Citation: Prince MJ, Acosta D, Castro-Costa E, Jackson J, Shaji KS (2009) Packages of Care for Dementia in Low- and Middle-Income Countries. PLoS Med 6(11): e1000176. doi:10.1371/journal.pmed.1000176
Academic Editor: Vikram Patel, London School of Hygiene and Tropical Medicine, United Kingdom
Published: November 3, 2009
Copyright: © 2009 Prince et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: No specific funding was received for this piece.
Competing interests: DA is Chair of Alzheimer's Disease International. JJ is the ex-Chief Executive of Alzheimer Scotland.
Abbreviations: BPSD, behavioural and psychological symptoms; ChEI, cholinesterase inhibitor; HIC, high income country; LMIC, low- and middle-income country; RCT, randomised controlled trial
Provenance: Commissioned; externally peer reviewed.
This is the fifth in a series of articles highlighting the delivery of “packages of care” for mental health disorders in low- and middle-income countries. Packages of care are combinations of treatments aimed at improving the recognition and management of conditions to achieve optimal outcomes.
- Two-thirds of people with dementia live in low- and middle-income countries (LMICs), where there are few services available and levels of awareness and help-seeking are low.
- After early diagnosis, the principal goals for management of dementia are optimising physical health, cognition, activity, and wellbeing; detecting and treating behavioural and psychological symptoms (BPSD); and providing information and long-term support to carers.
- Routine packages of continuing care should comprise diagnosis coupled with information, regular needs assessments, physical health checks, and carer support, and where necessary carer training, respite care, and assessment and treatment of BPSD.
- Care can be delivered by trained primary care teams working in a collaborative care framework. Continuing care with practice-based care coordination, and community outreach are essential components of this model.
- Efficient care delivery in LMICs involves integrating dementia care with that of other chronic diseases and community-support programs for the elderly and disabled.
Dementia is a chronic organic brain syndrome, characterised by progressive impairment of multiple cortical functions, including memory, learning, orientation, language, comprehension, and judgement. Diagnosis requires decline in cognitive function and independent living skills (Box 1) . However, for carers and people with dementia, the behavioural and psychological symptoms of dementia (BPSD) affect most quality of life, are an important cause of carer strain , and a common reason for institutionalisation . Alzheimer's disease, vascular dementia, dementia with Lewy bodies, and frontotemporal dementia are the most common dementia subtypes, but mixed pathologies may be the norm . Some rare causes (subdural haematoma, normal pressure hydrocephalus, hypercalcaemia, and deficiencies of thyroid hormone, vitamin B12, and folic acid) can be treated. Otherwise, the progressive course of dementia cannot be altered, but symptomatic treatments and support can be helpful.
Box 1. International Classification of Diseases 10 Criteria for Dementia and Commonly Occurring Features
Diagnostic criteria (ICD-10 Diagnostic Guidelines)
“The primary requirement for diagnosis is evidence of a decline in both memory and thinking which is sufficient to impair personal activities of daily living. The impairment of memory typically affects the registration, storage, and retrieval of new information, but previously learned and familiar material may also be lost, particularly in the later stages. There is also impairment of thinking and of reasoning capacity, and a reduction in the flow of ideas. The processing of incoming information is impaired, in that the individual finds it increasingly difficult to attend to more than one stimulus at a time, such as taking part in a conversation with several persons, and to shift the focus of attention from one topic to another. If dementia is the sole diagnosis, evidence of clear consciousness is required. The above symptoms and impairments should have been evident for at least 6 months for a confident clinical diagnosis of dementia to be made” .
The diagnostic criteria do not convey a sense of the typical progression of the disorder:
A person with mild dementia has noticed deterioration in their memory for recent events. For example, they may forget that their daughter had visited the previous day. They also find it difficult to concentrate, think flexibly, plan, and take decisions. They are likely to feel bewildered, anxious and sad. They may become angry and defensive when others point out errors.
A person with moderate dementia has severe memory problems. Only early memories are retained. Recent events are not remembered, or rapidly forgotten. They may not know the day, date or time of day. They often do not know where they are. They cannot communicate clearly, having problems finding the right word and using the wrong words. They may hear voices or see things that are not there, and can develop false beliefs, for example that children are entering their house and stealing things. They are likely to be anxious, sad, bewildered, and can become agitated or aggressive.
A person with severe dementia has complete memory loss. They may no longer recognise their close family. They have severe speech difficulties or are unable to communicate. They may be apathetic and totally inactive, but at times can be agitated and verbally and physically aggressive. They cannot coordinate their physical movements; may have lost the ability to walk and feed themselves and have difficulty swallowing. They are likely to be incontinent.
Dementia mainly affects older people. Few cases start before the age of 65 y, after which prevalence doubles with every 5-y increase in age . Globally, 24.3 million people are affected by dementia and 4.6 million new cases occur annually . The prevalence of dementia is expected to double every 20 y, reaching 81.1 million by 2040, an increase of 100% in developed countries and of more than 300% in India, China, and their neighbours. Prevalence is lower in low- and middle-income countries (LMICs) than in high income countries (HICs) , perhaps because of underdetection of mild cases . Nevertheless, most people with dementia live in LMICs—60% in 2001 rising to 71% by 2040 .
