Psychiatric disorders in elderly from the Indian sub-continent living in Bradford

Recruitment and methodological issues in conducting dementia research in British ethnic minorities: A qualitative systematic review

OBJECTIVE

Identifying existing recruitment and methodological issues within dementia research conducted in UK studies that included ethnic minorities.

METHODS

We searched for and included any publication detailing dementia research in the UK that included any ethnic minority. The search results and all titles and abstracts were screened according to the inclusion criteria followed by screening of the full texts. We extracted data regarding the recruitment and methodological issues faced by the researchers. This data was combined and listed, and related issues were grouped into overarching themes and subthemes.

RESULTS

Of 52 publications suitable for analysis, 33 provided data collated into six themes: attitudes and beliefs about dementia in ethnic minority communities, recruitment process, data collection issues, practical issues, researcher characteristics, and lack of published research and normative data. These themes allowed us to identify three areas responsible for addressing these recruitment and methodological issues: community and patient education, health services, and researchers' training.

CONCLUSIONS

This is the first review identifying recruitment and methodological issues within UK dementia research that included ethnic minorities. We now have a compilation of reported existing issues and a framework of areas responsible for addressing them and devising solutions.

Awareness and understanding of dementia in South Asians: A synthesis of qualitative evidence

Background

Despite a growing elderly South Asian population, little is known about the experience of diagnosis and care for those living with dementia. There have been a number of individual qualitative studies exploring the experiences of South Asian people living with dementia and their carers across different contexts. There has also been a growing interest in synthesizing qualitative research to systematically integrate qualitative evidence from multiple studies to tell us more about a topic at a more abstract level than single studies alone. The aim of this qualitative synthesis was to clearly identify the gaps in the literature and produce new insights regarding the knowledge and understanding of the attitudes, perceptions, and beliefs of the South Asian community about dementia.

Methods

Following a systematic search of the literature, included qualitative studies were assessed by two independent reviewers for methodological quality. Data were extracted and pooled using the Joanna Briggs Institute Qualitative Assessment and Review Instrument (QARI). Findings were synthesized using the Joanna Briggs Institute approach to qualitative synthesis by meta-aggregation.

Results

Seventeen papers were critically appraised, with 13 meeting the inclusion criteria. Participants were mostly of South Asians of Indian background; followed by Pakistani with a few Sri Lankans. Missing South Asian countries from the current evidence base included those from Bangladesh, Bhutan, Maldives, and Nepal. Three meta-synthesis themes emerged from the analysis: (1) a poor awareness and understanding of dementia, (2) the experience of caregiving, and (3) the attitudes toward dementia care provision.

Conclusions

A consistent message from this qualitative synthesis was the limited knowledge and understanding of dementia amongst the South Asians. Whilst symptoms of dementia such as ‘memory loss’ were believed to be a part of a normal ageing process, some South Asian carers viewed dementia as demons or God’s punishments. Most studies reported that many South Asians were explicit in associating stigmas with dementia.

Dementia in UK South Asians: a scoping review of the literature

OBJECTIVE

Over 850 000 people live with dementia in the UK. A proportion of these people are South Asians, who make up over 5% of the total UK population. Little is known about the prevalence, experience and treatment of dementia in the UK South Asian population. The aim of this scoping review is to identify dementia studies conducted in the UK South Asian population to highlight gaps in the literature which need to be addressed in future research.

METHOD

Databases were systematically searched using a comprehensive search strategy to identify studies. A methodological framework for conducting scoping reviews was followed. An extraction form was developed to chart data and collate study characteristics and findings. Studies were then grouped into six categories: prevalence and characteristics; diagnosis validation and screening; knowledge, understanding and attitudes; help-seeking; experience of dementia; service organisation and delivery.

RESULTS

A total of 6483 studies were identified, 27 studies were eligible for inclusion in the scoping review. We found that studies of prevalence, diagnosis and service organisation and delivery in UK South Asians are limited. We did not find any clinical trials of culturally appropriate interventions for South Asians with dementia in the UK. The existing evidence comes from small-scale service evaluations and case studies.

