Dementia in old age: an anthropological perspective

Diagnosis of mental illness in elderly people from ethnic minorities

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

How people with dementia and carers understand and react to social functioning changes in mild dementia: a UK-based qualitative study

OBJECTIVES

To analyse people with dementia and their family carers' attribution of social changes in dementia and the consequences of these attributions.

DESIGN

Qualitative study, using a semi-structured interview guide. Individual interviews continued to theoretical saturation. Two researchers independently analysed interview transcripts.

SETTING AND PARTICIPANTS

People with mild dementia and family carers purposively selected from London-based memory services for diverse demographic characteristics to encompass a range of experiences.

PRIMARY AND SECONDARY OUTCOMES

Attribution of social changes experienced by the person with dementia and the consequences of these attributions.

RESULTS

We interviewed nine people with dementia and nine carers, encompassing a range of age, ethnicity and educational backgrounds.Both groups reported that the person with dementia had changed socially. People with dementia tended to give one or two explanations for social change, but carers usually suggested several. People with dementia were often socially embarrassed or less interested in going out, and they or their relatives' physical illness or fear of falls led to reduced social activity. Carers often attributed not going out to a choice or premorbid personality. Carers found that their relative needed more support to go out than they could give and carers needed time to themselves because of carer stress or other problems from which they shielded the person with dementia. Additionally, there was decreased opportunity to socialise, as people were bereaved of friends and family. Participants acknowledged the direct impact of dementia symptoms on their ability to socially engage but sometimes decided to give up socialising when they knew they had dementia. There were negative consequences from social changes being attributed to factors such as choice, rather than dementia.

CONCLUSION

Clinicians should ask about social changes in people with dementia. Explaining that these may be due to dementia and considering strategies to overcome them may be beneficial.

Explaining the effects of symptom attribution by carers on help-seeking for individuals living with dementia

This study investigated the effects of carer attributions on help-seeking behaviour for people with dementia using interviews with 84 carers recruited through general practice. Memory loss was the most commonly reported first symptom but psychological and behavioural symptoms were also common at onset. In over a third of individuals help-seeking was delayed for a mean of 25 months (range 6-69, SD 19.3). Help-seeking between those who attributed symptoms to dementia, or to unknown causes, and those who attributed symptoms to personality, ageing, life events or other illnesses was statistically significant ( p < 0.001). No statistically significant associations between help-seeking and patient or carer characteristics were found. There is a need to raise public awareness about the range of symptoms suggestive of dementia. Assumptions that age and other conditions may be the likely cause of an individual's cognitive decline needs to be challenged by practitioners. Attribution of symptoms to characteristics other than dementia delays help-seeking.

Dementia Diagnosis and Management in Primary Care

Dementia presents a challenge for primary care and the advent of new therapeutic options has highlighted the need to improve its detection so that early decisions about medication use can be made. Efforts at earlier diagnosis should be targeted at primary care as the gateway to specialist health and social services. There is, however, evidence that dementia remains under-detected and sub-optimally managed in general practice throughout the world. This article reviews the obstacles to early recognition of dementia and the factors causing sub-optimal management in the community, and discusses educational approaches to enhancing professional skills in the recognition of and response to dementia. Three educational interventions with different characteristics and methods of delivery are described.

Developing Awareness about Awareness in Early-Stage Dementia

Unawareness in dementia is often viewed as a ‘symptom’ that is wholly or primarily the product of biological factors. While neurological damage may be sufficient to produce unawareness in some disorders, it is argued that this is not generally the case in early-stage dementia. Instead, it is suggested that the apparent degree of awareness is an expression of adaptive psychological responses constructed in a social situation in the context of neurologically based cognitive impairment. Drawing on examples from detailed interviews with people who have dementia and their partners, the contribution of psychological and social factors to the expression of awareness is explored. It is further argued that, because evaluations of awareness are constructed in dialogue through the interpretative activity of the researcher or clinician, reflexivity is essential in considering awareness.

