Health care experiences of people with dementia and their caregivers: a meta-ethnographic analysis of qualitative studies

Mini-Cog for the diagnosis of Alzheimer's disease dementia and other dementias within a secondary care setting

BACKGROUND

The diagnosis of Alzheimer's disease dementia and other dementias relies on clinical assessment. There is a high prevalence of cognitive disorders, including undiagnosed dementia in secondary care settings. Short cognitive tests can be helpful in identifying those who require further specialist diagnostic assessment; however, there is a lack of consensus around the optimal tools to use in clinical practice. The Mini-Cog is a short cognitive test comprising three-item recall and a clock-drawing test that is used in secondary care settings.

OBJECTIVES

The primary objective was to determine the diagnostic accuracy of the Mini-Cog for detecting Alzheimer's disease dementia and other dementias in a secondary care setting. The secondary objectives were to investigate the heterogeneity of test accuracy in the included studies and potential sources of heterogeneity. These potential sources of heterogeneity will include the baseline prevalence of dementia in study samples, thresholds used to determine positive test results, the type of dementia (Alzheimer's disease dementia or all causes of dementia), and aspects of study design related to study quality.

SEARCH METHODS

We searched the following sources in September 2012, with an update to 12 March 2019: Cochrane Dementia Group Register of Diagnostic Test Accuracy Studies, MEDLINE (OvidSP), Embase (OvidSP), BIOSIS Previews (Web of Knowledge), Science Citation Index (ISI Web of Knowledge), PsycINFO (OvidSP), and LILACS (BIREME). We made no exclusions with regard to language of Mini-Cog administration or language of publication, using translation services where necessary.

SELECTION CRITERIA

We included cross-sectional studies and excluded case-control designs, due to the risk of bias. We selected those studies that included the Mini-Cog as an index test to diagnose dementia where dementia diagnosis was confirmed with reference standard clinical assessment using standardised dementia diagnostic criteria. We only included studies in secondary care settings (including inpatient and outpatient hospital participants).

DATA COLLECTION AND ANALYSIS

We screened all titles and abstracts generated by the electronic database searches. Two review authors independently checked full papers for eligibility and extracted data. We determined quality assessment (risk of bias and applicability) using the QUADAS-2 tool. We extracted data into two-by-two tables to allow calculation of accuracy metrics for individual studies, reporting the sensitivity, specificity, and 95% confidence intervals of these measures, summarising them graphically using forest plots.

MAIN RESULTS

Three studies with a total of 2560 participants fulfilled the inclusion criteria, set in neuropsychology outpatient referrals, outpatients attending a general medicine clinic, and referrals to a memory clinic. Only n = 1415 (55.3%) of participants were included in the analysis to inform evaluation of Mini-Cog test accuracy, due to the selective use of available data by study authors. There were concerns related to high risk of bias with respect to patient selection, and unclear risk of bias and high concerns related to index test conduct and applicability. In all studies, the Mini-Cog was retrospectively derived from historic data sets. No studies included acute general hospital inpatients. The prevalence of dementia ranged from 32.2% to 87.3%. The sensitivities of the Mini-Cog in the individual studies were reported as 0.67 (95% confidence interval (CI) 0.63 to 0.71), 0.60 (95% CI 0.48 to 0.72), and 0.87 (95% CI 0.83 to 0.90). The specificity of the Mini-Cog for each individual study was 0.87 (95% CI 0.81 to 0.92), 0.65 (95% CI 0.57 to 0.73), and 1.00 (95% CI 0.94 to 1.00). We did not perform meta-analysis due to concerns related to risk of bias and heterogeneity.

AUTHORS' CONCLUSIONS

This review identified only a limited number of diagnostic test accuracy studies using Mini-Cog in secondary care settings. Those identified were at high risk of bias related to patient selection and high concerns related to index test conduct and applicability. The evidence was indirect, as all studies evaluated Mini-Cog differently from the review question, where it was anticipated that studies would conduct Mini-Cog and independently but contemporaneously perform a reference standard assessment to diagnose dementia. The pattern of test accuracy varied across the three studies. Future research should evaluate Mini-Cog as a test in itself, rather than derived from other neuropsychological assessments. There is also a need for evaluation of the feasibility of the Mini-Cog for the diagnosis of dementia to help adequately determine its role in the clinical pathway.

Development of a self-management support program for caregivers of relatives with dementia in Shanghai

The purposes of this study were to develop a caregiver-education booklet and to elicit intervention strategies for a self-management support program for caregivers of relatives with dementia in Shanghai. Two focus groups with 32 eligible caregivers were conducted to clarify the knowledge and information about the scope and main points of, as well as the barriers to and support for caregiver self-management. Content analysis revealed that the main challenges caregivers faced were a lack of reliable and accessible information about dementia care, frustrations related to communication with the care recipient, disturbances in daily routines, and unfamiliarity with and/or difficulty in balancing the caregiver's own health needs. Access to individualized and reliable instruction and/or group support were the major types of support the participants expected for their self-management. Based on the findings and relevant literature, an illustrated caregiver-education booklet was developed and the intervention strategies were also discussed for the program.

I becomes we, but where is me? The unity-division paradox when caring for a relative with dementia: A qualitative study

BACKGROUND

The number of older people living with dementia is increasing. Admiral Nurses work with these individuals and their families in the UK to manage challenges associated with the condition, providing guidance, advice and reassurance, alongside practical solutions.

AIM

To explore the input of Admiral Nurses as part of people's journey to becoming and being a carer for someone with dementia.

DESIGN

A qualitative study was conducted to describe and understand how Admiral Nurses are experienced and encountered by carers as part of their narrative around supporting a relative with dementia.

METHODS

Semi-structured interviews were conducted with 19 carers between November 2017-April 2018. They lasted between 45 and 90 min. Thematic analysis was used to interpret data.

FINDINGS

An overarching concept of "the unity-division paradox" was derived from the data. This highlights the complex interchange between the carer with (a) the person with dementia, (b) other individuals and (c) external services. Such interactions can make carers feel part of a larger network (unity) but also as if they are on their own, fighting on behalf of the person with dementia (division). This concept was underpinned by the following themes: (a) I becomes we; (b) My private world is encroached by dementia; (c) I'm left navigating an unwieldy system; (d) Are you with or against us?; and (e) Recreating boundaries to rediscover me.

CONCLUSION

The identity and unique characteristics and interests of those caring for a person with dementia may be lost as they encounter tensions associated with the unity-division paradox. Admiral Nurses can help carers feel less alone in managing internal and external struggles by supporting them to do their best for a loved one with dementia.

IMPLICATIONS FOR PRACTICE

Understanding carers' experience and supporting their work may help to increase and sustain their capacity to provide care.

Specialist and family physician collaboration: Insights from primary care-based memory clinics

Given limited available geriatric specialists and complexity of dementia care, there is a need for greater collaboration between primary care and specialists to better meet the needs of persons with dementia. Meaningful family physician-specialist collaboration has the potential to improve health outcomes, timely access to care and more appropriate healthcare resource utilisation. Primary Care Collaborative Memory Clinics (PCCMCs), which include specialist support, provide a significant opportunity for studying the family physician-specialist interface. This study aimed to explore the nature of collaborative relationships between memory clinic family physicians and specialists caring for persons with memory concerns in PCCMCs across Ontario, Canada. Family physicians (N = 71) attending an education session and specialists (N = 21) completed a survey in the fall of 2017 that measured frequency and amount of collaboration, perceptions of their relationship and identified factors that enable and challenge collaboration. Descriptive statistics were generated for quantitative data and themes for responses to open-ended questions were explored using descriptive qualitative content analysis. Specialists and memory clinic family physicians valued their collaboration particularly as related to capacity building for dementia care and desired more time devoted to collaboration. Identified enablers and barriers to collaboration have implications for further integration of specialist support to potentially support improved patient care and further build capacity in primary care to manage dementia care. Opportunities exist for expanding and more intentionally supporting how family physicians and specialists interact with the creation of more formalised processes to support optimal collaboration, including a clear delineation of roles, responsibilities and expectations, more formally planned and structured relationship building and monitoring, identifying and addressing unique barriers to collaboration and use of a variety of methods of communication. Study findings have implications for how specialists and family physicians communicate and collaborate in other programmes for complex chronic conditions.

