Depressive symptoms and self-rated health among Brazilian older adults: baseline data from the ELSI-Brazil study

Objective: To investigate whether having a higher number of depressive symptoms is associated with negative self-rated health (SRH) even in the absence of illness. Methods: This is a secondary analysis of baseline data from the Brazilian Longitudinal Study of Aging (ELSI-Brazil), conducted in 2015-2016, using a national sample of 9,412 people aged 50 or over. SRH was dichotomized into poor or very poor and very good or excellent, good, or average. Depressive symptoms were assessed through the eight-item Center for Epidemiologic Studies Depression Scale (CES-D8). Sociodemographic variables, information about unhealthy behaviors, and the number of chronic conditions were also analyzed. Results: Having depressive symptoms was strongly associated with poor or very poor SRH both in the unadjusted and adjusted analyses. The magnitude of the association was reduced when the number of chronic illnesses was included in the multivariate analysis, along with the other sociodemographic variables and unhealthy behaviors (OR 1.35, 95%CI 1.31-1.39). Conclusion: Having depressive symptoms may contribute towards having a poorer perception of health, even in the absence of health conditions. SRH is a multidimensional construct that can accurately reflect a person's state of general mental health.

The dementia severity rating scale: A potential community screening tool for dementia in low- and middle-income countries.

BACKGROUND: The Dementia Severity Rating Scale (DSRS) is an informant report, dementia staging tool that is quick to administer and has previous been shown to differentiate between people with dementia and healthy controls. However, it is not clear how accurate the tool is screening against diagnostic criteria in middle-income settings. METHODS: Embedded within the STRiDE programme, older adults (aged ≥65 years) and their informants were randomly recruited from four sites across Indonesia and South Africa. All informants were asked to complete DSRS. We report the tool's psychometric properties and accuracy against the 10/66 short diagnostic algorithm. RESULTS: Between September and December 2021, data was collected from 2110 older adults in Indonesia and 408 in South Africa. Overall, the DSRS scores significantly differed between those with and without dementia, as identified on the 10/66 short algorithm (p < .05). The difference between groups remained significant after controlling for key factors related to older adult and informant demographics. A score >2 on the DSRS had the greatest agreement with the 10/66 short algorithm and had excellent discriminative properties in both Indonesia (Area Under Curve (AUC) = .75, 95% CIs = .72-.77) and South Africa (AUC = .82, 95% CIs = .76-.88). CONCLUSIONS: The DSRS has potential as a screening tool for dementia in middle-income countries, with high sensitivity and specificity against a standardized diagnostic algorithm.

Depressive Symptoms and Self-Rated Health among Brazilian Older Adults: Baseline Data from the Elsi Brazil Study.

OBJECTIVE: This study investigates whether having a higher number of depressive symptoms is associated with negative self-rated health even in the presence of illnesses. METHODS: This is a secondary analysis of the baseline data from the Longitudinal Study of the Health of Elderly Brazilians (ELSI - Brazil), conducted in 2015-2016, using a national sample of 9,412 people aged 50 or over. Self-rated health was dichotomized into "bad or very bad" and "very good or excellent, good or average". Depressive symptoms were assessed through the eight-item Center for Epidemiologic Studies Depression (CES-D8). Sociodemographic variables, information about unhealthy behaviours, and the number of chronic conditions were also analysed. RESULTS: Having depressive symptoms was strongly associated with bad or very bad self-rated health both in the unadjusted and adjusted analyses. There was a reduction in the magnitude of the association when the number of chronic illnesses was included in the multivariate analysis, along with the other sociodemographic variables and unhealthy behaviours (OR 1,35 95% CI 1,31 - 1,39). CONCLUSION: Having depressive symptoms may contribute towards having a poorer perception of health, even in the absence of health conditions. Self-rated health is a multidimensional construct that can accurately reflect a person's state of general mental health.

Experiences of stigma and discrimination among people living with dementia and family carers in Brazil: Qualitative study.

