Community-based dementia screening initiative in Brunei: pilot study
Abstract
Objective. To screen older people and /or those with risk factors for dementia in the community to identify risk factors and possible symptoms of dementia
Methods. A community-based cross-sectional survey was conducted among older people aged 60 years and older or aged 50 years and older with non-communicable diseases or risk factors for developing dementia. Participants were recruited from Senior Citizen Activity Centres and other areas where older people meet in the community, such as marketplaces. Participants completed a structured, self-administered questionnaire regarding self-reported dementia risk factors, cognitive symptoms, concerns regarding symptoms and a brief cognitive assessment tool (Mini-COG). This approach was piloted in the Senior Citizen Activity Centres.
Results. There were 178 participants, median age 67 years with two-thirds being female. Two-thirds had hypertension and over 40% had hypercholesterolaemia. The most commonly reported symptoms were misplacing things (41.6%), visuospatial difficulties (22.7%) and forgetfulness (20.8%). Among those with symptoms, 7.3% reported worsening symptoms, 5.1% had impaired activities of daily living, and 22.5% thought they should get their cognition assessed. For the Mini-COG, 65% recalled all 3 words, while a quarter made at least one error in the clock-drawing test.
Conclusions. Community-based dementia screening using a questionnaire on risk factors, cognitive symptoms and the Mini-COG was feasible and acceptable in Brunei. Despite participants being socially active, there was a surprisingly high prevalence of risk factors for dementia and symptoms of possible cognitive impairment. Further roll-out of the community screening is planned in other locations.
INTRODUCTION
Dementia is a progressive neurological condition affecting memory, cognition and behaviour, causing impairment in activities of daily living (ADL) 1. Dementia is the leading cause of disability in older people and the number of people with dementia will increase rapidly with the projected global trend in population ageing 2.
Brunei is a small country in South East Asia with a population of approximately 442,000. There is a concern regarding a significant increase in dementia incidence in Brunei due to its rapid increase in the proportion of older people and a high rate of non-communicable diseases, such as hypertension, diabetes mellitus, ischaemic heart disease, stroke, and renal impairment, which are risk factors for dementia 3,4. Based on the Global Burden of Disease Study 2019, there was an estimated 1574 people living with dementia in Brunei in 2019, which is predicted to increase to 7317 by 2050 2 .
The World Health Organisation (WHO) Global action plan on the public health response to dementia 2017-2025 lays out actions and targets for member states; one of which is ‘in at least 50% of countries, as a minimum, 50% of the estimated number of people with dementia are diagnosed by 2025’ 1. However, based on ICD-10 codes related to dementia obtained from national electronic health records (Bru-HIMS) in Brunei, there were only 291 (18.5%) people identified 5. In addition, people with dementia tend to present late to clinical services, mainly due to complications such as falls, immobility, and aspiration pneumonia 6. This may be due to poor public awareness regarding dementia and not seeking medical attention for cognitive symptoms.
During the COVID-19 pandemic, information regarding dementia and support in Brunei was disseminated via social media 7. The post-pandemic recovery period is an opportunity to strengthen community awareness regarding dementia to facilitate early diagnosis, particularly with the advent of new amyloid-targeted treatment 8, and risk reduction measures as a public health approach to reduce dementia incidence 9.
One of the initiatives carried out to improve awareness and facilitate early diagnosis in Brunei was a community-based screening project. The aim of the study was to screen older people and those with risk factors for dementia, identify risk factors and potential symptoms in the community, and provide information to raise awareness of dementia risk factors, symptoms, and risk reduction. In this paper, the community-based screening for dementia initiative is described, with findings from the pilot phase.
METHODS
This was a community cross-sectional survey with cluster sampling of older people aged 60 years and older or aged 50 years and older with non-communicable diseases or risk factors for developing dementia carried out between June to September 2022. Participants were recruited from Senior Citizen Activity Centres and other areas where older people meet in the community, such as marketplaces.