Completeness of reporting in Indian qualitative public health research: a systematic review of 20 years of literature

BACKGROUND

This study reviewed the completeness of reporting in Indian qualitative public health research (QPHR) studies using the 'Consolidated Criteria for Reporting Qualitative Research' (COREQ) checklist.

METHODS

Search results from five electronic databases were screened by two independent reviewers. We included English-language, primary QPHR studies from India, which were assessed for their compliance with the COREQ checklist. Each COREQ item was noted as either reported or unreported. Descriptive statistics for the number of COREQ items reported by each study, and the number of studies that reported each COREQ item were reported, as were the items reported in each year, and in pre- and post-COREQ time periods.

RESULTS

Of 537 citations, 246 articles were included. Trends demonstrated an increasing number of Indian QPHR studies being published annually, and an overall increase in reporting completeness since 1997. Only two COREQ items were reported in all studies. 52.4% of articles reported between 16 and 21 items, corresponding to 43-57% of items being reported. Six items were reported in fewer than 10% of studies. COREQ domain 1 was least frequently reported.

CONCLUSIONS

Despite improving trends, the reporting of QPHR in India is incomplete. Authors and journals should ensure adherence to reporting guidelines.

Prioritizing the Needs of Caregivers of Older Adults to Support Their Help-Seeking Process as a First Step to Developing an eHealth Tool: The Technique for Research of Information by Animation of a Group of Experts (TRIAGE) Method

BACKGROUND

Caregivers of functionally dependent older persons sometimes seek formal services to support their relatives. However, this process of help-seeking is complex.

OBJECTIVE

The overall aim of the study was to use a co-design approach to develop an electronic health (eHealth) tool to support caregivers in their process of help-seeking. This study presents the first step of the design phase, which aimed to prioritize the user needs to be considered during the development of an eHealth tool.

METHODS

A total of 3 groups of caregivers, community workers, and health and social service professionals participated in either a co-design session (1 or 2) or an advisory committee in 2 rural areas and 1 urban area. The needs identified in the academic literature and during a previous study were sorted (Technique for Research of Information by Animation of a Group of Experts [TRIAGE] method) by the participants (referred to in this study as co-designers) to obtain a consensus on those to be prioritized. Needs identified, grouped, and removed were ranked and compared.

RESULTS

Of the initial list of 32 needs, 12 were modified or merged, 3 added, and 7 deleted as the co-designers felt that the needs were poorly formulated, redundant, irrelevant, or impossible to meet. In the end, 19 needs were identified for the design of the eHealth tool.

CONCLUSIONS

Many of the identified needs are informational (eg, having access to up-to-date information) and are probably met by existing tools. However, many others are emotional (eg, being encouraged to use the services) and offer an interesting challenge to eHealth tool development.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/11634.

Oral health care for patients with Alzheimer's disease: An update

Alzheimer's disease and related disorders (ADRD) are among the age-associated chronic conditions that are most challenging to health care systems around the globe, as patients with dementia require full-time, intensive care for multiple years. Oral health care is negatively impacted by cognitive decline, and consequently poor oral health is common among people with ADRD. Poor oral health status is linked with many undesirable consequences for the well-being of people with ADRD, from excruciating local pain to life-threatening conditions, as aspiration pneumonia. In this paper, the authors provide an update on the most current concepts about Alzheimer's disease epidemiology, etiology, and management, current oral health care for patients with Alzheimer's disease, oral health promotion strategies for this population, as well as current research and future direction for improving oral health care for patients with Alzheimer's disease. It concludes that oral health care should be included in the patient's routine health care as early as possible in the progression of Alzheimer's disease for preventing rapid oral health deterioration. Establishing oral hygiene routines and providing dental treatment that is customized to the patients' individual needs and disease stage are important to achieve good oral health outcomes and prevent quality of life decline.

Perceived Needs of The Family Caregivers of People with Dementia in a Mediterranean Setting: A Qualitative Study

The purpose of this study was to identify, classify and analyze the perceived needs of caregivers of elderly people with dementia during the care process. A descriptive phenomenological qualitative study using seven focus groups was conducted in different primary health care centers in the province of Jaén (Spain) between July 2012 and February 2013. Eighty-two family caregivers who were caring for people with dementia in different stages of the disease were selected by purposeful maximum variation sampling. Data were analyzed and organized thematically, considering the semantic and pragmatic content and field notes. Two main categories of the perceived needs of caregivers were identified. The first was related to the management of caring for a relative with dementia, and the second was related to the management of the caregivers’ own care. Our findings support the provision of comprehensive interventions for the improvement of caregivers’ emotional health that encompass more than one care need. This is where psycho-educational interventions aimed at managing the various aspects of dementia and self-care in caregivers can be accommodated. In addition, proactive interventions to develop important skills to care for a relative with dementia, which are not perceived as needs by the caregivers, are needed. These include skills in family negotiation, planning and searching for resources outside the family.

Influences on the access to and use of formal community care by people with dementia and their informal caregivers: a scoping review

BACKGROUND

The literature describes the obstacles to sufficient care faced by people with dementia and their informal caregivers. Although factors influencing access and utilisation are frequently studied, the body of knowledge lacks an overview of aspects related to influence. The frequently used Behavioural Model of Health Care Use (BM) could be used to structure and explain these aspects. An adaptation of the BM emphasises psychosocial influences and appears to enrich the understanding of the use of long-term care for dementia.

METHODS

We conducted a scoping review with the aim of providing an overview of the aspects influencing the access to and utilisation of formal community care in dementia. Our search covered the PubMed, CINAHL, Social Science Citation Index and PsychInfo databases, as well as grey literature. Two researchers assessed the full texts for eligibility. A data extraction form was developed and tested. We analysed the main topics investigated by the studies and mapped and described the investigated psychosocial aspects according to the BM after narratively summarising the findings. We used the Mixed Method Appraisal Tool (MMAT) to critically appraise the included studies.

RESULTS

A total of 94 studies were included: n = 55 with quantitative designs, 35 with qualitative designs and four with mixed methods. The studies investigated different services, mainly focusing on health care services. One third of the studies provided information regarding the severity of dementia. The most frequently investigated main topics were ethnicity and attitudes towards services. Psychosocial aspects were frequently investigated, although few studies considered the perspectives of people with dementia. Approximately half of the studies reported a theoretical framework. The adapted BM facilitated the structuring and description of psychosocial aspects. However, this instrument did not address topics beyond the scope of psychosocial aspects, such as sociodemographic characteristics.

CONCLUSIONS

The access to and utilisation of formal community care for dementia can only be partly explained by individual influencing aspects. Therefore, a theoretical framework would likely help to describe this complex subject. Our findings indicate that the psychosocial categories of the adapted BM enriched the original BM, and that people with dementia should more often be included in healthcare service research to ensure a better understanding of the barriers to accessing formal community care.

Caregivers' perspectives and experiences of withdrawing acetylcholinesterase inhibitors and memantine in advanced dementia: a qualitative analysis of an online discussion forum

BACKGROUND

There is considerable uncertainty surrounding the medications used to delay the progression of dementia, especially their long-term efficacy and when to withdraw treatment with these agents. Current research regarding the optimal use of antidementia medication is limited, contributing to variability in practice guidelines and in clinicians' prescribing practices. Little is currently known about the experiences encountered by caregivers of people with dementia after antidementia medication is withdrawn.

AIM

To investigate the experiences and perspectives of carers and family members when antidementia medications (cholinesterase inhibitors and/or memantine) are stopped, by analysing archived threads and posts of an online discussion forum for people affected by dementia.

METHODS

Archived discussions from Talking Point, an online discussion forum hosted by the Alzheimer's Society UK, were searched for threads discussing antidementia medication withdrawal and relevant threads were analysed thematically using the Framework method. Participant demographics were not established due to usernames which ensured anonymity.

RESULTS

Four key themes emerged: (1) expectations about withdrawal, (2) method of withdrawal, (3) clinical condition on withdrawal, and (4) the effect of withdrawal on caregivers.

CONCLUSIONS

Online discussion forums such as Talking Point provide dementia carers with an outlet to seek help, offer advice and share experiences with other members. The study findings highlight the complexity surrounding optimising dementia pharmacotherapy and antidementia medication withdrawal, highlighting the need for treatment to be person-centred and highly individualised.

