To tell or not to tell-comparison of older patients' reaction to their diagnosis of dementia and depression

Ethical issues when using digital biomarkers and artificial intelligence for the early detection of dementia

Dementia poses a growing challenge for health services but remains stigmatized and under-recognized. Digital technologies to aid the earlier detection of dementia are approaching market. These include traditional cognitive screening tools presented on mobile devices, smartphone native applications, passive data collection from wearable, in-home and in-car sensors, as well as machine learning techniques applied to clinic and imaging data. It has been suggested that earlier detection and diagnosis may help patients plan for their future, achieve a better quality of life, and access clinical trials and possible future disease modifying treatments. In this review, we explore whether digital tools for the early detection of dementia can or should be deployed, by assessing them against the principles of ethical screening programs. We conclude that while the importance of dementia as a health problem is unquestionable, significant challenges remain. There is no available treatment which improves the prognosis of diagnosed disease. Progression from early-stage disease to dementia is neither given nor currently predictable. Available technologies are generally not both minimally invasive and highly accurate. Digital deployment risks exacerbating health inequalities due to biased training data and inequity in digital access. Finally, the acceptability of early dementia detection is not established, and resources would be needed to ensure follow-up and support for those flagged by any new system. We conclude that early dementia detection deployed at scale via digital technologies does not meet standards for a screening program and we offer recommendations for moving toward an ethical mode of implementation. This article is categorized under:Application Areas > Health CareCommercial, Legal, and Ethical Issues > Ethical ConsiderationsTechnologies > Artificial Intelligence.

The psychological benefits of neuropsychological assessment feedback as a psycho-educational therapeutic intervention: A randomized-controlled trial with cross-over in multiple sclerosis

ABSTRACTEvidence supporting the direct therapeutic benefits of neuropsychological assessment (NPA) feedback relies mostly upon post-feedback consumer surveys. This randomized-controlled trial with cross-over investigated the benefits of NPA feedback in multiple sclerosis (MS). Seventy-one participants were randomly allocated to NPA with feedback or a "delayed-treatment" control group. The primary hypotheses were that NPA feedback would lead to improved knowledge of cognitive functioning and improved coping. Outcome instruments were administered by a research assistant blinded to group allocation. At 1-week post-NPA feedback there were no significant group-by-time interaction effects, indicating no improvement. But nor was there any significant deterioration in psychological wellbeing, despite most participants receiving "bad news" confirming cognitive impairment. At 1-month follow-up, within-subjects' analyses not only found no evidence of any delayed deterioration, but showed clinically significant improvement (small-medium effects) in perceived everyday cognitive functioning, MS self-efficacy, stress and depression. Despite lack of improvement in the RCT component at 1-week post-NPA feedback, the absence of deterioration at this time, in addition to significant improvements in perceived cognitive functioning, self-efficacy and mood at follow-up, together with high satisfaction ratings, all support NPA feedback as a safe psycho-educational intervention that is followed by improved psychological wellbeing over time.Trial registration: Uniform Trial Number identifier: U1111-1127-1585.Trial registration: Australian New Zealand Clinical Trials Registry identifier: ACTRN12612000161820.

Ethical Implications of Alzheimer's Disease Prediction in Asymptomatic Individuals through Artificial Intelligence

Biomarker-based predictive tests for subjectively asymptomatic Alzheimer’s disease (AD) are utilized in research today. Novel applications of artificial intelligence (AI) promise to predict the onset of AD several years in advance without determining biomarker thresholds. Until now, little attention has been paid to the new ethical challenges that AI brings to the early diagnosis in asymptomatic individuals, beyond contributing to research purposes, when we still lack adequate treatment. The aim of this paper is to explore the ethical arguments put forward for AI aided AD prediction in subjectively asymptomatic individuals and their ethical implications. The ethical assessment is based on a systematic literature search. Thematic analysis was conducted inductively of 18 included publications. The ethical framework includes the principles of autonomy, beneficence, non-maleficence, and justice. Reasons for offering predictive tests to asymptomatic individuals are the right to know, a positive balance of the risk-benefit assessment, and the opportunity for future planning. Reasons against are the lack of disease modifying treatment, the accuracy and explicability of AI aided prediction, the right not to know, and threats to social rights. We conclude that there are serious ethical concerns in offering early diagnosis to asymptomatic individuals and the issues raised by the application of AI add to the already known issues. Nevertheless, pre-symptomatic testing should only be offered on request to avoid inflicted harm. We recommend developing training for physicians in communicating AI aided prediction.

The Effects and Meanings of Receiving a Diagnosis of Mild Cognitive Impairment or Alzheimer's Disease When One Lives Alone

BACKGROUND

One third of older adults with cognitive impairment live alone and are at high risk for poor health outcomes. Little is known about how older adults who live alone experience the process of receiving a diagnosis of mild cognitive impairment (MCI) or Alzheimer's disease (AD).

OBJECTIVE

The aim of this study was to understand the effects and meanings of receiving a diagnosis of MCI or AD on the lived experience of older adults living alone.

METHODS

This is a qualitative study of adults age 65 and over living alone with cognitive impairment. Participants' lived experiences were elicited through ethnographic interviews and participant observation in their homes. Using a qualitative content analysis approach, interview transcripts and fieldnotes were analyzed to identify codes and themes.

RESULTS

Twenty-nine older adults and 6 members of their social circles completed 114 ethnographic interviews. Core themes included: relief, distress, ambiguous recollections, and not knowing what to do. Participants sometimes felt uplifted and relieved by the diagnostic process. Some participants did not mention having received a diagnosis or had only partial recollections about it. Participants reported that, as time passed, they did not know what to do with regard to the treatment of their condition. Sometimes they also did not know how to prepare for a likely worsening of their condition, which they would experience while living alone.

CONCLUSION

Findings suggest the need for more tailored care and follow-up as soon as MCI or AD is diagnosed in persons living alone.

Effectiveness of a peer-mediated educational intervention in improving general practitioner diagnostic assessment and management of dementia: a cluster randomised controlled trial

OBJECTIVE

Test effectiveness of an educational intervention for general practitioners (GPs) on quality of life and depression outcomes for patients.

DESIGN

Double-blind, cluster randomised controlled trial.

SETTING

General practices in Australia between 2007 and 2010.

PARTICIPANTS

General practices were randomly allocated to the waitlist (n=37) or intervention (n=66) group, in a ratio of 1:2. A total of 2030 (1478 intervention; 552 waitlist) community-dwelling participants aged 75 years or older were recruited via 168 GPs (113 intervention; 55 waitlist).