A Neglected Drama for Elders: Discrepancy Between Self-Perception and Objective Performance Regarding Financial Capacity in Patients With Cognitive Deficits

The article aims at investigating whether patients from Greece with different kinds of cognitive deficits (resulting from Alzheimer’s Disease, Parkinson’s Disease Dementia, and Mild Cognitive Impairment) can be characterized as financially capable (based on neuropsychological assessment), and if this claimed (in)capacity is in accordance with their personal belief of (in)capacity. Results revealed that the vast majority of the mild, moderate and severe Alzheimer’s disease patients as well as patients with Mild Cognitive Impairment and Parkinson’s disease, who scored significantly lower than normal on a relevant financial decision-making capacity test, believed that they were capable to handle their finances. This finding is in contrast with their actual financial capacity scores and the beliefs of their family members-caregivers on this issue. Some critical questions concerning incapacity and intellectual insight are raised, and future cross-cultural investigative attempts on this issue are suggested.

Dementia and migration: Pakistani immigrants in the Norwegian welfare state

This article is about dementia disease in the context of transnational migration. Focusing on the example of Pakistani immigrants in Norway, the article explores response processes surrounding signs and symptoms of dementia. Particular attention is lent to understanding how Norwegian-Pakistani families ‘negotiate dementia’ in the space between their own imported, culturally defined system of cure and care, and the Norwegian health-care culture, which is characterised by an inclination towards public care and biomedical intervention. Based on field observations and in-depth interviews with Norwegian-Pakistani families and hospital professionals working with dementia, we show that the centrality of the traditional family in Norwegian-Pakistanis' identity claims has significant implications for how Norwegian-Pakistanis relate to the Norwegian health-care culture, and for how signs and symptoms of cognitive decline are read and responded to in a migratory context.

Socio-Cultural Perceptions and Representations of Dementia in Brazzaville, Republic of Congo: The EDAC Survey

Background

Dementia will concern more and more people in the developing countries, but the perception people have of dementia in these areas has not yet been studied.

Method

During a general population survey (EDAC) carried out in Brazzaville (Republic of Congo), 27 elderly persons suspected of having dementia and 31 of their relatives, 90 cognitively impaired elderly persons and 92 of their relatives, as well as 33 hospital workers were interviewed according to the Explanatory Model Interview Catalogue.

Results

Item prominence ratings indicate that the attention was mainly on the emotional and socio-economic consequences (scores >1.0 out of 5 points). Ageing and mental stress are the main perceived causes. Hospital workers are more aware of public stigma.

Conclusion

The socio-cultural components of the dementia phenomenon have to be taken into account to enforce public health and social measures.

Underdiagnosis of dementia in primary care: variations in the observed prevalence and comparisons to the expected prevalence

OBJECTIVES

Dementia is a major and growing health problem. Diagnosis is an important step in the access to care, but many dementia patients remain undiagnosed. This study investigated the magnitude and variation in the difference between 'observed' and 'estimated' prevalence of dementia in general practices. We also explored practice characteristics associated with observed prevalence rates.

METHOD

Six Primary Care Trusts (PCTs) provided data on all general practices (N = 351) in their area in terms of number of doctors, patient list size, number of patients over 65 years of age, socio-economic deprivation status of practices and number of patients on dementia registers.

RESULTS

The average observed prevalence overall of dementia amongst patients 65 years and over was 3.0% [95CI 2.8, 3.2]. The observed prevalence was 54.5% [95CI 49.2, 58.9] lower than the prevalence observed in the epidemiological studies in the UK. For an average size general practice (list size of 5269 patients) approximately 27 [95CI 22, 32] patients with dementia may remain undiagnosed. Statistically significant differences in prevalence rates were found between the different PCTs (Wald chi-square = 103.8 p < 0.001). The observed prevalence of dementia was significantly lower among practices run by one GP compared to multiple GPs (p = 0.003), and in more affluent areas (p < 0.001).

CONCLUSION

Just under a half of the expected numbers of patients with dementia are recognised in GP dementia registers. The underdiagnosis of dementia varies with practice characteristics, socio-economic deprivation and between PCTs, which has implications for the local implementation of the National Dementia Strategy.

