Understanding Chinese–Canadian pathways to a diagnosis of dementia through a critical-constructionist lens

Intersectionality in nursing research: A scoping review

Background

An intersectional approach to health research provides an analytical foundation to explain the multidimensionality of health status, resource accessibility, privilege, oppression, and current and historical context. The use of intersectionality in health research has known limitations. Its use in health-related fields too often focuses on outcomes, such as health disparities, rather than processes, such as power structures and social determinants.

Objective

This scoping review serves to examine how intersectionality has been implemented by nurses in the peer-reviewed literature. We offer insight into how it may be incorporated to inform future nursing research and healthcare provision.

Design & Methods

Systematic searches of PubMed (n = 257), SCOPUS (n = 807), EMBASE (n = 396), CINAHL (n = 224), and Health Source: Nursing and Academics (n = 491), published since the seminal publication on intersectionality (1989 - 2023), identified 131 research articles that met inclusion and exclusion criteria. Data extraction and synthesis were used to describe the breadth and depth of the literature specific to the application of intersectionality in nursing research.

Results

The included studies used intersectionality to examine the intersections of numerous identities, such as race, gender, and immigration status. However, most studies were descriptive/observational in nature, underreported their methods, and conducted deficit-based research instead of strength-based inquiries. Of note, the vast majority of included articles were published within the last five years.

Conclusions

Future researchers using intersectionality as a framework can improve their approach by reporting clear definitions and operationalization of intersectionality. Observational science dominated the included studies; future research should focus on intervention development and evaluation using an intersectional lens. Lastly, caution should be placed on research that focuses solely on deficits among marginalized communities, which places scientists at risk of perpetuating stereotypes or enhancing already-existing stigmas.

"Now at least we have something to call it": Patient and care partner experiences receiving an amyloid PET scan

BACKGROUND

The primary objective of this paper was to examine perspectives and experiences of individuals with cognitive impairment who received an amyloid PET scan and their care partners, with regard to the process, logistics, and decision-making associated with receiving an amyloid PET scan and its results.

METHODS

Structured telephone interviews were conducted with 200 randomly sampled scan recipient/care partner dyads from the CARE IDEAS study. The audio-recorded, transcribed responses were analyzed using an inductive qualitative content analytic approach.

RESULTS

Participating individuals and care partners described their experiences in seeking a diagnosis for memory issues, including decision-making and logistics involved with receiving an amyloid PET scan. Participants discussed the factors contributing to their decision to seek a diagnosis for their memory issues and their hopes and expectations in completing the scan. Participants also described the trajectory of this process, and although some described relatively straightforward trajectories, others described problems associated with identifying appropriate providers and coordinating care across numerous providers to obtain a diagnosis for their memory issues. Participants described an additional challenge of physicians attributing cognitive decline to normal aging, rather than signs of a neurodegenerative disorder.

CONCLUSIONS

Findings shed light on the barriers and delays that individuals and care partners experience in connecting with physicians and obtaining a comprehensive evaluation for cognitive problems. Results from this study have implications for physicians who provide care to older adults, and specifically highlight the need for greater care coordination and clearer communication with and systems of referral for patients.

A new model for general practice-led, regional, community-based, memory clinics

Background

Dementia is a major international health issue with high impact on the patient, relatives, and broader society. Routine screening for dementia is limited, despite known benefit of early detection and intervention on quality of care and patient outcomes. Screening is particularly limited in rural and regional areas, despite high burden and projected growth of dementia in these populations. The current study aimed to implement a new general practitioner (GP) led, multidisciplinary, model of care providing dementia detection and referral pathway to a community-based specialist clinic across six regional general practices.

Methods

Cross-sectional analysis of dementia screening and referral characteristics in the St Anthony Family Medical Practices group based in the regional area of Loddon-Mallee, Victoria. Data were collected on demographics and relevant medical history. Cognitive state was assessed using the Mini-Mental State Examination (MMSE), GP Assessment of Cognition (GPCog), and Geriatric Depression Scale (GDS). Referrals and referral outcomes were recorded for geriatrician, psycho-geriatrician, or both.