INTERVENTIONS

A practice-based academic detailing intervention led by a peer educator that included: (1) training in use of the GP assessment of cognition dementia screening instrument; (2) training in diagnosis and management based on Royal Australian College of General Practitioners Dementia Guidelines; (3) addressing GPs' barriers to dementia diagnosis; and (4) a business case outlining a cost-effective dementia assessment approach.

OUTCOME MEASURES

Primary outcome measures were patient quality of life and depression; secondary outcome measures were: (1) sensitivity and specificity of GP identification of dementia; (2) referral to medical specialists and/or support services; (3) patient satisfaction with care; and (4) carer quality of life, depression and satisfaction with care.

RESULTS

The educational intervention had no significant effect on patient quality of life or depression scores after 12 months. There were however improvements in secondary outcome measures including sensitivity of GP judgement of dementia (p=0.002; OR 6.0, 95% CI 1.92 to 18.73), satisfaction with GP communication for all patients (p=0.024; mean difference 2.1, 95% CI 0.27 to 3.93) and for patients with dementia (p=0.007; mean difference 7.44, 95% CI 2.02 to 12.86) and enablement of carers (p=0.0185; mean difference 24.77, 95% CI 4.15 to 45.40).

CONCLUSION

Practice-based academic detailing did not improve patient quality of life or depression scores but did improve detection of dementia in primary care and patient satisfaction with GP communication.

TRIAL REGISTRATION NUMBER

ACTRN12607000117415; Pre-results.

General Practitioner's Attitudes and Confidence in Managing Patients with Dementia in Singapore

The number of people living with dementia is increasing globally as a result of an ageing population. General practitioners (GPs), as the front-line care providers in communities, are important stakeholders in the system of care for people with dementia. This commentary describes a study conducted to understand GPs' attitudes and self-perceived competencies when dealing with patients with dementia and their caregivers in Singapore. A set of study information sheet and survey questionnaires were mailed to selected GP clinics in Singapore. The survey, comprising the "GP Attitudes and Competencies Towards Dementia" questionnaire, was administered. A total of 400 GPs returned the survey, giving the study a response rate of 52.3%. About 74% of the GPs (n=296) were seeing dementia patients in their clinics. Almost all the GPs strongly agreed that early recognition of dementia served the welfare of the patients (n=385; 96%) and their relatives (n=387; 97%). About half (51.5%) of the respondents strongly agreed or agreed that they felt confident carrying out an early diagnosis of dementia. Factor analysis of questionnaire revealed 4 factors representing "benefits of early diagnosis and treatment of patients with dementia", "confidence in dealing with patients and caregiver of dementia", "negative perceptions towards dementia care" and "training needs". GPs in Singapore held a generally positive attitude towards the need for early dementia diagnosis but were not equally confident or comfortable about making the diagnosis themselves and communicating with and managing patients with dementia in the primary care setting. Dementia education and training should therefore be a critical step in equipping GPs for dementia care in Singapore. Shared care teams could further help build up GPs' knowledge, confidence and comfort in managing patients with dementia.

Acceptability and Results of Dementia Screening Among Older Adults in the United States

OBJECTIVES

To measure older adults acceptability of dementia screening and assess screening test results of a racially diverse sample of older primary care patients in the United States.

DESIGN

Cross-sectional study of primary care patients aged 65 and older.

SETTING

Urban and suburban primary care clinics in Indianapolis, Indiana, in 2008 to 2009.

PARTICIPANTS

Nine hundred fifty-four primary care patients without a documented diagnosis of dementia.

MEASUREMENTS

Community Screening Instrument for Dementia, the Mini-Mental State Examination, and the Telephone Instrument for Cognitive Screening.

RESULTS

Of the 954 study participants who consented to participate, 748 agreed to be screened for dementia and 206 refused screening. The overall response rate was 78.4%. The positive screen rate of the sample who agreed to screening was 10.2%. After adjusting for demographic differences the following characteristics were still associated with increased likelihood of screening positive for dementia: age, male sex, and lower education. Patients who believed that they had more memory problems than other people of their age were also more likely to screen positive for dementia.

CONCLUSION

Age and perceived problems with memory are associated with screening positive for dementia in primary care.

Caregivers' attitude toward disclosure of Alzheimer's disease diagnosis in Urban China

BACKGROUND

Disclosing the diagnosis of Alzheimer's disease (AD) to a patient is controversial. There is significant stigma associated with a diagnosis of AD or dementia in China, but the attitude of the society toward disclosure of such a diagnosis had not been formally evaluated prior to our study. Therefore, we aimed to evaluate the attitude toward disclosing an AD diagnosis to patients in China with cognitive impairment from their caregivers, and the factors that may affect their attitude.

METHODS

We designed a 17-item questionnaire and administered this questionnaire to caregivers, who accompanied patients with cognitive impairment or dementia in three major hospitals in Shanghai, China. The caregiver's attitude toward disclosing the diagnosis of AD as evaluated by the questionnaire was compared to that of disclosing the diagnosis of terminal cancer.

RESULTS

A majority (95.7%) of the 175 interviewed participants (mean 14.2 years of education received) wished to know their own diagnosis if they were diagnosed with AD, and 97.6% preferred the doctor to tell their family members if they were diagnosed with AD. If a family member of the participants suffered from AD, 82.9% preferred to have the diagnosis disclosed to the patient. "Cognitive impairment" was the most accepted term by caregivers to disclose AD diagnosis in Chinese.

CONCLUSION

This study suggests most of the well-educated individuals in a Chinese urban area favored disclosing the diagnosis when they or their family members were diagnosed with AD.

An evaluation of the additional benefit of population screening for dementia beyond a passive case-finding approach

OBJECTIVE

General practitioners (GPs) fail to identify more than 50% of dementia cases using the existing passive case-finding approach. Using data from the "Ageing in General Practice" study, we sought to establish the additional benefit of screening all patients over the age of 75 for dementia beyond those patients already identified by passive case-finding.

METHOD

Patients were classified as "case-finding" (n = 425) or "screening" (n = 1006) based on their answers to four subjective memory related questions or their GP's clinical judgement of their dementia status. Cognitive status of each patient was formally assessed by a research nurse using the Cambridge Cognition Examination (CAMCOG-R). Patients then attended their usual GP for administration of the GP assessment of Cognition (GPCOG) dementia screening instrument, and follow-up care and/or referral as necessary in light of the outcome.

RESULTS

The prevalence of dementia was significantly higher in the case-finding group (13.6%) compared to the screening group (4.6%; p < 0.01). The GPCOG had a positive predictive value (PPV) of 61% in the case-finding group and 39% in the screening group; negative predictive value was >95% in both groups. GPs and their patients both found the GPCOG to be an acceptable cognitive assessment tool. The dementia cases missed via case-finding were younger (p = 0.024) and less cognitively impaired (p = 0.020) than those detected.

