Access to community care for people with dementia and their informal carers : Case vignettes for a European comparison of structures and common pathways to formal care

BACKGROUND

People with dementia and their informal carers often do not receive appropriate professional support or it is not received at the right time.

OBJECTIVES

Description and comparison of common pathways to formal community dementia care in eight European countries as a part of the transnational Actifcare project.

MATERIALS AND METHODS

The German team was responsible for creating an individual case scenario as a starting point. The research teams in Ireland, Italy, the Netherlands, Norway, Portugal, Sweden, and the United Kingdom were then asked to describe a common pathway to formal dementia care by writing their own vignette using the provided individual case scenario.

RESULTS

A transnational qualitative content analysis was used to identify the following categories as being the most important: involved professionals, dementia-specific and team-based approaches, proactive roles, and financial aspects. General practitioners (GPs) are described as being the most important profession supporting the access to formal care in all the involved countries. In some countries other professionals take over responsibility for the access procedure. Dementia-specific approaches are rarely part of standard care; team-based approaches have differing significances in each of the countries. Informal carers are mainly proactive in seeking formal care. The Nordic countries demonstrate how financial support enhances access to the professional system.

CONCLUSION

Enhanced cooperation between GPs and other professions might optimize access to formal dementia care. Team-based approaches focusing on dementia care should be developed further. Informal carers should be supported and relieved in their role. Financial barriers remain which should be further investigated and reduced.

Role of Psychiatrists in Memory Clinics

Memory clinics (MCs) are multidisciplinary teams involved with early diagnosis and treatment of people with dementia. In this presentation, we will discuss several trends of the role of psychiatrists over the last twenty years, on the basis of five questionnaires that were sent to MCs every 5 years in the Netherlands.

MCs have developed in Europe using a range of service models but providing similar functions, which include assessment, information, treatment monitoring, education, training and research. MCs may vary among each other, and across countries. Psychiatrists used to play a coordinating role in most MCs, but there is now a tendency that MCs are more frequently led by other specialists, notably neurologists. In 1998 in the Netherlands, only a small minority of the MCs had a structural cooperation with local service providers, but 10 years later, most of them were collaborating with other regional care organizations. In most cases, the collaborating partner was a community mental health team or a long-term care facility.

Disclosure of interest

The author has not supplied his declaration of competing interest.

Assessing fitness to drive-A validation study on patients with mild cognitive impairment

OBJECTIVES

There is no consensus yet on how to determine which patients with cognitive impairment are able to drive a car safely and which are not. Recently, a strategy was composed for the assessment of fitness to drive, consisting of clinical interviews, a neuropsychological assessment, and driving simulator rides, which was compared with the outcome of an expert evaluation of an on-road driving assessment. A selection of tests and parameters of the new approach revealed a predictive accuracy of 97.4% for the prediction of practical fitness to drive on an initial sample of patients with Alzheimer's dementia. The aim of the present study was to explore whether the selected variables would be equally predictive (i.e., valid) for a closely related group of patients; that is, patients with mild cognitive impairment (MCI).

METHODS

Eighteen patients with mild cognitive impairment completed the proposed approach to the measurement of fitness to drive, including clinical interviews, a neuropsychological assessment, and driving simulator rides. The criterion fitness to drive was again assessed by means of an on-road driving evaluation. The predictive validity of the fitness to drive assessment strategy was evaluated by receiver operating characteristic (ROC) analyses.

RESULTS

Twelve patients with MCI (66.7%) passed and 6 patients (33.3%) failed the on-road driving assessment. The previously proposed approach to the measurement of fitness to drive achieved an overall predictive accuracy of 94.4% in these patients. The application of an optimal cutoff resulted in a diagnostic accuracy of 100% sensitivity toward unfit to drive and 83.3% specificity toward fit to drive. Further analyses revealed that the neuropsychological assessment and the driving simulator rides produced rather stable prediction rates, whereas clinical interviews were not significantly predictive for practical fitness to drive in the MCI patient sample.

CONCLUSIONS

The selected measures of the previously proposed approach revealed adequate accuracy in identifying fitness to drive in patients with MCI. Furthermore, a combination of neuropsychological test performance and simulated driving behavior proved to be the most valid predictor of practical fitness to drive.

Social health and dementia: a European consensus on the operationalization of the concept and directions for research and practice

BACKGROUND

Because the pattern of illnesses changes in an aging population and many people manage to live well with chronic diseases, a group of health care professionals recently proposed reformulating the static WHO definition of health towards a dynamic one based on the ability to physically, mentally and socially adapt and self-manage. This paper is the result of a collaborative action of the INTERDEM Social Health Taskforce to operationalize this new health concept for people with dementia, more specifically the social domain, and to formulate directions for research and practice to promote social health in dementia.

