Sarah Urasa

Background: Healthcare systems in low‐ and middle‐income countries are under pressure to adapt services for ageing populations, and frailty screening has gained interest as a means of identifying older adults at risk of adverse outcomes. Aims: The aim of this study was to examine two frailty instruments for the prediction of mortality in older adults admitted to hospital in Tanzania. Methods: This study followed 308 people, aged ≥ 60 years, admitted to four hospitals in the Kilimanjaro Region between March and August 2022. Baseline frailty was assessed using the Clinical Frailty Scale (CFS) and the Brief Frailty Instrument for Tanzania (B‐FIT). The primary outcome was all‐cause mortality, with secondary outcomes of length of stay and change in functional status. Cox regression estimated hazard ratios (HRs) for mortality, with Harrell's C statistic and receiver operator characteristics used to compare instrument performance. Results: Follow‐up data were available for 194 participants (63%). After a mean of 10.8 months of follow‐up, adjusted models demonstrated frailty was associated with higher mortality (CFS HR 2.26, 95% CI 1.34–3.83; B‐FIT HR 2.63, 95% CI 1.45–4.77, p = 0.001). The two instruments showed similar discriminatory power. Neither was associated with length of stay. Among survivors, frailty was associated with decline in physical function, but not social function. Conclusions: Frailty screening, using either the CFS or B‐FIT, offered a feasible method for identifying older adults at the greatest risk of adverse outcomes. Such tools should be investigated as a means of targeting limited resources towards the most vulnerable older adults in an African setting.

Background The global burden of Parkinson′s disease (PD) has increased substantially over recent decades, driven by population ageing and rising age–standardized prevalence. In Africa, accurate estimates remain limited due to a lack of recent, methodologically robust population–based studies. Objectives To determine the current age–standardized and sex–specific prevalence rates of PD in Nigeria. Methods We conducted a 2–stage, cross-sectional population–based door–to–door survey among adults aged ≥18 years in two densely populated urban local government areas in Lagos State, Nigeria, between April 1, 2024 and January 31, 2025. The first stage involved a household census and screening for parkinsonism using a standardized screening tool. The second stage consisted of in–person clinical assessment and diagnostic confirmation by physicians using established clinical diagnostic criteria. Crude and age–standardized prevalence rates (to the World Health Organization World Standard and European Standard Populations) were calculated. Results 31,009 individuals (52.7% female) from 13,222 households were surveyed, and 70 persons were diagnosed with PD. The crude prevalence ratio was 225.7 per 100,000, with higher prevalence in males (53/14658, 361.6) than females (17/16,351, 104.0). The age–standardized prevalence rate (95% confidence interval) was 193 per 100,000 (150 — 245) (females: 86 (50 — 137); males: 277 (207 — 362)), and increased with advancing age. The diagnostic gap (previously undiagnosed) was 60.0% (42/70). Treatment gap (never treated) was 44/70 (62.9%). Conclusions The age–standardized prevalence of PD is higher than previously reported in sub-Saharan Africa. These findings provide contemporary data to inform updated estimates of disease burden and support health systems planning.

Background: Multimorbidity is an urgent public health threat in sub-Saharan Africa (SSA). However, data on the experiences of people living with multimorbidity (PLWMM) in this context are limited. We explored patient and carer experiences of living with (or caring for) multimorbidity to inform the development of patient-centred interventions for managing multimorbidity. Methods: This qualitative study is nested within a broader programme of multimorbidity research conducted in Malawi and Tanzania across four hospitals. We recruited patients recently discharged from hospital with known two or more combinations of hypertension (HTN), diabetes mellitus (DM), HIV and chronic kidney disease (CKD) and their carers. We conducted primary in-depth interviews at discharge and follow-up interviews 90 days after initial hospital admission to explore longitudinal experiences and care trajectories. FGDs were conducted after hospital discharge. Data were analysed thematically and presented through the lens of an existing Expanded Conceptual Model on Multimorbidity for SSA. Results: We conducted 32 in-depth-interviews (IDI) and 8 focus group discussion (FGDs) with PLWMM and carers in Malawi; and 21 IDIs and 7 FGDs in Tanzania. We identified, and present findings under three key crosscutting themes: experiences of living with multimorbidity; self-management and adaptation; and prioritisation of individual diseases within the multimorbidity paradigm. Age, sex, disease combinations and settings impacted on experiences living with multimorbidity. Out-of-pocket expenditure and poor quality of care dominated both settings with CKD and DM comorbidities exerting the heaviest burden on PLWMM and carers. Treatment discontinuation was common for HTN in Malawi and CKD in Tanzania, whilst living with HTN was linked to emotional distress in both. Older PLWMM reported greater family disruption due to loss of independence. Health crises, health literacy, and financial constraints were major drivers of disease management. Individuals particularly experienced stigma when conditions caused visible signs, and described moral and spiritual concerns. Conclusions: Multimorbidity experiences in Malawi and Tanzania reflect complex interactions between individual, socioeconomic, and health system factors. Effective interventions require multidisciplinary, patient-centred approaches addressing structural barriers, improving health literacy, and promoting collaborative care involving patients, carers, and peers.