The inclusion criteria for the study were people aged 60 years and older or 50 years and older with non-communicable diseases or risk factors for developing dementia, including but not limited to cardiac disease, diabetes mellitus, renal impairment, and previous stroke, able to read and write in English or Malay, or accompanied by family members who can assist and translate, and able to consent to participate. Interested participants outside the target age groups were still allowed to join the awareness talks, fill out the questionnaire and receive information regarding dementia but would be excluded from analysis. Participants who had difficulty reading or writing in English or Malay were given assistance to complete the forms. Exclusion criteria included severe sensory impairment, acute medical illness, or inability to participate meaningfully in the screening session.
Currently, available cognitive assessment tools have not yet been validated in Brunei 10.
The screening used a structured, self-administered questionnaire, which consists of questions regarding basic demographics, risk factors, symptoms of possible cognitive deficits, whether symptoms (if present) are worsening or affecting ADLs, whether they had concerns regarding cognition or feel they should have cognitive testing done. The brief cognitive screening test used was the Mini-COG, which consists of three-word registration, the clock-drawing test and three-word recall 11. The screening tool used and the rationale for the questions are shown in Table I.
The questionnaire may be administered individually or done in a group setting. For the pilot at the four Senior Citizen Activity Centres, the screening session was scheduled as part of the regular health awareness talks for older people organised by the Health Promotion Centre. Participants were invited to the dementia talk covering dementia symptoms, risk factors and risk reduction approaches. Participants were given the information sheet, consent form and questionnaire before the talk. After the presentation, they were guided as a group by the facilitator and roving assistants to work through the questionnaire. They were also given information sheets on dementia risk factors, symptoms and risk reduction. Participants with concerns or issues identified from the questionnaire were encouraged to seek medical attention from primary care for further evaluation and management.
Data collected was entered into Microsoft Excel and analysed using R-Studio. Continuous variables were summarized as medians with ranges, and categorical variables as frequencies with percentages. Univariate comparisons between male and female participants were performed using Mann-Whitney U tests for continuous variables, and chi-square tests or Fisher’s exact tests for categorical variables. Cross-sectional associations between dementia risk factors and cognitive outcomes using binomial logistic regression models was explored, adjusting for age, gender and education level. Statistical significance was set at p < 0.05.
RESULTS
There were 187 participants screened, among whom 178 (95.2%) met the age inclusion criteria. Median age was 67 years (range 51 to 81 years). There were 60 (33.7%) males and 118 (66.3%) females. In terms of education, while 66 (37.1%) did not respond to this question, there were 109 (61.2%) who had at least primary level education. There was a high prevalence of dementia risk factors; about two-thirds had high blood pressure, 75 (42.1%) had high cholesterol, a quarter had diabetes mellitus and one-fifth were overweight. The most common cognitive symptoms were misplacing things in 74 (41.6%), visuospatial difficulties in 40 (22.7%), forgetfulness in 37 (20.8%), and difficulty making judgements in 24 (13.5%). Figures 1 and 2 illustrate the distribution of risk factors and cognitive symptoms respectively.
Table II summarises the characteristics of male and female participants. Males had a higher median age. There were no statistically significant differences in prevalence of risk factors between genders. Cognitive symptoms were also similar between genders, although male participants were more likely to report difficulty keeping track of things (p = 0.013) and less likely to report changes in mood or behaviour.
For those with symptoms, 13 (7.3%) thought they were getting worse, 9 (5.1%) felt symptoms affected ADLs, and 22.5% thought they should get their memory checked. For the Mini-COG, 65% could recall all 3 words. One-quarter had at least an error in the clock-drawing test. Among the 142 participants that completed the Mini-COG, 16 (11.3%) may have cognitive impairment.
Associations between dementia risk factors and cognitive deficits were evaluated using logistic regression, adjusting for age, gender and education. Lower education levels (primary level) was associated with higher odds of difficulty performing tasks (OR 53, p = 0.021) and impaired judgement (OR 25, p = 0.015) respectively. Male gender was associated with increased odds of difficulty keeping track of things (OR 6.1) but lower odds of mood or behaviour changes (OR 0.2, p = 0.032). There were no significant associations found between the other risk factors, other cognitive symptoms and Mini-COG scores. However, several logistic regression models showed convergence warnings, likely due to small sample size, outcome events, or collinearity. Thus, these findings should be interpreted cautiously.