Results

Eight hundred and eighteenth patients over 65 years were screened, accounting for approximately 24.2% of 65 and over presentations for the practice network. Of those screened, 68.9% were indicated for referral and 30.3% of these were successfully referred. Of the indicated patients who received referrals, 34.2% declined. Many who declined referral had intermediate scores on the cognitive assessments utilized.

Conclusion

Standardised models of care, integrated within community services, are necessary to improve access to early detection, referral and quality management of dementia. The St Anthony Memory Service model will be invaluable in informing future service development, and in particular the development of services for people living with dementia in rural and regional communities.

Examine Race/Ethnicity Disparities in Perception, Intention, and Screening of Dementia in a Community Setting: Scoping Review

Background: Delayed detection and diagnosis of Alzheimer’s Disease and related dementia (ADRD) can lead to suboptimal care and socioeconomic burdens on individuals, families, and communities. Our objective is to investigate dementia screening behavior focusing on minority older populations and assess whether there are ethnic differences in ADRD screening behavior. Methods: The scoping review method was utilized to examine ADRD screening behavior and contributing factors for missed and delayed screening/diagnosis focusing on race/ethnicity. Results: 2288 papers were identified, of which 21 met the inclusion criteria. We identified six dimensions of ADRD screening behavior: Noticing Symptoms, Recognizing a problem, Accepting Screen, Intending Screen, Action, and Integrating with time. Final findings were organized into study race/ethnicity, theoretical background, the methods of quantitative and qualitative studies, description and measures of ADRD screening behavior, and racial/ethnic differences in ADRD screening behavior. Conclusions: A trend in ethnic disparities in screening for ADRD was observed. Our findings point to the fact that there is a scarcity of studies focusing on describing ethnic-specific ADRD screening behavior as well as a lack of those examining the impact of ethnicity on ADRD screening behavior, especially studies where Asian Americans are almost invisible.

Fostering trust and sharing responsibility to increase access to dementia care for immigrant older adults

Objectives: This paper explores the role of immigrant-serving agencies in facilitating access to dementia services and supports provided by dementia service agencies (particularly the health authority and local chapters of the Alzheimer Society) through their propensity to develop trusting relationships between staff and clients.Design: Our research is a qualitative case study of Punjabi and Korean speakers living in the Lower Mainland of BC, Canada. Data are drawn from interviews with 15 dyads of persons with dementia and their family caregivers (10 Punjabi, 5 Korean), six focus groups (one focus group with each of 8-10 older men, older women, and mixed gender working age adults in each community). We also interviewed 20 managerial and frontline staff of dementia service agencies, i.e. the health authority and the local Alzheimer Society (n = 11) and two immigrant-serving agencies (n = 9), each dedicated to either Punjabi or Korean-speaking clients. We adopted the Candidacy framework for understanding access to dementia services and supports and the concept of trust as guiding precepts in this study.Results: Families of persons with dementia are pivotal to identification of a problem requiring professional help, navigation to appropriate services and acceptance of services offered. However, trust in family members should not be taken for granted, since family dynamics are complex. Alternative sources of trusted support are therefore needed. Immigrant-serving agencies are more often instrumental in establishing trusted relationships between their staff and clients, but they often lack detailed knowledge about heath conditions, their treatment and management, and they lack power to implement statutory care.Conclusions: Partnerships between mainstream mental health/dementia services and the community sector have proven successful in increasing the accessibility of specialized resources, while maximizing their combined trustworthiness, accessibility and effectiveness. Such partnerships should become fundamental components of health service strategy and provision for vulnerable and underserved immigrant older adults.

Understanding help-seeking decisions in people with subjective cognitive decline: A systematic review of qualitative studies

OBJECTIVE

To synthesize the findings of qualitative research on help-seeking in people with subjective cognitive decline.

METHODS

Relevant qualitative studies were identified by searching the PubMed, CINAHL, Ovid Medline, PsycInfo, Embase, and Web of Science databases. Studies that investigated help-seeking behavior in older adults with subjective cognitive decline were retrieved. The systematic review was conducted in line with JBI methodology for systematic reviews of qualitative evidence.

RESULTS

11 studies were included and three themes related to the process of help-seeking for cognitive problems emerged. These themes included: detected changes, challenges in identifying the need for help and decision to seek professional help.

CONCLUSION

Making decisions to seek help for people with subjective cognitive decline is a multi-stage process. A better understanding of the complex psychological responses to subjective cognitive decline among older adults may help health care professionals to develop strategies to improve help-seeking in clinical practice.