HIV-associated neurocognitive disorders (HAND) are highly prevalent in those ageing with HIV. High-income country data suggest that vascular risk factors (VRFs) may be stronger predictors of HAND than HIV-disease severity, but data from sub-Saharan Africa are lacking. We evaluated relationships of VRFs, vascular end-organ damage and HAND in individuals aged ≥ 50 in Tanzania. c-ART-treated individuals were assessed for HAND using consensus criteria. The prevalence of VRFs and end organ damage markers were measured. The independent associations of VRFs, end organ damage and HAND were examined using multivariable logistic regression. Data were available for 153 individuals (median age 56, 67.3% female). HAND was highly prevalent (66.7%, 25.5% symptomatic) despite well-managed HIV (70.5% virally suppressed). Vascular risk factors included hypertension (34%), obesity (10.5%), hypercholesterolemia (33.3%), diabetes (5.3%) and current smoking (4.6%). End organ damage prevalence ranged from 1.3% (prior myocardial infarction) to 12.5% (left ventricular hypertrophy). Measured VRFs and end organ damage were not independently associated with HAND. The only significant association was lower diastolic BP (p 0.030, OR 0.969 (0.943–0.997). Our results suggest that vascular risk factors are not major drivers of HAND in this setting. Further studies should explore alternative aetiologies such as chronic inflammation.

Background The prevalence of multimorbidity (the presence of two or more chronic health conditions) is rapidly increasing in sub–Saharan Africa. Hospital care pathways that focus on single presenting complaints do not address this pressing problem. This has the potential to precipitate frequent hospital readmissions, increase health system and out-of-pocket expenses, and may lead to premature disability and death. We aim to present a description of inpatient multimorbidity in a multicentre prospective cohort study in Malawi and Tanzania. Primary objectives Clinical: Determine prevalence of multimorbid disease among adult medical admissions and measure patient outcomes. Health Economic: Measure economic costs incurred and changes in health-related quality of life (HRQoL) at 90 days post-admission. Situation analysis: Qualitatively describe pathways of patients with multimorbidity through the health system. Secondary objectives Clinical: Determine hospital readmission free survival and markers of disease control 90 days after admission. Health Economic: Present economic costs from patient and health system perspective, sub-analyse costs and HRQoL according to presence of different diseases. Situation analysis: Understand health literacy related to their own diseases and experience of care for patients with multimorbidity and their caregivers. Methods This is a prospective longitudinal cohort study of adult (≥18 years) acute medical hospital admissions with nested health economic and situation analysis in four hospitals: 1) Queen Elizabeth Central Hospital, Blantyre, Malawi; 2) Chiradzulu District Hospital, Malawi; 3) Hai District Hospital, Boma Ng’ombe, Tanzania; 4) Muhimbili National Hospital, Dar-es-Salaam, Tanzania. Follow-up duration will be 90 days from hospital admission. We will use consecutive recruitment within 24 hours of emergency presentation and stratified recruitment across four sites. We will use point-of-care tests to refine estimates of disease pathology. We will conduct qualitative interviews with patients, caregivers, healthcare providers and policymakers; focus group discussions with patients and caregivers, and observations of hospital care pathways.

