Exploring the relationship between pain, cognition, and chronic conditions: insights from the HAALSI study in rural South Africa

BackgroundThere are no nationally representative population-based studies investigating the relationship between physical activity, chronic conditions and multimorbidity (i.e., two or more chronic conditions) in low- and middle-income countries (LMICs), and studies on a multi-national level are lacking. This is an important research gap, given the rapid increase in the prevalence of chronic diseases associated with lifestyle changes in these countries. This cross-sectional study aimed to assess the association between chronic conditions, multimorbidity and low physical activity (PA) among community-dwelling adults in 46 LMICs, and explore the mediators of these relationships.MethodsWorld Health Survey data included 228,024 adults aged ≥18 years from 46 LMICs. PA was assessed by the International Physical Activity Questionnaire (IPAQ). Nine chronic physical conditions (chronic back pain, angina, arthritis, asthma, diabetes, hearing problems, tuberculosis, visual impairment and edentulism) were assessed. Multivariable logistic regression and mediation analyses were used to assess the association between chronic conditions or multimorbidity and low PA.ResultsOverall, in the multivariable analysis, arthritis (OR = 1.12), asthma (1.19), diabetes (OR = 1.33), edentulism (OR = 1.46), hearing problems (OR = 1.90), tuberculosis (OR = 1.24), visual impairment (OR = 2.29), multimorbidity (OR = 1.31; 95% CI = 1.21–1.42) were significantly associated with low PA. More significant associations were observed in individuals aged ≥50 years. In older adults, depression mediated between 5.1% (visual impairment) to 23.5% (angina) of the association between a chronic condition and low PA. Mobility difficulties explained more than 25% of the association for seven of the eight chronic conditions. Pain was a strong mediator for angina (65.9%) and arthritis (64.9%), while sleep problems mediated up to 43.7% (angina) of the association.ConclusionsIn LMICs, those with chronic conditions and multimorbidity are significantly less physically active (especially older adults). Research on the efficacy and effectiveness of PA in the management of chronic diseases in LMICs is urgently needed. Targeted promotion of physical activity to populations in LMICs experiencing chronic conditions may ameliorate associated depression, mobility difficulties and pain that are themselves important barriers for initiating or adopting an active lifestyle.

Differential diagnosis of facial pain and guidelines for management

To assess the association between chronic physical conditions and multimorbidity and mild cognitive impairment (MCI) in low- and middle-income countries (LMICs). Nationally representative, cross-sectional, community-based study. Six countries that participated in the World Health Organization Study on Global Ageing and Adult Health. Individuals aged 50 and older (N=32,715; mean age 62.1 ± 15.6; 51.7% female). The definition of MCI was based on the recommendations of the National Institute on Ageing and Alzheimer's Association. Ten chronic conditions were assessed (angina pectoris, arthritis, asthma, cataract, chronic lung disease, diabetes mellitus, edentulism, hearing problems, hypertension, stroke). Multivariable logistic regression analysis was conducted to assess the association between chronic physical conditions, multimorbidity (≥2 chronic conditions), and MCI. The prevalence of multimorbidity was 49.8% (95% confidence interval (CI)=48.1-51.5%) and of MCI was 15.3% (95% CI=14.4-16.3%). After adjustment for potential confounders, edentulism (odds ratio (OR)=1.24), arthritis (OR=1.24), chronic lung disease (OR=1.29), cataract (OR=1.33), stroke (OR=1.94), hearing problems (OR=2.27), and multimorbidity (OR=1.40) were significantly associated with MCI. There was a gradual increase in the likelihood of MCI (1 condition: OR=1.21, 95% CI=1.03-1.42; ≥4 conditions: OR=2.07, 95% CI=1.70-2.52). These results highlight the need to investigate the underlying mechanisms linking chronic conditions and MCI and whether prevention or treatment of chronic conditions or multimorbidity can reduce the onset of cognitive decline and subsequent dementia, especially in LMICs.