This study aimed to understand stigma in relation to people living with dementia in Sao Paulo, Brazil. Critical Narrative Inquiry methodology was used. Semi-structured interviews were conducted between January and March 2020 with six people living with dementia and 15 family carers. Inductive and deductive techniques were used. The latter was informed by Link and Phelan's (2001) sociological theory of stigma. Dementia was commonly viewed by people living with dementia as part of ageing and carers reported low levels awareness about the condition. To avoid negative reactions from people, people living with dementia managed the negative views of dementia by minimising and normalising the condition, by expressing their ability to live an active life, and by emphasising the positive impacts of dementia in their lives. Fear of negative reactions appeared to lead to a selective disclosure of their diagnosis. Among carers, stigmatising attitudes coincided with a strong willingness to provide good care, to protect the person cared for, as well as to understand and validate their caring experiences, rather than to cause harm. In doing so, however, carers ended up depersonalising and infantilising people living with dementia, underestimating their capacities, demanding 'obedience', and restricting their freedom. There is a need to increase awareness about dementia and to provide support and training on person-centred care for carers in Brazil.

Comprehensive measurement of the prevalence of dementia in low- and middle-income countries: STRiDE methodology and its application in Indonesia and South Africa.

BACKGROUND: A core element of the Strengthening Responses to Dementia in Developing Countries (STRiDE) programme was to generate novel data on the prevalence, cost and impact of dementia in low- and middle-income countries, to build better health policy. Indonesia and South Africa are two middle-income countries in need of such data. AIMS: To present the STRiDE methodology and generate estimates of dementia prevalence in Indonesia and South Africa. METHOD: We conducted community-based, single-phase, cross-sectional studies in Indonesia and South Africa, randomly sampling participants aged 65 years or older in each country. Dementia prevalence rates for each country were generated by using the 10/66 short schedule and applying its diagnostic algorithm. Weighted estimates were calculated with national sociodemographic data. RESULTS: Data were collected between September and December 2021 in 2110 people in Indonesia and 408 people in South Africa. The adjusted weighted dementia prevalence was 27.9% (95% CI 25.2-28.9) in Indonesia and 12.5% (95% CI 9.5-16.0) in South Africa. Our results indicate that there could be >4.2 million people in Indonesia and >450 000 people in South Africa who have dementia. Only five participants (0.2%) in Indonesia and two (0.5%) in South Africa had been previously diagnosed with dementia. CONCLUSIONS: Despite prevalence estimates being high, formal diagnosis rates of dementia were very low across both countries (<1%). Further STRiDE investigations will provide indications of the impact and costs of dementia in these countries, but our results provide evidence that dementia needs to be prioritised within national health and social care policy agendas.

Estimating the number of people living with dementia at different stages of the condition in India: A Delphi process.

INTRODUCTION: Numerous studies have previously estimated the dementia prevalence in India. However, as these estimates use different methodologies and sampling strategies, generating definitive prevalence estimates can be difficult. METHODS: A Delphi process involving eight clinical and academic experts provided prevalence estimates of dementia within India, split by sex and age. The experts were also asked to estimate the number of people potentially living at different stages of the condition. A priori criteria were used to ascertain the point in which consensus was achieved. RESULTS: Our consensus estimates generated a dementia prevalence of 2.8% (95% CI = 1.9 to 3.6) for those aged 60 years and above in India. Consensus was achieved across age and sex prevalence estimates, with the exception of one (females aged 60-64). Our experts estimated that 42.9% of people living with dementia in India had a mild severity. CONCLUSIONS: The findings indicate that there could be approximately 3.9 million people living with dementia in India, of which 1.7 million could be living with dementia of mild severity. Such estimates can better help researchers and policy makers to estimate the true cost and impact of dementia in India and can inform resource allocation decisions.

Accessing Dementia Care in Brazil: An Analysis of Case Vignettes.

BACKGROUND AND OBJECTIVES: Despite the rapid increase in the number of people living with dementia in Brazil, dementia care is limited. This study describes how people living with dementia and their carers access care, treatment, and support, and identifies what characteristics are likely to enable or prevent access. RESEARCH DESIGN AND METHODS: We created 10 vignettes to illustrate fictitious but realistic scenarios involving people living with dementia in Brazil. The vignettes explore a combination of socioeconomic and demographic variables. They were completed using an in-depth desk review of the dementia care landscape in Brazil; a Strengths, Opportunities, Weaknesses, and Threats (SWOT) analysis of the desk review; and expert knowledge. The analysis focused on identifying common sources of service provision, barriers of access to care and support, and specific issues experienced by some population groups. FINDINGS: Access to a dementia diagnosis, care, and support for people living with dementia in Brazil is limited. Demographic and socio-economic circumstances play a role in determining the type of services to which a person might have access. Poor knowledge about dementia, lack of capacity in the health system, and lack of formal long-term care support are among the identified barriers to accessing timely diagnosis, care, and support in the country. DISCUSSION AND IMPLICATIONS: Understanding the barriers and facilitators of access to diagnosis, treatment, and support for people with dementia and families with different demographic and socioeconomic characteristics is crucial for designing dementia policies that are context-specific and responsive to the care needs of different socioeconomic groups in Brazil.