Availability and utilization of support services for South African male caregivers of people with Alzheimer’s disease in low-income communities

The purpose of this study was to explore the needs of male caregivers of people with Alzheimer’s disease, by ascertaining the availability and utilization of Alzheimer’s disease-related resources in low-income communities in the Western Cape. Semi-structured interviews were conducted with 11 adult males who were familial caregivers of persons with Alzheimer’s disease. They were recruited via purposeful sampling methods. Thematic analysis of the data generated four major themes, namely Awareness, Knowledge and Education; Caregivers who do not use services; Caregivers who use services and Service needs identified by male caregivers. Predominant findings were that male caregivers in lower income communities do not make use of formal Alzheimer’s disease-related services – albeit being aware of them – because they do not perceive a need for its utilization. Instead, male caregivers prefer assistance in the form of respite care in the home environment to relieve and assist them with household needs. The role of culture may have a substantial influence on these patterns of help-seeking behavior due to the emphasis on a collective approach to caregiving using wider, informal social networks. Needs that were identified by the male caregivers in this study included the general awareness of Alzheimer’s disease, access to information regarding service provision, psychoeducation and affordable services within improved care facilities for low-income communities. The findings of this study suggest a starting point for the needs that should be prioritized to facilitate culturally appropriate service use amongst male caregivers in similar settings.

Persistent barriers and facilitators to seeking help for a dementia diagnosis: a systematic review of 30 years of the perspectives of carers and people with dementia

OBJECTIVE

To identify barriers and facilitators to help seeking for a dementia diagnosis from the perspective of carers and people with dementia.

DESIGN

A systematic review of the literature was conducted according to the PRISMA guidelines (PROSPERO protocol registration CRD42018092524). Nine electronic databases were searched for qualitative, quantitative, and mixed methods primary research studies. Two independent reviewers screened titles and abstracts, full texts of eligible studies, and conducted quality appraisal of included articles. A convergent qualitative synthesis approach was used.

RESULTS

From 7496 articles, 35 papers representing 32 studies from 1986 to 2017 were included. Studies originated from 13 countries across 4 continents. Barriers and facilitators were reported predominantly by carers. A small number of studies included people with dementia. Barriers included denial, stigma and fear, lack of knowledge, normalization of symptoms, preserving autonomy, lack of perceived need, unaware of changes, lack of informal network support, carer difficulties, and problems accessing help. Facilitators included recognition of symptoms as a problem, prior knowledge and contacts, and support from informal network.

CONCLUSIONS

Studies from a 30-year period demonstrated that barriers to help seeking persist globally, despite increasing numbers of national dementia policies. Barriers and facilitators rarely existed independently demonstrating the complexity of help seeking for a diagnosis of dementia. Multiple barriers compounded the decision-making process and more than one facilitator was often required to overcome them. Multi-faceted interventions to reduce barriers are needed, one approach would be a focus on the development of dementia friendly communities to reduce stigma and empower people with dementia and carers.

Perspectives of dementia from Asian communities living in New Zealand: A focus group of Asian health care professionals

OBJECTIVE

The number of Asian New Zealanders with dementia is growing. The objective of this study was to explore with a group of Asian health care professionals about public attitudes towards dementia in Asian communities in New Zealand, the stigma of dementia, and how best to develop culturally appropriate services for Asian people and families living with dementia.

METHODS

A focus group was conducted with a group of bilingual Asian health care professionals. A topic guide was developed based on the discussion at a prior meeting with the Cross Cultural Interest Group. The data were independently analysed by three researchers using the thematic qualitative methodology.

RESULTS

Eleven overseas-born Asian health care professionals (Chinese: n = 9, 82%) participated in the focus group. Four main themes emerged from the data: (a) cultural interpretations of dementia; (b) stigma; (c) filial piety; and (d) inequity in the availability of resources.

CONCLUSION

Our findings suggest that much work is needed to destigmatise dementia in New Zealand Asian communities, through psychoeducation, public awareness, and the availability of readily accessible services that can meet their cultural and language needs.