Medicines management issues in dementia and coping strategies used by people living with dementia and family carers: A systematic review

OBJECTIVES

Medicines play a key role in the lives of people with dementia, primarily to manage symptoms. Managing medicines is complex for people with dementia and their family carers and can result in multiple problems leading to harm. We conducted a systematic review to identify and model medication issues experienced and coping strategies used by people with dementia and/or family carers.

METHODS

Eleven general databases and four systematic review databases were searched. Studies were quality assessed using an established framework and thematically analysed.

RESULTS

Twenty-one articles were included in this study, and four domains affecting medication use were identified: cognitive, medication, social and cultural, and knowledge/educational and communication. People with dementia reported medication issues in all four domains, but few coping strategies were developed. Family carers reported issues and coping strategies related to the medication and knowledge/educational and communication domains. Common issues with regards to knowledge and communication about medicines remain unresolved. The "voices" of people with dementia appeared largely missing from the literature so were in-depth understanding of how, whether, and in which circumstances coping strategies work in managing medicines.

CONCLUSIONS

Medicines management is a complex set of activities and although current coping strategies exists, these were primarily used by family carers or the person with dementia-carer dyad. Health and social care practitioners and researchers should seek to understand in-depth the "mechanisms of action" of existing coping strategies and actively involve people with dementia as co-producers of knowledge to underpin any further work on medicines management.

Persons with dementia and care partners’ perspectives on memory clinics in primary care

Aims: To understand persons with dementia (PWD) and care partners’ experiences with the Primary Care Collaborative Memory Clinic (PCCMC) care model. Methods: Interviews were conducted with a purposeful sample of PWD (n = 12) and care partners (N = 16) to identify their perspectives of care received in the clinic and suggestions for improvement. Results: PWD and care partners were satisfied with care received within the PCCMC, had positive interactions with and perceived a strong sense of support from team members and felt listened to; the necessity of cognitive testing was recognized but disliked. Conclusions: The PCCMC care model can address many existing gaps in dementia care as experienced by PWD and care partners.

Dementia and immigrant groups: a qualitative study of challenges related to identifying, assessing, and diagnosing dementia

Background

Along with the ageing of the general population, Europe’s migrant populations are also ageing, thus posing new challenges for dementia care services, particularly if the services are to be adjusted to persons with different linguistic and cultural backgrounds. From the perspective of health professionals, this study aims to explore challenges involved in identifying, assessing and diagnosing people with cognitive impairment/dementia who have different linguistic and cultural backgrounds.

Methods

Research on health professionals experiences regarding the management of dementia among immigrants is scarce and qualitative methods was used to address the objective of the study. Using qualitative in-depth interviews and focus-group discussions, we sought to gather participants’ experiences regarding the diagnostic process for immigrants with dementia. The material was analysed and interpreted based on Kvale and Brinkmann’s descriptions of three different contexts of interpretation: self-understanding, critical common-sense understanding, and theoretical understanding.

Results

Health professionals described how families could attribute symptoms of dementia to processes of normal ageing, while others saw the symptoms as something shameful; both instances delayed or hindered help-seeking. Many clinicians had limited experience with older immigrants suffering from dementia, and general practitioners (GPs) in particular experienced difficulties assessing dementia due to language barriers and difficulties related to the involvement of the family or an interpreter. The findings illustrate challenges in assessment, such as unfamiliarity with test situations among those being assessed and lack of knowledge regarding appropriate diagnostic tools among health professionals. Lack of continuity and poor information exchange in the chain of care seem to reinforce many of these challenges.

Conclusions

Detection, treatment and care may be improved if primary care professionals strengthen their cross-cultural competences. Training in communication skills and in the use of cross-cultural assessment tools may help build competence and confidence when assessing and caring for people with different cultural and linguistic backgrounds. Closer collaboration among families, nurses in home-based services, dementia teams, and GPs may facilitate close monitoring of a patient over time. Such collaboration requires sufficient information exchange during transitions in the chain of care, continuity among health professionals, and a shared understanding of the goals for treatment and care.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3720-7) contains supplementary material, which is available to authorized users.

The start of caring for an elderly dependent family member: a qualitative metasynthesis

BACKGROUND

The family often takes care of an elderly person who suddenly becomes dependent. This greatly affects different aspects of the caregivers' lives. The aim of this study is to explore the initial experiences, during the first year of care, of persons who suddenly become caregivers for elderly dependent relatives.

METHODS

A search in CINAHL, PsycINFO, WOS, Medline, and Scopus and a metasynthesis of qualitative research were conducted including 19 articles.

RESULTS

Three categories were developed to explain the process of becoming a caregiver 'taking on the role' (life changes, uncertainty and confusion, and acceptance or resistance); 'beginning to realise' (new needs, impact, and appraisal); and 'implementing strategies' (seeking help and self-learning, reordering family and social relationships, solving problems, and devising strategies to decrease negative emotions and stress).

CONCLUSIONS

The synthesis provides a comprehensive understanding of the experience of becoming a caregiver in order to help health-care professionals to adapt care plans to this situation.

Understanding the educational and support needs of informal care-givers of people with dementia attending an outpatient geriatric assessment clinic

Informal (unpaid) care-givers of older people with dementia experience stress and isolation, causing physical and psychiatric morbidity. Comprehensive geriatric assessment clinics represent an important geriatrician-led model of dementia care. Our qualitative study examined the educational and support needs of care-givers of people diagnosed with dementia at a geriatric assessment clinic, resources used to address those needs and challenges experienced in doing so. We conducted structured thematic analysis of interviews with 18 informal care-givers. Participants’ narratives reflected four themes. First, care-givers sought information from varied sources, including the Alzheimer Society, the internet and clinic staff. Responsive behaviours, the expected progression of dementia and system navigation were topics of particular interest. Second, care-givers obtained assistance from public, for-profit and voluntary sources. Third, care-givers received little assistance. Two-thirds received fewer than four hours of help weekly from all sources combined, and none more than 15. Several received no assistance whatsoever. Publicly funded support workers’ tasks, and their timing, were often unhelpful. Finally, while numerous care-givers felt physical and emotional strain, and worried about how poor health impaired their care-giving, many hesitated to seek help. The needs of this unique population of informal care-givers can be met by improved home-care service flexibility, and access to trustworthy information about the expected progression of dementia and skills for managing behavioural and psychological symptoms.

Estimation of diagnostic performance of dementia screening tests: Mini-Mental State Examination, Mini-Cog, Clock Drawing test and Ascertain Dementia 8 questionnaire

OBJECTIVE

Dementia is one of the leading causes of dependence in the elderly. This study was conducted to estimate diagnostic performance of dementia screening tests including Mini-Mental State Examination (MMSE), Mini-Cog, Clock Drawing Test (CDT) and Ascertain Dementia 8 questionnaire (AD8) by Bayesian models.

METHOD

A total of 2015 participants aged 65 years or more in eastern China were enrolled. The four screening tests were administered and scored by specifically trained psychiatrists. The prior information of sensitivity and specificity of every screening test was updated via Bayes' theorem to a posterior distribution. Then the results were compared with the estimation based on National Institute of Aging-Alzheimer's Association criteria (NIA-AA).

RESULTS

The diagnostic characteristics of Mini-Cog, including sensitivity, specificity, PPV, NPV, especially the Youden index, performed well, even better than the combinations of several screening tests.

CONCLUSION

The Mini-Cog with excellent screening characteristics, spending less time, could be considered to be used as a screening test to help to screen patients with cognitive impairment or dementia early. And Bayesian method was shown to be a suitable tool for evaluating dementia screening tests.

CONCLUSION

The Mini-Cog with excellent screening characteristics, spending less time, could be considered to be used as a screening test to help to screen patients with cognitive impairment or dementia early. And Bayesian method was shown to be a suitable tool for evaluating dementia screening tests.