Dementia contributes 11.2% of years lived with disability among people aged 60 y and over, a higher proportion than stroke (9.5%), musculoskeletal disorders (8.9%), cardiovascular disease (5.0%), and cancer (2.4%) . Its global cost is estimated to be US$317 billion, 77% of this total arising in HICs where formal sector care costs increase with disease progression, and institutionalization is the main cost driver . Family care is more important in resource-poor countries, accounting for 56% of costs in low-income countries, 42% in middle-income countries, and 31% in HICs . In a pilot study in 26 LMIC centers, carers were economically disadvantaged . A fifth of carers had cut back on paid work, and paid carers were common, which added to the economic strain . Compensatory benefits were practically nonexistent ,.
In three qualitative studies in India, features of dementia were widely recognized and named –. However, dementia was perceived as normal ageing rather than as a medical condition. The consequences were limited help seeking  despite disability and carer strain , no structured training on the recognition and management of dementia, and no constituency to advocate for more responsive care services . People with dementia were excluded from residential care . Carers misinterpreted BPSD as deliberate misbehavior . BPSD can also lead to stigma and blame attaching to the carers . In India, likely causes of dementia were cited as “neglect by family members, abuse, tension and lack of love” .
In this article, we focus on the effective management of dementia in LMICs, reviewing the evidence on efficacy of interventions and their delivery derived from LMICs where possible. Given the paucity of relevant evidence from LMICs, we also cite systematic reviews and meta-analyses based on trials from HICs. On the basis of our review we propose a package of care—a combination of treatments aimed at improving the recognition and management of conditions to achieve optimal outcomes—for dementia.
The Evidence on the Management of Dementia
The principal goals of management of dementia are: early diagnosis; optimization of physical health, cognition, activity, and wellbeing; detection and treatment of BPSD; and the provision of information and long-term support to carers. The evidence base for dementia care comes, overwhelmingly, from HICs (Table 1). All the studies discussed below refer to HICs, unless otherwise specified.
Detection and Diagnosis of Dementia
Many cases of dementia, particularly in LMICs, go undetected,in part because of lack of awareness. Awareness of this disorder can be boosted by dissemination of information from governments, health care providers, and media. Help-seeking can be encouraged by improved case-finding. In India and Brazil, for example, community health care workers could, with a few hours training, identify dementia in the community with a positive predictive value of 66% ,. Population screening for dementia is not considered cost-effective even in HICs . Selective screening can be accomplished by cognitive testing or by informant report of cognitive and functional decline. The Mini-Mental State Examination  is widely used in HICs, and adapted versions have been developed for use in many LMICs –. However, this assessment takes 10 min to administer and is prone to educational and cultural bias ,. A systematic review of brief screening assessments identified three tests (the General Practitioner Assessment of Cognition, Mini-Cog, and Memory Impairment Screen) that took less than 5 min to administer and were considered suitable and valid for routine use in general practice ; none of these tests has been validated in LMICs.
Dementia diagnosis requires cognitive testing, clinical interview, informant interview, and physical examination. The 10/66 Dementia Research Group's culture- and education-fair diagnostic protocol is validated in many LMICs ,, but requires adaptation for clinical use. Practice guidelines in HICs  advocate a routine “dementia screen” to exclude treatable causes, which includes haematology, biochemistry, thyroid function tests, vitamin B12 and folate levels. The feasibility and cost-effectiveness of this approach needs to be tested in LMICs.
Finally, a recent systematic review based on evidence collected in HICs identified good practice for disclosing dementia diagnosis. This practice should include: preparation; integrating family members; exploring the patient's perspective; disclosing the diagnosis; responding to patient reactions; focusing on quality of life and wellbeing; planning for the future; and communicating effectively . The person assessed should be asked if they, and/or others wish to be told the diagnosis. If so, they should be given information about the signs, symptoms, and course of dementia, available treatments, care and support services.
To avoid missing underlying conditions, a physical assessment is recommended before specific treatments for BPSD are initiated , and should be a regular part of care for all patients. BPSD may sometimes be caused by pain, constipation, and urinary tract infection, although such associations are not always observed . Pain is common and poorly controlled in severe dementia . Hearing and visual impairment impede communication and exacerbate disorientation, and deafness predicts rapid cognitive decline ,. Visual and auditory impairment can be associated with hallucinations and delusions ,. Studies indicate that all these impairments are overrepresented in people with cognitive impairment –.
There have been very few trials of the effects of physical assessments and interventions on the course of dementia. In a randomised controlled trial (RCT), pain assessment among nursing home residents with dementia was associated with increased analgesic use, reduced pain, and improvements in staff morale . Uncontrolled studies show that audiological assessment is feasible, that hearing aids can be beneficial , and that referral to an optician to improve visual acuity may reduce visual hallucinosis . Nutrition is often impaired because of apathy, aversive feeding behaviours, poor dental health, and dysphagia. Although difficult to sustain, nutritional supplementation improved nutrition among nursing home residents ; nutritional education for carers had the same effect in the community . A “vascular care” secondary preventive intervention for people with dementia and cerebrovascular disease (part of current good practice guidelines ) that addressed hypercholesterolemia, hypertension, smoking, obesity, exercise, and micronutrient deficiency had no impact on subsequent cognition, disability, or institutionalisation .
A well-conducted RCT of cognitive stimulation (reality orientation, games, discussions based on information processing rather than knowledge) conducted in the United Kingdom as a group intervention , and a small pilot trial from Brazil , suggest that cognitive benefits from this intervention are similar to those for cholinesterase inhibitors (ChEIs). More specific cognitive training produced no benefits . Cognitive rehabilitation, an individualised therapy designed to enhance residual cognitive skills and cope with deficits, showed promise in uncontrolled case series undertaken in HICs . A meta-analysis of four trials of reminiscence therapy (the discussion of past activities, events, and experiences)  provides evidence for short-term improvement in cognition, mood, and carer strain, but the quality of these trials was poor.