Individual risk factors for possible undetected dementia amongst community-dwelling older people in New Zealand

There is general acknowledgement of the importance of early diagnosis of dementia, yet there are still high rates of undetected dementia internationally. The aim of this cross-sectional study was to determine the sociodemographic characteristics associated with possible undetected dementia in a large sample of community-dwelling older New Zealanders. The sample consisted of older people (age ≥ 65) who had received the homecare version of the international Residential Home Care Assessment version 9.1 over a two-year period and who were screened positive for possible dementia on the international Residential Assessment’s Cognitive Performance Scale. People with possible alternative explanations for impaired cognitive performance such as depression and other neurological conditions were excluded from analysis. The 5202 eligible individuals were categorized into two groups: (1) those with a recorded diagnosis of dementia (64%) and (2) those without a recorded diagnosis of dementia (i.e. possible undetected dementia group) (36%). Logistic regression was used to evaluate the association between individual characteristics and possible undetected dementia. Significant risk factors for being in the possible undetected dementia group included Asian ethnicity, living alone, not having participated in long-standing social activities recently, major life stressors, and limited accessibility of their house. The knowledge gained from this study could enable targeting of services and resources for the groups at risk of undetected dementia to have a more equitable access to early diagnosis.

'It's Like Chicken Talking to Ducks' and Other Challenges to Families of Chinese Immigrant Older Adults in Long-Term Residential Care

Immigrant older adults are increasingly moving into long term residential care (LTRC) homes; however, most were designed and continue to be run in accordance with Anglocentric norms and values. Participation and interest in Family Councils-through which they might collectively voice concerns-was low within our purposive sample of nine Chinese-origin residents living in LTRC homes and 11 family carers. Our study, conducted in two LTRC homes in British Columbia, Canada between January and March 2016, further explored participants' perceptions of quality of care by staff and quality of life of residents. Our findings negate participants' rationale that they do not attend because they have no issues to raise. Solutions must recognize that carers' time is precious and care-work is gendered; language incongruity and failure to address it marginalizes residents and their family members. A culturally informed reticence to speak out is reinforced when attempts to do so are silenced.

How people come to recognise a problem and seek medical help for a person showing early signs of dementia: A systematic review and meta-ethnography

Evidence suggests that there is usually a long delay between noticing first signs of dementia and seeking medical help. We conducted a systematic review of what people experience and how they make decisions during this time, and used a meta-ethnographic approach to synthesise the findings. Screening and quality assessment resulted in nine studies eligible for inclusion. People with dementia mainly report experiencing memory lapses, while carers focus on more subtle changes in personality. People respond to these changes in one of three ways: 1) they discount them as normal; 2) they reserve judgement as to their cause and significance, or 3) they misattribute them. Pivotal events can finally trigger help seeking. Active reflection and seeking of further evidence may lead to earlier recognition of the possibility of dementia and the need to seek help; it also reduces the risk of a pivotal event. Public education should aim to improve recognition of more subtle signs and to encourage repeated evaluation and reflection.

Barriers and facilitators in accessing dementia care by ethnic minority groups: a meta-synthesis of qualitative studies

BACKGROUND

It is estimated that there are about 25,000 people from UK ethnic minority groups with dementia. It is clear that there is an increasing need to improve access to dementia services for all ethnic groups to ensure that everyone has access to the same potential health benefits. The aim was to systematically review qualitative studies and to perform a meta-synthesis around barriers and facilitators to accessing care for dementia in ethnic minorities.

METHODS

Databases were searched to capture studies on barriers and facilitators to accessing care for dementia in ethnic minorities. Analysis followed the guidelines for meta-ethnography. All interpretations of data as presented by the authors of the included papers were extracted and grouped into new themes.

RESULTS

Six hundred and eighty four papers were identified and screened. Twenty eight studies were included in the meta-synthesis. The analysis developed a number of themes and these were incorporated into two overarching themes: 'inadequacies' and 'cultural habitus'.

CONCLUSIONS

The two overarching themes lend themselves to interventions at a service level and a community level which need to happen in synergy.

TRIAL REGISTRATION

The review was registered with PROSPERO: CRD42016049326 .

