The Panama Aging Research Initiative is a cohort study of 423 adults aged ≥65 years recruited from an outpatient geriatric department of Panama’s largest public hospital, the Social Security Fund’s Dr Arnulfo Arias Madrid Hospital Complex (Complejo Hospitalario Dr Arnulfo Arias Madrid de la Caja de Seguro Social). The study provides the first reports of modifiable and non-modifiable risk factors of cognitive impairment and dementia, as well as various health conditions common among older adults in Panama, including chronic illnesses, polypharmacy and rates of comorbidity. The initial study, conducted September 2012–May 2016, included a clinical interview; physical assessments of body mass index and handgrip strength; and cognitive testing, plus non-fasting blood draws for measurements of genetic (Apolipoprotein E genotype) and blood-based biological markers.

Information was collected regarding limitations in activities of daily living, symptoms of depression and fall incidents. A subsample of participants provided cerebrospinal fluid to measure proteins related to Alzheimer’s disease; another subsample underwent ultrasonography and electroencephalography.

This report describes the general study design and highlights lessons learned and future directions. In particular, drawing on lessons learned from this clinical research, a community-based prospective cohort study is currently under way among older adults in Panama to validate a blood-based biomarker profile for detecting mild cognitive impairment and Alzheimer’s disease, as well as risk factors for cognitive decline.

KEYWORDS: Dementia, biomarkers, Latin America, aging, cognition, chronic disease, Panama

INTRODUCTION Alzheimer disease is the main cause of dementia associated with aging in Cuba and the world. Development of methods for early diagnosis is vital to increasing intervention effectiveness and improving patient quality of life. Recent studies have shown associations between alterations in serum levels of antineuronal antibodies and Alzheimer disease pathology. However, the specific relationship between such antineuronal antibodies and Alzheimer pathogenesis remains unclear because of the great variety of antibodies identified and their heterogeneity among patients and nondemented controls.

OBJECTIVE Assess the association between serum levels of antibodies against neuronal antigens (total brain protein, aldolase and amyloid beta protein) and cognitive performance in older Cuban adults.

METHODS A cross-sectional pilot study was conducted of adults aged ≥65 years living in Havana’s Playa Municipality and Artemisa Province (southwest of Havana). A sociodemographic and risk factor questionnaire was administered, neuropsychological assessment conducted, and physical and neurological examinations performed. A relative or caregiver was also interviewed. Laboratory tests included: complete blood count, glycemia, lipid panel, and apolipoprotein E genotype. Of 143 individuals studied, 33 were cognitively normal, 52 had mild cognitive impairment, and 58, probable Alzheimer disease. Serum antibody levels were determined by ELISA and compared using covariance analysis with a significance level of 0.05. ELISA specificity, sensitivity and predictive value were assessed by analyzing their respective diagnostic performance curves.

RESULTS Patients with probable Alzheimer disease performed least well on the mini mental state examination (cognitively normal 28.8, SD 1.2; mild cognitive impairment 27.4, SD 2.2; probable Alzheimer disease 12.9, SD 6.5; ANOVA p <0.001). The percentage of Apo E4 carriers was seven times greater in the group with probable Alzheimer disease than in the cognitively normal group. Among the antibodies studied, only those against amyloid beta peptide had levels significantly higher in the Alzheimer disease group than in the cognitively normal group (p = 0.007) and the group with mild cognitive impairment (p = 0.002).

CONCLUSIONS Results support the presence of an autoimmune component in Alzheimer disease and suggest that serum anti–amyloid-beta could be used for its diagnosis.

KEYWORDS Dementia, Alzheimer disease, mild cognitive impairment, autoantibodies, E4 apolipoprotein, Apo E4, enzyme-linked immunosorbent assay, ELISA, immunoassay, immunosorbent techniques, amyloid beta protein, Cuba

Aging and Alzheimer is a prospective, longitudinal cohort study involving 2944 adults aged ≥65 years from selected areas in Cuba’s Havana and Matanzas Provinces. This door-to-door study, which began in 2003, includes periodic assessments of the cohort based on an interview; physical exam; anthropometric measurements; and diagnosis of dementia and its subtypes, other mental disorders, and other chronic non-communicable diseases and their risk factors. Information was gathered on sociodemographic characteristics; disability, dependency and frailty; use of health services; and characteristics of care and caregiver burden. The first assessment also included blood tests: complete blood count, blood glucose, kidney and liver function, lipid profile and ApoE4 genotype (a susceptibility marker). In 2007–2011, the second assessment was done of 2010 study subjects aged ≥65 years who were still alive. The study provides data on prevalence and incidence of dementia and its risk factors, and of related conditions that affect the health of older adults. It also contributes valuable experiences from field work and interactions with older adults and their families. Building on lessons learned, a third assessment to be done in 2016–2018 will incorporate a community intervention strategy to respond to diseases and conditions that predispose to dementia, frailty and dependency in older adults.