CONCLUSION

There is a very limited benefit of screening for dementia, as most people with dementia could be detected using a case-finding approach, and considerable potential for social and economic harm because of the low PPV associated with screening.

Views and experience of communication when receiving a serious mental health diagnosis: satisfaction levels, communication preferences, and acceptability of the SPIKES protocol

BACKGROUND

There is limited research investigating how information about a mental health diagnosis is discussed and received.

AIMS

To measure community-based service users' satisfaction and preferences toward receiving news of a serious mental health diagnosis and to assess the acceptability of a diagnostic communication protocol (SPIKES: Setting; Perception; Invitation; Knowledge; Empathy; Summarizing).

METHOD

A survey was conducted with 101 participants.

RESULTS

Participants rated the methods clinicians use to facilitate diagnostic discussions are highly important; however, they were not wholly satisfied with their experience. Higher satisfaction was reported if participants were provided with information in a face-to-face meeting (p < 0.001), and if they received supplementary support at the time of diagnosis from additional health professionals rather than only a sole practitioner (p < 0.001). The SPIKES protocol was rated as highly acceptable, with Empathy being rated as the most important feature.

CONCLUSIONS

This research indicates there were specific areas of communication practices which can be improved within mental health service provision, as a gap existed between participants' desire for support and their experience. Strategies outlined in the SPIKES protocol, and others such as addressing stigma concerns, may prove useful in development of clinician training and service improvement.

Targeted case finding for dementia in primary care: Surrey Downs dementia diagnosis project

Currently less than half of the estimated number of people with dementia in England receive a formal diagnosis of dementia or have contact with specialist dementia services. Case finding focused on high risk groups may be an effective way to identify the undiagnosed. This joint Surrey Downs Clinical Commissioning Group and Surrey and Borders NHS Foundation Trust quality improvement project aimed to increase the rate of dementia diagnosis across Surrey Downs using specialist link nurses (SLNs).

Thirty three GP surgeries covering the entire Surrey Downs area took part in the project. Individuals at high risk of developing dementia were identified from GP electronic disease registers, and were offered screening at their GP practices by SLNs, using a combination of mini cognitive test (Mini-Cog) and functional assessment questionnaire (FAQ). Suitable individuals who screened positive were seen by their GP and where appropriate referred to secondary care services for further evaluation.

Based on the presence of risk factors, 6657 (11.9%) people were identified from a total population of 55 845 over 65s, and 1980 (29.7%) completed the screening assessment. Three hundred and fifty eight (18.1%) individuals screened positive and were referred to their GP, who referred 205 (57.2%) of them to the memory services for further assessment. Of those referred, 164 (80%) had a comprehensive specialist assessment. Forty one (20%) declined further assessment, and their GPs were informed.

The mean age of the cohort who completed the comprehensive assessment was 82.3 years (SD=4.26), and were predominantly white and male. Fifty four (32.9%) had mild cognitive disorder (MCD), and 101 (61.6%) patients were diagnosed with dementia. The most common dementia was mixed type (43; 42.6%), followed by Alzheimer's dementia (32; 31.7%). The most common risk factor among patients with cognitive impairment (MCD or dementia) was hypertension (69; 44.5 %), followed by ischemic heart disease (64, 41.3%).

Nurse led case finding for cognitive impairment in a high risk population identifies people with dementia who are not yet formally diagnosed. The combined use of brief instruments to assess cognitive functioning and functional capabilities is helpful in identifying individuals with possible dementia.

2015 Alzheimer's disease facts and figures

This report discusses the public health impact of Alzheimer’s disease (AD), including incidence and prevalence, mortality rates, costs of care and the overall effect on caregivers and society. It also examines the challenges encountered by health care providers when disclosing an AD diagnosis to patients and caregivers. An estimated 5.3 million Americans have AD; 5.1 million are age 65 years, and approximately 200,000 are age <65 years and have younger onset AD. By mid-century, the number of people living with AD in the United States is projected to grow by nearly 10 million, fueled in large part by the aging baby boom generation. Today, someone in the country develops AD every 67 seconds. By 2050, one new case of AD is expected to develop every 33 seconds, resulting in nearly 1 million new cases per year, and the estimated prevalence is expected to range from 11 million to 16 million. In 2013, official death certificates recorded 84,767 deaths from AD, making AD the sixth leading cause of death in the United States and the fifth leading cause of death in Americans age 65 years. Between 2000 and 2013, deaths resulting from heart disease, stroke and prostate cancer decreased 14%, 23% and 11%, respectively, whereas deaths from AD increased 71%. The actual number of deaths to which AD contributes (or deaths with AD) is likely much larger than the number of deaths from AD recorded on death certificates. In 2015, an estimated 700,000 Americans age 65 years will die with AD, and many of them will die from complications caused by AD. In 2014, more than 15 million family members and other unpaid caregivers provided an estimated 17.9 billion hours of care to people with AD and other dementias, a contribution valued at more than $217 billion. Average per-person Medicare payments for services to beneficiaries age 65 years with AD and other dementias are more than two and a half times as great as payments for all beneficiaries without these conditions, and Medicaid payments are 19 times as great. Total payments in 2015 for health care, long-term care and hospice services for people age 65 years with dementia are expected to be $226 billion. Among people with a diagnosis of AD or another dementia, fewer than half report having been told of the diagnosis by their health care provider. Though the benefits of a prompt, clear and accurate disclosure of an AD diagnosis are recognized by the medical profession, improvements to the disclosure process are needed. These improvements may require stronger support systems for health care providers and their patients.

A pilot randomised controlled trial to compare changes in quality of life for participants with early diagnosis dementia who attend a 'Living Well with Dementia' group compared to waiting-list control

OBJECTIVES

The aim of this paper is to report a pilot study in which participants who had recently received a diagnosis of dementia were randomised to either a 10-week group intervention or a waiting-list control.

METHOD

Memory clinic staff with limited previous experience of group therapy were trained to lead a 10-week group therapy intervention called 'Living Well with Dementia'. Fifty-eight participants, all of whom had received a diagnosis of Alzheimer's disease, vascular or Lewy body dementia within the previous 18 months, were randomised to receive either the intervention or treatment as usual (waiting-list control). Data collection occurred at baseline, within two weeks after the intervention finished and at 10-week follow-up.

RESULTS

The study met its recruitment targets, with a relatively low attrition rate for the intervention arm. The acceptability of the intervention and research methods was examined qualitatively and will be reported on elsewhere. For the primary outcome, measure of quality of life in Alzheimer's disease (QoL-AD), and secondary outcome, self-esteem, there was some evidence of improvement in the intervention group compared to the control group. There was, also, evidence of a reduction in cognitive functioning in the treatment group compared to the control. Such reported differences should be treated with caution because they are obtained from a pilot and not a definitive study.