Social Isolation, Loneliness, and Cognitive Performance in Older Adults: Evidence From the ELSI-Brazil Study.

BACKGROUND: The association between social isolation and cognitive performance has been less investigated in low-to-middle-income countries (LMIC) and the presence of depression as a moderator on this association has not been examined. The authors examined the associations of social isolation and perceived loneliness with cognitive performance in the Brazilian Longitudinal Study of Aging. METHODS: In this cross-sectional analysis, social isolation was evaluated by a composite score including marital status, social contact, and social support. The dependent variable was global cognitive performance, which considered memory, verbal fluency, and temporal orientation tests. Linear and logistic regressions were adjusted for sociodemographic and clinical variables. The authors added interaction terms of depressive symptoms with social isolation and loneliness to examine whether depression, measured through the Center for Epidemiologic Studies-Depression Scale, modified these associations. RESULTS: Among 6,986 participants (mean age = 62.1 ± 9.2 years), higher levels of social connections were associated with better global cognitive performance (B = 0.02, 95%CI: 0.02; 0.04). Perceived loneliness was associated with worse cognition (B = -0.26, 95%CI = -0.34; -0.18). Interactions of depressive symptoms with social connections scores were found on memory z-score and with loneliness on global and memory z-scores, suggesting a weaker association between social isolation or loneliness and cognition among those with depressive symptoms. CONCLUSION: In a large sample from an LMIC, social isolation and loneliness were associated with worse cognitive performance. Surprisingly, depressive symptoms decrease the strength of these associations. Future longitudinal studies are important to assess the direction of the association between social isolation and cognitive performance.

The association of hearing loss with depressive symptoms and cognitive function among older people: Results from the Brazilian Longitudinal Study of Aging.

OBJECTIVES: Hearing loss, depression, and cognitive decline are common among older people. We investigated the association of hearing loss with depressive symptoms and cognitive function in a nationally representative sample of people aged 50+ in Brazil. METHODS: Data from the Brazilian Longitudinal Study of Aging (ELSI-Brazil) included information on self-reported hearing loss, hearing aid use (effective or not effective), depressive symptoms (CES-D-8), and a global cognitive score (composed of immediate and late recall, verbal fluency, orientation and prospective memory) in a sample of 9412 individuals. Multiple linear regression was used to estimate the association of hearing loss and hearing aid use with both depressive symptoms and cognitive performance. The analyses were conducted with 7837 participants with complete data, and then repeated with data from the whole sample after multiple imputation. RESULTS: Compared to those without hearing loss, those with hearing loss were more likely to have a higher number of depressive symptoms (ß: 0.53 (0.40-0.67) p < 0.001) but not worse cognitive performance (ß: -0.01 (-0.03 to 0.19) p = 0.631). Among those with hearing loss, the use of hearing aid was neither associated with cognitive performance (ß: -0.08 (-0.19 to 0.03) p = 0.169) or depressive symptoms (ß: -0.42 (-0.98 to 0.14) p = 0.143); its effective use was associated with less depressive symptoms (ß: -0.62 (-1.23 to -0.01) p = 0.045) but not worse cognitive performance (ß: -0.15 (-0.030 to 0.03) p = 0.057). Sensitivity analyses revealed that hearing loss is associated with a worse performance in two non-amnestic cognitive domains. CONCLUSIONS: Hearing loss may negatively affect specific cognitive domains and depressive symptoms among older people, and the use of a hearing aid may mitigate the association with depressive symptoms.

Prevalence of Dementia and Cognitive Impairment No Dementia in a Large and Diverse Nationally Representative Sample: The ELSI-Brazil Study.

