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Ethico-Political aspects of clinical judgment in opportunistic screening for cognitive impairment: Arendtian and aristotelian perspectives. MEDICINE, HEALTH CARE AND PHILOSOPHY 2022; 25:495-507. [PMID: 35687216 PMCID: PMC9427887 DOI: 10.1007/s11019-022-10095-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 03/18/2022] [Accepted: 05/17/2022] [Indexed: 11/10/2022]
Abstract
This article examines a population-based opportunistic screening practice for cognitive impairment that takes place at a hospital in Sweden. At the hospital, there is a routine in place that stipulates that all patients over the age of 65 who are admitted to the ward will be offered testing for cognitive impairment, unless they have been tested within the last six months or have been diagnosed with any form of cognitive impairment. However, our analysis shows that this routine is not universally and mechanically applied. Rather, the health care professionals have developed and use an ethico-political judgment, concerning, for example, whom to test, when to offer the tests, and how to explain and perform them. This article explores the role and practice of this form of judgment, emphasising its political and ethical nature. The analysis is based on qualitative interviews with professionals and patients, and draws on the theories of Aristotle and Hannah Arendt.
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Gunnarson M, Kapeller A, Zeiler K. Ethico-Political Aspects of Conceptualizing Screening: The Case of Dementia. HEALTH CARE ANALYSIS 2021; 29:343-359. [PMID: 33725216 PMCID: PMC8560671 DOI: 10.1007/s10728-021-00431-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2021] [Indexed: 11/20/2022]
Abstract
While the value of early detection of dementia is largely agreed upon, population-based screening as a means of early detection is controversial. This controversial status means that such screening is not recommended in most national dementia plans. Some current practices, however, resemble screening but are labelled "case-finding" or "detection of cognitive impairment". Labelled as such, they may avoid the ethical scrutiny that population-based screening may be subject to. This article examines conceptualizations of screening and case-finding. It shows how the definitions and delimitations of the concepts (the what of screening) are drawn into the ethical, political, and practical dimensions that screening assessment criteria or principles are intended to clarify and control (the how of screening, how it is and how it should be performed). As a result, different conceptualizations of screening provide the opportunity to rethink what ethical assessments should take place: the conceptualizations have different ethico-political implications. The article argues that population-based systematic screening, population-based opportunistic screening, and case-finding should be clearly distinguished.
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Affiliation(s)
- Martin Gunnarson
- Department of Thematic Studies, Division of Technology and Social Change, Linköping University, Linköping, Sweden.
- Centre for Studies in Practical Knowledge, School of Culture and Learning, Södertörn University, Huddinge, Sweden.
| | - Alexandra Kapeller
- Department of Thematic Studies, Division of Technology and Social Change, Linköping University, Linköping, Sweden
| | - Kristin Zeiler
- Department of Thematic Studies, Division of Technology and Social Change, Linköping University, Linköping, Sweden
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Sagbakken M, Spilker RS, Nielsen TR. Dementia and immigrant groups: a qualitative study of challenges related to identifying, assessing, and diagnosing dementia. BMC Health Serv Res 2018; 18:910. [PMID: 30497459 PMCID: PMC6267848 DOI: 10.1186/s12913-018-3720-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 11/15/2018] [Indexed: 01/12/2023] Open
Abstract
Background Along with the ageing of the general population, Europe’s migrant populations are also ageing, thus posing new challenges for dementia care services, particularly if the services are to be adjusted to persons with different linguistic and cultural backgrounds. From the perspective of health professionals, this study aims to explore challenges involved in identifying, assessing and diagnosing people with cognitive impairment/dementia who have different linguistic and cultural backgrounds. Methods Research on health professionals experiences regarding the management of dementia among immigrants is scarce and qualitative methods was used to address the objective of the study. Using qualitative