01-1.26, I 2 = 10.1%) and China (HR = 1.58, 95% CI 1.03-2.41), but there were no associations in India. Conclusion: Our 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., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Gao, Prina, Prince, Acosta, Luisa Sosa, Guerra, Huang, Jimenez-Velazquez, Llibre Rodriguez, Salas, Williams, Liu, Acosta Castillo and Mayston.)

Aim: This study aimed to investigate the relationships between multimorbidity, healthy aging and mortality., Methods: Using data from 9171 individuals aged ≥50 years at wave 2 and mortality data at wave 5 of the English Longitudinal Study of Aging, a multiple linear regression model and a Cox proportional hazards model were used to investigate how multimorbidity patterns (identified as cardiorespiratory/arthritis/cataracts, metabolic and relatively healthy) were associated with a composite index of healthy aging (derived from 41 intrinsic capacity and functional ability items) and with mortality., Results: A total of 60% of the sample with multimorbidity had a moderate or high level of healthy aging. Both the cardiorespiratory/arthritis/cataracts group (n = 1826) and the metabolic group (n = 844) were negatively associated with healthy aging. The expected healthy aging index score decreased by 5.81 points (95% CI -6.69, -4.92) for the first group, and by 2.39 points (95% CI -3.54, -1.24) for the latter group. Only the cardiorespiratory/arthritis/cataracts group was positively associated with mortality. The risk of death for this group was 1.27-fold (95% CI: 1.14, 1.43) than the relatively healthy group. The relationship between multimorbidity patterns and mortality did not differ when considering levels of healthy aging., Conclusions: Although it is not impossible for people with multimorbidity to age healthily, those with the most complex combination of diseases are at higher risk of death and have lower levels of healthy aging. Geriatr Gerontol Int 2020; 20: 1126-1132., (© 2020 The Authors. Geriatrics & Gerontology International published by John Wiley & Sons Australia, Ltd on behalf of Japan Geriatrics Society.)

Objectives: Patient preferences are increasingly important in informing clinical and policy decisions. Health-state utility values (HSUVs) are quantitative measures of people's preferences over different health states. In schizophrenia, there is no clarity about HSUVs across the symptoms' severity spectrum. This meta-analysis aims to synthesize the literature on HSUVs in people with schizophrenia., Methods: We searched Medline, PsycInfo, Embase, EconLit, The Cochrane Library, and specialized databases. The studies reporting HSUVs in people with schizophrenia were selected and pooled in a random-effects meta-analysis. The primary outcome was the mean HSUV obtained from participants., Results: A total of 54 studies involving 87 335 participants were included. The pooled estimate using direct elicitation was a mean HSUV of 0.79 (95% CI: 0.70-0.88) for mild symptomatic states, 0.69 (95% CI: 0.54-0.85) in moderate states, and 0.34 (95% CI: 0.13-0.56) in severe states. Studies using indirect techniques resulted in a pooled mean HSUV of 0.73 (95% CI: 0.67-0.78) applying the EuroQol 5-dimension, 0.66 (95% CI: 0.62-0.71) in the Short-Form 6-dimension, and 0.59 (95% CI: 0.57-0.61) using the Quality of Well-Being scale. All the estimates resulted in considerable heterogeneity, partially reduced by meta-regression., Conclusion: Our findings suggest that the severity of psychotic symptoms has an important effect on HSUVs in schizophrenia, with values mirroring patients with disabling physical conditions such as cancer and stroke. Decision makers should be aware of these results when including people's preferences in trials, models, and policy decisions., (Copyright © 2020 ISPOR–The Professional Society for Health Economics and Outcomes Research. Published by Elsevier Inc. All rights reserved.)

Aims: Widowed people have increased mortality compared to married people of the same age. Although most widowed people are of older age, few studies include the oldest old. As life expectancy is increasing, knowledge of widowhood into older age is needed. This study aimed to examine mortality and widowhood in older age by comparing mortality in widowed and married people by sex, age, time since spousal loss and cause of death., Methods: A Danish register-based matched cohort study of 10% of widowed persons ⩾65 years in the years 2000-2009. For each randomly drawn widowed person, five married persons were matched on sex and age. Mortality rate ratios (MRR) were calculated using Poisson regression, and stratified according to sex and 5-year age intervals. MRRs were furthermore calculated by time since spousal loss and by specific cause of death., Results: The study included 82 130 persons contributing with 642 914.8 person-years. The overall MRR between widowed and married persons with up to 16 years of follow-up was 1.25 (95% CI 1.23-1.28). At age ⩾95 years for men, and ⩾90 years for women, no differences in mortality rates were seen between widowed and married persons. Mortality in widowed persons was increased for most specific causes of death, with the highest MRR from external causes (MRR 1.53 [1.35-1.74]) and endocrine diseases (MRR 1.51 [1.34-1.70])., Conclusions: Widowhood was associated with increased mortality in older age for both men and women until age ⩾95 and ⩾90 years, respectively. Increased mortality was observed for almost all causes of death.