CONCLUSION

This pilot study succeeded in collecting data to inform a future definitive cost effectiveness clinical trial of Living Well with Dementia group therapy.

A qualitative exploration of service users' information needs and preferences when receiving a serious mental health diagnosis

Helpful strategies for communicating news of a serious mental health diagnosis are poorly understood. This study explored service users' preferences for how they would like clinicians to deliver such news when a diagnosis of mental illness is made. Qualitative interviews were conducted with forty-five individuals identifying with serious mental illness in eleven community based mental health facilities. Inductive thematic analysis resulted in eight primary themes. Five themes related to the structure and content of the discussion; including a focus on information exchange, using an individualized collaborative partnership paradigm, addressing stigma, balancing hope with realism, and recognizing the dynamic nature of diagnosis. The remaining themes related to the involvement of others; including the importance of clinicians' communication and relationship skills, involvement and education of carers, and offering an opportunity for peer support. The product of the synthesis of themes is a step-wise model for communicating news of mental health diagnosis.

Voluntary cognitive screening: characteristics of participants in an Asian setting

BACKGROUND

Mild cognitive impairment (MCI) and dementia are reaching epidemic proportions in Asia. Lack of awareness and late presentation are major obstacles to early diagnosis and timely intervention. Cognitive screening may be an effective method for early detection of dementia in Asia. The purpose of this work was to study the characteristics of subjects volunteering for cognitive screening in an Asian setting and to determine the prevalence of MCI.

METHODS

Retrospective and cross-sectional data from community subjects attending a screening program from 2008 to 2013 were analyzed. Information on demographics, vascular risk factors, subjective symptoms, and cognitive measures were analyzed over the 6-year period.

RESULTS

Over the 6 years from 2008 to 2013, 1,243 community subjects voluntarily turned up for cognitive screening (91.2% were Chinese, 5.23% were Indian, 1.37% were Malay, and 2.25% were Eurasian). The mean age of the participants was 61.3 years and the mean number of years of education was 11.0 years. A total of 71.1% of participants were living in public housing, 59.8% had at least one cardiovascular risk factor, and 56.2% reported subjective cognitive symptoms. Over a period of 6 years, no significant change in demographic or clinical variables was noted. High cholesterol and hypertension were consistently the top two risk factors found in the population screened. In total, 17.2% of the total cohort had MCI. Across the 6 years, the proportion with MCI and depression was relatively constant.

CONCLUSION

A significant proportion of participants attending voluntary cognitive screening have MCI. Low level of education and presence of vascular risk factors are general predisposing characteristics for MCI, and there are more specific factors pertaining to sex and employment status.

Changing practice in dementia care in the community: developing and testing evidence-based interventions, from timely diagnosis to end of life (EVIDEM)

Background

The needs of people with dementia and their carers are inadequately addressed at all key points in the illness trajectory, from diagnosis through to end-of-life care. The EVIDEM (Evidence-based Interventions in Dementia) research and development programme (2007–12) was designed to help change this situation within real-life settings.

Objectives

The EVIDEM projects were (1) evaluation of an educational package designed to enhance general practitioners’ (GPs’) diagnostic and management skills; (2) evaluation of exercise as therapy for behavioural and psychological symptoms of dementia (BPSD); (3) development of a toolkit for managing incontinence in people with dementia living at home; (4) development of a toolkit for palliative care for people with dementia; and (5) development of practice guidance on the use of the Mental Capacity Act (MCA) 2005.

Design

Mixed quantitative and qualitative methods from case studies to large database analyses, including longitudinal surveys, randomised controlled trials and research register development, with patient and public involvement built into all projects.

Setting

General practices, community services, third-sector organisations and care homes in the area of the North Thames Dementia and Neurodegenerative Diseases Research Network local research network.

Participants

People with dementia, their family and professional carers, GPs and community mental health team members, staff in local authority social services and third-sector bodies, and care home staff.

Main outcome measures

Dementia management reviews and case identification in general practice; changes in behavioural and psychological symptoms measured with the Neuropsychiatric Inventory (NPI); extent and impact of incontinence in community-dwelling people with dementia; mapping of pathways to death of people with dementia in care homes, and testing of a model of collaborative working between primary care and care homes; and understandings of the MCA 2005 among practitioners working with people with dementia.

Results

An educational intervention in general practice did not alter management or case identification. Exercise as a therapy for BPSD did not reduce NPI scores significantly, but had a significant positive effect on carer burden. Incontinence is twice as common in community-dwelling people with dementia than their peers, and is a hidden taboo within a stigma. Distinct trajectories of dying were identified (anticipated, unexpected and uncertain), and collaboration between NHS primary care and care homes was improved, with cost savings. The MCA 2005 legislation provided a useful working framework for practitioners working with people with dementia.

Conclusions

A tailored educational intervention for general practice does not change practice, even when incentives, policy pressure and consumer demand create a favourable environment for change; exercise has potential as a therapy for BPSD and deserves further investigation; incontinence is a common but unrecognised problem for people with dementia in the community; changes in relationships between care homes and general practice can be achieved, with benefits for people with dementia at the end of life and for the UK NHS; application of the MCA 2005 will continue to improve but educational reinforcements will help this. Increased research capacity in dementia in the community was achieved. This study suggests that further work is required to enhance clinical practice around dementia in general practice; investigate the apparent beneficial effect of physical activity on BPSD and carer well-being; develop case-finding methods for incontinence in people with dementia; optimise working relationships between NHS staff and care homes; and reinforce practitioner understanding of the MCA 2005.

Trial registration

EVIDEM: ED-NCT00866099; EVIDEM: E-ISRCTN01423159.

Funding

This project was funded by the Programme Grants for Applied Research programme of the National Institute for Health Research.

Screening for traumatic brain injury: findings and public health implications

OBJECTIVE

To provide an overview of a series of projects that used a structured self-report screening tool in diverse settings and samples to screen for lifetime history of traumatic brain injury (TBI).

SETTING

Diverse community settings.

PARTICIPANTS

Homeless persons (n = 111), individuals with HIV seeking vocational rehabilitation (n = 173), youth in the juvenile justice system (n = 271), public schoolchildren (n = 174), substance users (n = 845), intercollegiate athletes (n = 90), and other community-based samples (n = 396).

DESIGN

Cross-sectional.

MAIN MEASURE

Brain Injury Screening Questionnaire.

RESULTS

Screening using the Brain Injury Screening Questionnaire finds that 27% to 54% of those in high-risk populations report a history of TBI with chronic symptoms. Associations between TBI and social, academic, or other problems are evident in several studies. In non-high-risk community samples, 9% to 12% of individuals report TBI with chronic symptoms.