BACKGROUND: Approximately 77% of older adults with dementia in Brazil have not been diagnosed, indicating a major public health issue. Previous epidemiological dementia studies in Brazil were based on data from 1 geopolitical region. METHODS: We aimed to estimate the general and subgroup-specific (age, education, and sex) prevalence of dementia and cognitive impairment no dementia (CIND) classification using data from 5 249 participants aged 60 years and older from the ELSI-Brazil, a large nationally representative sample. Participants were classified as having normal cognitive function, CIND, or dementia based on a combination of the individual's cognitive and functional status. RESULTS: We found a general prevalence of 5.8% (95% CI = 4.7-7.2) for dementia and 8.1% (95% CI = 6.8-9.5) for CIND. Dementia prevalence ranged from 3.2% (60-64 years old) to 42.8% (≥90 years old) by age, and from 2.1% (college level or higher) to 16.5% (illiterates) by education. Females had a higher dementia prevalence (6.8%) than males (4.6%). CIND prevalence was similar across age, sex, and education. CONCLUSIONS: The estimated dementia prevalence is lower than that in previous Brazilian epidemiological studies, but is in line with other Latin American studies. Only 1.2% of the ELSI-Brazil participants reported having a previous diagnosis of dementia, revealing that underdiagnosis is rampant and a common reality. Based on our results and national statistics projections, we estimate that in 2019, there were 1 757 480 people aged 60 years and older living with dementia in Brazil and, at least, another 2 271 314 having to deal with some form of cognitive impairment.

Risk factors for dementia in Brazil: Differences by region and race.

INTRODUCTION: Twelve risk factors (RFs) account for 40% of dementia cases worldwide. However, most data for population attributable fractions (PAFs) are from high-income countries (HIC). We estimated how much these RFs account for dementia cases in Brazil, stratifying estimates by race and socioeconomic level. METHODS: We calculated the prevalence and communalities of 12 RFs using 9412 Brazilian Longitudinal Study of Aging participants, then stratified according to self-reported race and country macro-regions. RESULTS: The overall weighted PAF was 48.2%. Less education had the largest PAF (7.7%), followed by hypertension (7.6%), and hearing loss (6.8%). PAF was 49.0% and 54.0% in the richest and poorest regions, respectively. PAFs were similar among White and Black individuals (47.8% and 47.2%, respectively) but the importance of the main RF varied by race. DISCUSSION: Brazil's potential for dementia prevention is higher than in HIC. Education, hypertension, and hearing loss should be priority targets.

Late-life drinking and smoking in primary care users in Brazil.

To estimate the prevalence of at-risk drinking and smoking and associated factors among older adults in primary care in Brazil.A cross-sectional study carried out in seven primary care units with 503 older adults (60+), in a city in the state of Sao Paulo, Brazil. At-risk drinking was defined by AUDIT-C and by consumption of units per week. Poisson regression was used to assess the association between the sociodemographic and health characteristics and smoking and at-risk drinking.The median age of the 503 participants was 69.6 (SD ± 6.7; range:60-93). One third of participants (33.6%) were current drinkers, 16% were at-risk drinkers (AUDIT-C), 4% at-risk drinkers (units per week), and 13% of the sample were regular smokers. The prevalence of at-risk drinking (AUDIT-C) was higher for males (RP: 4.89; 95% CI: 2.52-9.49) and for those with higher levels of education (RP: 1,861.85 95% CI: 1.08-3.14), and lower for those over the age of 70 (RP: 0.50; 95% CI: 0.30-0.84). The prevalence of smoking was higher for those with depressive symptoms (RP: 1.95; 95% CI: 1.03-3.66), and lower for those over age 70 (RP: 0.52; 95% CI: 0.29-0.94).The results point to a set of factors associated with at-risk drinking (being male, younger and having a higher education), and with smoking (being younger and having depressive symptoms). Our findings could help health professionals to identify at-risk drinkers and smokers, as well as support strategies for future interventions by the identification of the groups most vulnerable to these behaviors.

Description of the cross-cultural process adopted in the STRiDE (STrengthening Responses to dementia in DEveloping countries) program: A methodological overview.

Cross-cultural adaptation is an important part of using validated questionnaires across countries and settings. Here we describe the cross-cultural process adopted in the STRiDE (STrengthening Responses to dementia in DEveloping countries) program. We adopted a cross-cultural adaptation process including forward translation, back translations, and cognitive interviews of the STRiDE toolkit. In total, 50 older adults and 41 carers across sites in Indonesia and South Africa participated in cognitive interviews; field notes and verbatim quotes are reported. We describe the cross-cultural adaptation process of the STRiDE toolkit. During the process, issues were identified with the translated toolkit, including aspects related to cultural appropriateness, terminology equivalence, and timings. The data demonstrate that a rigorous, yet pragmatic, cross-cultural adaptation process can be achieved even with limited resources. Our process should help the design and conduct of future dementia research in various contexts.