Background and Objectives: There is a link between sensory and cognitive functioning across old age. However, there are no integrative measures for assessing common determinants of sensory-cognitive functioning. This study aims to develop a combined measure of sensory-cognitive functioning, and to identify heterogeneous trajectories and associated risk factors., Research Design and Methods: Two thousand two hundred and fifty-five individuals aged 60 years and over selected from the first six waves (2002-2012) of the English Longitudinal Study of Ageing completed a set of five self-reported visual and hearing functioning items and four cognitive items. Several health-related outcomes were also collected., Results: The common cause model presented longitudinal factorial invariance (Tucker-Lewis index [TLI] = 0.989; Comparative Fit Index [CFI] = 0.991; Root Mean Square Error of Approximation [RMSEA] = 0.026). A common factor explained 32%, 36%, and 26% of the visual, hearing, and cognitive difficulties, respectively. The developed sensory-cognitive measure predicted incident dementia over 10 years (area under the curve = .80; 95% confidence interval [CI] = .75, .86). A three-trajectory model was proved to fit better, according to growth mixture modeling. Low levels of education and household wealth, disability, diabetes, high blood pressure, depressive symptoms, and low levels of physical activity were risk factors associated with the classes showing trajectories with a steeper increase of sensory-cognitive difficulties., Discussion and Implications: A time-invariant factor explains both sensory and cognitive functioning over 8 years. The sensory-cognitive measure derived from this factor showed a good performance for predicting dementia 10 years later. Several easily identifiable socioeconomic and health-related risk factors could be used as early markers of subsequent sensory-cognitive decline. Therefore, the proposed latent measure could be useful as a cost-effective indicator of sensory-cognitive functioning., (© The Author(s) 2019. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The rapid growth of the size of the older population is having a substantial effect on health and social care services in many societies across the world. Maintaining health and functioning in older age is a key public health issue but few studies have examined factors associated with inequalities in trajectories of health and functioning across countries. The aim of this study was to investigate trajectories of healthy ageing in older men and women (aged ≥45 years) and the effect of education and wealth on these trajectories., Methods: This population-based study is based on eight longitudinal cohorts from Australia, the USA, Japan, South Korea, Mexico, and Europe harmonised by the EU Ageing Trajectories of Health: Longitudinal Opportunities and Synergies (ATHLOS) consortium. We selected these studies from the repository of 17 ageing studies in the ATHLOS consortium because they reported at least three waves of collected data. We used multilevel modelling to investigate the effect of education and wealth on trajectories of healthy ageing scores, which incorporated 41 items of physical and cognitive functioning with a range between 0 (poor) and 100 (good), after adjustment for age, sex, and cohort study., Findings: We used data from 141 214 participants, with a mean age of 62·9 years (SD 10·1) and an age range of 45-106 years, of whom 76 484 (54·2%) were women. The earliest year of baseline data was 1992 and the most recent last follow-up year was 2015. Education and wealth affected baseline scores of healthy ageing but had little effect on the rate of decrease in healthy ageing score thereafter. Compared with those with primary education or less, participants with tertiary education had higher baseline scores (adjusted difference in score of 10·54 points, 95% CI 10·31-10·77). The adjusted difference in healthy ageing score between lowest and highest quintiles of wealth was 8·98 points (95% CI 8·74-9·22). Among the eight cohorts, the strongest inequality gradient for both education and wealth was found in the Health Retirement Study from the USA., Interpretation: The apparent difference in baseline healthy ageing scores between those with high versus low education levels and wealth suggests that cumulative disadvantage due to low education and wealth might have largely deteriorated health conditions in early life stages, leading to persistent differences throughout older age, but no further increase in ageing disparity after age 70 years. Future research should adopt a lifecourse approach to investigate mechanisms of health inequalities across education and wealth in different societies., Funding: European Union Horizon 2020 Research and Innovation Programme., (Copyright © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

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.

Objective: The Center for Epidemiologic Studies Depression Scale (CES-D) is a 20-item, self-report metric intended to measure depression. Despite being one of the most popular depression scales, the psychometric properties, specifically the underlying factor structure of the scale, have come under scrutiny. The latent structure of a scale is a key indicator of its construct validity, i.e. the degree to which the intended variable is captured. To date, a comprehensive review of the latent structure of the CES-D in older adult populations (≥65 years old) has not been conducted. We aimed to examine the latent structure of the CES-D in samples of older adults to assess its ability to capture depressive symptoms. Methods: A systematic review across Scopus, Web of Science, and PsycINFO databases was conducted. Original studies conducting latent variable analysis of the 20-item CES-D in samples aged ≥65 years old were included. Results: Included studies ( n  = 6) were primarily conducted with community-dwelling older adults in the United States. Studies that conducted exploratory and confirmatory factor analysis ( n  = 2) revealed two latent factors, whereas those conducting confirmatory factor analysis of previously identified structures ( n  = 4) revealed four-factor structures in line with the original four-factor structure. Conclusions: A general alignment with the original four-factor structure of the CES-D provides tentative support for continued use amongst older adults; however, further research is required to provide conclusive evidence for these psychometric properties.

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 I 2  = 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., (© 2019 The Authors. International Journal of Geriatric Psychiatry published by John Wiley & Sons Ltd.)

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, ω Η  = 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.