The assessment experience of spousal dementia care-givers: ‘It's made me realise that I am a person also’

This article is based on a study that used a validated care-giver assessment instrument known as ‘The C.A.R.E. (Caregivers’ Aspirations, Realities, and Expectations) Tool’ to understand its usefulness in working with older adults caring for a spouse with cognitive impairment. It draws on data collected as part of a larger, quasi-experimental pre- and post-test study examining the impact of a care-giver assessment on older spousal care-givers of a partner with cognitive impairment. One hundred community-living individuals (average age of 74) participated in the study. Participants met with a third-year nursing student who administered The C.A.R.E. Tool. Within three to seven days following this, a research team member conducted a semi-structured interview by telephone. This interview provided participants with the opportunity to comment on their experience and the usefulness of The C.A.R.E. Tool. Transcriptions of the interviews were analysed using a thematic analysis. Results indicate that the assessment experience was evaluated positively by most participants. Two broad themes emerged: assessment encourages care-givers to take stock of their situation, and it provides a relationship with a caring professional. In particular, the assessment experience gave these care-givers to have the opportunity to reflect, while expressing emotions and developing awareness, and provided them with an appreciated relationship with a caring professional who helped to validate and normalise their situation. For care-givers, the results suggest that assessment may serve as a catalyst for taking action in their care-giving situation or turning to services for help. For practitioners, assessment may increase awareness of the experience of spousal care-givers, potentially leading to interventions to support them. This study found that the attitudes and knowledge of practitioners play a role in care-givers’ experience of the assessment as positive. However, the goal of assessment must be clarified, as outcomes of other tools will differ depending on the aims.

The male familial caregiver experience of caring for persons with Alzheimer's disease from low socio-economic status: A South African perspective

The aim of this study was to explore the experiences of male familial caregivers of persons with Alzheimer’s disease from low socio-economic status using the ecological systems theory perspective. The data were obtained from 11 semi-structured interviews that were conducted with the familial caregivers of persons with Alzheimer’s disease. Data were analyzed using thematic analysis, where four main themes emerged, namely, relationship difficulties, understanding Alzheimer’s disease, support networks, and finding meaning and satisfaction in the caregiving role. Behavioral problems, erosion of the relationship with the significant other, familial conflict, experience of diagnosis, lack of information, lack of free time, and financial concerns were identified challenges facing caregivers. Provision of information, support groups, social support, community-based support, and finding meaning and satisfaction in the caregiving role were reported as resources that assist in caregiver coping. Men seem to be capable of providing effective care and are able to successfully manage in their caregiving role. Culture seems to play a significant role in help-seeking behavior and the approach to caregiving. The findings provide the basis for the specific needs of male caregivers that should be focused on in order to provide culturally appropriate services to enhance caregiver coping amongst male caregivers in similar settings.

General practitioners' knowledge, attitudes, and experiences of managing behavioural and psychological symptoms of dementia: A mixed-methods systematic review

OBJECTIVES

To synthesise the existing published literature on general practitioners (GP)'s knowledge, attitudes, and experiences of managing behavioural and psychological symptoms of dementia (BPSD) with a view to informing future interventions.

METHODS

We conducted a systematic review and synthesis of quantitative and qualitative studies that explored GPs' experiences of managing BPSD (PROSPERO protocol registration CRD42017054916). Seven electronic databases were searched from inception to October 2017. Each stage of the review process involved at least 2 authors working independently. The meta-ethnographic approach was used to synthesise the findings of the included studies while preserving the context of the primary data. The Confidence in the Evidence from Reviews of Qualitative research (CERQual) was used to assess the confidence in our individual review findings.

RESULTS

Of the 1638 articles identified, 76 full texts were reviewed and 11 were included. Three main concepts specific to GPs' experiences of managing BPSD emerged: unmet primary care resource needs, justification of antipsychotic prescribing, and the pivotal role of families. A "line of argument" was drawn, which described how in the context of resource limitations a therapeutic void was created. This resulted in GPs being over reliant on antipsychotics and family caregivers. These factors appeared to culminate in a reactive response to BPSD whereby behaviours and symptoms could escalate until a crisis point was reached.

CONCLUSION

This systematic review offers new insights into GPs' perspectives on the management of BPSD and will help to inform the design and development of interventions to support GPs managing BPSD.

Do people with early stage dementia experience Prescribed Disengagement®? A systematic review of qualitative studies

ABSTRACTBackground:Prescribed Disengagement® is the description of the post-diagnostic advice given to people after a diagnosis of dementia, which explicitly or implicitly suggests that the person should be slowing down or pulling back from activities. This results in isolation, loss of hope, self-esteem and self-identity, and threatens social health. This study aims to review whether Prescribed Disengagement® can be identified in the literature on subjective experiences of people living with early dementia.

METHODS

A systematic search was performed. Inclusion criteria were original empirical qualitative studies published in English that addressed the subjective experiences of living with a diagnosis of objectively defined early dementia. Thematic synthesis was undertaken.

RESULTS

Thirty-five papers involving 373 participants were included. Following a diagnosis, people with dementia struggled with self-identity, independence, control and status, activities, stigma, and how to view the future. Reactions in these areas ranged from active and positive to negative and passive. Many studies reported participants' dissatisfaction with the way the diagnosis was communicated. There was insufficient information provided about dementia and limited treatments and support offered. The diagnosis process and post-diagnostic support may have contributed to disempowerment of the person with dementia, made it more difficult to accept the diagnosis, and exacerbated negative views and self-stigma around dementia.

CONCLUSIONS

These results do not support the idea of Prescribed Disengagement®. However disengagement may have been implied during the diagnosis process and post-diagnostic support. Research is needed on how to improve the communication of dementia diagnosis and support people to live well post-diagnosis.

A qualitative exploration of proxy decision makers' expectations of prescribed medications for people with advanced dementia

Background:

Proxy decision makers often have to make decisions for people with advanced dementia. Their expectations regarding prescribed medications have the potential to influence prescription or withdrawal of medications. However, few studies to date have explored this.

Aim:

To explore proxy decision makers’ expectations of prescribed medications for people with advanced dementia and to consider how these change with changing goals of care and dementia progression.

Design:

This is a qualitative semi-structured interview study.

Setting/participants:

In total, 15 proxy decision makers of people with advanced dementia were recruited via general practitioners ( n = 9), Join Dementia Research ( n = 3) and the Alzheimer’s Society Northern Ireland ( n = 3).

Results:

Five key themes emerged: the role as advocate, attitudes to medicines and medicine taking, uncertainty over the benefit of anti-dementia medications, stopping medications, and communication and decision-making. Proxy decision makers desired more information about prescribed medicines, particularly the indications, benefits and risks of treatment. Despite uncertainty about the benefits of anti-dementia medications, proxy decision makers were reluctant for these medications to be withdrawn. Reluctance to stop other prescribed medicines was also expressed but reduced with changing goals of care and dementia progression. Although some proxy decision makers expected to be involved in medication-related decisions, the majority preferred to delegate these decisions to healthcare professionals. However, they expected to be informed of any medication-related decisions made.

Conclusion:

Proxy decision makers vary in terms of their desire for active involvement in the medication decision-making process. Healthcare professionals should facilitate proxy decision maker involvement if desired. Further research is required to consider the impact of proxy decision maker involvement in decision-making.

A cross-sectional study of family caregiver burden and psychological distress linked to frailty and functional dependency of a relative with advanced dementia

Psychological health of caregivers of people with dementia is a major public concern. This study sought to determine the relationship between caregiver burden, psychological distress, frailty and functional dependency of a relative with advanced dementia. Persons with dementia and their caregivers (102 dyads) participated in this Portuguese community based cross-sectional study. Data were collected using the Clinical Dementia Rating Scale, a sociodemographic questionnaire, the Zarit Burden Interview, the Brief Symptoms Inventory and the Edmonton Frail Scale. Alzheimer's disease was the most common type of dementia among the recipients of care, who showed moderate (42.2%) to severe (52.9%) dementia. Among them 35.3% exhibited moderate and 45.1% severe frailty. Family caregivers reported moderate (76.5%) to severe burden (18.6%). Psychological distress was very high among family caregivers. Results show that people with dementia exhibited moderate (35.3%) or severe frailty (45.1%) and that a severe frailty was found in people with moderate dementia. A one-way ANOVA was conducted between the Global Severity Index and some sociodemographic variables. ANOVA reached p < .01 for employment status of the caregiver, assistance and professional support, and psychiatric history; and p = 0.01 for caregiver age and years of caregiving. Although caregivers reported benefit from the supportive approach offered by the multidisciplinary home care team, high levels of distress and associated burden were found, which might decrease their capacity to care for the person with dementia and their own health and well-being.

Interpreter-mediated Cognitive Assessments: Who Wins and Who Loses?

OBJECTIVES

The number of people with dementia from culturally and linguistically diverse (CALD) backgrounds is increasing dramatically in Australia. Accurate cognitive assessments of people from CALD backgrounds can be achieved with the use of skilled interpreters. This study aimed to explore the experience of interpreter-mediated assessments from the perspectives of clinicians, interpreters and carers.