DISCUSSION
This paper describes the preliminary findings from a pilot of a community-based dementia screening initiative. The questionnaire asks participants regarding whether they had risk factors, symptoms, followed by the Mini-COG as a brief cognitive test. After competing the questionnaire, participants were given information regarding risk factors, encouraged to attend primary care services if they were unaware regarding their risk factors, not seen regularly or poorly controlled. They were also informed regarding symptoms suggestive of cognitive impairment and to see a doctor if present, especially if they were worsening or affecting ADLs. This approach personalised the information given to the participant’s risk factors and symptoms, with an emphasis on the importance of prevention.
An online survey carried out in south Switzerland and north Italy showed that misconceptions about dementia were common, and there was a general lack of knowledge regarding dementia causes, characteristics, risk factors and risk reduction 13. A Flemish study showed that up to 65% of participants were not aware of opportunities for dementia risk reduction, which improved after a public health campaign 14. These factors combined with the concern regarding a dramatic increase in dementia incidence in Brunei prompted the dementia screening initiative. While this was a pilot phase, there was already a surprisingly high rate of risk factors and symptoms among the Senior Citizen Activity Centre members, a group thought to be more physically and socially active compared to non-members.
A similar community screening approach carried out in a primary care centre in India found over 40% of possible dementia, with detection of comorbid vascular risk factors useful, as these can be managed along with cognitive impairment for risk reduction, and strengthen non-communicable disease screening and management 15. While our screening initiative took place outside primary care, participants were permitted to take a copy of their questionnaire as a basis for discussion during their next clinical consultation. The questionnaire was easily adapted into a ‘self-referral’ form, summarizing their risk factors, symptoms, or Mini-COG scores.
In this study, there were significant associations found between low education attainment and specific cognitive deficits, including difficulty performing familiar tasks and impaired judgement. This is consistent with previous research identifying low education as a risk factor for dementia 9. The association between male gender and difficulty keeping track of things, but lower reporting of mood or behavioural changes, may reflect gendered differences in symptom perception or willingness to report emotional concerns. This has been observed in other community studies, where men are often under-represented in help-seeking behaviours for cognitive and mental health symptoms 16.
The pilot phase showed that it was feasible to carry out this community-based dementia screening initiative in Brunei. This experience also found that the public found answering the questionnaire acceptable and were interested to know more about risk factors, symptoms and risk reduction for dementia.
CONCLUSIONS
While participants from the Senior Citizen Activity Centres are physically and socially active within the community, there was a surprisingly high prevalence of risk factors for dementia and symptoms of possible cognitive impairment. Further roll-out of the community screening is planned in other locations in Brunei.
Acknowledgements
We would like to acknowledge support from the Health Promotion Centre, Ministry of Health, Ministry of Culture Youth and Sports, Universiti Brunei Darussalam and Demensia Brunei for this community screening programme. We would also like to thank the community volunteers and respondents for their interest and participation in the study.
Conflict of interest statement
The authors declare no conflict of interest.
Funding
This study was supported by a grant received from the Davos Alzheimer’s Collaborative under the Healthcare System Preparedness Early Detection programme. The sponsor was not involved in the research process such as study design, data analysis, interpretation or writing the manuscript.
Author contributions
All authors were involved in conceptualisation and design of the study, data collection, analysis, interpretation, drafting and finalizing the manuscript.
Ethical consideration
This study was approved by the Medical and Health Research and Ethics Committee, Ministry of Health, Brunei Darussalam Reference MHREC/MOH/2022/14(1).
History
Received: March 15, 2025
Accepted: July 28, 2025
Figures and tables
Figure 1.Distribution of risk factors for dementia.
Figure 2.Distribution of warning signs/symptoms of dementia.