Objectives: This study aimed to estimate the incidence of DSM5 anorexia nervosa in young people in contact with child and adolescent mental health services in the UK and Ireland., Design: Observational, surveillance study, using the Child and Adolescent Psychiatry Surveillance System, involving monthly reporting by child and adolescent psychiatrists between 1st February 2015 and 30th September 2015., Setting: The study was based in the UK and Ireland., Participants: Clinician-reported data on young people aged 8-17 in contact with child and adolescent mental health services for a first episode of anorexia nervosa., Main Outcome Measures: Annual incidence rates (IRs) estimated as confirmed new cases per 100 000 population at risk., Results: 305 incident cases of anorexia nervosa were reported over the 8-month surveillance period and assessed as eligible for inclusion. The majority were young women (91%), from England (70%) and of white ethnicity (92%). Mean age was 14.6 years (±1.66) and mean percentage of median expected body mass index for age and sex was 83.23% (±10.99%). The overall IR, adjusted for missing data, was estimated to be 13.68 per 100 000 population (95% CI 12.88 to 14.52), with rates of 25.66 (95% CI 24.09 to 27.30) for young women and 2.28 (95% CI 1.84 to 2.79) for young men. Incidence increased steadily with age, peaking at 15 (57.77, 95% CI 50.41 to 65.90) for young women and 16 (5.14, 95% CI 3.20 to 7.83) for young men. Comparison with earlier estimates suggests IRs for children aged 12 and under have increased over the last 10 years., Conclusion: These results provide new estimates of the incidence of anorexia nervosa in young people. Service providers and commissioners should consider evidence to suggest an increase in incidence in younger children., Trial Registration Number: ISRCTN12676087., Competing Interests: Competing interests: Tamsin Ford reports she is Chair of the Child and Adolescent Psychiatry Surveillance Service that was used to run part of the study, which is an unpaid position (other than travel expenses). Kandarp Joshi reports that he was principal investigator for the Aberdeen site for a Sunovion sponsored multisite trial on effectiveness of Lurasidone in paediatric schizophrenia., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Objective: Frailty and depression are highly comorbid conditions, but the casual direction is unclear and has not been explored in low- and middle-income countries. The aim of this study was to investigate the potential impact of depression on incident frailty in older people living in Latin America., Methods: This study was based on a population-based cohort of 12,844 people aged 65 or older from six Latin American countries (Cuba, Dominican Republic, Mexico, Venezuela, Puerto Rico, and Peru), part of the 10/66 cohort study. Two types of frailty measures were used: a modified Fried frailty phenotype and a multidimensional frailty criterion, which included measures from cognition, sensory, nutrition, and physical dimensions. Depression was assessed using EURO-D and International Classification of Diseases, Tenth Revision criteria. A competing risk model was used to examine the associations between baseline depression and incidence of frailty in the 3-5 years of follow-up, accounting for sociodemographic and health factors and the competing event of frailty-free death., Results: Depression was associated with a 59% increased hazard of developing frailty using the modified Fried phenotype (subdistribution hazard ratio [SHR]: 1.59; 95% confidence interval [CI]: 1.40, 1.80) and 19% for multidimensional frailty (SHR: 1.19; 95% CI: 1.06, 1.33) after adjusting for sociodemographic factors, physical impairments, and dementia. The associations between depression and the multidimensional frailty criteria were homogenous across all the sites (Higgins I 2  = 0%)., Conclusion: Depression may play a key role in the development of frailty. Pathways addressing the association between physical and mental health in older people need to be further investigated in future research., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: With ageing world populations, multimorbidity (presence of two or more chronic diseases in the same individual) becomes a major concern in public health. Although multimorbidity is associated with age, its prevalence varies. This systematic review aimed to summarise and meta-analyse the prevalence of multimorbidity in high, low- and middle-income countries (HICs and LMICs)., Methods: Studies were identified by searching electronic databases (Medline, Embase, PsycINFO, Global Health, Web of Science and Cochrane Library). The term 'multimorbidity' and its various spellings were used, alongside 'prevalence' or 'epidemiology'. Quality assessment employed the Newcastle-Ottawa scale. Overall and stratified analyses according to multimorbidity operational definitions, HICs/LMICs status, gender and age were performed. A random-effects model for meta-analysis was used., Results: Seventy community-based studies (conducted in 18 HICs and 31 LMICs) were included in the final sample. Sample sizes ranged from 264 to 162,464. The overall pooled prevalence of multimorbidity was 33.1% (95% confidence interval (CI): 30.0-36.3%). There was a considerable difference in the pooled estimates between HICs and LMICs, with prevalence being 37.9% (95% CI: 32.5-43.4%) and 29.7% (26.4-33.0%), respectively. Heterogeneity across studies was high for both overall and stratified analyses ( I 2 > 99%). A sensitivity analysis showed that none of the reviewed studies skewed the overall pooled estimates., Conclusion: A large proportion of the global population, especially those aged 65+, is affected by multimorbidity. To allow accurate estimations of disease burden, and effective disease management and resources distribution, a standardised operationalisation of multimorbidity is needed., Competing Interests: Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Early intervention in psychosis (EIP) has been developed as an approach to improve the prognosis of people with psychotic disorders and it has been claimed to be a more efficient model of care. However, the evidence is not definitive and doubts have spread regard to the economic outcomes of EIP services amid the usually restricted mental health budget.AimsWe aimed to review the cost-effectiveness evidence of EIP services worldwide., Method: We systematically reviewed the economic literature about EIP following the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement guidelines. Studies were selected according to previously stated criteria and analysed with standardised critical appraisal tools for trial-based economic evaluations and modelling studies., Results: A total of 16 studies were selected after applying the eligibility criteria. Most of them were economic evaluations alongside clinical trials. The overall evidence was consistent in the cost-effectiveness of EIP compared with standard care for first episode of psychosis and the Clinical High Risk for Psychosis paradigm. Such evidence was replicated among different health systems, but mainly in high-income countries. The methodological quality of such evidence, however, was moderate and heterogeneity was significant across the studies., Conclusions: There is consistent evidence that the implementation of EIP services might be a cost-effective alternative across different health systems. Such evidence, nevertheless, derives from heterogeneous and sometimes methodologically flawed studies, reducing the certainty of such statement. More efforts must be done to rigorously assess the value of this intervention, before expanding it among systems where mental health budgets are more constrained.Declaration of interestNone.