CONCLUSION

Systematic TBI screening can be implemented efficiently and inexpensively in a variety of settings. Lifetime TBI history data gathered using a structured self-report instrument can augment existing estimates of the prevalence of TBI, both as an acute event and as a chronic condition. Identification of individuals with TBI can facilitate primary prevention efforts, such as reducing risk for reinjury in high-risk groups, and provide access to appropriate interventions that can reduce the personal and societal costs of TBI (tertiary prevention).

Preferences regarding disclosure of a diagnosis of dementia: a systematic review

BACKGROUND

Studies in memory clinics suggest that the majority of patients would like to know of a diagnosis of dementia. It is less clear what preferences are in the community. Our objective was to review the literature on preferences regarding disclosure of a diagnosis of dementia and to assess key arguments in favor of and against disclosure.

METHODS

Systematic search of empirical studies was performed in Pubmed, Embase, and Psycinfo. We extracted preferences of individuals without cognitive impairment (general population; relatives of dementia patients; and physicians) and preferences of individuals referred to a memory clinic or already diagnosed with dementia. A meta-analysis was done using a random effects model. Our main conclusions are based on studies with a response rate ≥75%.

RESULTS

We included 23 articles (9.065 respondents). In studies with individuals without cognitive impairment, the pooled percentage in favor of disclosure was 90.7% (95%CI: 83.8%-97.5%). In studies with patients who were referred to a memory clinic or already diagnosed with dementia, the pooled percentage that considered disclosure favorable was 84.8% (95%CI: 75.6%-94.0%). The central arguments in favor of disclosure pertained to autonomy and the possibility to plan one's future. Arguments against disclosure were fear of getting upset and that knowing has no use.

CONCLUSIONS

The vast majority of individuals without and with cognitive impairment prefers to be informed about a diagnosis of dementia for reasons pertaining to autonomy.

Screening for dementia in general hospital inpatients: a systematic review and meta-analysis of available instruments

OBJECTIVE

Dementia is common and often undiagnosed. Improving rates of diagnosis has become a key part of current dementia guidelines. Older people admitted to hospital are a potential target population for screening for dementia. The objective was to report whether instruments advocated in screening for dementia had been validated in hospital inpatients and to make recommendations on evidence-based screening for dementia in this population.

DESIGN

a systematic review was performed by an initial electronic database search using three key search criteria. Studies were then selected in a systematic fashion using specific predetermined criteria. Pooled meta-analysis was performed. Inclusion criteria were studies where the study group were inpatients in general hospitals, including a clearly defined group of older people (60 or older), they used a recognised screening instrument compared with a reference standard, and included at least 10 cases of dementia. Demographic data as well as sensitivity and specificity were recorded from the selected studies.

RESULTS

in total nine studies describing validation of six discreet instruments satisfied all our criteria and we were able to perform meta-analysis with one instrument, the Abbreviated Mental Test Score (AMTS). With a cut-off of <7, pooled analysis of the AMTS showed a sensitivity of 81%, a specificity of 84% and an area under the curve (AUC) of 0.88.

CONCLUSION

a small number of instruments have been validated for screening for dementia in general hospital. Understanding strengths and weaknesses of currently available instruments allows informed decisions about screening in this setting.

Emotional and psychological implications of early AD diagnosis

This article reviews the current recommendations in early diagnosis and the desires of the patients and their relatives, put in perspective with the reality of the clinical practices. More specific situations covered are: (1) the issue of young diseased patients, taking into account the psychological implications of the early occurrence of the disease in life and of the longer delay for these patients between the first observable signs and the diagnosis and (2) the issue of genetic testing, taking into account the implications of this extremely early form of bad news on the individual's existence and on the family structure.

Experiences of the patients and their caregivers regarding the disclosure of the diagnosis of Alzheimer's disease: a Belgian retrospective survey

Although the disclosure of the diagnosis of Alzheimer's disease (AD) is recommended by several guidelines, many clinicians do not announce the diagnosis to their patient. One of the main arguments against disclosure is the fear of a depressive reaction. Our aim was to report the experience and agreement of patients and their caregivers regarding the disclosure of the diagnosis of AD. All the patients with a diagnosis of AD attending our memory clinic were screened during 1 year. The patients and their caregivers were interviewed with a structured questionnaire. We included 108 patients (mean age = 77; Mini-Mental State Examination = 21) and matched caregivers (mean age 65). Twenty-nine percent of patients said they had suffered when the diagnosis was disclosed and 5% wished they had not been informed. Four percent felt more sad or depressed and 14% more anxious since the disclosure. The caregivers reported that 32% of patients had suffered from the disclosure, but only 15% were still suffering. In 85% of cases, the caregivers thought that the disclosure was useful. If they could go back in time and decide whether to disclose or not the diagnosis, only 4% of caregivers would retrospectively disagree to disclose the diagnosis to the patient. The disclosure of AD can induce anxiety and sadness. However, these negative feelings seem to persist only in a minority of patients. The vast majority of patients and caregivers agrees with the disclosure.

Developing an educational intervention on dementia diagnosis and management in primary care for the EVIDEM-ED trial

BACKGROUND

Dementia syndromes are under-diagnosed and under-treated in primary care. Earlier recognition of and response to dementia syndrome is likely to enhance the quality of life of people with dementia, but general practitioners consistently report limited skills and confidence in diagnosis and management of this condition. Changing clinical practice is difficult, and the challenge for those seeking change it is to find ways of working with the grain of professional knowledge and practice. Assessment of educational needs in a practice has the potential to accommodate variations in individual understanding and competence, learning preferences and skill mix. Educational prescriptions identify questions that need to be answered in order to address a clinical problem. This paper reports the development of an educational needs assessment tool to guide tailored educational interventions designed to enhance early diagnosis and management of dementia in primary care, in the Evidence Based Interventions in Dementia in the Community - Early Diagnosis trial.

METHODS

A multidisciplinary team, including a lay researcher, used an iterative technology development approach to create an educational needs assessment tool, from which educational prescriptions could be written. Workplace learning was tailored to each practice using the educational prescription, and the method was field-tested in five pilot practices.

RESULTS

The educational prescriptions appeared acceptable and useful in volunteer practices. The time commitment (no more than four hours, spread out at the practice's discretion) appeared manageable. The pilot group of practices prioritised diagnosis, assessment of carers' needs, quality markers for dementia care in general practice, and the implications of the Mental Capacity Act (2005) for their clinical practice. The content of the educational needs assessment tool seemed to be comprehensive, in that no new topics were identified by practices in the field trial.

CONCLUSIONS

The educational needs assessment tool took into account practitioners' knowledge of the local health and social care systems, reflected the complexity of the diagnostic and care processes for people with dementia, and acknowledged the complexity of the disease process itself.