Rationale and Design of the COVID-19 Outpatient Prevention Evaluation (COPE - Coalition V) Randomized Clinical Trial: Hydroxychloroquine vs. Placebo in Non-Hospitalized Patients. / Justificativa e Desenho do Ensaio Clínico Randomizado COVID-19 Outpatient Prevention Evaluation (COPE - Coalition V): Hidroxicloroquina vs. Placebo em Pacientes Não Hospitalizados.

BACKGROUND: Despite the need for targeting specific therapeutic options for coronavirus disease 2019 (COVID-19), there has been no evidence of effectiveness of any specific treatment for the outpatient clinical setting. There are few randomized studies evaluating hydroxychloroquine (HCQ) in non-hospitalized patients. These studies indicate no benefit from the use of HCQ, but they assessed different primary outcomes and presented important biases for outcome evaluation. OBJECTIVE: To evaluate if HCQ may prevent hospitalization due to COVID-19 compared to a matching placebo. METHODS: The COVID-19 Outpatient Prevention Evaluation (COPE) study is a pragmatic, randomized, double-blind, placebo-controlled clinical trial evaluating the use of HCQ (800 mg on day 1 and 400 mg from day 2 to day 7) or matching placebo for the prevention of hospitalization due to COVID-19 in early non-hospitalized confirmed or suspected cases. Inclusion criteria are adults (≥ 18 years) seeking medical care with mild symptoms of COVID-19, with randomization ≤ 7 days after symptom onset, without indication of hospitalization at study screening, and with at least one risk factor for complication (> 65 years; hypertension; diabetes mellitus; asthma; chronic obstructive pulmonary disease or other chronic lung diseases; smoking; immunosuppression; or obesity). All hypothesis tests will be two-sided. A p-value < 0.05 will be considered statistically significant in all analyses. Clinicaltrials.gov: NCT04466540. RESULTS: Clinical outcomes will be centrally adjudicated by an independent clinical event committee blinded to the assigned treatment groups. The primary efficacy endpoint will be assessed following the intention-to-treat principle. CONCLUSION: This study has the potential to reliably answer the scientific question of HCQ use in outpatients with COVID-19. To our knowledge, this is the largest trial evaluating HCQ in non-hospitalized individuals with COVID-19.

FUNDAMENTO: Apesar da necessidade de opções terapêuticas específicas para a doença do coronavírus 2019 (covid-19), ainda não há evidências da eficácia de tratamentos específicos no contexto ambulatorial. Há poucos estudos randomizados que avaliam a hidroxicloroquina (HCQ) em pacientes não hospitalizados. Esses estudos não indicaram benefício com o uso da HCQ; no entanto, avaliaram desfechos primários diferentes e apresentaram vieses importantes na avaliação dos desfechos. OBJETIVO: Investigar se a HCQ possui o potencial de prevenir hospitalizações por covid-19 quando comparada ao placebo correspondente. MÉTODOS: O estudo COVID-19 Outpatient Prevention Evaluation (COPE) é um ensaio clínico randomizado, pragmático, duplo-cego, multicêntrico e controlado por placebo que avalia o uso da HCQ (800 mg no dia 1 e 400 mg do dia 2 ao dia 7) ou placebo correspondente na prevenção de hospitalizações por covid-19 em casos precoces confirmados ou suspeitos de pacientes não hospitalizados. Os critérios de inclusão são adultos (≥ 18 anos) que procuraram atendimento médico com sintomas leves de covid-19, com randomização ≤ 7 dias após o início dos sintomas, sem indicação de hospitalização na triagem do estudo e com pelo menos um fator de risco para complicações (> 65 anos, hipertensão, diabetes melito, asma, doença pulmonar obstrutiva crônica ou outras doenças pulmonares crônicas, tabagismo, imunossupressão ou obesidade). Todos os testes de hipótese serão bilaterais. Um valor de p < 0,05 será considerado estatisticamente significativo em todas as análises. Clinicaltrials.gov: NCT04466540. RESULTADOS: Os desfechos clínicos serão avaliados centralmente por um comitê de eventos clínicos independente cegado para a alocação dos grupos de tratamento. O desfecho primário de eficácia será avaliado de acordo com o princípio da intenção de tratar. CONCLUSÃO: Este estudo apresenta o potencial de responder de forma confiável a questão científica do uso da HCQ em pacientes ambulatoriais com covid-19. Do nosso conhecimento, este é o maior estudo avaliando o uso de HCQ em indivíduos com covid-19 não hospitalizados.