KEYWORDS Dementia, Alzheimer disease, chronic disease, aging, chronic illness, frailty, dependency, cohort studies, Cuba

Dementia is a great challenge to public health in Cuba due to its impact on society and families. Cuba’s National Intervention Strategy for Alzheimer Disease and Dementia Syndromes is designed to address this challenge. The Strategy includes working guidelines for primary and secondary care, education about rights of people with cognitive impairment, professional development, research, and health promotion and dementia prevention. An associated action plan, focused on primary care, includes proposals for creation of memory clinics, day centers and comprehensive rehabilitation services for cognitive stimulation. Short-term measures proposed include increasing early detection; creating a dementia morbidity and mortality registry; promoting professional training; providing support for families; and promoting basic and clinical research on dementia. Medium-term proposals aim to reduce dementia incidence and mortality by controlling risk factors and promoting healthy lifestyles, offering new treatment options and optimizing early detection. A set of indicators has been developed to evaluate strategy implementation. With this strategy, Cuba joins the small number of developing countries that have responded to WHO’s call to improve care for patients with dementia and alleviate its impact on society and families.

KEYWORDS Dementia, Alzheimer disease, aging, national health programs, social stigma, primary prevention, health promotion, civil rights, Cuba

A review/analysis of current literature on exemplary multicenter registries of clinical dementias was conducted as a comparative basis for a proposed Cuban registry on cognitive impairment and dementia.

The study of mental health disorders has been predominantly based on clinical concepts and criteria, and only in recent years a public health approach has been applied. Traditional epidemiological studies do not reveal patterns of cognitive impairment and behavioral disorders (particularly dementias) in routine clinical practice in a defined geographic area, which would provide essential information for long-term planning and allocation of health and social resources. Thus, multicenter clinical registries have become an important source of clinical and epidemiological data on dementias in recent decades. This article addresses the Cuban proposal for an automated national dementia registry, comparing it to others internationally. The registry would be housed in the Neurology and Neurosurgery Institute, and would include a duly protected surveillance network hosted on the Institute’s website.

Such a multicenter dementia registry based on epidemiological surveillance methods and limited to a defined area would provide new, valid, representative and current data on dementia occurrence patterns by subtype, flow of case identification and referral from primary care, as well as the main clinical features of patients at the time of their first contact with health services. This information would support development of health planning policies for implementation of programs aimed at improved distribution of social and health resources in the affected population, monitoring of the disorder’s natural evolution and identification of preventive measures. The scientific benefits would be equally important: production of new knowledge, generation of hypotheses for clinical research projects, standardization of diagnostic criteria, and promotion of multicenter research in both national and multinational centers.

KEYWORDS Dementia, Alzheimer disease, cognitive impairment, disease registries, public health, surveillance, Cuba

INTRODUCTION Population aging translates into more people with chronic non-communicable diseases, disability, frailty and dependency. The study of frailty—a clinical syndrome associated with an increased risk of falls, disability, hospitalization, institutionalization and death—is important to improve clinical practice and population health indicators. OBJECTIVES In a cohort of older adults in Havana and Matanzas provinces, Cuba, estimate prevalence of frailty and its risk factors; determine incidence of dependency; estimate mortality risk and identify mortality predictors. METHODS A prospective longitudinal study was conducted door to door, from June 2003 through July 2011, in a cohort of 2813 adults aged ≥65 years living in selected municipalities of Havana and Matanzas provinces; mean followup time was 4.1 years. Independent variables included demographics, behavioral risk factors and socioeconomic indicators, chronic non-communicable diseases (hypertension, stroke, dementia, depression, diabetes, anemia), number of comorbidities, and APOE ε4 genotype. Dependent variables were frailty, dependency and mortality. Criteria for frailty were slow walking speed, exhaustion, weight loss, low physical activity and cognitive decline. Prevalence and frailty risk were estimated by Poisson regression, while dependency and mortality risks and their predictors were determined using Cox regression. RESULTS Frailty syndrome prevalence was 21.6% (CI 17.9%–23.8%) at baseline; it was positively associated with advanced age, anemia and presence of comorbidities (stroke, dementia, depression, three or more physically debilitating diseases). Male sex, higher educational level, married or partnered status, and more household amenities were inversely associated with frailty prevalence. In followup, dependency incidence was 33.1 per 1000 person-years (CI 29.1–37.6) and mortality was 55.1 per 1000 person-years. Advanced age, male sex, lower occupational status during productive years, dependency, frailty, dementia, depression, cerebrovascular disease and diabetes were all associated with higher risk of death. CONCLUSIONS Given the challenge for developing countries presented by demographic and epidemiologic transition; the high prevalence in older adults of frailty syndrome, dependency and chronic non-communicable diseases; and the association of all these with higher mortality, attention should be targeted to older adults as a risk group. This should include greater social protection, age-appropriate health services, and modification and control of cardiovascular risk factors.