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

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

S4AC Case Study: Enhancing Underserved Seniors’ Access to Health Promotion Programs

Les Services de soutien pour les aînés projet communautaire sud-asiatique (SSAPCSA) ont été développé en réponse à la sous-utilisation des loisirs disponibles et des installations pour les aînés par des aînés sud-asiatiques qui étaient particulièrement nombreux dans une banlieue en Colombie-Britannique. Abordant ce problème a nécessité la collaboration de la municipalité et un organisme enregistré à but non-lucratif offrant un large éventail de services et de programmes aux communautés immigrantes et réfugiées. Grâce à la sensibilisation créative et l’hébergement, le projet a engagé plus de 100 personnes âgées qui parlent panjabi chaque année à diverses activités impliquant l’exercice. Les méthodes de recherche ont porté sur l’étude de cas avec le personnel et les participants actuels et anciens cadres de SSAPCSA comprennent l’observation participante, entretiens individuels, et des groupes de discussion. Les conclusions, vues à travers le prisme d'interprétation critique de la “cadre de la candidature,” révèlent les multiples façons dans lesquelles l’accès à la promotion de la santé et l’activité physique pour les immigrants plus âgés est un processus complexe et itératif de négociation à plusieurs niveaux.

Honoring Identity Through Mealtimes in Chinese Canadian Immigrants

Mealtimes are opportunities for social interactions and expressions of individual and family identity, and serve as a microcosm of the broader lives of families living with dementia. The Eating Together study and its resulting Life Nourishment Theory (LNT) explicated the importance of mealtimes for honouring individual and family identities in the context of dementia. This sub-study examined a specific ethnocultural group with cultural food-ways and caring expectations, to determine if the concept of honouring identity needed to be modified or extended. Using active interview techniques, two Cantonese speaking researchers completed dyad/triad family and individual interviews with six Chinese Canadian immigrant families, recruited from two service providers in a large, urban, multicultural city. This sub-study provided insight into the challenges and rewards of mealtimes for Chinese immigrant families with dementia in the community and specifically provided further insights into the honouring identity concept. Although LNT and specifically the honouring identity concept was generally confirmed in this group, some culturally-specific themes were also identified. This work serves as a basis for future studies examining the meaning and experience of mealtimes in specific cultural groups living with dementia. Such work would confirm if the LNT can be applied to specific ethnocultural groups as well as the general population living with dementia.

Help-seeking for dementia: a systematic review of the literature

BACKGROUND

Help-seeking (HS) for dementia presents a great challenge, especially because a timely and appropriate HS process might be associated with better outcomes for the person with dementia, their caregivers, and society. A clear understanding of the HS concept and its measurement in the area of dementia might improve the effectiveness of the process.

AIMS

The aims of our systematic review were: (1) to systematically obtain and evaluate the relevant literature on HS and dementia; and (2) to summarize current research findings and draw conclusions for future research and clinical care in this area.

METHOD

A systematic review of the literature on HS and dementia was conducted up till June 2013.

RESULTS

From the 478 retrieved articles, 48 were included in the review. Conceptually, the studies examined professional and nonprofessional sources of help; showed preference for seeking help from close relatives followed by primary health caregivers; and identified inadequate knowledge and stigmatic beliefs as the main barriers to HS. The majority of the studies did not rely on a theoretical framework.

CONCLUSIONS

Although the body of literature in the area of HS and dementia is growing, several conceptual and methodological limitations still have to be resolved to advance knowledge in the area.

"Tangled wires in the head": older migrant Chinese's perception of mental illness in Britain

In this article, the authors explored Cantonese-speaking older Chinese migrants knowledge, attitudes and expectations regarding mental illness. They obtained verbatim data from semi-structured interviews with eight participants recruited from London-based Chinese and church communities in Britain. They analyzed the data using the principles of Grounded Theory and in-depth content analysis. They examined cultural idioms in participants' accounts. Findings suggested that Western diagnostic categories of mental illness were alien to participants. They had a culturally constructed way of defining and characterizing mental illness. Participants used idioms of 'nerve', 'mood', 'behavior', 'personality', 'normal life', 'compassion' and the idiom of 'others' to construct an alternative world for stigma management. They erected an invisible but permeable barrier to limit access to their normal world. The role of traditional Chinese culture of Confucianism was significant in shaping perceptions and conceptions of mental illness. This article offered another perspective on the alternative world of Chinese migrants' cultural understandings of mental illness, an area with limited understanding at present. The authors discussed important implications for future research and social policy.