Minority ethnic groups in dementia care: a review of service needs, service provision and models of good practice

Assessment of dementia in ethnic minority patients in Europe: a European Alzheimer's Disease Consortium survey

BACKGROUND

In most European countries the ethnic minority migrant populations are currently reaching an age where dementia becomes an increasingly important issue. There is no European consensus on good clinical practice with these patient groups, who often have special needs and expectations with regard to dementia services.

METHODS

A survey was conducted in clinical dementia centers in 15 European countries. Questionnaires focusing on different points in the clinical assessment of dementia in ethnic minority patients were mailed to leading dementia experts of the European Alzheimer's Disease Consortium.

RESULTS

Thirty-six centers from 15 countries responded to the survey. Ethnic minority patients were seen on a regular basis in 69% of these centers. The diagnostic evaluation was in accordance with evidence-based clinical guidelines in 84-100% of the centers, but most centers performed cognitive assessment with instruments that are only validated in Western cultures and frequently relied on family members for interpretation. Diagnostic evaluation of the patients was considered to be challenging in 64% of the centers, mainly because of communication problems and lack of adequate assessment tools. In general, there were few indicators of culturally sensitive dementia services in the centers.

CONCLUSIONS

Ethnic minority patients are seen on a regular basis in European dementia clinics. Assessment of such patients is difficult for a number of reasons. Results from this study show that the most challenging issues are communication problems and assessment of cognitive function where there is a need to develop specific tests for ethnic minority patients.

A systematic review of ethnicity and pathways to care in dementia

OBJECTIVE

To explore why people from minority ethnic (ME) groups with dementia present later to specialist diagnostic and therapeutic dementia services. We systematically reviewed the literature exploring how and why ME people with dementia present to specialist services.

METHOD

We included qualitative and quantitative studies that explored pathways to dementia specialist care in ME groups or determinants of whether ME people with dementia accessed specialist services. Included studies were independently evaluated for quality by two authors.

RESULTS

We found 3 quantitative and 10 qualitative papers meeting our inclusion criteria. Barriers to accessing specialist help for dementia included: not conceptualizing dementia as an illness; believing dementia was a normal consequence of ageing; thinking dementia had spiritual, psychological, physical health or social causes; feeling that caring for the person with dementia was a personal or family responsibility; experiences of shame and stigma within the community; believing there was nothing that could be done to help; and negative experiences of healthcare services. Recognition of dementia as an illness and knowledge about dementia facilitated accessing help.

CONCLUSIONS

There are significant barriers to help seeking for dementia in ME groups. These may explain why people from ME groups often presented to therapeutic and diagnostic services at a late stage in their illness. Further study is needed to elucidate the role that ethnicity and culture play in the help-seeking pathway for dementia, and to design and test interventions to improve equity of access to healthcare services.

A systematic review and meta-analysis of ethnic differences in use of dementia treatment, care, and research

The number of people with dementia from minority ethnic (ME) groups in western countries is projected to rise dramatically, and they may be less able to access dementia services. To compare the use of health and social services, treatments for dementia and dementia research between different ethnic groups. A systematic review of 33 articles fitting predetermined criteria. Compatible results were pooled in a meta-analysis. ME people with dementia were more cognitively impaired, and Hispanic people reported a longer duration of memory loss than non-ME people, at the time of referral to diagnostic dementia services in the United States and Australia {pooled weighted mean difference on Mini-Mental State Examination = 3.48 (95% confidence interval [CI]: 2.87-4.09); z = 11.19, p <0.0001; N = 2,090}. These differences remained after controlling for premorbid level of education. The use of community social services did not vary between ME and non-ME people with dementia, but African Americans were 30% less likely to be prescribed cholinesterase inhibitors {odds ratio (OR) 0.7 [0.6-0.9]; z = -3.1, p = 0.002; N = 175}, and ME groups were underrepresented in U.S. dementia drug trials. ME people with dementia were 40% less likely to enter 24-hour care (pooled hazard ratio 0.59 [95% CI: 0.52-0.69]; z = -7.15, p <0.0001; N = 12,053). The authors found consistent evidence, mostly from the United States, that ME people accessed diagnostic services later in their illness, and once they received a diagnosis, were less likely to access antidementia medication, research trials, and 24-hour care. Increasing community engagement and specific recruitment strategies for ME groups might help address inequalities, and these need to be evaluated. More research is also needed to evaluate ME access to dementia services outside the United States.

What do community-dwelling people with dementia need? A survey of those who are known to care and welfare services

BACKGROUND

The aging society will bring an increase in the number of people with dementia living in the community. This will mean a greater demand on care and welfare services to deliver efficient and customized care, which requires a thorough understanding of subjective and objective care needs. This study aims to assess the needs of community-dwelling people with dementia as reported by themselves and by their informal carers. The study also aims to give insight into the service use and gaps between needs and the availability of services.

METHODS

236 community-dwelling people with dementia and 322 informal carers were interviewed separately. (Un)met needs were assessed using the Camberwell Assessment of Needs for the Elderly (CANE).

RESULTS

Most unmet needs were experienced in the domains of memory, information, company, psychological distress and daytime activities. People with dementia reported fewer (unmet) needs than their carers. Type and severity of dementia, living situation and informal carer characteristics were related to the number of reported needs.

CONCLUSIONS

This study showed a large number of unmet needs in dementia. Reasons for unmet needs are lack of knowledge about the existing service offer, a threshold to using services and insufficient services offer. These results provide a good starting point for improving community care for people with dementia.