METHODS

Consultations with interpreters, clinicians and carers were conducted through individual interviews and focus groups. The consultations explored participants' experiences of interpreter-mediated assessments, including perception of the interpreting process, roles of interpreters, and challenges associated with interpreter-mediated assessments.

RESULTS

Four themes emerged across groups: (1) the importance of having professional interpreters, (2) different perceptions of the roles of interpreters, (3) clinicians' feelings of having less control over assessments, and (4) particular challenges associated with cognitive assessments.

CONCLUSIONS

Finding from this study highlight the important role that interpreters play in cognitive assessments with immigrants. However, there appears to be different perceptions of the role between clinicians and interpreters. When these different understandings are not resolved, they will lead to tension between clinicians and interpreters. These findings highlight the importance of relational aspects in interpreter-mediated assessment and suggest that the negotiation of the relationships between clinicians and interpreters is an important factor that determines the effectiveness and accuracy of these assessments.

CLINICAL IMPLICATIONS

This study highlights the need for clinicians and interpreters education of roles of all parties in interpreter-mediated cognitive assessment. Areas to be covered in education could include: common misunderstandings of interpreters roles, and practice tips on how to improve communications in assessments, such as briefing before and after the assessment. Such education will enable more accurate assessment and less stress for patients and their families.

The experience of psychological distress in family caregivers of people with dementia: A cross-sectional study

PURPOSE

To evaluate the degree of psychological distress in family caregivers of people with dementia.

DESIGN AND METHODS

A nonprobabilistic sample of 54 dyads (people with dementia and family caregivers) was recruited. A sociodemographic questionnaire, the Brief Symptom Inventory (BSI), and the Barthel Index were used for data collection.

FINDINGS

About half of the caregivers had significant levels of psychological distress. Caregivers showed high scores in some BSI dimensions: somatization, obsessive-compulsion, interpersonal sensitivity, anxiety, and paranoid ideation.

PRACTICE IMPLICATIONS

Alleviating the caregivers' distress is likely to have positive effects on the overall health and capacity to care. Frameworks for providing palliative care to people with advanced dementia and support the caregivers would enhance the quality of care provided and may reduce the distress on the caregiver.

Mini-Cog for the diagnosis of Alzheimer's disease dementia and other dementias within a primary care setting

BACKGROUND

Alzheimer's disease and other forms of dementia are becoming increasingly common with the aging of most populations. The majority of individuals with dementia will first present for care and assessment in primary care settings. There is a need for brief dementia screening instruments that can accurately diagnose dementia in primary care settings. The Mini-Cog is a brief, cognitive screening test that is frequently used to evaluate cognition in older adults in various settings.

OBJECTIVES

To determine the diagnostic accuracy of the Mini-Cog for diagnosing Alzheimer's disease dementia and related dementias in a primary care setting.

SEARCH METHODS

We searched the Cochrane Dementia and Cognitive Improvement Register of Diagnostic Test Accuracy Studies, MEDLINE, Embase and four other databases, initially to September 2012. Since then, four updates to the search were performed using the same search methods, and the most recent was January 2017. We used citation tracking (using the databases' 'related articles' feature, where available) as an additional search method and contacted authors of eligible studies for unpublished data.

SELECTION CRITERIA

We only included studies that evaluated the Mini-Cog as an index test for the diagnosis of Alzheimer's disease dementia or related forms of dementia when compared to a reference standard using validated criteria for dementia. We only included studies that were conducted in primary care populations.

DATA COLLECTION AND ANALYSIS

We extracted and described information on the characteristics of the study participants and study setting. Using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) criteria we evaluated the quality of studies, and we assessed risk of bias and applicability of each study for each domain in QUADAS-2. Two review authors independently extracted information on the true positives, true negatives, false positives, and false negatives and entered the data into Review Manager 5 (RevMan 5). We then used RevMan 5 to determine the sensitivity, specificity, and 95% confidence intervals. We summarized the sensitivity and specificity of the Mini-Cog in the individual studies in forest plots and also plotted them in a receiver operating characteristic plot. We also created a 'Risk of bias' and applicability concerns graph to summarize information related to the quality of included studies.

MAIN RESULTS

There were a total of four studies that met our inclusion criteria, including a total of 1517 total participants. The sensitivity of the Mini-Cog varied between 0.76 to 1.00 in studies while the specificity varied between 0.27 to 0.85. The included studies displayed significant heterogeneity in both methodologies and clinical populations, which did not allow for a meta-analysis to be completed. Only one study (Holsinger 2012) was found to be at low risk of bias on all methodological domains. The results of this study reported that the sensitivity of the Mini-Cog was 0.76 and the specificity was 0.73. We found the quality of all other included studies to be low due to a high risk of bias with methodological limitations primarily in their selection of participants.

AUTHORS' CONCLUSIONS

There is a limited number of studies evaluating the accuracy of the Mini-Cog for the diagnosis of dementia in primary care settings. Given the small number of studies, the wide range in estimates of the accuracy of the Mini-Cog, and methodological limitations identified in most of the studies, at the present time there is insufficient evidence to recommend that the Mini-Cog be used as a screening test for dementia in primary care. Further studies are required to determine the accuracy of Mini-Cog in primary care and whether this tool has sufficient diagnostic test accuracy to be useful as a screening test in this setting.

Informal carers' perspectives on the delivery of acute hospital care for patients with dementia: a systematic review

Background

Providing high quality acute hospital care for patients with dementia is an increasing challenge as the prevalence of the disease rises. Informal carers of people with dementia are a critical resource for improving inpatient care, due to their insights into patients’ needs and preferences. We summarise informal carers’ perspectives of acute hospital care to inform best practice service delivery.

Methods

We conducted a systematic search of bibliographic databases and sought relevant grey literature. We used thematic synthesis analysis to assimilate results of the studies and describe components of care that influence perceived quality.

Results

Twenty papers met the inclusion criteria. Findings identified four overarching components of care that influenced carer experience and their perceptions of care quality: ‘Patient care’, ‘Staff interactions’, ‘Carer’s situation’ and ‘Hospital environment’. Need for improvement was identified in staff training, provision of help with personal care needs, and dignified treatment of patients. Carers need to be informed, involved and supported during hospital admission in order to promote the most positive experience.

Conclusion

This review identifies common perspectives of informal carers of people with dementia in the acute hospital setting and highlights important areas to address to improve the experience of an admission for both carer and patient.

Availability of information on young onset dementia for patients and carers in six European countries

OBJECTIVES

To identify information available in six European countries (England, France, Germany, Netherlands, Portugal, Sweden) that addresses the specific needs of people with young onset dementia (YOD) and their carers, and identify gaps.

METHODS

Search of websites of organisations with potential interest in dementia. Narrative synthesis and comparative analysis.

RESULTS

21 sources of information were identified (Netherlands 6, England 6, France 3, Germany 2, Portugal 2, Sweden 2); 11 were from voluntary sector organisations. Sources dedicated to YOD were limited (4 websites, 4 books); all other YOD information was sub-entries in generic dementia sources, difficult to locate and with limited coverage of relevant topics. Gaps related to implications of living with YOD in Germany, Portugal and Sweden.

CONCLUSION

Availability of information varies among countries, some having no dedicated source and incomplete coverage of issues of importance to YOD.

PRACTICAL IMPLICATIONS

Information is an important means of supporting carers; their needs change as the condition progresses. A comprehensive resource collating key information is needed so that the issues that differentiate the specific needs of people living with YOD from those of people with dementia in older age are available and easily located.

Epistemic injustice in dementia and autism patient organizations: An empirical analysis

Patient organizations (POs) represent patient collectives in health care policy. The inclusion of people with a 'neuro-psychiatric' condition poses a particular challenge for the organizational processes and political representation of such collectives. In recent years, new POs (POs of) have been established in the field of autism spectrum disorder and dementia that advocate a different agenda and have a different organizational structure than traditional POs (POs for). The divide between these two types of POs indicates a different standpoint with regard to who should be included on an organizational level, which voices are accepted and who should represent these voices on the political level. The inclusion and exclusion of voices needs to be normatively justified in order to be regarded legitimate representation of such a collective. With the help of Miranda Fricker's theory of epistemic injustice, we scrutinize whether and, if so, which types of epistemic injustices (wrongdoings to a person as a knower) can be found within POs' practices and the political field in which they operate, by analyzing 37 interviews with PO representatives, their members and policy makers. Our in-depth analysis indicates that persistent stereotypes hamper the inclusion of affected members both within POs and on the health political level. Being affected causes distrust in having the 'capacity to know' in a two-fold way; it is assumed that those who can represent themselves are "not affected enough" to present valuable insights into the condition and those who have difficulties to express themselves due to their condition are excluded because of their affectedness. We conclude that our analysis of the epistemic practices of POs serves as a good starting point to address these shortcomings from a theoretical and practical perspective and offers a valuable starting point for bioethics to understand unjust structures in the health political context.