Targets for pharmacological treatment include cognitive impairment, behavioural symptoms (agitation and aggression), and psychological symptoms (depression, anxiety, and psychosis).
There is a strong evidence base for the efficacy of ChEIs (donepezil , rivastigmine , and galantamine ). The use of each of these drugs is associated with modest and comparable improvements in cognitive function, global clinical state, and activities of daily living . The evidence base for ChEIs from LMICs is limited to one small RCT of donepezil in Brazil  and open-label trials of galantamine in Brazil  and China . The efficacy of this class of drugs in severe dementia is unclear, although useful cognitive benefits were identified for galantamine . A fourth drug for the treatment of cognitive impairment, memantine, has a different mode of action, and is well tolerated, but evidence for its efficacy is limited to people with moderate to severe dementia . ChEIs and memantine are less efficacious in vascular dementia than in other forms of dementia . Their efficacy for the treatment of disturbed behaviour is not established; manufacturer-sponsored licensing trials  and post hoc analyses  indicate small improvements that have not been confirmed in independent trials  and meta-analyses .
Meta-analyses of RCTs of haloperidol  and atypical antipsychotic drugs for the treatment of agitation  and BPSD  indicate small treatment effects, most evident for aggression ,. Atypical antipsychotic drugs have also been widely prescribed for psychosis in dementia, but a meta-analysis of their efficacy indicated that only aripiprazole had a statistically and clinically significant effect . Use of these drugs in dementia is associated with an increased risk of death and cerebrovascular adverse events ,–.
The benefits of antidepressant treatment in older people are clear , but a meta-analysis of their efficacy in people with dementia was inconclusive . Only two small trials were included in this meta-analysis, one of which suggested a benefit of sertraline for some depression outcomes . Antidepressants have also been proposed for the treatment of BPSD. A meta-analysis of two small RCTs of trazodone was inconclusive . Citalopram showed efficacy over placebo for the treatment of agitation in one small RCT , while sertraline showed no benefit on any primary behavioural endpoint .
A systematic review of trials of anticonvulsants to treat BPSD found sodium valproate to be ineffective . Carbamezepine may be more promising with large benefits noted for global clinical outcomes and agitation in one small parallel group trial  and more marginal effects in a small pilot trial .
Various sensory therapies have been proposed as treatments for BPSD but the evidence base for this approach is small and limited by the poor quality of the trials. Current evidence does not support the use of bright light therapy  or multisensory stimulation . One small RCT of aromatherapy suggested considerable benefit across a range of behavioural outcomes . Another small but well-conducted trial suggested that hand massage may be effective in reducing agitation ,. More evidence is required to confirm efficacy, exclude the possibility of harm, and define the optimal content and mode of administration of sensory therapies in both HICs and LMICs, where the approach is untested.
A large literature attests to the benefits of carer interventions in dementia . These include: psychoeducational interventions, often including carer training; psychological therapies such as cognitive behavioural therapy (CBT) and counselling; carer support; and respite care. Many interventions combine several of these elements. There are several systematic reviews and meta-analyses of these interventions –; all of the constituent trials in these studies were conducted in HICs, and many were nonrandomised . Outcomes studied include carer strain, depression, and subjective wellbeing; behaviour disturbance and mood in the care recipient; and institutionalisation. Most carer-focused interventions seemed to reduce carer strain and depression, CBT having the largest impact on depression . Psychoeducational interventions required the active participation of the carer (for example, in role-playing activities) to be effective . Carer support increased carer wellbeing but no other outcomes . For respite care, three methodologically flawed RCTs showed no benefit on any outcome . However, nonrandomised studies suggest that respite care significantly reduces carer strain and psychological morbidity . Interventions targeting the carer may also have small but significant beneficial effects upon the behaviour of the person with dementia . A systematic review of ten RCTs indicated a 40% reduction in the pooled odds of institutionalisation ; the effective interventions were structured, intensive, and multicomponent, offering a choice of services and supports ,. Two small trials in LMICs of a brief carer education and training intervention, one from India  and one from Russia  indicated much larger treatment effects on carer psychological morbidity  and strain  than typically seen for such interventions in HICs.
Delivery of Effective Interventions
The mechanisms by which effective dementia care treatments may be delivered in LMIC settings are summarized in Table 2.
Interventions to Increase Demand for Services
Alzheimer's Disease International has identified raising awareness of dementia among the public, carers, and health workers as a global priority, with an increase in demands for services as one of the intended benefits . Awareness can be raised in several ways. The establishment of a critical mass of informed carers can assist awareness-raising, provide advice and support to families, and work with Alzheimer's disease associations to lobby for more services that better meet the needs of carers. Community solidarity can also effect change through support for health and social welfare policies based on equity and justice. Aware communities can provide support and reduce stigma and exclusion. Policymakers can be held to account by media campaigns and advocacy from committed NGOs. In HICs, awareness is growing rapidly, with the media playing an important role . Media in LMICs can be receptive to these stories, but efforts are required to alert them to the importance of ageing and dementia, and to build their capacity to report the problem .