METHOD

Based on the expertise of the Social Health Taskforce members (N = 54) three groups were formed that worked on operationalizing the three social health dimensions described by Huber et al.: (1) capacity to fulfil potential and obligations; (2) ability to manage life with some degree of independence; (3) participation in social activities. For each dimension also influencing factors, effective interventions and knowledge gaps were inventoried. After a consensus meeting, the operationalizations of the dimensions were reviewed by the European Working Group of People with Dementia (EWGPWD).

RESULTS

The social health dimensions could be well operationalized for people with dementia and are assessed as very relevant according to the Social Health Taskforce and EWGPWD. Personal (e.g. sense of coherence, competencies), disease-related (e.g. severity of cognitive impairments, comorbidity), social (support from network, stigma) and environmental factors (e.g. enabling design, accessibility) that can influence the person with dementia's social health and many interventions promoting social health were identified.

CONCLUSION

A consensus-based operationalization of social health in dementia is proposed, and factors that can influence, and interventions that improve, social health in dementia identified. Recommendations are made for research and practice.

Access to timely formal dementia care in Europe: protocol of the Actifcare (ACcess to Timely Formal Care) study

Background

Previous findings indicate that people with dementia and their informal carers experience difficulties accessing and using formal care services due to a mismatch between needs and service use. This mismatch causes overall dissatisfaction and is a waste of the scarce financial care resources. This article presents the background and methods of the Actifcare (ACcess to Timely Formal Care) project. This is a European study aiming at best-practice development in finding timely access to formal care for community-dwelling people with dementia and their informal carers. There are five main objectives: 1) Explore predisposing and enabling factors associated with the use of formal care, 2) Explore the association between the use of formal care, needs and quality of life and 3) Compare these across European countries, 4) Understand the costs and consequences of formal care services utilization in people with unmet needs, 5) Determine the major costs and quality of life drivers and their relationship with formal care services across European countries.

Methods

In a longitudinal cohort study conducted in eight European countries approximately 450 people with dementia and informal carers will be assessed three times in 1 year (baseline, 6 and 12 months). In this year we will closely monitor the process of finding access to formal care. Data on service use, quality of life and needs will be collected.

Discussion

The results of Actifcare are expected to reveal best-practices in organizing formal care. Knowledge about enabling and predisposing factors regarding access to care services, as well as its costs and consequences, can advance the state of the art in health systems research into pathways to dementia care, in order to benefit people with dementia and their informal carers.

Prediction of Fitness to Drive in Patients with Alzheimer's Dementia

The number of patients with Alzheimer’s disease (AD) is increasing and so is the number of patients driving a car. To enable patients to retain their mobility while at the same time not endangering public safety, each patient should be assessed for fitness to drive. The aim of this study is to develop a method to assess fitness to drive in a clinical setting, using three types of assessments, i.e. clinical interviews, neuropsychological assessment and driving simulator rides. The goals are (1) to determine for each type of assessment which combination of measures is most predictive for on-road driving performance, (2) to compare the predictive value of clinical interviews, neuropsychological assessment and driving simulator evaluation and (3) to determine which combination of these assessments provides the best prediction of fitness to drive. Eighty-one patients with AD and 45 healthy individuals participated. All participated in a clinical interview, and were administered a neuropsychological test battery and a driving simulator ride (predictors). The criterion fitness to drive was determined in an on-road driving assessment by experts of the CBR Dutch driving test organisation according to their official protocol. The validity of the predictors to determine fitness to drive was explored by means of logistic regression analyses, discriminant function analyses, as well as receiver operating curve analyses. We found that all three types of assessments are predictive of on-road driving performance. Neuropsychological assessment had the highest classification accuracy followed by driving simulator rides and clinical interviews. However, combining all three types of assessments yielded the best prediction for fitness to drive in patients with AD with an overall accuracy of 92.7%, which makes this method highly valid for assessing fitness to drive in AD. This method may be used to advise patients with AD and their family members about fitness to drive.

Can FreeSurfer Compete with Manual Volumetric Measurements in Alzheimer's Disease?