Purpose: To conduct a systematic review and meta-analysis examining the association of the prevalence of depression and time since spousal loss in widowed people., Methods: The databases MEDLINE, Embase and PsycInfo were searched (May 2017) for papers reporting on time since spousal loss in widowed people and the prevalence of common mental disorders. A systematic review was conducted according to MOOSE guidelines. Random effects meta-analyses of the prevalence of depression were conducted by intervals of time since spousal loss., Results: The literature search identified 12,982 studies of which 22 were eligible for inclusion in the systematic review. Of these, 14 were furthermore eligible for inclusion in the meta-analysis. The summary estimates found in the meta-analysis for the prevalence of depression in the intervals of time since spousal loss were: ≤ 1 month: 38.2% (21.9-55.8%); > 1 month to 3 months: 25.0% (17.3-33.5%); > 3 months to 6 months: 23.1% (18.0-28.7%); > 6 months to 12 months: 19.4% (15.2-24.0%); > 12 months to 18 months: 11.1% (5.3-18.7%); > 18 months to 24 months: 15.2% (12.3-18.2%); > 24 months to 60 months: 10.5% (4.3-18.5%)., Conclusion: Widowhood is associated with a high prevalence of depression and the study identifies a population group needing special attention in daily clinical practice. The prevalence is highest in the first month of widowhood, however, continues to be high at least 5 years into widowhood.

Background: Late life depression is associated with a significant burden of disease. Estimating depression in older adults can be difficult and requires different methodological approaches from those fitting younger adults. As community prevalence data is scarce in Portugal, we estimated the prevalence of depression in a sample of older Portuguese adults. Moreover, we investigated the association between depression and disability., Methods: A cross-sectional comprehensive one-phase survey was conducted of all residents aged 65 and over of one urban and one rural catchment area in Southern Portugal. Standardized 10/66 assessments include a comprehensive cognitive module and the Geriatric Mental State (GMS)-AGECAT. Information on demographics, non-communicable disease risk factors and disability/functioning (WHODAS 2.0) was also recorded. Depression was assessed using both ICD-10 and EURO-D criteria., Results: We interviewed 1405 older people (mean age 74.9, SD = 6.7 years; 55.5% women) after 313 (18.2%) refusals to participate. The prevalence rate for ICD-10 depression was 4.4 (95% CI 3.5-5.6) and 18.0 (95% CI 16.0-20.1) using the EURO-D case definition. As compared with having no depression, ICD-10 depression was associated with a higher level of disability, even after adjusting for confounders (4.8, 95% CI 2.8-8.1). The same happened with subsyndromal depression ('EURO-D only') cases (2.2, 95% CI 1.4-3.5)., Limitations: Non-generalisability of findings outside of catchment areas., Conclusions: In this sample of older Portuguese people, the prevalence of depression was high and so were the associated levels of disability. EURO-D diagnoses may provide a better picture of clinically significant old age depression as a basis for health and social service planning., (Copyright © 2018. Published by Elsevier B.V.)

Background: Widowed people have a high risk of common mental disorders, however no summary estimates of the prevalences exist. The aim of this study was to conduct a systematic review and meta-analysis of the prevalence of common mental disorders in widowed people in the community., Methods: MEDLINE, Embase and PsycInfo were searched for papers reporting on prevalence of common mental disorders and widowhood. Eligible studies were included in random effects meta-analyses of the prevalence of depression and anxiety disorders. Subgroup analyses were performed on method of assessment of depression and age and sex., Results: The literature search identified 13,781 titles of which 42 were eligible for meta-analysis. The pooled prevalence of depression in studies using a screening scale was 40.6% (33.6%-47.6%) (n = 30). For studies using full diagnostic criteria the pooled prevalence of depression was 19.2% (13.4%-25.0%) (n = 12). Subgroup analyses of age (≥ or < 65) and sex did not show any differences regarding depression. Five studies reported the prevalence of anxiety disorders. The pooled prevalence estimate was 26.9% (8.1%-45.7%)., Limitations: The prevalence estimates in this study are summary estimates of prevalences from existing literature. Although the reporting bias assessment showed no evidence, there could be some reporting bias, as studies might only present results if there is a high prevalence., Conclusions: Widowed people have a high prevalence of depression and anxiety disorders. The high prevalence of depression was independent of age and sex. The study identifies a population group at high risk needing special attention in clinical practice., (Copyright © 2018. Published by Elsevier B.V.)

Background: A growing body of evidence suggests that depression is related to dementia in older adults. Previous research has been done in high-income countries and there is a lack of studies in low- and middle income countries (LMICs)., Objective: To examine the relationship between depressive symptoms and incidence of dementia in a population-based study of older adults in Latin America., Methods: The study is a part of the 10/66 Dementia Research Group's population survey and includes 11,472 older adults (baseline mean age 74 years) from Cuba, Dominican Republic, Mexico, Peru, Puerto Rico, and Venezuela. The baseline examinations were done in 2003-2007 and the follow-up examinations 4 years later. Semi-structured psychiatric interviews gave information about ICD-10 depression and sub-syndromal depression (i.e., ≥4 depressive symptoms) at baseline. Information on dementia were collected at the follow-up examination. Competing risk models analyzed the associations between depression and incidence of dementia and the final model were adjusted for age, sex, education, stroke, and diabetes. Separate analyses were conducted for each site and then meta-analyzed by means of fixed effect models., Results: At baseline, the prevalence of depression was 26.0% (n = 2,980): 5.4% had ICD-10 depression and 20.6% sub-syndromal depression. During the follow-up period, 9.3% (n = 862) developed dementia and 14.3% (n = 1,329) deceased. In the pooled analyses, both ICD-10 depression (adjusted sub-hazard ratio (sHR) 1.63, 95% confidence interval (CI) 1.26-2.11) and sub-syndromal depression (adjusted sHR 1.28, 95% CI: 1.09-1.51) were associated with increased incidence of dementia. The Higging I2 tests showed a moderate heterogeneity across the study sites., Conclusion: Our findings suggest that late-life depression is associated with the incidence of dementia in LMICs in Latin America, which support results from earlier studies conducted in high-income countries.