in-depth interviews and focus-group discussions, we sought to gather participants’ experiences regarding the diagnostic process for immigrants with dementia. The material was analysed and interpreted based on Kvale and Brinkmann’s descriptions of three different contexts of interpretation: self-understanding, critical common-sense understanding, and theoretical understanding. Results Health professionals described how families could attribute symptoms of dementia to processes of normal ageing, while others saw the symptoms as something shameful; both instances delayed or hindered help-seeking. Many clinicians had limited experience with older immigrants suffering from dementia, and general practitioners (GPs) in particular experienced difficulties assessing dementia due to language barriers and difficulties related to the involvement of the family or an interpreter. The findings illustrate challenges in assessment, such as unfamiliarity with test situations among those being assessed and lack of knowledge regarding appropriate diagnostic tools among health professionals. Lack of continuity and poor information exchange in the chain of care seem to reinforce many of these challenges. Conclusions Detection, treatment and care may be improved if primary care professionals strengthen their cross-cultural competences. Training in communication skills and in the use of cross-cultural assessment tools may help build competence and confidence when assessing and caring for people with different cultural and linguistic backgrounds. Closer collaboration among families, nurses in home-based services, dementia teams, and GPs may facilitate close monitoring of a patient over time. Such collaboration requires sufficient information exchange during transitions in the chain of care, continuity among health professionals, and a shared understanding of the goals for treatment and care. Electronic supplementary material The online version of this article (10.1186/s12913-018-3720-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mette Sagbakken
- Department of Nursing and Health Promotion, Faculty of Health Sciences, OsloMet - Oslo Metropolitan University, Pilestredet 32, 0130, Oslo, Norway.
| | - Ragnhild Storstein Spilker
- Norwegian Center for Migration and Minority Health, Norwegian Institute of Public Health, P.O. Box 222 Skøyen, 0213, Oslo, Norway
| | - T Rune Nielsen
- Danish Dementia Research Centre, Rigshospitalet, University of Copenhagen, Section 6922 Blegdamsvej 9, DK-2100, Copenhagen, Denmark
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Tsai PH, Liu JL, Lin KN, Chang CC, Pai MC, Wang WF, Huang JP, Hwang TJ, Wang PN. Development and validation of a dementia screening tool for primary care in Taiwan: Brain Health Test. PLoS One 2018; 13:e0196214. [PMID: 29694392 PMCID: PMC5918945 DOI: 10.1371/journal.pone.0196214] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 04/09/2018] [Indexed: 12/17/2022] Open
Abstract
Objectives To develop a simple dementia screening tool to assist primary care physicians in identifying patients with cognitive impairment among subjects with memory complaints or at a high risk for dementia. Design The Brain Health Test (BHT) was developed by several experienced neurologists, psychiatrists, and clinical psychologists in the Taiwan Dementia Society. Validation of the BHT was conducted in the memory clinics of various levels of hospitals in Taiwan. Participants All dementia patients at the memory clinics who met the inclusion criteria of age greater or equal to 50 years were enrolled. Besides the BHT, the Mini-Mental State Examination and Clinical Dementia Rating were used to evaluate the cognition state of the patients and the severity of dementia. Results The BHT includes two parts: a risk evaluation and a cognitive test (BHT-cog). Self or informants reports of memory decline or needing help from others to manage money or medications were significantly associated with cognitive impairment. Among the risk factors evaluated in the BHT, a total risk score greater or equal to 8 was defined as a high risk for dementia. The total score for the finalized BHT-cog was 16. When the cutoff value for the BHT-cog was set to 10 for differentiating dementia and a normal mental state, the sensitivity was 91.5%, the specificity was 87.3%, the positive predictive value was 94.8%, and the negative predictive value was 80.1% The area under the receiver operating characteristic curve between dementia and healthy subjects was 0.958 (95% CI = 0.941–0.975). Conclusions The BHT is a simple tool that may be useful in primary care settings to identify high-risk patients to target for cognitive screening.