Alzheimer's disease-related pathology results in tremendous structural and functional changes in the brain. These morphological changes might lead to a less precise performance of automated brain segmentation techniques in AD-patients, which in turn could possibly lead to false allocations of gray matter, white matter or cerebrospinal fluid. FreeSurfer has been shown to operate as an accurate and reliable instrument to measure cortical thickness and volume of neuroanatomical structures. Considering the principal role of FreeSurfer in the imaging field of AD, the present study aims to investigate the robustness of FreeSurfer to capture morphological changes in the brain against varying processing variables in comparison to manual measurements (the gold standard). T1-weighted MRI scan data were used pertaining to a sample of 53 individuals (18 healthy participants, 18 patients with mild cognitive impairment, and 18 patients with mild AD). Data were analyzed with different FreeSurfer versions (v4.3.1, v4.5.0, v5.0.0, v5.1.0), on a custom-built cluster (LINUX) and a Macintosh (UNIX) workstation. Group differences across versions and workstations were most consistent for both the hippocampus and posterior cingulate, regions known to be affected in the earliest stages of the disease. The results showed that later versions of FreeSurfer were more sensitive to identify group differences and corresponded best with the results of gold standard manual volumetric methods. In conclusion, later versions of FreeSurfer were more accurate than earlier versions, especially in medial temporal and posterior parietal regions. This development is very promising for future applications of FreeSurfer in research studies and encourages the future role of FreeSurfer output as a candidate marker in clinical practice.

Usually Available Clinical and Laboratory Data Are Insufficient for a Valid Medication Review: A Crossover Study

OBJECTIVES

To establish the quality of medication reviews performed by nursing home physicians, general practitioners and pharmacists.

DESIGN AND SETTING

15 Pharmacists, 13 general practitioners and 18 nursing home physicians performed a medication review for three cases (A, B and C), at three evaluation moments. First, they received the medication list. Secondly, they also received laboratory results and reason for admission and finally, we added medical history. Remarks were divided into 6 categories, i.e. indication without medication, medication without indication, contraindications/ interactions, dosage problems, double medication and wrong medication. Remarks were compared to the remarks made by our expert panel and scored according to our grading model as appropriate (0 to +3) or missed or potentially harmful (-1). For each medication error category, the percentage of participants who made this error was computed.

RESULTS

After the first evaluation moment, the overall estimated mean percentage score was -1.7% for case A, 3.9% for case B, and 8.7% for case C. After the second review, this score was 15.0% for case A, 19.8% for case B, and 22.2% for case C. This further increased to 30.0% for case A, 36.7% for case B and 44% for case C at the final evaluation. The absence of medication where there was an indication (indication without medication) was frequently missed and did not improve after adding the extra information regarding laboratory results, reason for admission and finally medical history.

CONCLUSION

Increasing clinical information helps physicians and pharmacists to improve their medication reviews, however, additional information was still related with a high margin of error. Detection of certain errors becomes easier with additional information, whereas other errors remain undetected. To achieve a high standard of medication review, we have to change the way medication reviews should be performed.

Comparative study of clinical and neuropsychological characteristics between early-, late and very-late-onset schizophrenia-spectrum disorders

OBJECTIVE

To compare the clinical and neurocognitive profile of early-onset (EOP, <40 years), late-onset (LOP, 40-59 years) and very-late-onset (VLOP, ≥60 years) psychosis.

DESIGN

Cross-sectional observational study.

SETTING

Secondary, tertiary, and community mental health care.

PARTICIPANTS

Patients with a DSM-IV diagnosis of non-affective psychotic disorder were included from two complementary studies (GROUP and PSITE) on genetic and environmental risk factors of psychosis in the Netherlands and Belgium.

MEASUREMENTS

Main outcome measures were the severity of positive and negative symptoms, quality of life, and age-corrected scores on measures of general intelligence, verbal memory, attention, and executive function. One-year follow-up data were used to validate diagnoses and exclude participants with possible or probable dementia.

RESULTS

286 EOP (85%), 24 LOP (7%) and 28 VLOP (8%) participated. VLOP patients reported significantly more positive symptoms than EOP patients. Age-at-onset groups had similar age-corrected scores on IQ, verbal memory, attention and executive functions. A significantly better performance was found in VLOP compared with LOP on the CAMCOG total score, though scores were still within the normal range. After controlling for possible confounding, however, VLOP differed significantly on an attention accuracy task compared with LOP patients. Re-entering data for probable dementia patients (N = 4) did change the results regarding cognition outcomes.

CONCLUSIONS

VLOP patients show more positive symptoms but do not appear to differ on neuropsychological tests from EOP and LOP when age is controlled for. This questions the idea that VLOP is the expression of underlying neurodegeneration.