HIV confers increased risk of myocardial infarction (MI), but there has been little study of ischemic electrocardiogram (ECG) findings among people with HIV in sub-Saharan Africa. To compare the prevalence of ischemic ECG findings among Tanzanians with and without HIV and to identify correlates of ischemic ECG changes among Tanzanians with HIV. Consecutive adults presenting for routine HIV care at a Tanzanian clinic were enrolled. Age- and sex-matched HIV-uninfected controls were enrolled from a nearby general clinic. All participants completed a standardized health questionnaire and underwent 12-lead resting ECG testing, which was adjudicated by independent physicians. Prior MI was defined as pathologic Q-waves in contiguous leads, and myocardial ischemia was defined as ST-segment depression or T-wave inversion in contiguous leads. Pearson’s chi-squared test was used to compare the prevalence of ECG findings among those with and without HIV and multivariate logistic regression was performed to identify correlates of prior MI among all participants. Of 497 participants with HIV and 497 without HIV, 272 (27.8%) were males and mean (sd) age was 45.2(12.0) years. ECG findings suggestive of prior MI (11.1% vs 2.4%, OR 4.97, 95% CI: 2.71–9.89, p < 0.001), and myocardial ischemia (18.7% vs 12.1% OR 1.67, 95% CI: 1.18–2.39, p = 0.004) were significantly more common among participants with HIV. On multivariate analysis, ECG findings suggestive of prior MI among all participants were associated with HIV infection (OR 4.73, 95% CI: 2.51–9.63, p = 0.030) and self-reported family history of MI or stroke (OR 1.96, 95% CI: 1.08–3.46, p = 0.023). There may be a large burden of ischemic heart disease among adults with HIV in Tanzania, and ECG findings suggestive of coronary artery disease are significantly more common among Tanzanians with HIV than those without HIV.

In sub-Saharan Africa (SSA),cognitive screening is complicated by both cultural and educational factors, and the existing normative values may not be applicable. The Identification of Dementia in Elderly Africans (IDEA) cognitive screen is a low-literacy measure with good diagnostic accuracy for dementia. Objective: The aim of this study is to report normative values for IDEA and other simple measures [i.e., categorical verbal fluency, the Consortium to Establish a Registry for Alzheimer’s Disease (CERAD) 10-word list] in representative community-dwelling older adults in SSA. Methods: Individuals aged ≥60 years resident in 12 representative villages in Kilimanjaro, Tanzania and individuals aged ≥65 years resident within three communities in Akinyele Local Government Area, Oyo State, Nigeria underwent cognitive screening. The normative data were generated by the categories of age, sex, and education. Results: A total of 3,011 people in Tanzania (i.e., 57.3% females and 26.4% uneducated) and 1,117 in Nigeria (i.e., 60.3% females and 64.5% uneducated) were screened. Individuals with higher age, lower education, and female gender obtained lower scores. The 50th decile values for IDEA were 13 (60–64 years) vs. 8/9 (above 85 years), 10–11 uneducated vs. 13 primary educated, and 11/12 in females vs. 13 in males. The normative values for 10-word list delayed recall and categorical verbal fluency varied with education [i.e., delayed recall mean 2.8 [standard deviation (SD) 1.7] uneducated vs. 4.2 (SD 1.2) secondary educated; verbal fluency mean 9.2 (SD 4.8) uneducated vs. 12.2 (SD 4.3) secondary educated], substantially lower than published high-income country values. Conclusions: The cut-off values for commonly used cognitive screening items should be adjusted to suit local normative values, particularly where there are lower levels of education.

There are over 3 million people in sub-Saharan Africa (SSA) aged 50 and over living with HIV. HIV and combined antiretroviral therapy (cART) exposure may accelerate the ageing in this population, and thus increase the prevalence of premature frailty. There is a paucity of data on the prevalence of frailty in an older HIV + population in SSA and screening and diagnostic tools to identify frailty in SSA. Patients aged ≥ 50 were recruited from a free Government HIV clinic in Tanzania. Frailty assessments were completed, using 3 diagnostic and screening tools: the Fried frailty phenotype (FFP), Clinical Frailty Scale (CFS) and Brief Frailty Instrument for Tanzania (B-FIT 2). The 145 patients recruited had a mean CD4 + of 494.84 cells/µL, 99.3% were receiving cART and 72.6% were virally suppressed. The prevalence of frailty by FFP was 2.758%. FFP frailty was significantly associated with female gender (p = 0.006), marital status (p = 0.007) and age (p = 0.038). Weight loss was the most common FFP domain failure. The prevalence of frailty using the B-FIT 2 and the CFS was 0.68%. The B-FIT 2 correlated with BMI (r = − 0.467, p = 0.0001) and CD4 count in females (r = − 0.244, p = 0.02). There is an absence of frailty in this population, as compared to other clinical studies. This may be due to the high standard of HIV care at this Government clinic. Undernutrition may be an important contributor to frailty. It is unclear which tool is most accurate for detecting the prevalence of frailty in this setting as levels of correlation are low.