IntroductionIn low/middle-income countries (LMICs), the prevalence of people diagnosed with dementia is expected to increase substantially and treatment options are limited, with acetylcholinesterase ...inhibitors not used as frequently as in high-income countries (HICs). Cognitive stimulation therapy (CST) is a group-based, brief, non-pharmacological intervention for people with dementia that significantly improves cognition and quality of life in clinical trials and is cost-effective in HIC. However, its implementation in other countries is less researched. This protocol describes CST-International; an implementation research study of CST. The aim of this research is to develop, test, refine and disseminate implementation strategies for CST for people with mild to moderate dementia in three LMICs: Brazil (upper middle-income), India (lower middle-income) and Tanzania (low-income).Methods and analysisFour overlapping phases: (1) exploration of barriers to implementation in each country using meetings with stakeholders, including clinicians, policymakers, people with dementia and their families; (2) development of implementation plans for each country; (3) evaluation of implementation plans using a study of CST in each country (n=50, total n=150). Outcomes will include adherence, attendance, acceptability and attrition, agreed parameters of success, outcomes (cognition, quality of life, activities of daily living) and cost/affordability; (4) refinement and dissemination of implementation strategies, enabling ongoing pathways to practice which address barriers and facilitators to implementation.Ethics and disseminationEthical approval has been granted for each country. There are no documented adverse effects associated with CST and data held will be in accordance with relevant legislation. Train the trainer models will be developed to increase CST provision in each country and policymakers/governmental bodies will be continually engaged with to aid successful implementation. Findings will be disseminated at conferences, in peer-reviewed articles and newsletters, in collaboration with Alzheimer’s Disease International, and via ongoing engagement with key policymakers.
Despite high burden of dementia in low‐and middle‐income countries (LMICs), only a small number of clinical trials of psychosocial interventions for persons with dementia (PwD) have been conducted in ...these settings. It is essential that such trials use appropriate outcome measures that are methodologically robust and culturally appropriate to evaluate the effectiveness of interventions. We carried out a systematic review to examine the evidence base and psychometric properties of measures employed in these studies in LMICs. A systematic search of published literature on randomised controlled trials (RCT) of psychosocial interventions for PwD in LMICs between 2008 and April 2020 was carried out. Measures employed in each of the eligible studies were identified and through a focused search, we further explored the evidence base and psychometric properties employing Terwee criteria. Data extraction and quality appraisal were conducted by two independent reviewers. The review identified 41 measures from 17 RCTS which fulfilled eligibility criteria and they examined effectiveness across the domains of cognition (n = 16), behaviour and psychological symptoms (n = 11) and quality of life (n = 8). Of these 41, we were able to access relevant literature only for 18 and they were subject to psychometric analysis. Psychometric properties of these 18 instruments were at best modest, with Terwee scores ranging from 3 (low) to 15 (moderate). A majority of the studies were from China (n = 5) and Brazil (n = 6). The evidence base for the routinely employed measures in RCTs of non‐pharmacological interventions for PwD in LMICs is limited. The quality of adaptation and validation of these instruments is variable and studies are largely uninformative about their psychometric properties and cultural appropriateness to the study setting. There is an urgent need to develop scientifically robust instruments in LMIC settings that can be confidently employed to measure outcomes in trials of psychosocial interventions for PwD.
Even with a strong evidence base, many healthcare interventions fail to be translated to clinical practice due to the absence of robust implementation strategies. For disorders such as Alzheimer's ...disease and other dementias, access to evidence-based interventions beyond research settings is of great importance. Cognitive Stimulation Therapy (CST) is a brief, group-based intervention, with consistent evidence of effectiveness.
An implementation focused, three-phase methodology was developed using extensive stakeholder engagement. The methods resulted in a standardized Implementation Plan for the successful translation of CST from research to practice. The methodology was developed using the Consolidated Framework for Implementation Research (CFIR) and refined in three countries that vary in levels of economic development and healthcare systems (Brazil, India and Tanzania).
Five Implemention Plans for CST were produced. Each plan contained implementation strategies and action plans devised in conjunction with policy professionals, healthcare professionals, people with dementia and family carers, and an international team of researchers and clinicians.
This novel methodology can act as a template for implementation studies in diverse healthcare systems across the world. It is an effective means of devising socio-culturally informed Implementation Plans that account for economic realities, health equity and healthcare access.
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.
Introduction
Recent evidence suggests that growth restriction in utero may lead to neurocognitive disorders in late life, either through impaired brain development or adverse metabolic programming.
...Methods
Systematic review of literature investigating the relationship between size at birth and cognitive abilities in late life. The search, data extraction, and rating for the quality of reporting were conducted independently by two researchers.