Background: In this review we discuss how the study of dementia epidemiology in Low- and Middle-Income Countries (LMICs) has changed in the last 20 years, and specifically to review the evidence created by the 10/66 Dementia Research Group (DRG) and discuss future directions for research., Methods: We identified and collated all the papers related to the 10/66 Dementia Research Group, including papers from groups who adopted the 10/66 methodology, that have been published in peer-reviewed journals., Results: Over 200 papers including data from Africa, Asia, Europe and Latin America and the Caribbean were identified by this review. Many of the findings revolved around the epidemiology of dementia, mental health and non-communicable diseases, including the cross-cultural development and validation of measurement tools of cognition and functioning, need for care, care arrangements and mental health. Social ageing, care dependence and caregiver interventions were also topics that the group had published on., Discussion: A body of evidence has been generated that has challenged the view, prevalent when the group started, that dementia is comparatively rare in LMICs. The experience of the 10/66 DRG has shown that descriptive epidemiological research can be important and impactful, where few data exist. Monitoring population trends in the prevalence and incidence of dementia may be our best chance to confirm hypotheses regarding modifiable risk factors of dementia.

Background: Chronic obstructive pulmonary disease (COPD) is a major disease burden which accounts for 5% of all deaths globally, with most of those (>90%) occurring in lower to middle income countries (LMIC). It is also emerging as an important modifiable dementia risk factor., Objective: To address the knowledge gap surrounding the nature of the associations between COPD, dementia, and mortality, and the geographical variation of those associations in LMIC., Methods: Data from the 10/66 study surveying 15,394 participants (mean age 74 years, 62% female) across 8 countries was used to estimate the prevalence of self-reported COPD and its association with incident dementia and premature death. Proportional sub-hazards models using a cumulative incidence function were applied to identify the probability of incident dementia onset given the risk of premature death, with estimates pooled across countries via random effect meta-analysis., Results: Over the 3-year follow-up, almost 10% of participants developed dementia and 14% were deceased. COPD was not significantly associated with dementia incidence except in Cuba. However, fully adjusted models indicated that individuals with COPD were at a 28% increased risk of premature death, a trend present across most countries when analyzed individually., Conclusion: The link between COPD and dementia is currently somewhat different and weaker in LMIC than in developed countries. This may be because premature death in the populations studied mask the development of clinical dementia. Given the global trend toward increased life expectancy, it is critical that the disease burden associated with COPD be addressed without delay if a further rise in dementia prevalence associated with COPD is to be avoided in LMIC.

Latin American and the Caribbean countries exhibit high life expectancy and projections show that they will experience the fastest growth of older people in the following years. As people live longer, it is important to maximise the opportunity to age healthily. We aimed to examine the associations of lifestyle behaviours with healthy ageing in Cuba, Dominican Republic, Peru, Mexico and Puerto Rico, part of the 10/66 study. Residents 65 years old and over (n = 10,900) were interviewed between 2003 and 2010. In the baseline survey, we measured four healthy behaviours: Physical activity, non-smoking, moderate drinking and fruits or vegetables consumption. Healthy ageing was conceptualised within the functional ability framework over a median of 4 years follow-up. Logistic models were calculated per country and then pooled together with fixed-effects meta-analysis. People engaging in physical activity and consuming fruits or vegetables had increased odds of healthy ageing in the follow-up (OR: 2.59, 95% CI: 2.20⁻3.03; OR: 1.24, 95% CI: 1.06⁻1.44, respectively). Compared with participants engaging in none or one healthy behaviour, the ORs of participants engaging in two, three or four healthy behaviours increased in a linear way (OR: 1.60, 95% CI: 1.40⁻1.84; OR: 2.29, 95% CI: 1.94⁻2.69; OR: 2.46, 95% CI: 1.54⁻3.92, respectively). Our findings highlight the importance of awareness of a healthy lifestyle behaviour among older people.

Background: Aging is a multidimensional process with a remarkable interindividual variability. This study is focused on identifying groups of population with similar aging patterns, and to define the health trajectories of these groups. Sociodemographic and health determinants of these trajectories are also identified., Methods: Data from the English Longitudinal Study of Aging (ELSA) and the Health and Retirement Study (HRS) were used. A set of self-reported health items and measured tests were used to generate a latent health metric by means of a Bayesian multilevel IRT model, assessing the ability of the metric to predict mortality. Then, a Growth Mixture Model (GMM) was conducted in each study to identify latent classes and assess health trajectories. Kaplan-Meier survival curves were obtained for each class and a multinomial logistic regression was used to identify determinants of these trajectories., Results: The health score generated showed an adequate ability to predict mortality over 10 years in ELSA (AUC = 0.74; 95% CI: 0.72, 0.75) and HRS (AUC = 0.74; 95% CI: 0.73, 0.75). By means of GMM, four latent classes were identified in ELSA and five in HRS. Chronic conditions, no qualification and low level of household wealth were associated to the classes which showed a higher mortality in both studies., Conclusion: The method based on the creation of a common metric of health and the use of GMM to identify similar patterns of aging, allows for the comparison of trajectories of health across longitudinal surveys. Multimorbidity, educational level, and household wealth could be considered as determinants associated to these trajectories.