BackgroundWith a rapidly aging population, physical frailty has become a significant public health concern globally. While the association between frailty, depression, and cognitive decline has been widely studied in developed countries, there is limited evidence from low- and middle-income countries, including India. Additionally, little is known about the sex-specific associations between frailty, and mental and cognitive health outcomes. We examined the associations of physical frailty with depressive symptoms and cognitive functioning among older Indian men and women, while also exploring how the frailty-cognition link differs between those with and without depression.MethodsWe used data from the Longitudinal Aging Study in India, conducted between 2017 and 2019. The analytic sample consisted of 14,652 males and 15,899 females aged ≥ 60 years. Frailty was assessed using a modified version of Fried’s frailty phenotype, depressive symptoms were evaluated using the Composite International Diagnostic Interview- Short Form, and cognitive ability was measured through memory, orientation, arithmetic, executive function, and object naming tasks. Univariate and multivariable linear regression models were used to examine the associations between frailty, depressive symptoms, and cognitive ability in older men and women, as well as frailty-cognition association by depressive status.ResultsThe prevalence of frailty was higher in older women than that in older men (32.2% vs. 27.4%). The mean depressive symptom score was higher (0.8 vs 1.0), and the mean cognitive score was lower (26.4 vs 22.1) among older women than men. Physical frailty was associated with higher levels of depressive symptoms (β = 0.51; 95% CI: 0.39, 0.64), and poor cognitive performance (β = -1.06; 95% CI: -1.37, -0.75). Non-frail older men had lower depressive symptoms than frail older men (β = -0.48; 95% CI: -0.66, -0.31), however, the association was not significant among older women. Furthermore, frail older women performed worse on cognitive tests than did frail older men (β = -2.14; 95% CI: -2.40, -1.87). In addition, non-frail older women had poorer cognitive performance than frail older men (β = -0.77; 95% CI: -1.22, -0.32). Conversely, stratification by depressive status showed that frailty was associated with worse cognitive ability, with no difference between individuals with and without depression.ConclusionsWe found that frail older individuals, particularly women, have significant mental and cognitive deficits compared with their non-frail counterparts. Our findings have major implications in both community and clinical settings. Appropriate policies and programs should be implemented to reinforce the strength of pre-frail and frail older adults and maintain improved mental health and cognition in older adults.

The study aimed to assess associations between chronic diseases and incident and persistent depressive symptoms (DSs) in a cohort study of ageing adults in South Africa. Participants in the baseline survey (in 2014/2015) were 5,059 persons (≥40 years) and at follow-up 4,176 (in 2018/2019). DSs were measured with the Center for Epidemiological Studies Depression scale. Logistic regression was used to estimate the associations between chronic conditions and incident and persistent DS. The prevalence of DS at baseline was 15.5%, incident DS (without DS and/or PTSD at baseline) was 25.1% and persistent DS (DS at both baseline and follow-up) was 4.8%. In unadjusted logistic regression analysis, diabetes had higher odds of incident DS. Participants with baseline heart attack/stroke/angina, dyslipidemia, tuberculosis, chronic bronchitis, kidney disease and three or more chronic conditions had a higher probability of persistent DS. In conclusion, of the eight chronic conditions evaluated, only diabetes (in unadjusted analysis) was associated with incident DS, and five chronic conditions (heart attack/stroke/angina, dyslipidaemia, tuberculosis, chronic bronchitis and kidney disease) and three or more chronic conditions were associated with persistent DS.

Evidence suggests links among tinnitus, depression, and cognition. We examined these associations over time. We hypothesized baseline tinnitus would predict poorer cognitive performance and more depressive symptoms an average of 11.4 years later. We examined 839 men at two timepoints (baseline age M=55.94; follow-up age M=67.56). At each time point participants responded yes/no if they had tinnitus. We created three tinnitus status groups – no tinnitus at either time, tinnitus at both, and no tinnitus at baseline but tinnitus at follow-up. At both time points we measured cognitive performance with tests of episodic memory, processing speed, executive function, and verbal fluency. Depressive symptoms were based on the Center for Epidemiological Studies Depression scale. There was no association between tinnitus and any measure of cognitive performance. Depressive symptoms declined from baseline to follow-up. In separate mixed models predicting depressive symptoms, there was a significant main effect for tinnitus status at baseline (p = .003) and follow-up (p < .001). Those with tinnitus at both times had significantly higher depressive symptoms than the “No tinnitus” group (p < .001). This association remained significant after accounting for baseline depressive symptoms (p = .011) at follow-up. Results did not support the hypothesis that tinnitus would be associated with poorer cognitive function. However, depressive symptoms declined among those with no tinnitus than the other groups. The relationship between tinnitus and depressive symptoms may have implications for future cognitive performance among older adults, given previous evidence that depressive symptoms are risk factors for cognitive decline.

Expand understanding of the role of selected workplace exposures (ie, occupational complexity, conflict in the workplace, pace of work, and physical hazards) in adults' cognitive function. Cross-sectional data (n = 1991) from the second wave of the Midlife in the United States (MIDUS) study; restricted to participants who completed telephone-based cognitive assessments of episodic memory, executive functioning, and self-perceived memory. Occupational exposure data were harvested from the ONET Release 6.0. Greater complexity was associated with better self-perceived memory among women and men, and better episodic memory and executive functioning among women. Greater physical hazards were independently associated with poorer episodic memory and executive functioning. Objective assessments of physical and psychosocial exposures in the workplace are independently associated with cognitive outcomes in adulthood, with psychosocial exposures being particularly pronounced among women.