Intergenerational solidarity can be promoted through awareness-raising among children and young adults. In many LMICs, many people with dementia live in multigenerational households with young children, and children or children-in-law are the most frequent carers for people with dementia , and the most likely to initiate help-seeking. Finally, in LMICs the provision of disability pensions and carer benefits will inevitably increase requests for diagnostic assessment. Importantly, however, efforts to increase awareness must be accompanied by health system and service reform, so that help-seeking is met with a supply of better-prepared, more responsive services.
Interventions to Improve the Capacity of Health Care Teams
Primary health care services in LMICs often fail older people because they are clinic-based and preoccupied with simple curative interventions –. A paradigm shift is needed to encompass continuing care and support as part of a wider chronic disease strategy. Given the frailty of many older people with dementia, there is also a need for outreach to assess and manage patients in their own homes. The World Health Organization (WHO) Innovative Care for Chronic Conditions framework  proposes that the delivery of care for chronic conditions can be improved through a dialogue to build commitment for change, extended and regular health care contact, a multisectoral approach, care centered on patients and families, support for patients in the community, and an emphasis on prevention. Dementia care should be an essential component of such chronic disease care strategies. Training of nonspecialist health professionals should focus on case-finding and on conveying the diagnosis to patients and carers together with information and support, needs assessment, and carer training and support. Training can be service-based as well as through changes to the medical and nursing school, public health, and rural health curricula. Medical and community care services should be planned and coordinated to respond to the increasing need for support as the disease progresses.
Interventions to Improve Recognition
The focus here should be first upon case-finding by community health workers ,, and then on selective screening coupled with simplified “quasi-diagnostic” algorithms and needs assessments  by nonspecialist clinicians. More research is needed to identify the most feasible and valid methods.
Interventions to Increase the Acceptability and Reduce the Costs of Treatments
At present, the costs of ChEIs are reimbursed in some Latin American countries and Chinese provinces, generic ChEIs are available in India, and Huperzine A, a cheap plant extract with similar properties to ChEIs is used in China . In what is a very active and promising field for drug development , any new agent with radical disease-modifying properties will be very expensive, which raises important ethical and practical challenges to securing equitable access. An international effort leveraged by grass roots advocacy (similar to that mounted for antiretroviral treatment for HIV) might be required to secure affordable supplies for people with dementia living in LMICs. More positively, costs of primary care and community interventions can be minimised through task-shifting to nonspecialist and paraprofessional staff and integration with more broadly based chronic disease , disability, and elder care programmes ,. In India a community-based palliative care program has been successfully extended to include dementia care .
Practice-Based Programs to Deliver Effective Treatment
Most LMICs have insufficient specialists to provide national frontline dementia services. Diagnosis and needs assessment can be conducted in primary care, although increased specialist input to help with advice, inpatient or outpatient review of refractory BPSD, and respite care would be desirable. Routine physical reviews within practice-based programs are important but research is needed into the cost-effectiveness of haematological and biochemical screening, and the feasibility and effectiveness of interventions to improve hearing, vision, nutrition, and continence. A commitment to continuing care is essential, with regular review and physical health and needs assessments. Practice-based case managers can coordinate this process; this collaborative care model reduced BPSD and carer strain in an RCT in the US .
Community-Based Programs to Deliver Effective Treatments
Carer-support programs can be delivered individually or in groups by community health workers or by experienced carers. Carer strain, whether or not associated with BPSD, should trigger more intensive intervention that includes psychological assessment and depression treatment for the carer , respite, and carer education and training. Such interventions could be incorporated into horizontally constructed community-based programs that address the generic needs of frail, dependent older people and their carers, whether these needs arise from cognitive, mental, or physical disorders.
Packages of Care for Dementia in LMICs
On the basis of our review, we have proposed a package of care for LMICs that considers the availability of resources for the detection, diagnosis, and treatment of dementia in this setting. In Table 3, the main features of this package are compared with typical recommendations for well-resourced HIC settings. To improve care for dementia in LMICs, we propose that the basic package of care should focus upon diagnosis coupled with information, regular needs assessments, physical health checks, and carer support. This package should be extended to include carer training, respite care, and assessment and treatment of BPSD where possible. We suggest that that care can best be delivered by trained primary care teams, with a paradigm shift towards chronic continuing care and community outreach. Practice-based care coordinators are an essential component of this package, ideally working within a collaborative-care framework. Finally, we note that care delivery will be more efficient when integrated with that of other chronic diseases, and more broadly based community-support programs for the elderly and disabled.
ICMJE criteria for authorship read and met: MJP DA ECC JJ KS. Wrote the first draft of the paper: MJP. Contributed to the writing of the paper: MJP DA ECC JJ KS.
- 1. World Health Organization (1992) International classification of diseases (10th Revision). Geneva: World Health Organization.
- 2. Ferri CP, Ames D, Prince M (2004) Behavioral and psychological symptoms of dementia in developing countries. Int Psychogeriatr 16: 441–459.
- 3. de Vugt ME, Stevens F, Aalten P, Lousberg R, Jaspers N, et al. (2005) A prospective study of the effects of behavioral symptoms on the institutionalization of patients with dementia. Int Psychogeriatr 17: 577–589.
- 4. Neuropathology Group Medical Research Council Cognitive Function and Aging Study (2001) Pathological correlates of late-onset dementia in a multicentre, community-based population in England and Wales. Neuropathology Group of the Medical Research Council Cognitive Function and Ageing Study (MRC CFAS) [comment]. Lancet 357: 169–175.
- 5. Ritchie K, Kildea D, Robine JM (1992) The relationship between age and the prevalence of senile dementia: a meta-analysis of recent data. Int J Epidemiol 21: 763–769.