Case-finding of dementia in general practice and effects of subsequent collaborative care; design of a cluster RCT

BACKGROUND

In the primary care setting, dementia is often diagnosed relatively late in the disease process. Case finding and proactive collaborative care may have beneficial effects on both patient and informal caregiver by clarifying the cause of cognitive decline and changed behaviour and by enabling support, care planning and access to services.We aim to improve the recognition and diagnosis of individuals with dementia in general practice. In addition to this diagnostic aim, the effects of case finding and subsequent care on the mental health of individuals with dementia and the mental health of their informal carers are explored.

METHODS AND DESIGN

DESIGN

cluster randomised controlled trial with process evaluation.

PARTICIPANTS

162 individuals ≥ 65 years, in 15 primary care practices, in whom GPs suspect cognitive impairment, but without a dementia diagnosis.Intervention; case finding and collaborative care: 2 trained practice nurses (PNs) invite all patients with suspected cognitive impairment for a brief functional and cognitive screening. If the cognitive tests are supportive of cognitive impairment, individuals are referred to their GP for further evaluation. If dementia is diagnosed, a comprehensive geriatric assessment takes place to identify other relevant geriatric problems that need to be addressed. Furthermore, the team of GP and PN provide information and support.

CONTROL

GPs provide care and diagnosis as usual.Main study parameters: after 12 months both groups are compared on: 1) incident dementia (and MCI) diagnoses and 2) patient and caregiver quality of life (QoL-AD; EQ5D) and mental health (MH5; GHQ 12) and caregiver competence to care (SSCQ). The process evaluation concerns facilitating and impeding factors to the implementation of this intervention. These factors are assessed on the care provider level, the care recipient level and on the organisational level.

DISCUSSION

This study will provide insight into the diagnostic yield and the clinical effects of case finding and collaborative care for individuals with suspected cognitive impairment, compared to usual care. A process evaluation will give insight into the feasibility of this intervention.The first results are expected in the course of 2013.

TRIAL REGISTRATION

NTR3389.

Education about dementia in primary care: Is person-centredness the key?

Primary care is ideally placed to recognise and manage dementia and yet dementia can be overlooked or misattributed by primary care practitioners and is underdiagnosed. This might be explained by a lack of formal training in the diagnosis of dementia combined with a reluctance to diagnose due to its associated stigma. This paper describes focus group work with service users, carers and health professionals, conducted to develop an educational intervention for primary care promoting person-centred responses to people experiencing cognitive decline and dementia. Data was analysed thematically and four themes emerged: Reframing dementia as cognitive decline (Individual level); triggers for the recognition of dementia (Practitioner level); engaging the whole primary care team (Practice level); the relationship between primary and secondary care (Service level). Findings are discussed in the context of their contribution to challenging attitudes to dementia in primary care and the positive aspects of person-centred primary care for dementia.

Government, professional and public efforts in Japan to change the designation of dementia (chihō)

In 2004, the label for dementia was officially changed in Japan as part of a publicity campaign to raise public awareness about dementia and replace the previously stigmatizing word ‘ chihō’, which translates as a ‘disease of cognition associated with idiocy’. The aim of this study is to examine the name-changing process and to explore its implications for Japan and the field of dementia studies in general. First, this article explains the process through which the new name for ‘dementia’, ‘ ninchishō’, was selected and why. It then addresses Alzheimer’s Association Japan (AAJ), describing the influence of this organization on the name-changing process. Finally, the article delineates how an educational initiative was developed in response to the decision to advance a new terminology, ninchishō, and evaluates the initial impact of the name-changing project.

[Informing of the diagnosis in dementia]

Dementia is a syndrome characterized by a progressive deterioration of cognitive functions, accompanied by psychiatric symptoms and behavioral disturbances that produce a progressive and irreversible disability. The way it should communicate the diagnosis of dementia is a key discussion point on which there is no unanimous agreement so far. The communicating of the diagnosis of dementia is a complex issue that affects not only, the patient but also to caregivers and health professionals who care and must conform to the ethical principles governing medical practice (autonomy, nonmaleficence, beneficence, and justice). Therefore, from the Dementia Working Group of the Catalan Geriatric Society (Grupo de Trabajo de Demencia de la Sociedad Catalana de Geriatría) arises the need to review the issue and propose a course of action for the disclosure of diagnosis.

Knowledge of documented dementia diagnosis and treatment in veterans and their caregivers

We studied perceptions of dementia diagnosis and treatment in patient-caregiver dyads enrolled in a care coordination intervention trial for veterans with dementia. We compared patient and caregiver perceptions of diagnosis and treatment to information in the medical record and assessed concordance between patient and caregiver perceptions. Data were derived from medical record abstraction and structured interviews with 132 patients and 183 caregivers. Most caregivers, but only about one fourth of patients, reported having received information about a diagnosis related to memory loss. Caregivers were more accurate than patients in recalling the patient's use of memory-enhancing medications. Within dyads there was poor agreement regarding a diagnosis of dementia. Our findings suggest that there is substantial room for improvement in disclosure and education of dementia diagnosis, especially at the level of the patient-caregiver dyad.

Validity of a short computerized assessment battery for moderate cognitive impairment and dementia

BACKGROUND

Computerized cognitive assessment tools have been developed to make precise neuropsychological assessment readily available to clinicians. Mindstreams batteries for mild impairment have been validated previously. We examined the validity of a Mindstreams battery designed specifically for evaluating those with moderate cognitive impairment.

METHODS

170 participants over the age of 60 years performed the computerized battery in addition to standard clinical evaluation. The battery consists of six technician-administered tests and one patient-administered interactive test sampling the cognitive domains of orientation (to time and place), memory, executive function, visual spatial processing, and verbal function. Staging was according to the Clinical Dementia Rating Scale (CDR) on the basis of clinical data but independent of computerized cognitive testing results, thus serving as the gold standard for evaluating the discriminant validity of the computerized measures.

RESULTS

Seven participants received a global CDR score of 0 (not impaired), 76 were staged as CDR 0.5 (very mildly impaired), 58 as CDR 1 (mildly impaired), 26 as CDR 2 (moderately impaired), and 3 as CDR 3 (severely impaired). Mindstreams Global Score performance was significantly different across CDR groups (p < 0.001), reflecting poorer overall battery performance for those with greater impairment. This was also true for the domain summary scores, with Executive Function (d = 0.67) and Memory (d = 0.65) distinguishing best between CDR 0.5 and 1, and Orientation best differentiating among CDR 1 and 2 (d = 1.20).

CONCLUSIONS

The Mindstreams battery for moderate impairment differentiates among varying degrees of cognitive impairment in older adults, providing detailed and distinct cognitive profiles.