CONCLUSIONS

This is the first scoping review of the literature to identify priority areas for research to improve care for UK South Asians with dementia. Future research should first focus on developing and validating culturally appropriate diagnostic tools for the UK South Asians and then conducting high-quality epidemiological studies in order to accurately identify the prevalence of dementia in this group. The cultural adaptation of interventions for dementia and testing in randomised controlled trials is also vital to ensure that there are appropriate treatments available for the UK South Asians to access.

Ageing, ethnicity and psychiatric services

In 2001, the Royal College of Psychiatrists produced Council Report (CR103) which concluded that services for Black and minority ethnic elders had received little attention. the report also called for an urgent need to establish a reliable and informative database of good practice and increased research. It is currently under review by the College. This article attempts to set out some of the issues that remain as well as newly identified ones. In particular, the article hopes to heighten awareness and raise debate about these issues and to link these with the College's Race Equality Action Plan.

Diagnosis of mental illness in elderly people from ethnic minorities

From the 1991 census (Office of Population Censuses and Surveys, 1993) it is estimated that 5.9% of the total population of England and Wales belong to an ethnic minority, and that 3% of this ethnic minority population are aged 65 years and older. This compares with 17% aged 65 years and older in the indigenous population. Although the numbers of elderly people from ethnic minorities are small in absolute terms, these groups are growing rapidly, and mental health professionals working with elderly patients will increasingly need to be equipped with the necessary services and skills to meet their specific needs. The elderly ethnic minority population of the UK is extremely diverse; the largest groups originate from the Indian subcontinent and the Caribbean, but there are also significant communities of Chinese, Somali, Vietnamese, Eastern European, Mediterranean and Irish origin, all of which require consideration when planning and providing services, whatever their numbers. This diversity is also important when considering the various factors that influence the presentation and diagnosis of mental disorders in these groups.

Mental health of the ageing immigrant population

About 6% of older people in the UK are immigrants. Concentrated in deprived inner-city areas, their numbers are rising rapidly, with the ageing of those arriving after the Second World War. Cultural, language and educational differences cause problems in studying this group's mental health. Idioms of distress may affect presentation, help-seeking behaviour and acceptability of treatment. Ethnic elders may be considered vulnerable to depression because of socio-economic deprivation, immigrant status and old age but studies are contradictory and may use inappropriate screening instruments. Relatively few consider immigrant status and dementia. Uncontrolled hypertension could relate to higher dementia rates in Black immigrants which are not reflected in the country of origin. No genetic risk has been found. There is potential for prevention in this population.

Suicides by country of birth groupings in England and Wales: age-associated trends and standardised mortality ratios

INTRODUCTION

Suicide rates in England and Wales have declined in recent years. A better understanding of age-associated trends in different ethnic groups may inform strategies to sustain this decline.

MATERIALS AND METHODS

This study examines suicide rates and age-associated trends in England and Wales by country of birth (used as a proxy for ethnicity) using the latest available national mortality data.

RESULTS

The main findings were (a) suicide rates were generally higher in males than females in all age bands in all country of birth groups except the China group, where suicides rates were higher in females than males in the older age bands; (b) male suicide rates increased with ageing in the Indian sub-continent group and female suicide rates increased with ageing in the Africa and China groups; (c) male standardised mortality ratios (SMRs) were generally higher in the younger age bands in the Eastern Europe and Caribbean groups and generally lower in the Australasian, Middle East and Western Europe groups; (d) male SMRs were generally higher in the older age bands in Eastern Europe, Caribbean, Australasian and Western Europe groups and lower in all age bands in the Indian sub-continent group, and (e) female SMRs were generally higher in the older age bands in the China, Africa and Caribbean groups.

CONCLUSION

There is a need for epidemiological data on suicides in BME groups, including age-associated trends, trends over time, risk and protective factors and methods of suicide to inform suicide prevention strategies.

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.

Psychiatry of old age and ethnic minority older people in the United Kingdom

This review examines the demographic changes, the epidemiology of mental disorders and suicides, the potential risk and protective factors, access to secondary care old age psychiatry services (OAPSs) and the policy context pertaining to older people from ethnic minority groups in the United Kingdom. The number of older people from ethnic minority groups is increasing. The prevalence of mental disorders in older people from ethnic minority groups is either similar to or higher than that in the indigenous population. Therefore, the number of older people from ethnic minority groups with psychiatric morbidity is also increasing. Ethnic minority older people also have inequity of access to secondary care OAPSs. There is an urgent need to develop and implement practical strategies to improve access by older people from ethnic minority groups to OAPSs.