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Affiliation(s)
- Ping-Huang Tsai
- Division of Neurology, Department of Internal Medicine, National Yang-Ming University Hospital, Yilan, Taiwan
- Center for Dementia Care and Evolution, National Yang-Ming University Hospital, Yilan, Taiwan
- Department of Neurology, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jian-Liang Liu
- Division of Neurology, Department of Medicine, Taipei City Hospital Heping Fuyou Branch, Taipei, Taiwan
| | - Ker-Neng Lin
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Psychology, Soochow University, Taipei, Taiwan
| | - Chiung-Chih Chang
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Ming-Chyi Pai
- Division of Behavioral Neurology, Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
- Alzheimer's Disease Research Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
| | - Wen-Fu Wang
- Department of Neurology, Changhua Christian Hospital, Changhua, Taiwan
| | - Jen-Ping Huang
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Tzung-Jeng Hwang
- Department of Psychiatry, College of Medicine and National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan
| | - Pei-Ning Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Brain Research Center, National Yang-Ming University, Taipei, Taiwan
- Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan
- * E-mail:
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Livingston G, Sommerlad A, Orgeta V, Costafreda SG, Huntley J, Ames D, Ballard C, Banerjee S, Burns A, Cohen-Mansfield J, Cooper C, Fox N, Gitlin LN, Howard R, Kales HC, Larson EB, Ritchie K, Rockwood K, Sampson EL, Samus Q, Schneider LS, Selbæk G, Teri L, Mukadam N. Dementia prevention, intervention, and care. Lancet 2017; 390:2673-2734. [PMID: 28735855 DOI: 10.1016/s0140-6736(17)31363-6] [Citation(s) in RCA: 3419] [Impact Index Per Article: 488.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 01/20/2017] [Accepted: 01/25/2017] [Indexed: 12/15/2022]
Affiliation(s)
- Gill Livingston
- Division of Psychiatry, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK.
| | | | - Vasiliki Orgeta
- Division of Psychiatry, University College London, London, UK
| | - Sergi G Costafreda
- Division of Psychiatry, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK
| | - Jonathan Huntley
- Division of Psychiatry, University College London, London, UK; Department of Old Age Psychiatry, King's College London, London, UK
| | - David Ames
- National Ageing Research Institute, Parkville, VIC, Australia; Academic Unit for Psychiatry of Old Age, University of Melbourne, Kew, VIC, Australia
| | | | - Sube Banerjee
- Centre for Dementia Studies, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Alistair Burns
- Centre for Dementia Studies, University of Manchester, Manchester, UK
| | - Jiska Cohen-Mansfield
- Department of Health Promotion, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Heczeg Institute on Aging, Tel Aviv University, Tel Aviv, Israel; Minerva Center for Interdisciplinary Study of End of Life, Tel Aviv University, Tel Aviv, Israel
| | - Claudia Cooper
- Division of Psychiatry, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK
| | - Nick Fox
- Dementia Research Centre, University College London, Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, UK
| | - Laura N Gitlin
- Center for Innovative Care in Aging, Johns Hopkins University, Baltimore, MD, USA
| | - Robert Howard
- Division of Psychiatry, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK
| | - Helen C Kales
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA; VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Eric B Larson
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA
| | - Karen Ritchie
- Inserm, Unit 1061, Neuropsychiatry: Epidemiological and Clinical Research, La Colombière Hospital, University of Montpellier, Montpellier, France; Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Kenneth Rockwood
- Centre for the Health Care of Elderly People, Geriatric Medicine Dalhousie University, Halifax, NS, Canada
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Quincy Samus
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview, Johns Hopkins University, Baltimore, MD, USA
| | - Lon S Schneider
- Department of Neurology and Department of Psychiatry and the Behavioural Sciences, Keck School of Medicine, Leonard Davis School of Gerontology of the University of Southern California, Los Angeles, CA, USA
| | - Geir Selbæk
- Norwegian National Advisory Unit on Aging and Health, Vestfold Health Trust, Tønsberg, Norway; Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway; Centre for Old Age Psychiatric Research, Innlandet Hospital Trust, Ottestad, Norway
| | - Linda Teri
- Department Psychosocial and Community Health, School of Nursing, University of Washington, Seattle, WA, USA
| | - Naaheed Mukadam
- Division of Psychiatry, University College London, London, UK
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