Ecological Assessment of Autonomy in Instrumental Activities of Daily Living in Dementia Patients by the Means of an Automatic Video Monitoring System

Currently, the assessment of autonomy and functional ability involves clinical rating scales. However, scales are often limited in their ability to provide objective and sensitive information. By contrast, information and communication technologies may overcome these limitations by capturing more fully functional as well as cognitive disturbances associated with Alzheimer disease (AD). We investigated the quantitative assessment of autonomy in dementia patients based not only on gait analysis but also on the participant performance on instrumental activities of daily living (IADL) automatically recognized by a video event monitoring system (EMS). Three groups of participants (healthy controls, mild cognitive impairment, and AD patients) had to carry out a standardized scenario consisting of physical tasks (single and dual task) and several IADL such as preparing a pillbox or making a phone call while being recorded. After, video sensor data were processed by an EMS that automatically extracts kinematic parameters of the participants’ gait and recognizes their carried out activities. These parameters were then used for the assessment of the participants’ performance levels, here referred as autonomy. Autonomy assessment was approached as classification task using artificial intelligence methods that takes as input the parameters extracted by the EMS, here referred as behavioral profile. Activities were accurately recognized by the EMS with high precision. The most accurately recognized activities were “prepare medication” with 93% and “using phone” with 89% precision. The diagnostic group classifier obtained a precision of 73.46% when combining the analyses of physical tasks with IADL. In a further analysis, the created autonomy group classifier which obtained a precision of 83.67% when combining physical tasks and IADL. Results suggest that it is possible to quantitatively assess IADL functioning supported by an EMS and that even based on the extracted data the groups could be classified with high accuracy. This means that the use of such technologies may provide clinicians with diagnostic relevant information to improve autonomy assessment in real time decreasing observer biases.

The trajectory of cognitive decline in the pre-dementia phase in memory clinic visitors: findings from the 4C-MCI study

BACKGROUND

We investigated the course of decline in multiple cognitive domains in non-demented subjects from a memory clinic setting, and compared pattern, onset and magnitude of decline between subjects who progressed to Alzheimer's disease (AD) dementia at follow-up and subjects who did not progress.

METHOD

In this retrospective cohort study 819 consecutive non-demented patients who visited the memory clinics in Maastricht or Amsterdam between 1987 and 2010 were followed until they became demented or for a maximum of 10 years (range 0.5-10 years). Differences in trajectories of episodic memory, executive functioning, verbal fluency, and information processing speed/attention between converters to AD dementia and subjects remaining non-demented were compared by means of random effects modelling.

RESULTS

The cognitive performance of converters and non-converters could already be differentiated seven (episodic memory) to three (verbal fluency and executive functioning) years prior to dementia diagnosis. Converters declined in these three domains, while non-converters remained stable on episodic memory and executive functioning and showed modest decline in verbal fluency. There was no evidence of decline in information processing speed/attention in either group.

CONCLUSIONS

Differences in cognitive performance between converters to AD dementia and subjects remaining non-demented could be established 7 years prior to diagnosis for episodic memory, with verbal fluency and executive functioning following several years later. Therefore, in addition to early episodic memory decline, decline in executive functions may also flag incident AD dementia. By contrast, change in information processing speed/attention seems less informative.

Automatic speech analysis for the assessment of patients with predementia and Alzheimer's disease

Background

To evaluate the interest of using automatic speech analyses for the assessment of mild cognitive impairment (MCI) and early-stage Alzheimer's disease (AD).

Methods

Healthy elderly control (HC) subjects and patients with MCI or AD were recorded while performing several short cognitive vocal tasks. The voice recordings were processed, and the first vocal markers were extracted using speech signal processing techniques. Second, the vocal markers were tested to assess their “power” to distinguish among HC, MCI, and AD. The second step included training automatic classifiers for detecting MCI and AD, using machine learning methods and testing the detection accuracy.

Results

The classification accuracy of automatic audio analyses were as follows: between HCs and those with MCI, 79% ± 5%; between HCs and those with AD, 87% ± 3%; and between those with MCI and those with AD, 80% ± 5%, demonstrating its assessment utility.

Conclusion

Automatic speech analyses could be an additional objective assessment tool for elderly with cognitive decline.