- 6. Ferri CP, Prince M, Brayne C, Brodaty H, Fratiglioni L, et al. (2005) Global prevalence of dementia: a Delphi consensus study. Lancet 366: 2112–2117.
- 7. Llibre Rodriguez JJ, Ferri CP, Acosta D, Guerra M, Huang Y, et al. (2008) Prevalence of dementia in Latin America, India, and China: a population-based cross-sectional survey. Lancet 372: 464–474.
- 8. (1996) The Global Burden of Disease. A comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. Cambridge (Massachusetts): Harvard School of Public Health, Harvard University Press.
- 9. Wimo A, Winblad B, Jonsson L (2007) An estimate of the total worldwide societal costs of dementia in 2005. Alzheimer's and Dementia 81–91.
- 10. 10/66 Dementia Research Group (2004) Care arrangements for people with dementia in developing countries. Int J Geriatr Psychiatry 19: 170–177.
- 11. Prince MJ (2009) The 10/66 dementia research group - 10 years on. Indian Journal of Psychiatry 51: S8–S15.
- 12. Cohen L (1995) Toward an anthropology of senility: anger, weakness, and Alzheimer's in Banaras, India. Med Anthropol Q 9: 314–334.
- 13. Patel V, Prince M (2001) Ageing and mental health in a developing country: who cares? Qualitative studies from Goa, India. Psychol Med 31: 29–38.
- 14. Shaji KS, Smitha K, Praveen Lal K, Prince M (2002) Caregivers Of patients with Alzheimer's disease: a qualitative study from the Indian 10/66 Dementia Research Network. Int J Geriatr Psych 18: 1–6.
- 15. Prince M, Livingston G, Katona C (2007) Mental health care for the elderly in low-income countries: a health systems approach. World Psychiatry 6: 5–13.
- 16. Shaji KS, Arun Kishore NR, Lal KP, Prince M (2002) Revealing a hidden problem. An evaluation of a community dementia case-finding program from the Indian 10/66 dementia research network. Int J Geriatr Psych 17: 222–225.
- 17. Ramos-Cerqueira AT, Torres AR, Crepaldi AL, Oliveira NI, Scazufca M, et al. (2005) Identification of dementia cases in the community: a Brazilian experience. J Am Geriatr Soc 53: 1738–1742.
- 18. National Collaborating Centre for Mental Health (2007) Dementia. A NICE-SCIE Guideline on supporting people with dementia and their carers in health and social care. National Clinical Practice Guideline number 42. London: National Institute For Health And Clinical Excellence.
- 19. Folstein MF, Folstein SE, McHugh PR (1975) ‘Mini-mental State’: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 12: 189–198.
- 20. Ganguli M, Ratcliff G, Chandra V, Sharma S, Gilby J, et al. (1995) A Hindi version of the MMSE: the development of a cognitive screening instrument for a largely illiterate rural elderly population in India. Int J Geriatr Psych 10: 367–377.
- 21. Xu G, Meyer JS, Huang Y, Du F, Chowdhury M, et al. (2003) Adapting mini-mental state examination for dementia screening among illiterate or minimally educated elderly Chinese. Int J Geriatr Psychiatry 18: 609–616.
- 22. Castro-Costa E, Fuzikawa C, Uchoa E, Firmo JO, Lima-Costa MF (2008) Norms for the mini-mental state examination: adjustment of the cut-off point in population-based studies (evidences from the Bambui health aging study). Arq Neuropsiquiatr 66: 524–528.
- 23. Ng TP, Niti M, Chiam PC, Kua EH (2007) Ethnic and educational differences in cognitive test performance on mini-mental state examination in Asians. Am J Geriatr Psychiatry 15: 130–139.
- 24. Black SA, Espino DV, Mahurin R, Lichtenstein MJ, Hazuda HP, et al. (1999) The influence of noncognitive factors on the Mini-Mental State Examination in older Mexican-Americans: findings from the Hispanic EPESE. Established Population for the Epidemiologic Study of the Elderly. J Clin Epidemiol 52: 1095–1102.
- 25. Brodaty H, Low LF, Gibson L, Burns K (2006) What is the best dementia screening instrument for general practitioners to use? Am J Geriatr Psychiatry 14: 391–400.
- 26. Prince M, Acosta D, Chiu H, Scazufca M, Varghese M (2003) Dementia diagnosis in developing countries: a cross-cultural validation study. The Lancet 361: 909–917.
- 27. Liu SI, Prince M, Chiu MJ, Chen TF, Sun YW, et al. (2005) Validity and reliability of a Taiwan Chinese version of the community screening instrument for dementia. Am J Geriatr Psychiatry 13: 581–588.
- 28. Lecouturier J, Bamford C, Hughes JC, Francis JJ, Foy R, et al. (2008) Appropriate disclosure of a diagnosis of dementia: identifying the key behaviours of ‘best practice’. BMC Health Serv Res 8: 95.
- 29. Ballard CG, Gauthier S, Cummings JL, Brodaty H, Grossberg GT, et al. (2009) Management of agitation and aggression associated with Alzheimer disease. Nat Rev Neurol 5: 245–255.
- 30. Leonard R, Tinetti ME, Allore HG, Drickamer MA (2006) Potentially modifiable resident characteristics that are associated with physical or verbal aggression among nursing home residents with dementia. Arch Intern Med 166: 1295–1300.
- 31. Husebo BS, Strand LI, Moe-Nilssen R, Borgehusebo S, Aarsland D, et al. (2008) Who suffers most? Dementia and pain in nursing home patients: a cross-sectional study. J Am Med Dir Assoc 9: 427–433.