Delivering Cognitive Stimulation Therapy (CST) Virtually: Developing and Field-Testing a New Framework.

PURPOSE: This feasibility and pilot study aimed to develop and field-test a 14-session virtual Cognitive Stimulation Therapy (vCST) programme for people living with dementia, developed as a result of services moving online during the COVID-19 pandemic. METHODS: The vCST protocol was developed using the existing group CST manual, through stakeholder consultation with people living with dementia, caregivers, CST group facilitators and dementia service managers. This protocol was then field-tested with 10 groups of people living with dementia in the Brazil, China (Hong Kong), India, Ireland and the UK, and feedback on the protocol was gathered from 14 facilitators. RESULTS: Field testing in five countries indicated acceptability to group facilitators and participants. Feedback from these groups was used to refine the developed protocol. The final vCST protocol is proposed, including session materials for delivery of CST over videoconferencing and a framework for offering CST virtually in global settings. CONCLUSION: vCST is a feasible online intervention for many people living with dementia. We recommend that it is offered to those unable to access traditional in-person CST for health reasons, lack of transport or COVID-19 restrictions. Further research is needed to explore if participant outcomes are comparable to in-person CST groups.

Beyond the project: Building a strategic theory of change to address dementia care, treatment and support gaps across seven middle-income countries.

Evidence from middle-income countries indicates high and increasing prevalence of dementia and need for services. However, there has been little investment in care, treatment or support for people living with dementia and their carers. The Strengthening Responses to Dementia in Developing Countries (STRiDE) project aims to build both research capacity and evidence on dementia care and services in Brazil, Indonesia, India, Jamaica, Kenya, Mexico and South Africa. This article presents the Theory of Change (ToC) approach we used to co-design our research project and to develop a strategic direction for dementia care, treatment and support, with stakeholders. ToC makes explicit the process underlying how a programme will achieve its impact. We developed ToCs in each country and across the STRiDE project with researchers, practitioners, people living with dementia, carers and policymakers at different levels of government. This involved (1) an initial ToC workshop with all project partners (43 participants); (2) ToC workshops in each STRiDE country (22-49 participants in each); (3) comparison between country-specific and overall project ToCs; (4) review of ToCs in light of WHO dementia guidelines and action plan and (5) a final review. Our experiences suggest ToC is an effective way to generate a shared vision for dementia care, treatment and support among diverse stakeholders. However, the project contribution should be clearly delineated and use additional strategies to ensure appropriate participation from people living with dementia and their carers in the ToC process.

Alcohol consumption among older adults: Findings from the ELSI-Brazil study.

OBJECTIVES: This study estimates the national prevalence of drinking patterns (current, heavy, and binge) and the associated factors, among older Brazilians. DESIGN: Cross-sectional study using survey data from ELSI-Brazil (2015-2016). SETTING/PARTICIPANTS: A total of 7839 adults aged 50 years or older. MEASUREMENTS: Respondents were asked about alcohol drinking. Alcohol consumption status was categorized as current drinkers (last month), heavy drinkers (≥7 drinks/week for females and ≥14 drinks/week for males), and binge drinkers (≥4 drinks on one occasion for females and ≥5 drinks on one occasion for males). Covariates included sociodemographic characteristics, tobacco smoking, depression, and number of chronic diseases. RESULTS: Of the 7839 participants, 29.4% were current drinkers, 5.1% were heavy drinkers, and 10.3% reported binge drinking. In the ≥60 years old age group, the prevalence of current drinking was 23.8%, 3.9% were heavy drinkers, and 6.7% reported binge drinking. All drinking patterns had similar associated factors: being male, being younger, having higher education, tobacco smoking, and falls. In addition, the greater the number of chronic conditions, the lower the prevalence of current drinking and binge drinking. CONCLUSION: Heavy drinking and binge drinking are often reported by older Brazilians, particularly among males, those with higher education and in the younger age groups. These behaviors can negatively affect the health of older adults. It is, therefore, important to identify the problems related to alcohol consumption among older adults to minimize the risks and harms.

Development and acceptability of a brief, evidence-based Dementia Awareness for Caregivers course in low- and middle-income countries.

