As a neurology resident, I had the opportunity to work and learn in Kilimanjaro Christian Medical Centre (KCMC) in Moshi (Tanzania) over 3 months. I observed that the circuits and usual presentation of patients with cognitive impairment were different to the ones I am used to in Spain. I took the initiative to interview the psychiatrist in charge about this topic and the answers were very instructive. We have published the interview at Spanish teaching website “Circunvalación del Hipocampo”.
Dr. Judith Boshe (Kibosho, Moshi, Tanzania) completed her degree in Medicine at Muhimbili National Hospital, in Dar Es Salaam, the main commercial city of Tanzania. After working on Human Immunodeficiency virus (HIV)-related research in the south of Tanzania (Kagera) for several years, she specialized in Psychiatry in Cape Town, South Africa, with a grant from Duke University. She is currently working in her native town of Moshi, in KCMC, referral hospital for the 15 million people in the north of Tanzania, being the sole available psychiatrist over there.
Dr. Boshe belongs to the team of professionals performing evaluation, diagnosis and treatment for most of the cognitively impaired patients who make it to KCMC, and is enthusiastic for the recognition of this Public Health problem. We thank her very much for giving us this interview.
Circunvalación del Hipocampo: Do you think cognitive impairment is a prevalent condition in Tanzanian population?
Dr. Boshe: It is really hard to say for sure since there is limited literature on the subject. But at a personal level I do think it’s a condition that is of significant incidence and a public health concern. My response is based on what I personally observe in the community I live in and the patients I attend to. It is however difficult to share exact national prevalence due to absence of national representative data or study. Existing regional studies such as that done by Paddick et al looking at the prevalence in rural Hai district, assist in demonstrating that the problem is of significant prevalence. This study helps to recognize that the problem exists at a significant magnitude, but the characteristics of Hai district are not nationally representative.
There are regional differences. We know that the most common neurodegenerative disease producing cognitive impairment is probably Alzheimer, but in areas like Moshi I have observed that I come across alcohol related cognitive impairment more often than other forms of cognitive impairment. It is also safe to say that the regional differences in HIV infections will also influence the provenance of HIV-associated neurocognitive disorders, another etiology of cognitive impairment in our setting that is still a problem despite good access to Highly Active Antiretroviral Therapy (HAART).
Circunvalación del Hipocampo: In which setting do you usually diagnose cognitive impairment?
Dr. Boshe: Both outpatient and inpatient. In outpatient it is usually more direct, referred for that reason. In inpatient, it tends to be a more incidental finding. Elderly patients presenting with fluctuating confusion, aggression and agitation will often be experiencing delirium superimposed on an undiagnosed cognitive impairment.
Circunvalación del Hipocampo: What are the main barriers you encounter to provide a diagnosis of cognitive impairment or dementia in your hospital?
Dr. Boshe: The barrier is at taking the history of progression of symptoms, then you find that the family did not identify the symptoms and hence they are not able to give comprehensive account of their progression. At the moment of presentation often the symptoms are very advanced, and there is little you can do in terms of altering the rate of progression of the disease or to improve the quality of life of patient and care-givers. Another barrier is that at the moment of doing a cognitive assessment most of the tools are from foreign countries and they are not adapted, nor validated in Tanzanian population.
Even the ones that are validated like Montreal Cognitive Assessment (MOCA) and Mini-Mental, they still have phrases that are not relatable to the local population. And then, there is the issue of investigations, more than two thirds of the population do not have insurance and they are not able to afford imaging, or even blood tests like vitamin B12, folate, which does not allow to screen for treatable and prevalent causes of cognitive impairment (CI). In conclusion, you have challenges at all steps, at history taking, at examination and complementary tests.
Circunvalación del Hipocampo: What are the most common etiologies you usually encounter in outpatients?
Dr. Boshe: In the infectious field, HIV-related CI is common. In metabolic, alcohol chronic use produces CI frequently, also small vessel disease related to poorly controlled diabetes and hypertension. Neurodegenerative, Alzheimer’s and dementia due to Parkinson’s disease. Possibly there is more out there but this is what I see in my clinical settings.