- 32. Peters CA, Potter JF, Scholer SG (1988) Hearing impairment as a predictor of cognitive decline in dementia. J Am Geriatr Soc 36: 981–986.
- 33. Uhlmann RF, Larson EB, Koepsell TD (1986) Hearing impairment and cognitive decline in senile dementia of the Alzheimer's type. J Am Geriatr Soc 34: 207–210.
- 34. Chapman FM, Dickinson J, McKeith I, Ballard C (1999) Association among visual hallucinations, visual acuity, and specific eye pathologies in Alzheimer's disease: treatment implications. Am J Psychiatry 156: 1983–1985.
- 35. Ballard C, Bannister C, Graham C, Oyebode F, Wilcock G (1995) Associations of psychotic symptoms in dementia sufferers. Br J Psychiatry 167: 537–540.
- 36. Eriksson I, Gustafson Y, Fagerstrom L, Olofsson B (2009) Prevalence and factors associated with urinary tract infections (UTIs) in very old women. Arch Gerontol Geriatr. In press.
- 37. Natalwala A, Potluri R, Uppal H, Heun R (2008) Reasons for hospital admissions in dementia patients in Birmingham, UK, during 2002–2007. Dement Geriatr Cogn Disord 26: 499–505.
- 38. Rait G, Fletcher A, Smeeth L, Brayne C, Stirling S, et al. (2005) Prevalence of cognitive impairment: results from the MRC trial of assessment and management of older people in the community. Age Ageing 34: 242–248.
- 39. Fuchs-Lacelle S, Hadjistavropoulos T, Lix L (2008) Pain assessment as intervention: a study of older adults with severe dementia. Clin J Pain 24: 697–707.
- 40. Allen NH, Burns A, Newton V, Hickson F, Ramsden R, et al. (2003) The effects of improving hearing in dementia. Age Ageing 32: 189–193.
- 41. Gil GP, Ramirez Diaz SP, Ribera Casado JM (2003) Dementia and nutrition. Intervention study in institutionalized patients with Alzheimer disease. J Nutr Health Aging 7: 304–308.
- 42. Riviere S, Gillette-Guyonnet S, Voisin T, Reynish E, Andrieu S, et al. (2001) A nutritional education program could prevent weight loss and slow cognitive decline in Alzheimer's disease. J Nutr Health Aging 5: 295–299.
- 43. Richard E, Kuiper R, Dijkgraaf MG, van Gool WA (2009) Vascular care in patients with Alzheimer's disease with cerebrovascular lesions-a randomized clinical trial. J Am Geriatr Soc 57: 797–805.
- 44. Spector A, Thorgrimsen L, Woods B, Royan L, Davies S, et al. (2003) Efficacy of an evidence-based cognitive stimulation therapy programme for people with dementia: randomised controlled trial. Br J Psychiatry 183: 248–254.
- 45. Bottino CM, Carvalho IA, Alvarez AM, Avila R, Zukauskas PR, et al. (2005) Cognitive rehabilitation combined with drug treatment in Alzheimer's disease patients: a pilot study. Clin Rehabil 19: 861–869.
- 46. Clare L, Woods RT, Moniz Cook ED, Orrell M, Spector A (2003) Cognitive rehabilitation and cognitive training for early-stage Alzheimer's disease and vascular dementia. Cochrane Database Syst Rev CD003260.
- 47. Woods B, Spector A, Jones C, Orrell M, Davies S (2005) Reminiscence therapy for dementia. Cochrane Database Syst Rev CD001120.
- 48. Birks J, Harvey RJ (2006) Donepezil for dementia due to Alzheimer's disease. Cochrane Database Syst Rev CD001190.
- 49. Birks J, Grimley EJ, Iakovidou V, Tsolaki M, Holt FE (2009) Rivastigmine for Alzheimer's disease. Cochrane Database Syst Rev CD001191.
- 50. Loy C, Schneider L (2006) Galantamine for Alzheimer's disease and mild cognitive impairment. Cochrane Database Syst Rev CD001747.
- 51. Birks J (2006) Cholinesterase inhibitors for Alzheimer's disease. Cochrane Database Syst Rev CD005593.
- 52. Moraes W, Poyares D, Sukys-Claudino L, Guilleminault C, Tufik S (2008) Donepezil improves obstructive sleep apnea in Alzheimer disease: a double-blind, placebo-controlled study. Chest 133: 677–683.
- 53. Caramelli P, Chaves ML, Engelhardt E, Machado JC, Schultz RR, et al. (2004) Effects of galantamine on attention and memory in Alzheimer's disease measured by computerized neuropsychological tests: results of the Brazilian Multi-Center Galantamine Study (GAL-BRA-01). Arq Neuropsiquiatr 62: 379–384.
- 54. Chu LW, Yik PY, Mok W, Chung CP (2007) A 2-year open-label study of galantamine therapy in Chinese Alzheimer's disease patients in Hong Kong. Int J Clin Pract 61: 403–410.
- 55. Burns A, Bernabei R, Bullock R, Cruz Jentoft AJ, Frolich L, et al. (2009) Safety and efficacy of galantamine (Reminyl) in severe Alzheimer's disease (the SERAD study): a randomised, placebo-controlled, double-blind trial. Lancet Neurol 8: 39–47.
- 56. McShane R, Areosa SA, Minakaran N (2006) Memantine for dementia. Cochrane Database Syst Rev CD003154.