BACKGROUND: Knowledge of and attitudes towards dementia vary across countries, and for caregivers in low- and middle-income countries (LMICs), access to information can be challenging. There is an urgent need for brief, easily accessible and culturally appropriate educational courses for caregivers of persons with dementia, providing much needed information whilst addressing important psychological concepts such as stigma. METHODS: An international and multidisciplinary team developed Dementia Awareness for Caregivers (DAC) courses in four stages: (1) scoping review and module agreement, (2) development of an International template (DAC-International) containing a standardised process for adding information, (3) development of local DACs using a standardised format and (4) acceptability of courses in Brazil, India and Tanzania. FINDINGS: The DAC-International was developed, comprising three modules: 'What is dementia?'; 'Positive engagement' and 'Caring for someone with dementia'. Three local versions were developed from this (DAC-Brazil, DAC-India and DAC-Tanzania), where additions of country-specific information included prevalent stereotypes and the addition of culturally relevant case studies. An initial field test was conducted in each country (n = 85), which indicated acceptability to participants. CONCLUSIONS: The methods used here resulted in culturally valid and acceptable educational courses for carers of people with dementia. Future work will consist of large-scale, formal evaluations and the development of additional local courses.

Validating intrinsic capacity to measure healthy aging in an upper middle-income country: Findings from the ELSI-Brazil.

Background: While efforts have been made to validate intrinsic capacity (IC) as a multidimensional indicator of healthy aging in high-income countries, we still need evidence from lower-income countries. We examined associations of IC with wide ranges of activities of daily living in a nationally representative sample of Brazilians aged≥50 years. Methods: This cross-sectional analysis included 7175 participants from the Brazilian Longitudinal Study of Aging. IC domains (cognitive, psychological, sensory, locomotor, and vitality) were determined using self-reported and physical performance measures. IC was operationalized through factorial analysis. We investigated associations of IC and its domains with functional ability in basic, instrumental, and advanced activities of daily living (ADL, IADL, and AADL) using logistic regressions adjusted for sociodemographic, clinical, and modifiable risk factors. Findings: The IC bi-factorial model revealed satisfactory goodness-of-fit. Preserved ability in ADL and IADL, respectively, ranged from 69% and 29% to 89% and 74% across IC quartiles. In adjusted analyses, every standard deviation increment in IC composite score was associated with almost twice the odds of preserved ADL (OR=1·72; 95%CI=1·54-1·93), preserved IADL (OR=1·95; 95%CI=1·77-2·16), and high performance in AADL (OR=1·79; 95%CI=1·59-2·00). Similar results were reported using the IC domains as predictors. Although age, race/ethnicity, and education did not modify associations of IC with functional ability, we found sex differences with stronger relationships of IC with preserved ADL or IADL in females. Interpretation: Our results support IC validity and reliability to measure healthy aging in diverse socioeconomic and cultural settings. Incorporating IC in routine practices can promote holistic and person-centered care approaches in aging societies. Funding: The Brazilian Ministry of Health and Ministry of Science, Technology, Innovation, and Communication.

Reducing dementia-related stigma and discrimination among community health workers in Brazil: protocol for a randomised controlled feasibility trial.

INTRODUCTION: Stigma and discrimination among healthcare workers can hinder diagnosis and the provision of appropriate care in dementia. This study is aimed at developing, delivering and evaluating the feasibility of a group antistigma intervention to improve knowledge, attitudes and behaviours in relation to people living with dementia among community health workers (CHWs). METHODS AND ANALYSIS: This will be a randomised controlled feasibility trial conducted with 150 CHWs from 14 primary care units (PCUs) in São Paulo, Brazil. PCUs will be randomly allocated (1:1) in two parallel groups-experimental group or control group. Participants from PCUs allocated to the experimental group will receive a 3-day group intervention involving audio-visual and printed materials as well as elements of social contact. The control group will keep their usual routine. Knowledge, attitude and intended behaviour stigma-based outcomes will be assessed at baseline and at follow-up (30 days after intervention) to both groups, with additional questions on feasibility for the experimental group at follow-up. Around 10-15 participants will take part in follow-up semistructured interviews to further explore feasibility. Quantitative analyses will follow an 'intention to treat' approach. Qualitative data will be analysed using content analysis. ETHICS AND DISSEMINATION: This study was approved by the National Commission for Ethics in Research in Brazil (n. 5.510.113). Every participant will sign a consent form. Results will be disseminated through academic journals and events related to dementia. The intervention materials will be made available online.