Aspectos éticos de la investigación etnográfica en salud. El papel del comité de ética de la investigación

La presencia e integración de la investigación cualitativa a los protocolos de investigación biomédica ha cobrado cada vez mayor relevancia, por la importancia de la antropología cultural. El caso particular de la etnografía adquiere aún más preeminencia en relación con la definición de riesgo para el sujeto de investigación. El presente artículo expone las principales características de la investigación etnográfica que deben ser evaluadas por un comité de ética de la investigación, y define una serie de recomendaciones para la evaluación del riesgo para los sujetos que se someten a este tipo de estudio. Los miembros de los Comités de Ética en Investigación deben tener en cuenta la etnografía para realizar a cabalidad su función.

Supporting people with young onset dementia and their families: An evaluation of a training course for care workers

This article reports the findings of an evaluation of a training course for care workers who care for people with dementia in the community. Twenty-four care workers participated in the training which took place in London and Surrey, United Kingdom. The training had a significant positive impact on participants' confidence in understanding the experiences and social care needs of people with young onset dementia (YOD) and their families. Participants also perceived that the training would help them improve their working practice by furthering their understanding of practical approaches to supporting and caring for people with dementia in general. Additionally, participants reported many ways in which they perceived being able to specifically support and empower people with YOD. It was concluded that the short training course improved knowledge and confidence for care workers on dementia care, and specifically in understanding how to support people with YOD and their families. Dementia specific training should be considered by service managers as a way of potentially increasing care worker job satisfaction.

Perspectives of policy and political decision makers on access to formal dementia care: expert interviews in eight European countries

Background

As part of the ActifCare (ACcess to Timely Formal Care) project, we conducted expert interviews in eight European countries with policy and political decision makers, or representatives of relevant institutions, to determine their perspectives on access to formal care for people with dementia and their carers.

Methods

Each ActifCare country (Germany, Ireland, Italy, The Netherlands, Norway, Portugal, Sweden, United Kingdom) conducted semi-structured interviews with 4–7 experts (total N = 38). The interview guide addressed the topics “Complexity and Continuity of Care”, “Formal Services”, and “Public Awareness”. Country-specific analysis of interview transcripts used an inductive qualitative content analysis. Cross-national synthesis focused on similarities in themes across the ActifCare countries.

Results

The analysis revealed ten common themes and two additional sub-themes across countries. Among others, the experts highlighted the need for a coordinating role and the necessity of information to address issues of complexity and continuity of care, demanded person-centred, tailored, and multidisciplinary formal services, and referred to education, mass media and campaigns as means to raise public awareness.

Conclusions

Policy and political decision makers appear well acquainted with current discussions among both researchers and practitioners of possible approaches to improve access to dementia care. Experts described pragmatic, realistic strategies to influence dementia care. Suggested innovations concerned how to achieve improved dementia care, rather than transforming the nature of the services provided. Knowledge gained in these expert interviews may be useful to national decision makers when they consider reshaping the organisation of dementia care, and may thus help to develop best-practice strategies and recommendations.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2456-0) contains supplementary material, which is available to authorized users.

'I shouldn't have had to push and fight': health care experiences of persons with dementia and their caregivers in primary care

OBJECTIVES

Most persons with dementia (PWD) receive the majority of their care from primary care providers (PCPs). A number of challenges have been identified with providing quality dementia care in primary care from the perspective of PCP. However, less is known of the primary care health care experience (HCE) of PWD and their caregivers. We examined the primary care HCE of PWD and their caregivers in Ontario, Canada.

METHODS

Participants were recruited through local Alzheimer Society chapter support groups. A semi-structured interview guide was developed. Focus groups were audio recorded, transcribed verbatim, anonymized, and then reviewed and coded for themes independently by two study authors. Thematic analysis was conducted to identify major themes and a model proposing the common components of a perceived positive HCE was created.

RESULTS

Five focus groups were conducted across urban and rural settings. Each focus group included both PWD and their caregivers and a total of eight PWD and 21 caregivers participated. Four main themes emerged from the analysis: communication, caregiver as manager, system navigation, ease of access. The model for positive HCE included: an informed patient/caregiver; supported patient/caregiver; strong PCP-patient/caregiver relationship; an accessible provider; a knowledgeable provider; and strong communication by the provider.

CONCLUSION

The HCE of PWD and their caregivers is complex and a number of factors which are potentially modifiable by PCP may improve the HCE for the growing number of PWD in primary care. Understanding these experiences may help to identify strategies to improve care and patient and provider experiences.

Why aren't people with young onset dementia and their supporters using formal services? Results from the INSPIRED study

Background/Aims

Despite reporting high levels of burden, supporters of people with young onset dementia (YOD) underuse formal community services. Previous quantitative studies in YOD are of limited utility in guiding service design because they did not consider important contextual barriers to service use. The aim of this study was to identify all relevant barriers and describe the service features considered most important to improving uptake by people with YOD and their supporters.

Methods

Eighty-six people with consensus-confirmed YOD (mean onset age 55.3 years) and/or their primary supporter participated in quantitative interviews, and 50 also participated in one of seven qualitative focus groups. Interview participants reported levels of community service use and reasons for non-use, functional impairment, behavioural and psychological symptoms, supporter burden, social network, and informal care provision. Focus group participants expanded on reasons for non-use and aspects of an ideal service.

Results

Although at least one community service was recommended to most participants (96.8%), 66.7% chose not to use one or more of these. Few of the clinical or demographic factors included here were related to service use. Qualitative analyses identified that lack of perceived need, availability, and YOD-specific barriers (including ineligibility, unaffordability, lack of security, lack of childcare) were commonly reported. Five aspects of an ideal service were noted: unique, flexibile, affordable, tailored, and promoting meaningful engagement.

Conclusion

People with YOD and their families report that formal community services do not meet their personal and psychological needs. Researchers can provide ongoing assessment of program feasibility, suitability, and generalisability.

Promoting early dementia diagnosis: a video designed by patients, for patients

Early diagnosis of dementia allows people to access effective treatment and make advance decisions while they still have capacity. We aimed to encourage people to attend memory clinic, in order to boost rates of diagnosis. We created a patient information video about Oxford Health NHS Foundation Trust Memory Clinics, to inform and empower those awaiting assessment and to promote early diagnosis. Fourteen people (patients, carers, and staff) were approached prior to developing the video to ascertain their views on the themes the video should cover. The video consisted of unscripted interviews with patients, carers, and staff. We surveyed participants and new patients attending memory clinic to get feedback on the video and to assess patients' level of understanding and confidence about a memory assessment before and after watching the video. The video content was refined based on this feedback and a final version was produced. Patient feedback demonstrated that confidence and understanding increased after watching the video. Although this study is limited by its small sample size and lack of access to those with undiagnosed dementia, feedback suggested that the video empowered and reassured those awaiting assessment and could be used as a tool to reduce barriers to early diagnosis. Patients and carers involved in making the video found it a therapeutic activity in itself.

[Not Available]

Objectif

Permettre aux médecins de famille de comprendre « l’expérience vécue » de la démence de la bouche d’une personne atteinte de démence—Faye Forbes, ministre anglicane de 64 ans atteinte de la maladie d’Alzheimer, qui donne son point de vue sur comment vivre avec la démence—et utiliser cette information pour améliorer les soins et les résultats.

Sources d’information

Une recherche a été effectuée dans MEDLINE sur Ovid entre janvier 2005 et février 2015, à l’aide des mots-clés anglais suivants : dementia, caregiver, perspectives et quality of health care. Les articles qui s’adressaient aux médecins de famille ont été sélectionnés. Des revues pertinentes et des articles de recherche originaux ont été utilisés, le cas échéant, s’ils s’appliquaient aux personnes atteintes de démence et à leurs soignants.