Rapid appraisal of barriers to the diagnosis and management of patients with dementia in primary care: a systematic review

Background

The diagnosis of dementia in primary care is perceived as a problem across countries and systems, resulting in delayed recognition and adverse outcomes for patients and their carers. Improving its early detection is an area identified for development in the English National Dementia Strategy 2009; there are thought to be multiple benefits to the patient, family, and resources by doing this. The aim of this review was to carry out a rapid appraisal in order to inform the implementation of this policy.

Method

Publications in English up to August 2009 relating to barriers to the recognition of dementia, were identified by a broad search strategy, using electronic databases MEDLINE, EMBASE, and psycINFO. Exclusion criteria included non-English language, studies about pharmacological interventions or screening instruments, and settings without primary care.

Results

Eleven empirical studies were found: 3 quantitative, 6 qualitative, and 2 with mixed methodologies. The main themes from the qualitative studies were found to be lack of support, time constraints, financial constraints, stigma, diagnostic uncertainty, and disclosing the diagnosis. Quantitative studies yielded diverse results about knowledge, service support, time constraints, and confidence. The factors identified in qualitative and quantitative studies were grouped into 3 categories: patient factors, GP factors and system characteristics.

Conclusion

Much can still be done in the way of service development and provision, GP training and education, and the eradication of stigma attached to dementia, to improve the early detection and management of dementia. Implementation of dementia strategies should include attention to all three categories of barriers. Further research should focus on their interaction, using different methods from studies to date.

Understanding obstacles to the recognition of and response to dementia in different European countries: a modified focus group approach using multinational, multi-disciplinary expert groups

Experts from eight European countries (Belgium, France, The Netherlands, Ireland, Italy, Portugal, Spain and the United Kingdom) and the disciplines of clinical psychology, general practice, geriatric medicine, old age psychiatry, medical sociology, nursing and voluntary body organisation met in 2003 to explore obstacles to recognition of and response to dementia in general practice within Europe. A modified focus group methodology was used in this exploratory process. Groups were conducted over a two-day period, with five sessions lasting 1-1.5 hours each. An adapted nominal group method was used to record themes arising from the group discussion, and these themes were used in a grounded theory approach to generate explanations for delayed recognition of and response to dementia. The overarching theme that arose from the focus groups was movement, which had three different expressions. These were: population movement and its consequences for localities, services and professional experience; the journey of the person with dementia along the disease process; and the referral pathway to access services and support. Change is the core issue in dementia care, with multiple pathways of change that need to be understood at clinical and organisational levels. Practitioners and people with dementia are engaged in managing emotional, social and physical risks, making explicit risk management a potentially important component of dementia care. The boundary between generalist and specialist services is a particular problem, with great potential for dysfunctionality. Stigma and ageism are variably distributed phenomena both within and between countries.

Flexible hips? On Alzheimer's disease and aging in Brazil

This article examines one aspect of Alzheimer's disease, which describes it as a "memory disease". In the specific context of urban Brazil this relatively new illness category, which is creating a certain tension with older concepts of senility, is seen within the changing world of the Country's memory politics - and a changing culture of aging - which create new values and new ways of dealing with memory and its diseases. An important aspect of the older notion of senility is the way a person creatively and in a flexible way deals with life's stress and strain. And part of this highly valued flexibility is the capacity of forgetting negative events, of "letting go". The incapacity of this, not having "flexible hips", is one reason of becoming ill. It is not argued that a changing cultural context in Brazil is creating a disease like Alzheimer's, but that certain memory practices help to explain, to live and to contest traditional and new ways of dealing with senility and that this process is a dynamic one and still in the beginning in Brazil.

Cultural aspects of dementia

This paper critically reviews current knowledge regarding culture and dementia in order to identify unanswered questions in the field. Medline was searched from 1993-2000. One hundred nine articles were identified, of which 59 were critically reviewed, augmented by additional references from experts and by books. Limited research evidence was identified in four areas: 1) the recognition of dementia across cultures 2) cultural specificity of screening tools 3) identification of differences in risk factors, incidence, onset and prevalence across culture 4) culturally related issues in decision making about management. Implications for research and practice are described.