Background: Neurodegenerative processes in the elderly damage the brain, leading to progressive, incapacitating cognitive, behavioral, and motor dysfunctions which culminate in dementia. Fully manifest dementia is likely to be preceded by the presence of neurological signs, which could serve as early determinants of dementia and predictors of mortality. The aims of this study were to assess the construct validity of a neurological battery assessed among older adults living in Latin America, and to test the association of groups of neurological signs with dementia cross-sectionally, and mortality longitudinally., Methods: The 10/66 Dementia Research Group collected information on neurological symptoms via the NEUROEX assessment in population based surveys of older adults living in low and middle-income countries. Data from 10,856 adults participating in the baseline assessment of the 10/66 study and living in Cuba, Dominican Republic, Peru, Venezuela and Mexico were analysed. Exploratory and confirmatory analysis were used to explore dimensionality of neurological symptoms. Poisson regression analyses were used to link groups of neurological signs with dementia at baseline. Cox hazard regression models were used to explore the predictive validity of neurological signs with mortality at follow up., Results: Exploratory and confirmatory factor analyses revealed four dimensions of neurological signs, which are associated with lesions of specific brain regions. The identified factors showed consistency with groups of neurological signs such as frontal, cerebellar, extrapyramidal, and more generalized gait disturbance signs. Regression analyses revealed that all groups of neurological signs were positively associated with dementia at baseline and predicted mortality at follow up., Conclusions: Our findings support the construct and predictive validity of the NEUROEX assessment, linking neurological and gait impairments with dementia at baseline, and with mortality at follow up among older adults living in five Latin American countries.

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.

Background: There are several existing systematic reviews of prevalence of dementia for mainland China, Hong Kong and Taiwan, but several studies have been newly reported. The aim of this study is to update prevalence data in this region and test for variation across geographical areas and time periods using the new dataset., Methods: Twenty prevalence studies identified from World Alzheimer Report 2015 (January 2011-March 2015) and an updated search (March 2015-February 2017) were added to the original dataset (N = 76). Meta-regression was used to investigate geographical variation and time trends, taking methodological factors and characteristics of study population into account, and to estimate prevalence and number of people with dementia by geographical area., Results: Compared with northern China, the prevalence of dementia was lower in the central China [-1.0; 95% confidence interval (CI):-2.2, 0.3], south China (-1.7; 95% CI: -3.1, -0.3), Hong Kong and Taiwan (-3.0; 95% CI: -5.0, -1.0) but appeared to be higher in western China (2.8; 95% CI: 0.1, 5.5) after adjusting for methodological variation. The increasing trend from pre-1990 to post-2010 periods was considerably attenuated when taking into account methodological factors and geographical areas. The updated estimated number of people with dementia in all these areas is 9.5 million (5.3%; 95% CI: 4.3, 6.3) in the population aged 60 or above., Conclusions: Geographical variation in dementia prevalence is confirmed in this update, whereas evidence on increasing trends is still insufficient. Differing societal development across areas provides an opportunity to investigate risk factors at the population level operating across diverse life course experiences. Such research could advance global primary prevention of dementia., (© The Author(s) 2018. Published by Oxford University Press on behalf of the International Epidemiological Association.)

Objectives: The number of older people is growing across the world; however, quantitative synthesis of studies examining the impact of lifestyle factors on the ageing process is rare. We conducted a systematic review and meta-analysis of longitudinal studies to synthesise the associations of smoking and alcohol consumption with healthy ageing (HA)., Methods: Major electronic databases were searched from inception to March 2017 (prospectively registered systematic reviews registration number CRD42016038130). Studies were assessed for methodological quality. Random-effect meta-analysis was performed to calculate pooled ORs and 95% CI., Results: In total, we identified 28 studies (n=184 543); 27 studies reported results on smoking, 22 on alcohol consumption. 23 studies reported a significant positive association of never or former smoking with HA and 4 non-significant. 12 studies reported a significant positive association of alcohol consumption with HA, 9 no association and 1 negative. Meta-analysis revealed increased pooled OR of HA for never smokers compared with current smokers (2.36, 95% CI 2.03 to 2.75), never smokers compared with former smokers (1.32, 95% CI 1.23 to 1.41), former or never smokers compared with current smokers (1.72, 95% CI 1.20 to 2.47), never smokers compared with past or current smokers (1.29, 95% CI 1.16 to 1.43); drinkers compared with non-drinkers (1.28, 95% CI 1.08 to 1.52), light drinkers compared with non-drinkers (1.12, 95% CI 1.03 to 1.22), moderate drinkers compared with non-drinkers (1.35, 95% CI 0.93 to 1.97) and high drinkers compared with non-drinkers (1.25, 95% CI 1.09 to 1.44). There was considerable heterogeneity in the definition and measurement of HA and alcohol consumption., Conclusions: There is consistent evidence from longitudinal studies that smoking is negatively associated with HA. The associations of alcohol consumption with HA are equivocal. Future research should focus on the implementation of a single metric of HA, on the use of consistent drinking assessment among studies and on a full-range of confounding adjustment. Our research also highlighted the limited research on ageing in low-and-middle-income countries., Competing Interests: Competing interests: AMP was supported by the MRC MR/K021907/1. AK was supported by a grant funded by the National Institute for Health Research (NIHR) Biomedical Research Centre at South London and Maudsley National Health Service (NHS) Foundation Trust and Kings’ College London where most of this work was conducted. AK is now formally based at the Liverpool School of Tropical Medicine., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Adult 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., Methods: Population-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 dementia, and mortality, three to five years later., Results: Of 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 (ASHR 0.82, 95% CI 0.67-0.99). A priori hypotheses regarding effect modification by gender or educational level were not supported. However, the effect of skull circumference was modified by gender (M vs F ASHR 0.86, 95% CI 0.75-0.98), but in the opposite direction to that hypothesized with a greater protective effect of larger skull dimensions in men., Conclusions: Consistent 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.