Message principal

Plusieurs cadres de référence organisent les principales expériences décrites par les patients et leurs soignants. Nous avons utilisé une revue de la littérature qualitative pour fournir un cadre de référence résumant l’expérience de Faye, en fonction des thèmes suivants : tenter d’obtenir un diagnostic, accéder au soutien et aux services, besoins en matière d’information, prise en charge de la maladie, et communication et attitudes.

Conclusion

Les médecins doivent tenir compte de ces thèmes lorsqu’ils planifient la prise en charge des personnes atteintes de démence. Il importe de tenter de comprendre l’expérience et le point de vue des personnes atteintes de démence et de leurs soignants afin de pouvoir dispenser des soins optimaux.

A patient's experience in dementia care: Using the "lived experience" to improve care

OBJECTIVE

To give FPs an understanding of the "lived experience" of dementia via the words of a person with dementia (PWD)- Faye Forbes, a 64-year-old Anglican priest with Alzheimer disease who provides her perspectives on living with dementia-and to use these thoughts to improve care and outcomes.

SOURCES OF INFORMATION

Ovid MEDLINE was searched from January 2005 to February 2015 using subject headings for dementia, caregiver, perspectives, and quality of health care. Articles geared toward FPs were selected. Relevant review articles and original research articles were used when appropriate and if they were applicable to PWDs and their caregivers.

MAIN MESSAGE

There are several frameworks that organize the main experiences described by patients and caregivers. We used a review of the qualitative literature to provide the framework to summarize Faye's experience under the following headings: seeking a diagnosis, accessing supports and services, information needs, disease management, and communication and attitudes.

CONCLUSION

Physicians should consider these themes when developing a management plan for PWDs. Trying to understand the experiences and perspectives of PWDs and their caregivers is important in providing optimal care.

Enablers and barriers to implementing collaborative care for anxiety and depression: a systematic qualitative review

Background

Collaborative care is an increasingly popular approach for improving quality of care for people with mental health problems through an intensified and structured collaboration between primary care providers and health professionals with specialized psychiatric expertise. Trials have shown significant positive effects for patients suffering from depression, but since collaborative care is a complex intervention, it is important to understand the factors which affect its implementation. We present a qualitative systematic review of the enablers and barriers to implementing collaborative care for patients with anxiety and depression.

Methods

We developed a comprehensive search strategy in cooperation with a research librarian and performed a search in five databases (EMBASE, PubMed, PsycINFO, ProQuest, and CINAHL). All authors independently screened titles and abstracts and reviewed full-text articles. Studies were included if they were published in English and based on the original qualitative data on the implementation of a collaborative care intervention targeted at depression or anxiety in an adult patient population in a high-income country. Our subsequent analysis employed the normalization process theory (NPT).

Results

We included 17 studies in our review of which 11 were conducted in the USA, five in the UK, and one in Canada. We identified several barriers and enablers within the four major analytical dimensions of NPT. Securing buy-in among primary care providers was found to be critical but sometimes difficult. Enablers included physician champions, reimbursement for extra work, and feedback on the effectiveness of collaborative care. The social and professional skills of the care managers seemed critical for integrating collaborative care in the primary health care clinic. Day-to-day implementation was also found to be facilitated by the care managers being located in the clinic since this supports regular face-to-face interactions between physicians and care managers.

Conclusions

The following areas require special attention when planning collaborative care interventions: effective educational programs, especially for care managers; issues of reimbursement in relation to primary care providers; good systems for communication and monitoring; and promoting face-to-face interaction between care managers and physicians, preferably through co-location. There is a need for well-sampled, in-depth qualitative studies on the implementation of collaborative care in settings outside the USA and the UK.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0519-y) contains supplementary material, which is available to authorized users.

Screening for Dementia in Older Adults: Comparison of Mini-Mental State Examination, Mini-Cog, Clock Drawing Test and AD8

This study was conducted to estimate screening performance of dementia screening tools including Mini-Mental State Examination (MMSE), Mini-Cog, Clock Drawing Test (CDT) and Ascertain Dementia 8 questionnaire (AD8) for older adults. 2015 participants aged 65 years or more in eastern China were enrolled. 4 screening tests were administered and scored by specifically trained psychiatrists. We used data from two-by-two tables to calculate the sensitivity, specificity, and positive and negative predictive values (PPV/NPV). Our study showed that dementia was highly prevalent among elderly in Zhejiang province. The Mini-Cog, with excellent screening characteristics and spending less time, could be considered to be used as a screening tool among communities to help to diagnose dementia early.

Diagnosis and management of dementia in family practice

BACKGROUND

Improving quality of care for people with dementia is a high priority. Considerable resources have been invested in financial incentives, guideline development, public awareness and educational programmes to promote earlier diagnosis and better management.

OBJECTIVES

Evaluating family physicians' concordance with guidelines on diagnosis and management of people with dementia, from first documentation of symptoms to formal diagnosis.

METHOD

Analysis of medical records of 136 people with dementia recruited by 19 family practices in NW London and surrounding counties.

RESULTS

Practices invited 763 people with dementia to participate, 167 (22%) agreed. Complete records were available for 136 (18%). The majority of records included reference to recommended blood tests, informant history and caregiver concerns. Presence or absence of symptoms of depression, psychosis, other behavioural and psychological symptoms of dementia, and cognitive function tests were documented in 30%-40% of records. Documentation of discussions about signs and symptoms of dementia, treatment options, care, support, financial, legal and advocacy advice were uncommon. Comparison of these findings from a similar study in 2000-2002 suggests improvements in concordance with blood tests, recording informant history, presence or absence of depression or psychosis symptoms. There was no difference in documenting cognitive function tests. Immediate referral to specialists was more common in the recent study.

CONCLUSION

Five years after UK dementia guidelines and immediately after the launch of the dementia strategy, family physicians appeared concordant with clinical guidelines for dementia diagnosis (other than cognitive function tests), and referred most patients immediately. However, records did not suggest systematic dementia management.

Children's Experiences of Epilepsy: A Systematic Review of Qualitative Studies

CONTEXT

Epilepsy is a common and severe neurologic disease associated with increased mortality, seizure-related injury, and adverse psychological and quality-of-life outcomes.

OBJECTIVE

To describe the perspectives of children and adolescents with epilepsy.

DATA SOURCES

Medline, Embase, PsycINFO, and CINAHL from inception to August 2015.

STUDY SELECTION

Qualitative studies on children's experiences of epilepsy.

DATA EXTRACTION

Results from primary studies. We used thematic synthesis to analyze the findings.

RESULTS

Forty-three articles involving 951 participants aged 3 to 21 years across 21 countries were included. We identified 6 themes: loss of bodily control (being overtaken, susceptibility to physical harm, fragility of the brain, alertness to mortality, incapacitating fatigue), loss of privacy (declarative disease, humiliating involuntary function, unwanted special attention, social embarrassment of medicine-taking), inescapable inferiority and discrimination (vulnerability to prejudice, inability to achieve academically, consciousness of abnormality, parental shame, limiting social freedom), therapeutic burden and futility (unattainable closure, financial burden, overwhelming life disruption, exhaustion from trialing therapies, insurmountable side effects, awaiting a fabled remission), navigating health care (empowerment through information, valuing empathetic and responsive care, unexpected necessity of transition, fragmented and inconsistent care), and recontextualizing to regain normality (distinguishing disease from identity, taking ownership, gaining perspective and maturity, social and spiritual connectedness).

LIMITATIONS

Non-English articles were excluded.

CONCLUSIONS

Children with epilepsy experience vulnerability, disempowerment, and discrimination. Repeated treatment failure can raise doubt about the attainment of remission. Addressing stigma, future independence, and fear of death may improve the overall well-being of children with epilepsy.

Carers: The navigators of the maze of care for people with dementia—A qualitative study

Background

Dementia is a challenge in our society, with individuals accessing services across multiple settings. Carers are navigating and delivering care services in the home. This research sought to investigate the experiences of people with dementia and their carers when transitioning home from hospital.

Methods

This study used a qualitative descriptive design, employing in-depth interviews with 30 carers recruited through networks known to one state branch of Alzheimer’s Australia. Emerging themes were validated in one focus group.