Improving professional practice in the disclosure of a diagnosis of dementia: a modeling experiment to evaluate a theory-based intervention

BACKGROUND

Among health professionals, there is wide variation in the practice of disclosing a diagnosis of dementia to patients.

PURPOSE

The purpose of this study was to evaluate the effect of one theory-based and two pragmatic interventions on intention to perform three behaviors, namely (1) finding out what the patient already knows or suspects about their diagnosis; (2) using the actual words "dementia" or "Alzheimer's disease" when talking to the patient (i.e., the use of explicit terminology); (3) exploring what the diagnosis means to the patient.

METHOD

Within an intervention-modeling process, members of old-age mental health teams in England were sent postal questionnaires measuring psychological variables. Respondents were randomized by team to one of four groups to receive: theory-based intervention; evidence-based communication; patient-based intervention; or no intervention (control). Interventions were delivered as pen-and-paper exercises at the start of a second postal questionnaire that remeasured the same psychological variables. The outcome measures were intention and scenario-based behavioral simulation.

RESULTS

Responses were received from 644 of 1,103 (58%) individuals from 179 of 205 (87%) mental health teams. There were no significant differences in terms of intention or simulated behavior between the trial groups. The theory-based intervention significantly increased scores for attitudes to (p = 0.03) and perceived behavioral control (p = 0.001) for the behavior of "finding out what the patient already knows or suspects about their diagnosis."

CONCLUSIONS

The intervention had a limited effect. This may be partly explained by clinical or methodological factors. The use of a systematic intervention modeling process allows clearer understanding of the next appropriate steps which should involve further evaluation of the interventions using an interactive delivery method in a less selected group of study participants.

Primary care and dementia: 1. diagnosis, screening and disclosure

OBJECTIVES

To write a narrative review of the roles of primary care practitioners in caring for people with dementia in the community.

METHODS

The systematic review carried out for the NICE/SCIE Guidelines was updated from January 2006, Cochrane Reviews were identified, and other publications found by consultation with experts.

RESULTS

The insidious and very variable development of dementia syndromes makes recognition of the syndrome problematic in primary care. Dementia is probably under-diagnosed and under treated with an estimated 50% of primary care patients over 65 not diagnosed by their primary care physicians. This problem of under-diagnosis is probably not due to lack of diagnostic skills, but rather to the interaction of case-complexity, pressure on time and the negative effects of reimbursement systems. Primary care physicians often over-estimate the prevalence of dementia syndromes, but in some countries may also overestimate the prevalence of vascular dementia compared with Alzheimer's disease. Diagnosis is a step-wise process which can be aided by use of a cognitive function test, of which there are a number suitable for primary care use. Evidence based practice protocols can enhance detection rates in primary care, and there is growing evidence that communication skills in talking to people with dementia about dementia can be improved. Nevertheless there are multiple obstacles to bringing recognition forward in time, both in public awareness and professional understanding of the early changes in dementia.

CONCLUSIONS

There is insufficient evidence of benefit to justify population screening in primary care but earlier recognition of people with dementia syndrome is possible within primary care. The diagnosis of dementia is a shared responsibility between generalist and specialist disciplines. Primary care physicians should explore patients' ideas and concerns around their symptoms prior to referral and tentatively discuss possible diagnoses. Once the diagnosis has been confirmed, the primary care physician should provide both practical and emotional support to allow the patient and their family to come to terms with living with dementia, and refer them for additional psychosocial support if required.

Mild cognitive impairment: conceptual, assessment, ethical, and social issues

Mild cognitive impairment (MCI) is defined as a condition characterized by newly acquired cognitive decline to an extent that is beyond that expected for age or educational background, yet not causing significant functional impairment. The concept of MCI has received considerable attention in the literature over the past few years, and aspects related to its definition, prevalence, and evolution have been extensively studied and reviewed.

Here we attempt to synthesize the implications of the current status of this entity, focusing on the conceptual, methodological, and, in particular, the social and ethical aspects of MCI which have attracted less attention. We discuss the weaknesses of the concept of MCI, which is heterogeneous in etiology, manifestations, and outcomes, and suggest that the emergence of the syndrome at this stage reflects industrial interests related to possible development of drugs for this disorder. On the other hand, the formal diagnosis of MCI, with its implications that the person may develop dementia, may have a grave impact on the psychological state of the individual, at a stage when prediction of outcome is tenuous and possibilities of useful interventions are meager. We present suggestions for the direction of future research in these areas.

Diagnostic disclosure in Alzheimer's Disease: A review

Although growing, the literature on research into attitudes of general and specialized physicians towards disclosing the diagnosis of dementia and Alzheimer's disease (AD), or the current practice on AD disclosure, remains limited. Moreover, information is also scarce on what caregivers, or indeed patients themselves, wish to know with regard to their diagnosis. The goal of the present article was to present a review of the current available literature on the topic of truth telling in dementia, especially in AD. The studies discussed in this review were mainly conducted in Europe, particularly in the United Kingdom, as well as the United States. Disclosure of AD diagnosis is not a common practice among physicians. In the clinical context, the discussion on diagnosis disclosure can be valuable for improving the care of AD patients and their families.

Measuring primary care patients' attitudes about dementia screening

OBJECTIVES

To develop a questionnaire that will capture patients' attitudes about dementia screening in primary care.

METHODS

Cross-sectional study of 315 patients aged 65 and older attending urban and rural primary care clinics in Indianapolis and North Carolina. The Perceptions Regarding Investigational Screening for Memory in Primary Care (PRISM-PC) questionnaire was administered via face-to-face or telephone interview.

RESULTS

The PRISM-PC questionnaire consists of two separate scales: the patient's acceptance of dementia screening scale and the patient's perceived harms and benefits of dementia screening scale. The face validity of the PRISM-PC questionnaire was based on a systematic literature review and the opinions of 16 clinician-investigators with experience in screening for dementia. Exploratory factor analyses for the acceptance scale revealed the presence of two dimensions: knowledge about dementia risk and testing for dementia. For the benefits and harms scale, exploratory factor analyses identified four dimensions: perceived benefits of screening, stigma of screening, suffering from screening, and impact of screening on patients' independence. The internal consistency of each of the above subscales was good with Cronbach's alpha ranging from 0.58-0.85.

CONCLUSION

The PRISM-PC questionnaire captures primary care patients' acceptance, perceived harms, and perceived benefits of dementia screening.

