The Community Screening Interview for Dementia (CSI-D) has been widely used for dementia research among aging adults in low- and middle-income countries, where few specialists are available to diagnose and manage dementia. Yet, little is known about the psychometric validity of the participant interview, particularly among low-literacy individuals. We used factor analysis methods to assess and refine theoretically driven single- and multiple-factor structural models for the CSI-D participant interview using the population-based Zambian Cohort of Healthy Aging and Dementia (Z-CHAD) in Lusaka.
Trained community healthcare workers administered the CSI-D participant interview to 734 adults (68% female, mean age 66.9 years, mean education 7 years). For the four domains of cognitive functioning identified (memory, orientation, language, and visuospatial), single-factor models had satisfactory fit after the removal of five items with low factor loadings. The second-order factor model had adequate fit (confirmatory fit index = 0.96, root mean square error of approximation= 0.03, standardized root mean square residual = 0.08).
This factor structure of the CSI-D participant interview reasonably summarizes cognitive domain performance in this sample, yet there is a noticeable ceiling effect in items for orientation and language. Further, domains sensitive to dementia-related impairments, namely executive function, are not assessed. Alzheimer’s Disease and Alzheimer’s Disease Related Dementias (AD/ADRD) affect over 51 million people worldwide, with two-thirds of those living in low- and lower-middle income countries (LMICs) like Zambia1,2.
By 2050, the number of Zambian adults aged 60 and over is expected to increase to 3 million due to ongoing population growth as well as reductions in early childhood mortality3. The Zambian government has recognized the need for improved care for aging adults and, in 2015, introduced the National Policy on Aging4. Yet, informal caregivers continue to meet most care needs in Zambia and the number of healthcare providers with expertise in conditions that affect aging adults, particularly dementia, remains limited5.
Like several LMICs, Zambia has few neurologists and neuropsychologists6. Currently there are 18 Zambian neurologists and 39 neuropsychologists for over 21 million people. This expertise is concentrated at tertiary care centres in the capital city, Lusaka, whereas 60% of Zambians age 55 years and above reside in rural regions7.
Dementia prevalence in Zambia is largely unknown and may range from 4.6%, as in nearby Tanzania, to as high as 27%, as shown in one rural hospital-based study8,9. Dementia diagnosis in Zambia is limited by lack of access to neurocognitive expertise and is likely further compounded by limited community awareness of dementia. While there is a dearth of data regarding community knowledge and perceptions of dementia in Zambia, studies from nearby South Africa and Democratic Republic of Congo have found that cognitive impairment is highly stigmatized and often associated with misconceptions related to witchcraft10,11.
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