'It's like a revolving door syndrome': professional perspectives on models of access to services for people with early-stage dementia

As the need for services for people with dementia grows, and the benefits of early intervention become clear, it has become important to understand what factors may improve access to services for people with early-stage dementia. There are a number of models of service access, and these emphasise different areas, whether individual factors, relationships, or social context. The relevance of these models to variations in service access for people with early-stage dementia, and how well they relate to professional accounts, is not well known. In this study, 30 key professionals were interviewed about access to services for people with early-stage dementia in order to explore how different models of access were reflected in their own understandings. People with early-stage dementia were thought to have a range of complex needs, but participants felt these needs remained largely unmet. When articulating the reasons why they thought needs were unmet, participants focused on the impact of the framework within which services are delivered. The findings highlight the importance of considering relationships and socio-contextual factors, such as the impact of the framework of service delivery, when attempting to understand variations in access to services. In order to improve access to services, it will be necessary to move beyond addressing individual factors relating to access, and to consider the impact of the framework for service delivery and the relationships that influence contact with services.

'How can they tell?' A qualitative study of the views of younger people about their dementia and dementia care services

There is growing interest in eliciting the views of younger people with dementia (i.e. those under 65 years of age) within health and social care research. The often erroneous view that these individuals are not capable of expressing their views and experiences has now been seriously challenged. The present paper draws on the findings from 14 qualitative in-depth interviews with younger people with dementia conducted in the South-west of England, and considers some of the issues involved in interviewing people with dementia. Purposive and snowballing techniques were used to recruit participants. Data were transcribed and subjected to comparative textual analysis to index, code and analyse the data for emergent themes. Four major themes emerged: (1) the general experience of having dementia; (2) dementia diagnosis; (3) the importance of age; and (4) risk and danger issues. The results indicate that the majority of participants were articulate and insightful about their experiences and needs. The present paper concludes by arguing that the challenge for health and social care professionals is to engage with and consult such individuals about their experiences and what they want from dementia care services, and the authors consider some of the issues involved in interviewing people with dementia.

The debate on ethnicity and dementia: from category fallacy to person-centred care?

The concept of ethnicity remains attractive and meaningful to service developers and professionals, although research suggests that this disguises other facets of identity and difference. An epidemiological perspective on the relationship between ethnicity and dementia supports the idea that ethnicity (defined as particular shared cultural characteristics) is not likely to influence unduly the emergence of dementia in individuals. Cultural factors may protect against dementia, impeding its recognition and influencing its course and these deserve further investigation. Ethnicity is a general concept that subsumes and conceals the impact of migration, education, health beliefs and socio-economic status on health, and therefore is problematic. Empirical research on dementia and ethnicity reveals that intra-ethnic group variation is greater than inter-ethnic group variation; supporting the view that ethnicity as a category may not have great explanatory power and may foster a category fallacy. However, the experiences of people with dementia and their carers show that the important issues for service providers to consider are language, religious belief and observance, cultural practices (including food and personal care practices) and social support and coping mechanisms. In this position paper we argue that these issues are applicable to all individuals with dementia, independent of apparent ethnicity, and that promotion of cultural competence in service provision should not be relegated to an ethnic minority agenda. The task for health and social care providers is therefore to recognise the diversity of users and to increase access to appropriate quality mainstream person-centred services, rather than to develop segregated or specialized services.

'We didn't know it would get that bad': South Asian experiences of dementia and the service response

The aim of the present paper was to examine some views and experiences of dementia among older South Asian people, as well as their families and carers, and to explore central issues of service support. Data were collected in Scotland through interviews with 11 professionals working with South Asian people with dementia, and four case studies of South Asian people with a diagnosis of dementia, as well as their families and carers. The case studies demonstrated overwhelmingly negative experiences of dementia, with poor quality of life, desperate needs for support, lack of access to appropriate services, little knowledge of dementia, and isolation from community and family life. The interviews with professionals described a strong demand for services, a need to develop awareness and knowledge about dementia in South Asian communities, and a need to promote more culturally sensitive, individually responsive services. Similarities between South Asian people and the non-South Asian population include stress on carers, increasing isolation, problematic diagnostic practices, lack of knowledge and demand for service support. Differences include limited use of non-National Health Service (NHS) support, dealing with later stages of dementia at home, particularly negative views about residential care, culturally based attitudinal differences and use of the term 'dementia' in English as neutral rather than stigmatising. The present authors suggest that there is little knowledge and experience of dementia in South Asian communities, as well as restricted access to appropriate services, despite the efforts of voluntary sector and NHS special projects. There is demand for services, especially at home. Services need to develop individual responsiveness for effective working in a diverse society.

Younger people in dementia care: a review of service needs, service provision and models of good practice

This paper reviews the literature on younger people (under 65 years of age) with dementia, in dementia care. Seventy-four relevant papers were identified by use of a search strategy derived from the methodology of systematic reviews, the majority of which originated in the UK (69, 93.2%). The need for specialist, flexible, age-appropriate, and dedicated services was a central theme in the literature. A person-centred approach was advocated within an individual or 'tailor made' model of care. However, the available evidence suggests that this model of good practice is not currently reflected in the majority of services provided in the United Kingdom. Overall, the literature argues that the needs of younger people with dementia are best served by inter-agency collaboration, early assessment, and an awareness of individual needs. Clearly, these proposals could usefully serve anybody with dementia, irrespective of age. However, aside from a few prevalence studies, and some exploratory work with small numbers of service users, little in the way of empirical work is available. The recommendations that have been made regarding dementia services for younger people are based largely on the practical experience of professionals and paid carers, rather than scientific evidence.