Results

During the hospital stay carers experienced a paradox: being required to deliver care yet perceiving that they were being ignored in regard to decisions about care. The time in hospital was considered by some carers to be stressful, as they were concerned about the safety of the person with dementia. Many reported that discharge home was rarely planned and coordinated. Returning home carers found re-establishing and/or accessing new services challenging, with available services often inappropriate to need.

Conclusion

The paradox of the care experience in the acute setting, whereby the carer was either invited, or sought, to deliver care, yet was excluded in staff decisions about that care, challenges the current communication and coordination of care. For people with dementia and their carers, there is a need for a coordinated seamless service that enables continued unbroken care and support from acute care to home. Carers also need support navigating the wide range of services available and importantly both carers and care providers may need to understand service boundaries.

Recommendations

This study highlights the need to acknowledge the expertise of the carer, and their need for support. Enabling a smooth discharge from hospital and support to navigate care access in the community is paramount. These experiences provide insight into gaps in service provision and modifying existing services may lead to improved experiences.

Negotiating access to a diagnosis of dementia: Implications for policies in health and social care

The ‘Pathways to Diagnosis’ study captured the experience of the prediagnosis period of Alzheimer’s disease and related dementias through indepth interviews with 29 persons with dementia and 34 of their family caregivers across four sites: anglophones in Calgary, francophones in Ottawa, Chinese-Canadians in Greater Vancouver and Indo-Canadians in Toronto. In this cross-site analysis, we use the ‘Candidacy’ framework to comprehensively explore the challenges to securing a diagnosis of dementia in Canada and to develop relevant health and social policy. Candidacy views eligibility for appropriate medical care as a process of joint negotiation between individuals and health services, which can be understood relative to seven dimensions: identification of need, navigation, appearances at services, adjudication by providers, acceptance of/resistance to offers, permeability of services and local conditions. Interviewees experienced challenges relative to each of the seven dimensions and these varied in form and emphasis across the four ethno-linguistic groups.

Meta-synthesis of qualitative research: the challenges and opportunities

Synthesis of qualitative studies is an emerging area that has been gaining more interest as an important source of evidence for improving health care policy and practice. In the last decade there have been numerous attempts to develop methods of aggregating and synthesizing qualitative data. Although numerous empirical qualitative studies have been published about different aspects of health care research, to date, the aggregation and syntheses of these data has not been commonly reported, particularly in pharmacy practice related research. This paper describes different methods of conducting meta-synthesis and provides an overview of selected common methods. The paper also emphasizes the challenges and opportunities associated with conducting meta-synthesis and highlights the importance of meta-synthesis in informing practice, policy and research.

[Problems in the process of adapting to change among the family caregivers of elderly people with dementia]

OBJECTIVE

To identify and analyse problems in adapting to change among the family caregivers of relatives with dementia.

METHOD

Qualitative study based on the methodology of Charmaz's Constructivist Grounded Theory. Seven focus groups were conducted in different primary health care centres in the province of Jaen (Spain). Eighty-two primary family caregivers of relatives with dementia participated by purposeful maximum variation sampling and theoretical sampling. Triangulation analysis was carried out to increase internal validity.

RESULTS

We obtained three main categories: 'Changing Care', 'Problems in the process of adapting to change' and 'Facilitators of the process of adapting to change'. Family caregivers perform their role in a context characterized by personal change, both in the person receiving the care and in the social and cultural context. The challenge of adaptation lies in the balance between the problems that hamper adaptation of the caregiver to new situations of care and the factors that facilitate the caregiver role.

CONCLUSIONS

The adaptation of family caregivers to caring for a person with dementia is hindered by the lack of formal support and under-diagnosis of dementia. The adaptation process could be improved by strengthening formal support in the early stages of care to reduce the stress of family caregivers who must teach themselves about their task and by interventions adapted to each phase in the development of the caregiver role.

Medication-related burden and patients' lived experience with medicine: a systematic review and metasynthesis of qualitative studies

OBJECTIVE

To explore medication-related burden (MRB) and patients' lived experience with medicines (PLEM) without regard to particular medication therapies or medical conditions.

DESIGN

Systematic review and metasynthesis of qualitative studies.

DATA SOURCES

MEDLINE, EMBASE, International Pharmaceutical Abstracts, PsycINFO, Global health, CINAHL and Web of Science were searched from January 2000 to August 2014 using medication burden and patients' lived experience terms.

SYNTHESIS METHODS

Synthesis was undertaken following metaethnography methods and a comparative thematic analysis technique.

RESULTS

34 articles from 12 countries with a total of 1144 participants were included. 3 major inter-related themes emerged central to PLEM: MRB, medication related beliefs and medication taking practice. The negative impact of MRB, due to its interference on patients' daily lives and effects on well-being, its influence on patients' beliefs and behaviours, and a potential risk for drug-related problems (DRPs) was evident. This resulted in non-adherence and poorer outcomes (unachieved therapeutic goals and damage to patients' health). Patients who experienced MRB interference in their life over time begin to juggle their medicines. Others continue their medicines despite experiencing MRB resulting in compromised physical, social or psychological well-being.

CONCLUSIONS

There is a shared commonality of PLEM among the studies. MRB plays a central role in influencing patients' health and well-being, beliefs and behaviour towards medicines. Given the complexity of MRB and its impact evident from this review, there is a need for healthcare practitioners to have insight into PLEM in therapeutic care plans. Understanding PLEM is an opportunity for practitioners to identify particular MRBs that patients encounter, and provide individualised care through selection of therapeutic care plans that suit a patient's life. This may assist in helping to achieve patients' medication-related needs, and improve medication therapy and health outcomes.

[The experience of women care cargivers with chronic conditions of dependent relatives]

OBJECTIVE

To describe the experience of women caregivers with chronic conditions who care for a dependent relative.

DESIGN

Qualitative study based on constructivist grounded theory.

LOCATION

Study conducted on two Health Areas urban of the Community of Madrid.

PARTICIPANTS

Thirty nine women with a chronic condition who take care of dependent relatives were selected by means of purposive sampling.

METHOD

Data were collected through 23 semi-structured interviews and 2 focus groups between April 2010 and December 2011. Grounded theory procedures were used in the data analysis.

RESULTS

To feel their life hampered describes the subjective experience of family caregivers with chronic conditions who take care of a dependent relative. When comparing their past life with the current life they become aware of the losses they have suffered over time. They feel less strong, sadder and less free; they worry about how to meet the demands of family care. The life they are leading makes them question the meaning of their own lives.

CONCLUSIONS

This study shows the losses realized day by day by women caregivers with a chronic illness, which lead them to lose the meaning of their own lives. To know the experience of these women caregivers will help develop interventions and specific services that compensate for the losses they feel and help improve their quality of living.

Formal support for informal caregivers to older persons with dementia through the course of the disease: an exploratory, cross-sectional study

BACKGROUND

In European countries, knowledge about availability and utilization of support for informal caregivers caring for older persons (≥65 years) with dementia (PwD) is lacking. To be able to evaluate and develop the dementia support system for informal caregivers to PwD, a survey of European support systems and professionals involved is needed. The aim of this study was to explore support for informal caregivers to PwD in European countries. We investigated the availability and utilization of support in each of the participating countries, and the professional care providers involved, through the dementia disease.

METHODS

A mapping system was used in 2010-2011 to gather information about estimations of availability, utilization, and professional providers of support to informal caregivers caring for PwD. Data collected was representing each country as a whole.

RESULTS

There was high availability of counselling, caregiver support, and education from the diagnosis to the intermediate stage, with a decrease in the late to end of life stage. Utilization was low, although there was a small increase in the intermediate stage. Day care and respite care were highly available in the diagnosis to the intermediate stage, with a decrease in the late to end of life stage, but both types of care were utilized by few or no caregivers through any of the disease stages. Professionals specialized in dementia (Bachelor to Master's degree) provided counselling and education, whereas caregiver support for informal caregivers and day care, respite care, and respite care at home were provided by professionals with education ranging from upper secondary schooling to a Master's degree.

CONCLUSIONS

Counselling, caregiver support, and education were highly available in European countries from diagnosis to the intermediate stage of the dementia disease, decreasing in the late/end of life stages but were rarely utilized. Countries with care systems based on national guidelines for dementia care seem to be more aware of the importance of professionals specialized in dementia care when providing support to informal caregivers. Mapping the systems of support for informal caregivers of PwD is a valuable tool for evaluating existing systems, internationally, nationally and locally for policy making.