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., (Copyright © 2017. Published by Elsevier Inc.)

Objective: Frailty and pre-frailty are two common conditions in the older people, but whether these conditions could predict depression is still limited to a few longitudinal studies. In this paper, we aimed to investigate whether frailty and pre-frailty are associated with an increased risk of depression in a prospective cohort of community-dwelling older people., Methods: Four thousand seventy-seven community-dwelling men and women over 60 years without depression at baseline were included from the English Longitudinal Study of Ageing. Frailty status was defined according to modified Fried's criteria (weakness, weight loss, slow gait speed, low physical activity and exhaustion) and categorized as frailty (≥3 criteria), pre-frailty (1-2 criteria) or robustness (0 criterion). Depression was diagnosed as ≥4 out of 8 points of Center for Epidemiologic Studies Depression Scale, after 2 years of follow-up., Results: Over a 2-year follow-up, 360 individuals developed depression. In a logistic regression analysis, adjusted for 18 potential baseline confounders, pre-frailty (odds ratio (OR) = 0.89; 95% confidence interval (CI), 0.54-1.46; p = 0.64) and frailty (OR = 1.22; 95% CI, 0.90-1.64; p = 0.21) did not predict the onset of depression at follow-up. Among the criteria included in the frailty definition, only slow gait speed (OR = 1.82; 95% CI, 1.00-3.32; p = 0.05) appeared to predict a higher risk of depression., Conclusions: Among older community dwellers, frailty and pre-frailty did not predict the onset of depression during 2 years of follow-up, when accounting for potential confounders, whilst slow gait speed considered alone may predict depression in the older people. Copyright © 2017 John Wiley & Sons, Ltd., (Copyright © 2017 John Wiley & Sons, Ltd.)

Background: Dementia imposes a high burden of disease worldwide. Recent epidemiological studies in European community samples are scarce. In Portugal, community prevalence data is very limited. The 10/66 Dementia Research Group (DRG) population-based research programmes are focused in low and middle income countries, where the assessments proved to be culture and education fair. We applied the 10/66 DRG prevalence survey methodology in Portugal, where levels of illiteracy in older populations are still high., Methods: A cross-sectional comprehensive one-phase survey was conducted of all residents aged 65 and over of two geographically defined catchment areas in Southern Portugal (one urban and one rural site). Nursing home residents were not included in the present study. Standardized 10/66 DRG assessments include a cognitive module, an informant interview and the Geriatric Mental State-AGECAT, providing data on dementia diagnosis and subtypes, mental disorders including depression, physical health, anthropometry, demographics, disability/functioning, health service utilization, care arrangements and caregiver strain., Results: We interviewed 1405 old age participants (mean age 74.9, SD = 6.7 years; 55.5% women) after 313 (18.2%) refusals to participate. The prevalence rate for dementia in community-dwellers was 9.23% (95% CI 7.80-10.90) using the 10/66 DRG algorithm and 3.65% (95% CI 2.97-4.97) using DSM-IV criteria. Pure Alzheimer's disease was the most prevalent dementia subtype (41.9%). The prevalence of dementia was strongly age-dependent for both criteria, but there was no association with sex., Conclusions: Dementia prevalence was higher than previously reported in Portugal. The discrepancy between prevalence according to the 10/66 DRG algorithm and the DSM-IV criteria is consistent with that observed in less developed countries; this suggests potential underestimation using the latter approach, although relative validity of these two approaches remains to be confirmed in the European context. We improved the evidence base to raise awareness and empower advocacy about dementia in Portugal, so that the complex needs of frail older people may be met in better ways.

Background: empirical evidence from high-income countries suggests that self-rated health (SRH) is useful as a brief and simple outcome measure in public health research. However, in many low- and middle-income countries (LMIC) there is a lack of evaluation and the cross-cultural validity of SRH remains largely untested. This study aims to explore the prevalence of SRH and its association with mortality in older adults in LMIC in order to cross-culturally validate the construct of SRH., Methods: population-based cohort studies including 16,940 persons aged ≥65 years in China, India, Cuba, Dominican Republic, Peru, Venezuela, Mexico and Puerto Rico in 2003. SRH was assessed by asking 'how do you rate your overall health in the past 30 days' with responses ranging from excellent to poor. Covariates included socio-demographic characteristics, use of health services and health factors. Mortality was ascertained through a screening of all respondents until 2007., Results: the prevalence of good SRH was higher in urban compared to rural sites, except in China. Men reported higher SRH than women, and depression had the largest negative impact on SRH in all sites. Without adjustment, those with poor SRH showed a 142% increase risk of dying within 4 years compared to those with moderate SRH. After adjusting for all covariates, those with poor SRH still showed a 43% increased risk., Conclusion: our findings support the use of SRH as a simple measure in survey settings to identify vulnerable groups and evaluate health interventions in resource-scares settings., (© The Author 2017. Published by Oxford University Press on behalf of the British Geriatrics Society.)