Results
Of 533 selected studies, 11 were included in this systematic review and 10 of these were from high‐income setting. Of these 11 studies, eight indicated that lower birth weight is a risk factor for lower cognitive function in late life, at least in high‐income countries. The reported effect sizes were small and it was not possible to conduct meta‐analyses because of clinical heterogeneity
Discussion
A modest association of lower birth weight with lower cognitive abilities in late life is consistent with persisting effects of the prenatal environment on brain function. As with all observational studies, confounding is an alternative explanation. Further studies are required to elucidate the mechanisms.
Background: In community settings, neuropsychological assessment is the most commonly employed method for early recognition of dementia. However, little is known about the experience and perspectives ...of older adults when they undertake neuropsychological assessments in low-and middle-income countries (LMICs), including India. Methods: We conducted semi-structured interviews for 11 individuals (aged between 64 and 88 years) who had undergone cognitive assessment in the CST International (Cognitive Stimulation Therapy- International) study and were free from dementia. The transcripts were analysed manually utilising Interpretative Phenomenological Analysis to develop key themes. Results: When data were analysed three superordinate themes (experiences related to the process, content and outcomes) each with a set of subordinate themes emerged. Conclusions: This study highlights the need for a thorough planning of pre-assessment briefing for equipping participants with adequate information related to the neuropsychological assessment: its indication, length of procedure, contents of the test, possible outcomes, medical implications of those outcomes, possible therapeutic options if diagnosed with lower cognitive function. We discuss our findings in relation to extant knowledge and explore issues clinicians should consider when conducting neuropsychological assessments in LMIC settings.
Background:
Emerging evidence from high income settings indicates that lung function may be an independent determinant of cognitive abilities in late life. Despite a high burden of chronic lung ...disorders and neurocognitive disorders, there are limited data exploring the relationship between lung and cognitive function in later life in low- and middle-income (LMIC) settings.
Methods:
Between 2013 and 2016, 721 men and women from the Mysore Birth Records Cohort in South India, aged 55-80 years, were retraced and underwent standardised assessments for sociodemographic characteristics, cardiometabolic risk factors, lung function, cognitive function and mental health. Approximately 20 years earlier, a subset of them had assessments for cardiometabolic risk factors (n=522) and lung function (n=143).
Results:
Forced Expiratory Volume at one second (FEV1) and six seconds (FEV6) were higher among men than women. Women had higher immediate and delayed recall scores compared to men. Multivariate models indicated that those with lower FEV1 (lts) and FEV1/FEV6 ratio in late life had lower composite cognitive score (SD, standard deviation), independent of growth and environment in early life and childhood, attained education, socioeconomic position, cardiometabolic disorders in mid-and late life and lifestyle factors (0.29 SD per litre 95% confidence interval CI (0.10, 0.50) p=0.006 for FEV1 and 1.32 SD (0.20, 2.50) p=0.02 for FEV1/FEV6 ratio). Lung function in midlife was unrelated to cognitive outcomes in late life.
Conclusions:
Causality cannot be inferred from cross sectional associations. Therefore, causality is best explored in longitudinal studies with serial, but contemporaneous measurements of both lung and cognitive function. Mechanistic studies that examine the role of shared risk factors like environmental pollutants and biomass exposure on this relationship are urgently required in LMICs.
In many real-world problems, reward signals received by agents are delayed or sparse, which makes it challenging to train a reinforcement learning (RL) agent. An intrinsic reward signal can help an ...agent to explore such environments in the quest for novel states. In this work, we propose a general end-to-end diversity-augmented intrinsic motivation for deep reinforcement learning which encourages the agent to explore new states and automatically provides denser rewards. Specifically, we measure the diversity of adjacent states under a model of state sequences based on determinantal point process (DPP); this is coupled with a straight-through gradient estimator to enable end-to-end differentiability. The proposed approach is comprehensively evaluated on the MuJoCo and the Arcade Learning Environments (Atari and SuperMarioBros). The experiments show that an intrinsic reward based on the diversity measure derived from the DPP model accelerates the early stages of training in Atari games and SuperMarioBros. In MuJoCo, the approach improves on prior techniques for tasks using the standard reward setting, and achieves the state-of-the-art performance on 12 out of 15 tasks containing delayed rewards.
Artificial intelligence (AI) is being increasingly integrated into scientific discovery to augment and accelerate research, helping scientists to generate hypotheses, design experiments, collect and ...interpret large datasets, and gain insights that might not have been possible using traditional scientific methods alone. Here we examine breakthroughs over the past decade that include self-supervised learning, which allows models to be trained on vast amounts of unlabelled data, and geometric deep learning, which leverages knowledge about the structure of scientific data to enhance model accuracy and efficiency. Generative AI methods can create designs, such as small-molecule drugs and proteins, by analysing diverse data modalities, including images and sequences. We discuss how these methods can help scientists throughout the scientific process and the central issues that remain despite such advances. Both developers and users of AI toolsneed a better understanding of when such approaches need improvement, and challenges posed by poor data quality and stewardship remain. These issues cut across scientific disciplines and require developing foundational algorithmic approaches that can contribute to scientific understanding or acquire it autonomously, making them critical areas of focus for AI innovation.
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