Appropriate disclosure of a diagnosis of dementia: identifying the key behaviours of 'best practice'

Background

Despite growing evidence that many people with dementia want to know their diagnosis, there is wide variation in attitudes of professionals towards disclosure. The disclosure of the diagnosis of dementia is increasingly recognised as being a process rather than a one-off behaviour. However, the different behaviours that contribute to this process have not been comprehensively defined. No intervention studies to improve diagnostic disclosure in dementia have been reported to date. As part of a larger study to develop an intervention to promote appropriate disclosure, we sought to identify important disclosure behaviours and explore whether supplementing a literature review with other methods would result in the identification of new behaviours.

Methods

To identify a comprehensive list of behaviours in disclosure we conducted a literature review, interviewed people with dementia and informal carers, and used a consensus process involving health and social care professionals. Content analysis of the full list of behaviours was carried out.

Results

Interviews were conducted with four people with dementia and six informal carers. Eight health and social care professionals took part in the consensus panel. From the interviews, consensus panel and literature review 220 behaviours were elicited, with 109 behaviours over-lapping. The interviews and consensus panel elicited 27 behaviours supplementary to the review. Those from the interviews appeared to be self-evident but highlighted deficiencies in current practice and from the panel focused largely on balancing the needs of people with dementia and family members. Behaviours were grouped into eight categories: preparing for disclosure; integrating family members; exploring the patient's perspective; disclosing the diagnosis; responding to patient reactions; focusing on quality of life and well-being; planning for the future; and communicating effectively.

Conclusion

This exercise has highlighted the complexity of the process of disclosing a diagnosis of dementia in an appropriate manner. It confirms that many of the behaviours identified in the literature (often based on professional opinion rather than empirical evidence) also resonate with people with dementia and informal carers. The presence of contradictory behaviours emphasises the need to tailor the process of disclosure to individual patients and carers. Our combined methods may be relevant to other efforts to identify and define complex clinical practices for further study.

Reluctance to disclose difficult diagnoses: a narrative review comparing communication by psychiatrists and oncologists

INTRODUCTION

National guidance in most medical specialties supports the full and open disclosure of diagnoses to patients.

RESULTS

Surveys show that most patients want to know their diagnosis, whether it is medical or psychiatric, and a substantial proportion want to know detailed prognostic information. In the past, oncologists have been criticised for failing to reveal a diagnosis of cancer to patients in a sensitive and timely manner. Over the last 30 years, there is evidence that this practice has improved. Yet, clinicians still have difficulty when the diagnosis is not certain, when the prognosis is unfavourable, and when relatives request "not to tell." All of these influences are present in mental health settings.

DISCUSSION

Psychiatrists and general practitioners may be equally reluctant to reveal difficult diagnoses and prognoses of conditions such as schizophrenia and dementia. The reluctance to reveal a difficult diagnosis may be a routine, but little acknowledged the aspect of medical care that should be incorporated into undergraduate and postgraduate education and openly discussed during peer group supervision.

Dementia diagnosis disclosure: a study of patient and caregiver perspectives

This paper reports the findings of a descriptive, exploratory, qualitative study of patient and caregiver perspectives of the disclosure of a dementia diagnosis. Data were collected at 3 points in time: (1) the disclosure meeting, (2) patient and caregiver interviews, and (3) focus group interviews. Thirty patient-caregiver dyads participated in the disclosure meetings at the Geriatric Day Hospital at the Ottawa Hospital, Ottawa, Canada. Within a week of the disclosure of diagnosis, 27 (90%) patients and 29 (97%) caregivers were interviewed in their homes, and 12 caregivers participated in 3 focus group interviews within 1 month after the disclosure meeting. Most patients and caregivers said they preferred full disclosure of the diagnosis. Patients expressed satisfaction with the physician providing the diagnosis and with their caregivers being present at the disclosure meeting, however, wanted more information about their condition. Caregivers provided further insight regarding the patient response, and suggested the need to emphasize hope in the face of a difficult diagnosis, the use of progressive disclosure to allow the person (and caregivers) to prepare, and the provision of detail about the disease and its progression.

Which factors explain variation in intention to disclose a diagnosis of dementia? A theory-based survey of mental health professionals

BACKGROUND

For people with dementia, patient-centred care should involve timely explanation of the diagnosis and its implications. However, this is not routine. Theoretical models of behaviour change offer a generalisable framework for understanding professional practice and identifying modifiable factors to target with an intervention. Theoretical models and empirical work indicate that behavioural intention represents a modifiable predictor of actual professional behaviour. We identified factors that predict the intentions of members of older people's mental health teams (MHTs) to perform key behaviours involved in the disclosure of dementia.

DESIGN

Postal questionnaire survey.

PARTICIPANTS

Professionals from MHTs in the English National Health Service.

METHODS

We selected three behaviours: Determining what patients already know or suspect about their diagnosis; using explicit terminology when talking to patients; and exploring what the diagnosis means to patients. The questionnaire was based upon the Theory of Planned Behaviour (TPB), Social Cognitive Theory (SCT), and exploratory team variables.

MAIN OUTCOMES

Behavioural intentions.

RESULTS

Out of 1,269 professionals working in 85 MHTs, 399 (31.4%) returned completed questionnaires. Overall, the TPB best explained behavioural intention. For determining what patients already know, the TPB variables of subjective norm, perceived behavioural control and attitude explained 29.4% of the variance in intention. For the use of explicit terminology, the same variables explained 53.7% of intention. For exploring what the diagnosis means to patients, subjective norm and perceived behavioural control explained 48.6% of intention.

CONCLUSION

These psychological models can explain up to half of the variation in intention to perform key disclosure behaviours. This provides an empirically-supported, theoretical basis for the design of interventions to improve disclosure practice by targeting relevant predictive factors.

Dilemmas in the (un)veiling of the diagnosis of Alzheimer's disease: walking an ethical and professional tight rope

OBJECTIVE

To enhance the understanding and effect of physician's difficulties, attitudes and communication styles on the disclosure of the diagnosis of AD in practice.

METHODS

Qualitative, phenomenological study, combining pre-encounter interviews with physicians, observations of actual encounters of diagnosis disclosure of AD, and post-encounter interviews.

RESULTS

There were various ways or tactics to (un)veil the bad news that may be perceived as different ways of dulling the impact and avoiding full and therefore problematic statements. In the actual encounters this was accomplished by keeping encounters short, avoiding elaboration, confirmation of comprehension and explicit terminology and using fractured sentences.

CONCLUSION

The present study's findings highlight the difficulties encountered in breaking the news about AD, in the way it is actually done, and the problems that may arise from this way of un/veiling the news. The main problem is that the reluctance to make a candid disclosure of the diagnosis as was demonstrated in this study may violate basic moral and legal rights and may also deprive patients and caregivers of some of the benefits of early disclosure of diagnosis.

PRACTICE IMPLICATIONS

There is a need for assisting physicians to cope with their personal difficulties, problems and pitfalls in breaking the news.