Background: Older people constitute a significant proportion of the total population and their number is projected to increase by more than half by 2030. This increasing probability of late survival comes with considerable individual, economic and social impact. Physical activity (PA) can influence the ageing process but the specific relationship with healthy ageing (HA) is unclear., Methods: We conducted a systematic review and meta-analysis of longitudinal studies examining the associations of PA with HA. Studies were identified from a systematic search across major electronic databases from inception as January 2017. Random-effect meta-analysis was performed to calculate a pooled effect size (ES) and 95% CIs. Studies were assessed for methodological quality., Results: Overall, 23 studies were identified including 174,114 participants (30% men) with age ranges from 20 to 87 years old. There was considerable heterogeneity in the definition and measurement of HA and PA. Most of the identified studies reported a significant positive association of PA with HA, six reported a non-significant. Meta-analysis revealed that PA is positively associated with HA (ES: 1.39, 95% CI=1.23-1.57, n=17) even if adjusted for publication bias (ES: 1.27, 95% CI=1.11-1.45, n=20)., Conclusions: There is consistent evidence from longitudinal observational studies that PA is positively associated with HA, regardless of definition and measurement. Future research should focus on the implementation of a single metric of HA, on the use of objective measures for PA assessment and on a full-range of confounding adjustment. In addition, our research indicated the limited research on ageing in low-and-middle income countries., (Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Poor micro-scale environmental features, such as graffiti and broken windows, have been associated with crime and signs of social disorder with a potential impact on mental health. The aim of this study is to investigate the association between micro-scale environment and mental health problems in later life, including cognitive (cognitive impairment and dementia) and common mental disorders (depressive and anxiety symptoms)., Methods: The method of visual image audits was used to collect micro-scale environmental data for 3590 participants in the Cognitive Function and Ageing Study II, a population-based multicentre cohort of people aged 65 or above in England. Multilevel logistic regression was used to examine the associations between the quality of micro-scale environment and mental health problems taking into account urban/rural difference., Results: Poor quality of micro-scale environment was associated with nearly 20% increased odds of depressive (OR: 1.19; 95% CI: 0.99, 1.44) and anxiety symptoms (OR: 1.17; 95% CI: 0.99, 1.38) while the direction of association for cognitive disorders differed across urban and rural settings. Although higher odds of cognitive disorders were found in rural settings, living in a poor quality environment was associated with nearly twice higher odds of cognitive impairment (OR: 1.88; 95% CI: 1.18, 2.97) in urban conurbations but 20% lower odds in rural areas (OR: 0.80; 95% CI: 0.57, 1.11)., Limitations: The causal direction could not be fully determined due to the cross-sectional nature of the data. The visual nature of the environmental assessment tool means it likely does not fully capture features related to the availability of local support services, or opportunities for social participation and interaction., Conclusions: The quality of micro-scale environment appears to be important to mental health in older people. Interventions may incorporate the environmental aspect to reduce cognitive and common mental disorders., (Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.)

Within recent years, there has been a seismic shift in smoking rates from high-income to low- and middle-income countries (LMICs). Evidence indicates that perceived stress may comprise a barrier for smoking cessation, but little is known about the association of perceived stress and smoking in LMICs. We conducted a cross-sectional, community-based study comprising 217,561 people [mean age 38.5 (SD = 16.1) years, 49.4% males]. A perceived stress score [range 2 (lowest-stress) 10 (highest-stress)] was computed from the Perceived Stress Scale. Multivariable logistic regression analyses were conducted. In the overall sample, a one-unit increase in perceived-stress resulted in a 5% increased odds of smoking (OR = 1.05; 95%CI = 1.03-1.06). Increased stress was associated with smoking in Africa (OR = 1.06; 95%CI = 1.04-1.09), Americas (OR = 1.03; 95%CI = 1.01-1.05), and Asia (OR = 1.06; 95%CI = 1.04-1.08), but not Europe (OR = 0.99; 95%CI = 0.95-1.02). Increasing levels of perceived stress were significantly associated with heavy smoking (≥30 cigarettes per day) among daily smokers (OR = 1.08; 95%CI = 1.02-1.15). A country-wide meta-analysis showed that perceived stress is associated with daily smoking in most countries. Prospective studies are warranted to confirm/refute this relationship, which may have meaningful public health implications.

Introduction: Built environment features have been related to behavior modification and might stimulate cognitive activity with a potential impact on cognitive health in later life. This study investigated cross-sectional associations between features of land use and cognitive impairment and dementia, and also explored urban and rural differences in these associations., Methods: Postcodes of the 7,505 community-based participants (aged ≥65 years) in the Cognitive Function and Ageing Study II (collected in 2008-2011) were linked to environmental data from government statistics. Multilevel logistic regression investigated associations between cognitive impairment (defined as Mini-Mental State Examination score ≤25) and dementia (Geriatric Mental Status and Automatic Geriatric Examination for Computer-Assisted Taxonomy organicity level ≥3) and land use features, including natural environment availability and land use mix, fitting interaction terms with three rural/urban categories. Data were analyzed in 2015., Results: Associations between features of land use and cognitive impairment were not linear. After adjusting for individual-level factors and area deprivation, living in areas with high land use mix was associated with a nearly 30% decreased odds of cognitive impairment (OR=0.72, 95% CI=0.58, 0.89). This was similar, yet non-significant, for dementia (OR=0.70, 95% CI=0.46, 1.06). In conurbations, living in areas with high natural environment availability was associated with 30% reduced odds of cognitive impairment (OR=0.70, 95% CI=0.50, 0.97)., Conclusions: Non-linear associations between features of land use and cognitive impairment were confirmed in this new cohort of older people in England. Both lack of and overload of environmental stimulation may be detrimental to cognition in later life., (Copyright © 2017 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)