| Question | Rationale |
|---|---|
| Screening location | |
| Age | Older age, female gender, limited or low level of education and less cognitively stimulating occupations are associated with higher risk of cognitive impairment |
| Gender | |
| Education | |
| Occupation | |
| High blood pressure | Participants are asked to self-declare whether they have these conditions that are associated with risk of dementia. The responses participants may select are: Yes/No/ Don’t Know. If a participant selects ‘Yes’, they are advised that to seek regular review with primary care and ensure the risk factors are managedFor those who ‘Don’t Know’, they are also advised to seek review with primary care, as people aged 40 years and older are advised to get screened for non-communicable diseases |
| High cholesterol | |
| Diabetes mellitus | |
| Heart disease | |
| Lung disease | |
| Liver disease | |
| Kidney disease | |
| Previous head injuries | |
| Previous stroke | |
| Overweight | |
| Smoking | |
| Forgetfulness | Participants are asked if they have these symptoms or difficulty performing these tasks. These are the ’10 warning signs for dementia’12If a participant selects ‘Yes’, they are informed that there may be a reason for suboptimal cognitive function and advised to seek review with primary care for further assessment i.e. these do not confirm a diagnosis of dementia |
| Performing familiar tasks | |
| Language/word finding | |
| Orientation to time and place | |
| Judgement | |
| Keeping track of things | |
| Misplacing things | |
| Changes in mood/behaviour | |
| Visuospatial difficulties | |
| Withdrawing from work or social activities | |
| Are symptoms getting worse? | Diagnostic criteria for dementia, causing progressive decline in cognitive function |
| Are they affecting ADLs? | |
| Do you think you need to get your memory checked? | Single Screening Question for cognitive concerns |
| Mini-COG:3-item registrationClock Drawing Test (CDT)3 item recall | An additional screening test was added, as anecdotally, older people in Brunei tend to minimize symptoms.Scoring:3 item recall:Score 0 – suspected dementia;Score 3 – dementia unlikely;Score 1 or 2 – if CDT normal, dementia unlikely; if CDT abnormal, suspected dementia |
| Variable | Male (N = 60) | Female (N = 118) | p value |
|---|---|---|---|
| Age, Median (range) | 69.5 (54-81) | 66.0 (51-81) | 0.002 |
| Education Level: | 0.217 | ||
| Primary | 6 (10%) | 7 (5.9%) | |
| Secondary | 24 (40%) | 50 (42.4%) | |
| Tertiary | 9 (15%) | 13 (11.0%) | |
| High blood pressure | 35 (58.3%) | 76 (64.4%) | 0.531 |
| High cholesterol | 21 (35%) | 54 (45.8%) | 0.225 |
| Diabetes mellitus | 15 (25%) | 34 (28.8%) | 0.718 |
| Heart disease | 9 (15%) | 9 (7.6%) | 0.201 |
| Lung disease | 2 (3.3%) | 5 (4.2%) | 1.0 |
| Liver disease | 2 (3.3%) | 4 (3.4%) | 1.0 |
| Kidney disease | 2 (3.3%) | 3 (2.5%) | 1.0 |
| Previous head injuries | 2 (3.3%) | 1 (0.8%) | 0.263 |
| Previous stroke | 0 (0%) | 0 (0%) | N/A |
| Overweight | 8 (13.3%) | 29 (24.6%) | 0.121 |
| Smoking | 2 (3.3%) | 1 (0.8%) | 0.263 |
| Memory loss/forgetfulness | 12 (20%) | 25 (21.1%) | 1.0 |
| Difficulty performing familiar tasks | 6 (10%) | 11 (9.3%) | 1.0 |
| Language/word finding difficulty | 4 (6.7%) | 10 (8.5%) | 0.776 |
| Disoriented to time/place | 8 (13.3%) | 13 (11.0%) | 0.836 |
| Difficulty making judgements | 9 (15%) | 15 (12.7%) | 0.849 |
| Problem keeping track of things | 8 (13.3%) | 5 (4.2%) | 0.057 |
| Misplacing things | 21 (35%) | 53 (44.9%) | 0.268 |
| Changes in mood/behaviour | 3 (5%) | 18 (15.3%) | 0.051 |
| Visuospatial difficulties | 13 (21.7%) | 27 (22.9%) | 1.0 |
| Withdrawing from work or social activities | 3 (5%) | 5 (4.2%) | 1.0 |
| Are symptoms worsening? | 4 (6.7%) | 9 (7.6%) | 1.0 |
| Are they affecting ADLs? | 5 (8.3%) | 4 (3.4%) | 0.167 |
| Should your memory get checked? | 16 (26.7%) | 24 (20.3%) | 0.444 |
| Mini-COG outcome (suspected impairment) | 8 (13.3%) | 8 (6.8%) | 0.093 |
| Only ‘Yes’ responses are presented for dichotomous variables. The other responses are excluded from this table but accounted for in analyses. | |||
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