Circunvalación del Hipocampo: Which tests or questionnaires do you usually use in your daily practice?
Dr. Boshe: I use the fifth edition of the Diagnostic and Statistical Manual of mental disorders (DSM-V) criteria and I complement with cognitive tests that I modify a lot taking into account the presentation and the level of education, and also ancillary tests.
Circunvalación del Hipocampo: Which cognitive tests?
Dr. Boshe: Most common are Mini-Mental and MOCA, but I usually take only parts, and complement them with specific tests depending on presentation, like Frontal Assessment Battery (FAB) and specific for temporal, parietal or occipital lobe… And International HIV Dementia Scale (IHDS) for HIV patients.
Circunvalación del Hipocampo: What would a suitable Tanzanian-friendly cognitive assessment look alike?
Dr. Boshe: It would be in the national language Swahili and it would have nouns and pictures that are familiar to our setting.
Circunvalación del Hipocampo: How does the low average income and low access to medical insurance affect the patients living with cognitive impairment?
Dr. Boshe: It affects the time they present, already very confused and not able to attend to themselves. Even presenting later, it affects that they are not able to afford the management they need by that time, pharmacological approach for behavioral symptoms, care giver 24h, supplies like diapers, etc. Even if they can benefit from anticholinesterasic drugs, they are usually not able to afford them.
Circunvalación del Hipocampo: How is usually diagnosis accepted by patients and family?
Dr. Boshe: It is not easily accepted. The expectation is that if there is a diagnosis identified by a doctor, then the next step would be a treatment that bring the patient back to his usual condition. In other cases, family or patients would not understand that it is an illness, this is more common for those that are found to have CI incidentally rather than the ones referred for this.
Circunvalación del Hipocampo: Are there specific characteristics of the local culture that makes it easier or more difficult to adapt and live with a diagnosis of dementia?
Dr. Boshe: It is true that I have not trained in Swahili, but sometimes limitations of the language contribute to make it difficult to explain it. Is there a word to say dementia in Swahili? The link between language and culture makes it more difficult to cope with the illness. Also words that are well known internationally as Alzheimer would not be familiar to most Tanzanians because people have other explanations for the phenomenon. In a way, our culture is also protective. In our communities, there are extended families. The elder is respected and never questioned. If the person gets cognitive difficulties, others will help to take care of that person.
Thus, the cohesion in the community help care delivery. Furthermore, the fact that the elder is respected is therapeutic in a way; as they are not directly confronted, people would find a way to rectify the error that is not psychologically harmful. When an elder starts to talk about things that he lived in the past, the family will not dismiss that but it will be embraced and enhanced. This is called in the Western world “reminiscence therapy” and people would pay a psychologist for it, and that comes very natural in our culture.
And then orientation is also enhanced by the fact that our culture has a strong routine, most daily activities are carried out like clockwork and happen in a predictable way. Finally, the fact that it is understood as a normal way of aging also supports a natural support of the process by other members of the community.
Howlett WP. Neurology in Africa: Clinical Skills and Neurological Disorders [on-line]. Cambridge: Cambridge University Press; 2015. Available from: http://ebooks.cambridge.org/ref/id/CBO9781316287064.
Longdon AR, Paddick S-M, Kisoli A, Dotchin C, Gray WK, Dewhurst F, et al. The prevalence of dementia in rural Tanzania: a cross-sectional community-based study: Dementia prevalence in rural older Tanzanians. International Journal of Geriatric Psychiatry 2013 Jul;28(7):728–37.
Lewis E, Paddick S-M, Banks J, Duinmaijer A, Tucker L, Kisoli A, et al. Prevalence of Delirium in Older Medical Inpatients in Tanzania. Journal of the American Geriatrics Society 2016 Sep;64(9):e28–9.
Dr Iago Rego García is a Medical doctor with interest in Public Health, running a community-based health program in rural Tanzania since 2013, and specialising in Neurology since 2016. He studied in Madrid, including exchanged in Slovenia and Argentina, and I has lived in Granada since 2016. He is passionate about the mountains, whether on his bike, climbing or just enjoying the fauna.