KEYWORDS Frail elderly, frail older adults, aged, elderly, dependency, mortality, chronic disease, dementia, Alzheimer disease, risk factors, Cuba

The following error has been corrected in all online versions of this article. 

Page 24, Introduction, first paragraph, line 2, “600,000 to 2 billion” should read “600 million to 2 billion.”

Translated from the Spanish and reprinted with permission from the Revista Anales de la Academia de Ciencias de Cuba, [online] Vol. 2, No. 2, 2012. Original available at: http://www.revistaccuba.cu/index.php/acc/article/view/126

Dementia is a syndrome that has great repercussions for quality of life of patients and their families, as well as a high social cost. A [2009] systematic review of research evidence and consensus of expert opinions showed that 36 million people live with dementia worldwide, with 4.6 million new cases every year (similar to the global incidence of nonfatal stroke). The prevalence of dementia in older Cubans is high, with rates ranging from 6.4% to 10.2%, or about 130,000 persons (1.1% of the total population). This number is expected to rise to 260,000 by 2030. The age-standardized annual incidence of dementia is also high: 21 per 1000 population, with 28,750 new cases annually. Dementia is the leading cause of disability among older adults and is the main cause of dependency, financial burden and caregiver stress.

In this review, we highlight the importance of epidemiological research to obtain greater knowledge of the disease, improve health services, promote actions for prevention and early diagnosis, and implement a national strategy to address dementia in the Cuban population, itself now immersed in two processes: accelerated demographic aging and epidemiologic transition.

KEYWORDS Dementia, Alzheimer disease, epidemiology, risk factors, prevention, diagnosis, treatment

Introduction Approximately 24.2 million persons throughout the world suffer dementia with 4.6 million new cases reported annually. Only 10% of dementia and Alzheimer’s disease studies are conducted in developing countries where 66% of sufferers live. Cuba, a developing country, exhibits health indicators similar to those of developed nations. Its population of 11.2 million is aging rapidly: by the year 2020 it is estimated that personas aged ≥60 years will comprise 21.6 % of the population, making Cuban society the “oldest” in Latin America.

Objectives Ascertain and characterize behavior of dementia, its etiologies and risk factors in persons aged ≥65 years in the Havana City municipality of Playa.

Methods A two-phase, cross-sectional, door-to-door study was conducted in the municipality targeting all persons aged ≥65 years, achieving a 96.4% response rate (n=18,351). Folstein Mini Mental State Examination (MMSE), Hughes Clinical Dementia Rating (CDR) and a structured interview on risk factors were applied. DSM-IV, NINCDS-ADRDA and NINDS-AIREN criteria were used to determine dementia diagnosis, as well as other criteria for diagnosing Alzheimer’s and other specific forms of dementia.

Results Dementia prevalence was 8.2% of adults aged ≥65 years, with a slight predominance in males. The most frequent cause of dementia was Alzheimer’s disease, followed by mixed dementias. Dementia-associated risk factors were: history of stroke, hypertension, depression, skull-brain trauma, family history of dementia, low educational level and advanced age.

Conclusions This study corroborates that dementia and Alzheimer’s disease constitute an important and growing health problem for our country due to the accelerated aging of the Cuban population. It also underlines the importance of early diagnosis and proper treatment of hypertension and other vascular risk factors, as well as the need for a national public health program for the prevention and early diagnosis of dementia and Alzheimer’s disease, targeting elderly and at-risk populations.

Keywords Brain diseases, dementia, mental disorders, neurodegenerative diseases, Alzheimer’s disease, aging

The following errata have been corrected in all versions of this article.

Page 29, Abstract, Introduction, final sentence should read: “Its population of 11.2 million is aging rapidly: by the year 2020 it is estimated that personas aged ≥60 years will comprise 21.6 % of the population, making Cuban society the “oldest” in Latin America.”

Page 29, Introduction, paragraph 4 should read: “Cuba is a developing country with health indicators similar to those of developed countries and a rapidly aging population of 11.2 million. By the year 2020 Cuba will have the oldest population in Latin America, with adults aged ≥60 years accounting for 21.6% of total population.”