Study ObjectivesWe examined and compared cross-sectional and longitudinal associations between self-reported sleep disturbances and various cognitive domains in five separate Nordic European longitudinal aging studies (baseline N = 5631, mean age = 77.7, mean follow-up = 4.16 years).MethodsComparable sleep parameters across studies included reduced sleep duration/quality, insomnia symptoms (sleep latency, waking up at night, and early awakenings), short and long sleep duration, and daytime napping. The cognitive domains were episodic memory, verbal fluency, perceptual speed, executive functioning, and global cognition (aggregated measure). A series of mixed linear models were run separately in each study and then compared to assess the level and rate of change in cognitive functioning across each sleep disturbance parameter. Models were adjusted for age, sex, education, hypnotic usage, depressive symptoms, lifestyle factors, cardiovascular, and metabolic conditions. By using a coordinated analytic approach, comparable construct-level measurements were generated, and results from identical statistical models were qualitatively compared across studies.ResultsWhile the pattern of statistically significant results varied across studies, subjective sleep disturbances were consistently associated with worse cognition and steeper cognitive decline. Insomnia symptoms were associated with poorer episodic memory and participants sleeping less or more than 7–8 hours had a steeper decline in perceptual speed. In addition, daytime napping (>2 hours) was cross-sectionally and longitudinally associated with all examined cognitive domains. Most observed associations were study-specific (except for daytime napping), and a majority of association estimates remained significant after adjusting for covariates.ConclusionThis rigorous multicenter investigation further supports the importance of sleep disturbance, including insomnia, long and short sleep duration, and daytime napping on baseline cognitive functioning and rate of change among older adults. These sleep factors may be targeted in future lifestyle interventions to reduce cognitive decline.

Given the mixed evidence on whether women’s economic and social empowerment is beneficial or not for reducing intimate partner violence (IPV), we explored the relationship between women’s empowerment and IPV risk. We analyzed data from baseline interviews with married women (n = 415) from the Intervention with Microfinance and Gender Equity (IMAGE) longitudinal study in rural South Africa. IMAGE combines a poverty-focused microfinance program with a gender-training curriculum. We fitted logistic regression models to explore associations between women’s economic situation/empowerment and IPV. For the multivariable logistic regression, we fitted three models that progressively included variables to explore these associations further. Women who reported “few to many times” for not earning enough to cover their business costs faced higher odds of past year physical and/or sexual violence (adjusted odds ratio [aOR] = 6.1, 1.7-22.3, p = .01). Those who received a new loan experienced higher levels of past year emotional (aOR = 2.8, 1.1-7.4, p = .03) and economic abuse (aOR = 6.3, 2.2-18.5, p = .001). Women who reported that partners perceived their household contribution as not important faced higher odds of past year economic abuse (aOR = 2.8, 1.0-7.8, p = .05). Women who reported joint decision-making or partner making sole reproductive decisions reported higher levels of past year physical and/or sexual violence (aOR = 5.7, 0.9-39.4, p = .07) and emotional abuse (aOR = 3.0, 0.9-10.2, p = .08). Economic stress and aspects of women’s empowerment, alongside established gender roles within marital relationships is associated with IPV risk in rural South Africa. Although improved economic conditions for women appears to be protective against physical and sexual IPV, associations between certain indicators of women’s economic situation, empowerment, and IPV are inconsistent. We need to consider complementary programming and all types of IPV in research, intervention, and policy, as different aspects of empowerment have varying associations with different types of IPV (physical, sexual, emotional, and economic abuse).

Knowledge of the effect of socioeconomic status on HIV infection in Africa stems largely from cross-sectional studies. Cross-sectional studies suffer from two important limitations: two-way causality between socioeconomic status and HIV serostatus and simultaneous effects of socioeconomic status on HIV incidence and HIV-positive survival time. Both problems are avoided in longitudinal cohort studies. We used data from a longitudinal HIV surveillance and a linked demographic surveillance in a poor rural community in KwaZulu-Natal, South Africa, to investigate the effect of three measures of socioeconomic status on HIV incidence: educational attainment, household wealth categories (based on a ranking of households on an assets index scale) and per capita household expenditure. Our sample comprised of 3325 individuals who tested HIV-negative at baseline and either HIV-negative or -positive on a second test (on average 1.3 years later). In multivariable survival analysis, one additional year of education reduced the hazard of acquiring HIV by 7% (P = 0.017) net of sex, age, wealth, household expenditure, rural vs. urban/periurban residence, migration status and partnership status. Holding other factors equal, members of households that fell into the middle 40% of relative wealth had a 72% higher hazard of HIV acquisition than members of the 40% poorest households (P = 0.012). Per capita household expenditure did not significantly affect HIV incidence (P = 0.669). Although poverty reduction is important for obvious reasons, it may not be as effective as anticipated in reducing the spread of HIV in rural South Africa. In contrast, our results suggest that increasing educational attainment in the general population may lower HIV incidence.