- 57. Kavirajan H, Schneider LS (2007) Efficacy and adverse effects of cholinesterase inhibitors and memantine in vascular dementia: a meta-analysis of randomised controlled trials. Lancet Neurol 6: 782–792.
- 58. Wilcock GK, Ballard CG, Cooper JA, Loft H (2008) Memantine for agitation/aggression and psychosis in moderately severe to severe Alzheimer's disease: a pooled analysis of 3 studies. J Clin Psychiatry 69: 341–348.
- 59. Howard RJ, Juszczak E, Ballard CG, Bentham P, Brown RG, et al. (2007) Donepezil for the treatment of agitation in Alzheimer's disease. N Engl J Med 357: 1382–1392.
- 60. Lonergan E, Luxenberg J, Colford J (2002) Haloperidol for agitation in dementia. Cochrane Database Syst Rev CD002852.
- 61. Ballard C, Waite J (2006) The effectiveness of atypical antipsychotics for the treatment of aggression and psychosis in Alzheimer's disease. Cochrane Database Syst Rev CD003476.
- 62. Schneider LS, Dagerman K, Insel PS (2006) Efficacy and adverse effects of atypical antipsychotics for dementia: meta-analysis of randomized, placebo-controlled trials. Am J Geriatr Psychiatry 14: 191–210.
- 63. Ballard C, Howard R (2006) Neuroleptic drugs in dementia: benefits and harm. Nat Rev Neurosci 7: 492–500.
- 64. Schneider LS, Dagerman KS, Insel P (2005) Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. JAMA 294: 1934–1943.
- 65. Gill SS, Bronskill SE, Normand SL, Anderson GM, Sykora K, et al. (2007) Antipsychotic drug use and mortality in older adults with dementia. Ann Intern Med 146: 775–786.
- 66. Kales HC, Valenstein M, Kim HM, McCarthy JF, Ganoczy D, et al. (2007) Mortality risk in patients with dementia treated with antipsychotics versus other psychiatric medications. Am J Psychiatry 164: 1568–1576.
- 67. Kleijer BC, van Marum RJ, Egberts AC, Jansen PA, Knol W, et al. (2008) Risk of cerebrovascular events in elderly users of antipsychotics. J Psychopharmacol. In press.
- 68. Douglas IJ, Smeeth L (2008) Exposure to antipsychotics and risk of stroke: self controlled case series study. BMJ 337: a1227.
- 69. Hunkeler EM, Katon W, Tang L, Williams JW Jr, Kroenke K, et al. (2006) Long term outcomes from the IMPACT randomised trial for depressed elderly patients in primary care. BMJ 332: 259–263.
- 70. Bains J, Birks JS, Dening TR (2002) The efficacy of antidepressants in the treatment of depression in dementia. Cochrane Database Syst Rev CD003944.
- 71. Lyketsos CG, DelCampo L, Steinberg M, Miles Q, Steele CD, et al. (2003) Treating depression in Alzheimer disease: efficacy and safety of sertraline therapy, and the benefits of depression reduction: the DIADS. Arch Gen Psychiatry 60: 737–746.
- 72. Martinon-Torres G, Fioravanti M, Grimley EJ (2004) Trazodone for agitation in dementia. Cochrane Database Syst Rev CD004990.
- 73. Pollock BG, Mulsant BH, Rosen J, Sweet RA, Mazumdar S, et al. (2002) Comparison of citalopram, perphenazine, and placebo for the acute treatment of psychosis and behavioral disturbances in hospitalized, demented patients. Am J Psychiatry 159: 460–465.
- 74. Finkel SI, Mintzer JE, Dysken M, Krishnan KR, Burt T, et al. (2004) A randomized, placebo-controlled study of the efficacy and safety of sertraline in the treatment of the behavioral manifestations of Alzheimer's disease in outpatients treated with donepezil. Int J Geriatr Psychiatry 19: 9–18.
- 75. Lonergan ET, Cameron M, Luxenberg J (2004) Valproic acid for agitation in dementia. Cochrane Database Syst Rev CD003945.
- 76. Tariot PN, Erb R, Podgorski CA, Cox C, Patel S, et al. (1998) Efficacy and tolerability of carbamazepine for agitation and aggression in dementia. Am J Psychiatry 155: 54–61.
- 77. Olin JT, Fox LS, Pawluczyk S, Taggart NA, Schneider LS (2001) A pilot randomized trial of carbamazepine for behavioral symptoms in treatment-resistant outpatients with Alzheimer disease. Am J Geriatr Psychiatry 9: 400–405.
- 78. Forbes D, Morgan DG, Bangma J, Peacock S, Pelletier N, et al. (2004) Light therapy for managing sleep, behaviour, and mood disturbances in dementia. Cochrane Database Syst Rev CD003946.
- 79. Chung JC, Lai CK, Chung PM, French HP (2002) Snoezelen for dementia. Cochrane Database Syst Rev CD003152.
- 80. Ballard CG, O'Brien JT, Reichelt K, Perry EK (2002) Aromatherapy as a safe and effective treatment for the management of agitation in severe dementia: the results of a double-blind, placebo-controlled trial with Melissa. J Clin Psychiatry 63: 553–558.
- 81. Viggo HN, Jorgensen T, Ortenblad L (2006) Massage and touch for dementia. Cochrane Database Syst Rev CD004989.
- 82. Remington R (2002) Calming music and hand massage with agitated elderly. Nurs Res 51: 317–323.