Comparison of elderly suicide rates among migrants in England and Wales with their country of origin

BACKGROUND

The black and minority ethnic (BME) elderly population size in England and Wales has progressively increased over the last three decades. Only two studies, both well over a decade old, have compared suicide rates in BME groups in England and Wales with those in their country of origin.

METHODS

A study comparing suicide rates among elderly migrants in England and Wales and in their country of origin using the latest available mortality data from the Office of National Statistics and the World Health Organization was conducted.

RESULTS

There were wide variations in standardised mortality ratios for elderly suicides among migrants from different countries compared with those born in England and Wales and in their country of origin. There was convergence towards elderly suicide rates for England and Wales in some migrant groups in males in the age-bands 65-74 years and 75 + years, and in females in the age-band 75 + years. However, males aged 75 + years from most migrant groups had higher rates than those born in England and Wales.

CONCLUSION

A more detailed analysis of suicide of older people from migrant groups is required to determine vulnerability and protective influences.

Mental distress and the coping strategies of elderly Indian immigrant women

This article explores how elderly English-speaking Indian immigrant women living in Edmonton, Alberta, Canada perceive and manage mental distress. With elders' consent, in-depth interviews were recorded, transcribed and transcripts were thematically analyzed. The findings suggest that these women believed that to lower the risk of mental distress it is critical for individuals to ;maximize control over inner self' by ;being busy.' The elder's busy behavior is framed within the Indian cultural and spiritual/faith matrix in dialogue with acculturation experiences in Canada. ;Staying busy' allows these elders to use culture as a ;moral medicine' to facilitate coping and adaptation.

Predictors of depression in aging South Asian Canadians

This study examined the prevalence and factors of depression among aging South Asians in Canada. Telephone surveys were conducted with a random sample of aging South Asians aged 55 and above. Hierarchical regression analysis was used to determine the factors of depression, which was measured by an adapted 15-item Geriatric Depression Scale. Over one in five (21.4%) participants reported at least a mild level of depression. A stronger agreement with South Asian cultural values was significantly related to a higher probability of being depressed. Physical health variables were the most significant factors after controlling for socio-demographic and culture-related factors. The findings have demonstrated the linkages between the relationships among socio-cultural factors and depression in older South Asians. Mental health interventions should consider the cultural uniqueness of this target population and the service delivery system should ensure that services are known and accessible to the increasingly culturally diverse aging population.

Knowledge of dementia among South Asian (Indian) older people in Manchester, UK

OBJECTIVES

The aim of this study was to examine knowledge of dementia in South Asian older people, as compared with Caucasian older people.

METHODS

Attendees, not known to suffer from dementia, of one South Asian and two predominantly Caucasian day centres for older people in Manchester (UK) were asked to complete the Dementia Knowledge Questionnaire (DKQ). The DKQ was translated into Gujarathi and Urdu by the professional translators.

RESULTS

One hundred and ninety-one DKQs from Indian and 55 DKQs from Caucasian (white UK/Irish/European) older people were included in the analyses. Knowledge of dementia was poor in both Indian and Caucasian older people, especially so in the former. The median (25th-75th percentile) total DKQ scores were 3 (2-5) in Indians and 6 (3.5-9) in Caucasians (p < 0.001). Indian older people showed significantly less knowledge about basic aspects (p < 0.001) and epidemiology (p < 0.001) of dementia when compared to Caucasian older people. Both groups faired equally badly on questions about aetiology (p = 0.91) and symptomatology (p = 0.66). Indian older people were less aware of personality, reasoning, and speech being the affected in dementia (p < 0.001, p < 0.001 and p = 0.04, respectively).

CONCLUSION

Indian older people in Manchester (UK) do not seem to have sufficient knowledge about dementia, which may be one of the reasons for their relative absence in the local dementia treatment clinics.