BackgroundEpilepsy is one of the most common neurological conditions globally, estimated to constitute 0.75% of the global burden of disease, with the majority of this burden found in low- and middle- income countries (LMICs). Few studies from LMICs, including much of sub-Saharan Africa, have described the incidence, remission or mortality rates due to epilepsy, which are needed to quantify the burden and inform policy. This study investigates the epidemiological parameters of convulsive epilepsy within a context of high HIV prevalence and an emerging burden of cardiovascular disease.MethodsA cross-sectional population survey of 82,818 individuals, in the Agincourt Health and Socio-demographic Surveillance Site (HDSS) in rural northeast South Africa was conducted in 2008, from which 296 people were identified with active convulsive epilepsy. A follow-up survey was conducted in 2012. Incidence and mortality rates were estimated, with duration and remission rates calculated using the DISMOD II software package.ResultsThe crude incidence for convulsive epilepsy was 17.4/100,000 per year (95%CI: 13.1-23.0). Remission was 4.6% and 3.9% per year for males and females, respectively. The standardized mortality ratio was 2.6 (95%CI: 1.7-3.5), with 33.3% of deaths directly related to epilepsy. Mortality was higher in men than women (adjusted rate ratio (aRR) 2.6 (95%CI: 1.2-5.4)), and was significantly associated with older ages (50+ years versus those 0-5 years old (RR 4.8 (95%CI: 0.6-36.4)).ConclusionsThe crude incidence was lower whilst mortality rates were similar to other African studies; however, this study found higher mortality amongst older males. Efforts aimed at further understanding what causes epilepsy in older people and developing interventions to reduce prolonged seizures are likely to reduce the overall burden of ACE in rural South Africa.

BackgroundDepression is predicted to become one of the two most burdensome diseases worldwide by 2020 and is common in people with chronic physical conditions. However, depression is relatively uncommon in Asia. Family support is an important Asian cultural value that we hypothesized could protect people with chronic physical conditions from developing depression. We investigated depressive symptom prevalence and risk factors in a Chinese sample with chronic medical conditions, focusing on the possible protective role of family relationships.MethodsData were obtained from the Hong Kong Jockey Club FAMILY Project cohort study in 2009–2011, which included 6,195 participants (age ≥15) with self-reported chronic conditions. Depressive symptoms were recorded using the Patient Health Questionnaire-9 (PHQ-9). Demographic and lifestyle variables, stressful life events, perceived family support and neighborhood cohesion were assessed. Factors associated with a non-somatic (PHQ-6) depression score were also examined.ResultsThe prevalence of depressive symptoms (PHQ-9 scores ≥5) was 17% in those with one or more chronic conditions, and was more prevalent in women than in men (19.7% vs. 13.9%; p < 0.001). In multilevel analyses, life stress, number of chronic conditions and satisfaction with family support explained 43% of the variance in PHQ-9 scores (standardized regression coefficients of 0.46, 0.15, and −0.12 respectively, all p <0.001). Body mass index, problem alcohol drinking, physical activity, and unmarried status were significantly associated with PHQ-9 scores, although these associations were weak. Variables associated with depression explained 35% of the variance in non-somatic (PHQ-6) depression scores. Satisfaction with family support played a stronger protective role against depressive symptoms (both PHQ-9 and PHQ-6 scores) among women than men (p < 0.05).ConclusionsAcute life stress and the number of chronic conditions, together with socio-demographic factors, explain most variance in depressive symptoms among chronically ill Chinese individuals. Somatic items in the PHQ-9 increased the depression scores but they did not alter the pattern of predictors. Family support appears to be an important protective factor in Chinese cultures for individuals with chronic conditions.