Prevalence and prognosis of Alzheimer's disease at the mild cognitive impairment stage

Three sets of research criteria are available for diagnosis of Alzheimer's disease in subjects with mild cognitive impairment: the International Working Group-1, International Working Group-2, and National Institute of Aging-Alzheimer Association criteria. We compared the prevalence and prognosis of Alzheimer's disease at the mild cognitive impairment stage according to these criteria. Subjects with mild cognitive impairment (n = 1607), 766 of whom had both amyloid and neuronal injury markers, were recruited from 13 cohorts. We used cognitive test performance and available biomarkers to classify subjects as prodromal Alzheimer's disease according to International Working Group-1 and International Working Group-2 criteria and in the high Alzheimer's disease likelihood group, conflicting biomarker groups (isolated amyloid pathology or suspected non-Alzheimer pathophysiology), and low Alzheimer's disease likelihood group according to the National Institute of Ageing-Alzheimer Association criteria. Outcome measures were the proportion of subjects with Alzheimer's disease at the mild cognitive impairment stage and progression to Alzheimer's disease-type dementia. We performed survival analyses using Cox proportional hazards models. According to the International Working Group-1 criteria, 850 (53%) subjects had prodromal Alzheimer's disease. Their 3-year progression rate to Alzheimer's disease-type dementia was 50% compared to 21% for subjects without prodromal Alzheimer's disease. According to the International Working Group-2 criteria, 308 (40%) subjects had prodromal Alzheimer's disease. Their 3-year progression rate to Alzheimer's disease-type dementia was 61% compared to 22% for subjects without prodromal Alzheimer's disease. According to the National Institute of Ageing-Alzheimer Association criteria, 353 (46%) subjects were in the high Alzheimer's disease likelihood group, 49 (6%) in the isolated amyloid pathology group, 220 (29%) in the suspected non-Alzheimer pathophysiology group, and 144 (19%) in the low Alzheimer's disease likelihood group. The 3-year progression rate to Alzheimer's disease-type dementia was 59% in the high Alzheimer's disease likelihood group, 22% in the isolated amyloid pathology group, 24% in the suspected non-Alzheimer pathophysiology group, and 5% in the low Alzheimer's disease likelihood group. Our findings support the use of the proposed research criteria to identify Alzheimer's disease at the mild cognitive impairment stage. In clinical settings, the use of both amyloid and neuronal injury markers as proposed by the National Institute of Ageing-Alzheimer Association criteria offers the most accurate prognosis. For clinical trials, selection of subjects in the National Institute of Ageing-Alzheimer Association high Alzheimer's disease likelihood group or the International Working Group-2 prodromal Alzheimer's disease group could be considered.

Unmet needs and health-related quality of life in young-onset dementia

OBJECTIVES

Young-onset dementia (YOD) causes specific challenges and issues that are likely to affect health-related quality of life (HRQOL). This study explored patient and caregiver HRQOL and its association with unmet needs in YOD.

METHODS

A cross-sectional design was used to study 215 community-dwelling YOD patients and their primary caregivers. Multiple linear regression analyses were performed to determine the relationship between unmet needs assessed with the Camberwell Assessment of Need for the Elderly scale and patient and caregiver HRQOL, controlling for other variables such as demographic characteristics, patient functional status, neuropsychiatric symptoms, and caregiver sense of competence.

RESULTS

Patient HRQOL was not associated with unmet needs. However, we found that the unmet needs of both patient and caregiver were related to several domains of caregiver HRQOL.

CONCLUSIONS

This study shows that patient and caregiver unmet needs are related to caregiver HRQOL in YOD. However, the relationship between HRQOL and unmet needs is complex. The assessment of unmet needs within the context of HRQOL seems to be an important prerequisite for personalizing care in YOD. Adjusting supportive services to match the individual needs and preferences of these young patients and their caregivers is likely to enhance their quality of life.

A review of current information and communication technologies: can they be used to assess apathy?

BACKGROUND

Neuropsychiatric symptoms, such as apathy, have an important impact on the quality of life of both patients diagnosed with dementia and their caregivers and represent a strong predictor of progression of the illness. Current clinical assessment methods risk bias resulting from the assessor's subjectivity, pointing to a need for additional objective and systematic assessment tools. Therefore, the use of information and communication technologies (ICT) such as actigraphy and automatized video monitoring are of interest in addition to current assessment methods.

AIM

The goal of this study is to give an overview of current assessment tools for apathy in clinical practice and new approaches to assessment methods with the help ICT.

METHODS

This study was conducted with the use of narrative literature overview.

RESULTS

There is evidence that apart from the currently used assessment methods for apathy, new ICT approaches could provide clinicians with valuable additional information for an earlier detection and therefore more accurate diagnosis of apathy.

CONCLUSIONS

There are no ICT techniques specifically designed for the assessment of apathy, but nevertheless several techniques seem to be promising and deserve more study.