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

Sixty-seven English language articles were obtained for the review, the majority of which (44, 65.7%) had US origins. Broadly, the main issues covered in the literature were the under-utilization of services by minority ethnic groups; the prevalence of dementia in different ethnic groups; the experience of care giving in different racial groups and language as a factor in cognitive assessment. Although it has been argued that the instruments used to assess cognitive function are culturally biased, the available published evidence would seem to suggest that the fundamental issue is language ability, rather than minority group membership per se. Studies into the care giving experience amongst different ethnic or racial groups suffer from theoretical and methodological weaknesses. Studies of help-seeking among various ethnic groups in the US have found that many do not prioritize dementia as a health problem in the face of more pressing concerns. There was little consensus amongst the articles about whether services should be provided specifically for different ethnic groups, reflecting a lack of evidence concerning the efficacy of different models of service provision.

Mental health of migrant elders--the Islington study

BACKGROUND

In the UK, 6% of those aged 65 years and over were born abroad, most of whom now live in inner-city areas. It has been suggested that ethnic elders are particularly vulnerable to mental illness.

AIMS

To compare the prevalence of dementia and depression in older migrants with those born in the UK.

METHOD

A cross-sectional community study of 1085 people aged 65 years or older in an inner-London borough.

RESULTS

Compared with those born in the UK, the prevalence of dementia was raised in African-Caribbeans (17.3%, relative risk=1.72, Cl=1.06-2.81) and lower for the Irish-born (3.6%, relative risk=0.36, Cl=0.17-0.87). All those of African-Caribbean country of birth were significantly younger (P=0.000) but no more likely to be taking antihypertensive drugs. They were no more likely to report having cardiovascular problems but had increased rates of diabetes (P<0.0000). The overall prevalence of depression was 18.3% (95% Cl=16.1-20.7). The highest prevalence rate was found among those born in Greece and Turkey (27.2%, Cl=17.9-39.6). Migration per se does not appear to be a risk for depression and dementia in this population.

CONCLUSIONS

The excess of dementia may be of vascular aetiology. There is the potential for primary or secondary prevention.

Community study of depression in old age in Taiwan: prevalence, life events and socio-demographic correlates

BACKGROUND

Published studies of prevalence of depression in old age in Taiwan have yielded equivocal results.

AIMS

To study the prevalence of depressive disorders among community-dwelling elderly; further, to assess socio-demographic correlates and life events in relation to depression.

METHOD

A randomised sample of 1500 subjects aged 65 and over was selected from three communities. Research psychiatrists conducted all assessments using the Geriatric Mental State Schedule. The diagnosis of depression was made with the GMS-AGECAT (Automated Geriatric Examination for Computerised Assisted Taxonomy); data on life events were collected with the Taiwanese version of the Life Events and Difficulties Schedule.

RESULTS

One-month prevalence of psychiatric disorders was 37.7%, with 15.3% depressive neurosis and 5.9% major depression. A high risk of depressive disorders was found among widows with a low educational level living in the urban community, and among those with physical illnesses.

CONCLUSIONS

Contrary to most previous reports, we found that the prevalence of depressive disorders among the elderly in the community in Taiwan is high and comparable to rates reported in some studies of UK samples.

Validating screening instruments for cognitive impairment in older South Asians in the United Kingdom

BACKGROUND

The numbers of older South Asians in the United Kingdom are rising. Investigation of their mental health has been neglected compared to their physical health.

OBJECTIVES

This study aimed to determine the sensitivity and specificity of modified versions of two screening instruments for cognitive impairment (Mini-Mental State Examination and Abbreviated Mental Test) in a community-based population.

DESIGN

Two-stage study comparing screening instruments against diagnostic interview.

SETTING

South, central and north Manchester.

SUBJECTS

Community-resident South Asians aged 60 years and over.

METHODS

Subjects were approached via their general practitioners and interviewed at home. Sensitivity and specificity for the screening instruments were calculated using receiver operating characteristic (ROC) curve analysis.

RESULTS

For the Gujarati population, the MMSE cutoff was >/=24 (sensitivity 100%, specificity 95%) and AMT>/=6 (sensitivity 100%, specificity 95%). For the Pakistani population, the MMSE cutoff was >/=27 (sensitivity 100%, specificity 77%) and AMT>/=7 (sensitivity 100%, specificity 87%).