There is a scarcity of literature on the association between physical multimorbidity (i.e., ≥2 chronic physical conditions) and depression among older adults, especially from low- and middle-income countries (LMICs). In addition, the mediators in this association are largely unknown. Therefore, we aimed to examine this association among adults aged ≥50 years from six LMICs (China, Ghana, India, Mexico, Russia, and South Africa), and to identify potential mediators. Cross-sectional, nationally representative data from the Study on Global Ageing and Adult Health were analyzed. Depression was defined as past-12 months DSM-IV depression or receiving depression treatment in the last 12 months. Information on 11 chronic physical conditions were obtained. Multivariable logistic regression and mediation analyses were conducted. Data on 34,129 individuals aged ≥50 years were analyzed [mean (SD) age 62.4 (16.0) years; maximum 114 years; 52.1% females]. Compared to no chronic conditions, 2, 3, 4, and ≥5 chronic conditions were associated with 2.55 (95% CI = 1.90-3.42), 3.12 (95% CI = 2.25-4.34), 5.68 (95% CI = 4.02-8.03), and 8.39 (95% CI = 5.87-12.00) times higher odds for depression. Pain/discomfort (% mediated 39.0%), sleep/energy (33.2%), mobility (27.5%), cognition (13.8%), perceived stress (7.3%), disability (6.7%), loneliness (5.5%), and food insecurity (1.5%) were found to be significant mediators in the association between physical multimorbidity and depression. Older adults with physical multimorbidity are at increased odds of depression in LMICs. Future studies should assess whether addressing the identified potential mediators in people with physical multimorbidity can lead to reduction in depression in this population.

Short, reliable, easily administered executive function (EF) assessment tools are needed to measure EF in low- and middle-income countries, particularly in sub-Saharan Africa given the prevalence of human immunodeficiency virus (HIV)-associated neurocognitive disorder. We administered Oxford Cognitive Screen-Executive Function (OCS-EF) to 932 rural South African females (mean age 19.7 years). OCS-EF includes seven tasks: two hot inhibition tasks (a modified Iowa Gambling Task, emotional go/no-go) and five cool EF tasks, two switching tasks (visuospatial rule-finding, geometric trails) and three working memory tasks (digit recall, selection and figure drawing). We performed confirmatory factor analysis testing whether a three-factor, two-factor hot-cool, two-factor working memory and inhibition/switching, or one-factor EF model fitted the data better. The three-factor (switching, inhibition and working memory) model had the best local and global fit (χ2 (11) 24.21, p=0.012; RMSEA 0.036; CFI 0.920; CD 0.617). We demonstrated the feasibility of OCS-EF administration by trained laypeople, the tripartite structure of EF amongst adolescent females and the factorial validity of OCS-EF in this population and context. OCS-EF tablet-based cognitive assessment tool can be administered by trained laypeople and is a valid tool for assessing cognition at scale amongst adolescents in rural South Africa and similar environments.

BackgroundEpilepsy is a common neurological disorder, with over 80 % of cases found in low- and middle-income countries (LMICs). Studies from high-income countries find a significant economic burden associated with epilepsy, yet few studies from LMICs, where out-of-pocket costs for general healthcare can be substantial, have assessed out-of-pocket costs and health care utilization for outpatient epilepsy care.MethodsWithin an established health and socio-demographic surveillance system in rural South Africa, a questionnaire to assess self-reported health care utilization and time spent traveling to and waiting to be seen at health facilities was administered to 250 individuals, previously diagnosed with active convulsive epilepsy. Epilepsy patients’ out-of-pocket, medical and non-medical costs and frequency of outpatient care visits during the previous 12-months were determined.ResultsWithin the last year, 132 (53 %) individuals reported consulting at a clinic, 162 (65 %) at a hospital and 34 (14 %) with traditional healers for epilepsy care. Sixty-seven percent of individuals reported previously consulting with both biomedical caregivers and traditional healers. Direct outpatient, median costs per visit varied significantly (p < 0.001) between hospital (2010 International dollar ($) 9.08; IQR: $6.41-$12.83) and clinic consultations ($1.74; IQR: $0-$5.58). Traditional healer fees per visit were found to cost $52.36 (IQR: $34.90-$87.26) per visit. Average annual outpatient, clinic and hospital out-of-pocket costs totaled $58.41. Traveling to and from and waiting to be seen by the caregiver at the hospital took significantly longer than at the clinic.ConclusionsRural South Africans with epilepsy consult with both biomedical caregivers and traditional healers for both epilepsy and non-epilepsy care. Traditional healers were the most expensive mode of care, though utilized less often. While higher out-of-pocket costs were incurred at hospital visits, more people with ACE visited hospitals than clinics for epilepsy care. Promoting increased use and effective care at clinics and reducing travel and waiting times could substantially reduce the out-of-pocket costs of outpatient epilepsy care.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1460-0) contains supplementary material, which is available to authorized users.