- 83. Sorensen S, Duberstein P, Gill D, Pinquart M (2006) Dementia care: mental health effects, intervention strategies, and clinical implications. Lancet Neurol 5: 961–973.
- 84. Pinquart M, Sorensen S (2006) Helping caregivers of persons with dementia: which interventions work and how large are their effects? Int Psychogeriatr 18: 577–595.
- 85. Smits CH, de LJ, Droes RM, Meiland F, Vernooij-Dassen M, et al. (2007) Effects of combined intervention programmes for people with dementia living at home and their caregivers: a systematic review. Int J Geriatr Psychiatry 22: 1181–1193.
- 86. Brodaty H, Green A, Koschera A (2003) Meta-analysis of psychosocial interventions for caregivers of people with dementia. J Am Geriatr Soc 51: 657–664.
- 87. Lee H, Cameron M (2004) Respite care for people with dementia and their carers. Cochrane Database Syst Rev CD004396.
- 88. Spijker A, Vernooij-Dassen M, Vasse E, Adang E, Wollersheim H, et al. (2008) Effectiveness of nonpharmacological interventions in delaying the institutionalization of patients with dementia: a meta-analysis. J Am Geriatr Soc 56: 1116–1128.
- 89. Dias A, Dewey ME, D'Souza J, Dhume R, Motghare DD, et al. (2008) The effectiveness of a home care program for supporting caregivers of persons with dementia in developing countries: a randomised controlled trial from Goa, India. PLoS ONE 3: e2333. doi:10.1371/journal.pone.0002333.
- 90. Gavrilova SI, Ferri CP, Mikhaylova N, Sokolova O, Banerjee S, et al. (2008) Helping carers to care-The 10/66 dementia research group's randomized control trial of a caregiver intervention in Russia. Int J Geriatr Psychiatry 24: 347–354.
- 91. Graham N, Brodaty H (1997) Alzheimer's Disease International. Int J Geriatr Psych 12: 691–692.
- 92. Prince M, Acosta D, Albanese E, Arizaga R, Ferri CP, et al. (2008) Ageing and dementia in low and middle income countries-Using research to engage with public and policy makers. Int Rev Psychiatry 20: 332–343.
- 93. Epping-Jordan JE, Pruitt SD, Bengoa R, Wagner EH (2004) Improving the quality of health care for chronic conditions. Qual Saf Health Care 13: 299–305.
- 94. Sousa RM, Scazufca M, Menezes PR, Crepaldi AL, Prince MJ (2009) Feasibility and reliability of the elderly version of the Camberwell Assessment of Needs (CANE): results from the Sao Paulo Ageing & Health Study. Rev Bras Psiquiatr 31: 34–38.
- 95. Kalaria RN, Maestre GE, Arizaga R, Friedland RP, Galasko D, et al. (2008) Alzheimer's disease and vascular dementia in developing countries: prevalence, management, and risk factors. Lancet Neurol 7: 812–826.
- 96. Rafii MS, Aisen PS (2009) Recent developments in Alzheimer's disease therapeutics. BMC Med 7: 7.
- 97. World Health Organization (2004) Towards age-friendly primary health care. Geneva: World Health Organization. Available: http://whqlibdoc.who.int/publications/2004/9241592184.pdf. Accessed 5 October 2009.
- 98. United Nations (2002) In: Report of the Second World Assembly on Ageing; Madrid 8–12 April 2002. A/CONF.197/9. Available: http://www.un.org/esa/socdev/ageing/secondworld02.html. Accessed 5 October 2009.
- 99. Shaji KS (2009) Dementia care in developing countries: the road ahead. Indian Journal of Psychiatry 51: S5–S7.
- 100. Callahan CM, Boustani MA, Unverzagt FW, Austrom MG, Damush TM, et al. (2006) Effectiveness of collaborative care for older adults with Alzheimer disease in primary care: a randomized controlled trial. JAMA 295: 2148–2157.
- 101. Patel V, Simon G, Chowdhary N, Kaaya S, Araya R (2009) Packages of care for depression in low and middle income countries. PLoS Med 6: e1000159. doi:10.1371/journal.pmed.journal.pmed.1000159.
- 102. Hall KS, Hendrie HH, Brittain HM, Norton JA, Rodgers DD, et al. (1993) The development of a dementia screening interview in two distinct languages. Int J Meth Psych Res 3: 1–28.
- 103. Prince M, Acosta D, Chiu H, Scazufca M, Varghese M (2003) Dementia diagnosis in developing countries: a cross-cultural validation study. Lancet 361: 909–917.
- 104. Reynolds T, Thornicroft G, Abas M, Woods B, Hoe J, et al. (2000) Camberwell Assessment of Need for the Elderly (CANE). Development, validity and reliability. Br J Psychiatry 176: 444–452.
- 105. Thorgrimsen L, Spector A, Wiles A, Orrell M (2003) Aroma therapy for dementia. Cochrane Database Syst Rev CD003150.
- 106. Institute of Development and Policy Management/HelpAge International (2003) Non-contributory pensions and poverty prevention. A comparative study of Brazil and South Africa. Final Report, DFID Project R7897, Pensions and Poverty Prevention. Manchester (United Kingdom): Institute of Development and Policy Management and London: HelpAge International. Available: http://www.helpage.org/Resources/Researchreports/Non-contributorypensions. Accessed 5 October 2009.
- 107. UK Department of Health (2009) Living well with dementia. A National Dementia Strategy. Available: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_094058. Accessed 5 October 2009.