CONCLUSIONS

Culturally modified versions of the Mini-Mental State Examination and Abbreviated Mental Test are acceptable and may have a high degree of sensitivity. They may assist with the recognition of cognitive impairment, if an appropriate cutoff is used.

The characteristics of Indian subcontinent origin elders newly referred to a psychogeriatric service

BACKGROUND

The ethnic elderly population in the United Kingdom is increasing. Clinical, social and demographic characteristics of ethnic elders referred to and utilizing psychogeriatric services are unknown. Thus, this study was designed to compare these characteristics between Indian subcontinent origin ethnic elders and indigenous elders newly referred to a psychogeriatric service.

METHOD

All new referrals to a psychogeriatric service over a 2-year period were examined. Clinical, social and demographic characteristics of Indian subcontinent origin ethnic elders were compared with those of indigenous elders.

RESULTS

Ethnic elders were younger, had more children, had more people living in their household, were more likely to be married, were less likely to live alone, were more likely to have schizophrenia and less likely to have dementia. There were no differences between the two groups with regard to use of almost all health and social services resources at the time of the referral and after the initial assessment.

CONCLUSIONS

These findings do not support the traditional view that ethnic elders do not adequately access psychogeriatric and social services and that they are primarily cared for by extended families.

Social determinants of psychiatric morbidity and well-being in immigrant elders and whites in east London

OBJECTIVES

The social conditions under which migrants to the UK live may be more significant than the experience of migration itself in leading to increased risk of mental illness. We aimed to compare the prevalence of mental, physical and social health problems in elderly Somalis, Bengalis and whites living in a deprived inner London area and examine associations between environmental circumstances, social support, physical health status, mood and life satisfaction in these groups. In addition, we wanted to test the hypothesis that differences in mental health between immigrants and whites are explained by social disadvantages rather than ethnicity.

DESIGN

Cross-sectional survey with participants drawn from age-sex registers of general practices, augmented by other sources.

SETTING

East London--'first-generation' Somali and Bengali immigrants and white British.

SUBJECTS

A total of 274 people aged 60+ years: 72 Somalis, 75 Bengalis and 127 whites.

MAIN OUTCOME MEASURES

Symptoms of Anxiety and Depression Scale (SAD), Life Satisfaction Index (LSI). High SAD scores indicate more anxiety and depression symptoms; high LSI scores indicate greater life satisfaction.

MAIN RESULTS

Highest SAD scores were found among Bengalis; lowest LSI scores were found among Bengalis and Somalis. The prevalences of depression (SAD score 6+) were 25% in Somalis, 77% in Bengalis and 25% in east London whites. Physical health status and SAD scores were associated in Somalis (r = +0.31, p < or = 0.01). Bengalis (r = +0.47, p < or = 0.001) and east London whites (r = +0.27, p < or = 0.01). Physical health problems also related to lower LSI scores in Somalis (r = -0.24, p < or = 0.05) and east London whites (r = -0.24, p < or = 0.01). Social factors (i.e. poor housing conditions, low family support and reported need of community services) were strongly associated with SAD scores among Somalis (r = +0.5, p < or = 0.001) and, to a lesser extent, among Bengalis (r = +0.33, p < or = 0.01). Ethnicity (i.e. being an immigrant as opposed to a non-immigrant) became a statistically non-significant risk factor for high SAD scores after adjusting for the effects of age, weekly income, physical health and social problems (OR = 0.71, 95% CI = 0.5-1.1, p = 0.09). A residual, but much attenuated effect for ethnicity on LSI scores persisted in the estimated model after controlling for the same set of independent risk factors (OR = 0.7, 95% CI = 0.4-1, p = 0.05).

CONCLUSION

The marked variation in mental health between ethnic groups in east London might be a reflection of socioeconomic and health differentials acting concomitantly and adversely. Inequalities in housing, social support, income and physical health status accounted for variation in mood observed between immigrants and whites, and may partly explain differences in life satisfaction. These results seem to support a 'multiple jeopardy' theory of ageing in ethnic minorities in east London. Greater efforts are needed to recognize anxiety and depression in immigrant elders. Better social support and housing among 'minority ethnic' elders who live alone might be expected to alleviate social stress and improve mental health and psychological well-being.