The recognition, assessment and management of dementing disorders: conclusions from the Canadian Consensus Conference on Dementia

OBJECTIVE

i) To develop evidence based consensus statements on which to build clinical practice guidelines for primary care physicians towards the recognition, assessment and management of dementing disorders; ii) to disseminate and evaluate the impact of these statements and guidelines built on these statements.

OPTIONS

Structured approach to assessment, including recommended laboratory tests, choices for neuroimaging and referral; management of complications (especially behaviour problems and depression) and use of cognitive enhancing agents. POTENTIAL OUTCOMES: Consistent and improved clinical care of persons with dementia; cost containment by more selective use of laboratory investigations, neuroimaging and referrals; appropriate use of cognitive enhancing agents.

EVIDENCE

Authors of each background paper were entrusted to: perform a literature search, discover additional relevant material including references cited in retrieved articles; consult with other experts in the field and then synthesize information. Standard rules of evidence were applied. Based upon this evidence, consensus statements were developed by a group of experts, guided by a steering committee of eight individuals from the areas of Neurology, Geriatric Medicine, Psychiatry, Family Medicine, Preventive Health Care and Health Care Systems.

VALUES

Recommendations have been developed with particular attention to the context of primary care and are intended to support family physicians in their ongoing assessment and care of patients with dementia.

BENEFITS, HARMS AND COSTS

Potential for improved clinical care of individuals with dementia. A dissemination and evaluation strategy will attempt to measure the impact of the recommendations.

RECOMMENDATIONS

See text.

VALIDATION

Four other sets of consensus statements and/or guidelines have been published recently. These recommendations are generally congruent with our own consensus statements. The consensus statements have been endorsed by relevant bodies in Canada.

The epidemiology of dementia in Africa: a review

Very few of the 100 studies of the prevalence of dementia have been carried out in Africa. Much of the early work concerned small hospitalised samples. However, a series of studies from Ibadan, Nigeria, have produced consistently low rates for dementia, especially for Alzheimer's Disease. The most recent studies reveal rather higher rates, but still lower than surveys carried out elsewhere. The possible reasons for these findings are considered: differential survival rates, the hiding of cases by relatives because of stigma, reluctance to seek medical assistance as inappropriate, poor access to medical care, the feeling that the old person has come to the end of his useful life and defective case-finding techniques. The need for further research is emphasised.

The effects of childhood residence in Japan and testing language on cognitive performance in late life among Japanese American men in Hawaii

OBJECTIVES

To examine the association of years spent in Japan during childhood with cognitive test performance in late life among Japanese American men, and to assess the influence of the language used for testing on this association.

DESIGN

A cross-sectional study.

SETTING/PARTICIPANTS

A total of 3734 Japanese American men, aged 71-93 years, who were first- or second-generation migrants and living on Oahu Island, Hawaii.

MEASUREMENTS

The outcome variable was cognitive test performance assessed using the Cognitive Abilities Screening Instrument (CASI), which was developed for cross-cultural studies of cognitive impairment. The explanatory variable of main interest was the number of years spent in Japan during school-age childhood years (ages 6-17). The associations of CASI scores with childhood years in Japan was evaluated using a stepwise multiple linear regression model in which a total of 40 potential confounders were included as covariates.

RESULTS

In the total sample, there was an inverse association between CASI scores and middle childhood years in Japan. This association remained significant after controlling for age, education, socioeconomic status, traditional Japanese food consumption, pulmonary function, apolipoprotein E4, proficiency in speaking Japanese, and other possible confounders. When data were analyzed separately for subgroups according to the language preferred at testing (English or Japanese), associations between childhood years in Japan and CASI scores were in opposite directions negative for the group tested in English and positive for the group tested in Japanese. The interaction between the testing language and childhood years in Japan was statistically significant.

CONCLUSIONS

There was an inverse association between years spent in Japan during school-age years of childhood and cognitive test performance in late life. This association could not be accounted for by age, education, or other confounding factors. However, this finding was not observed in participants who preferred being tested in Japanese. To assess cognitive test performance in older people, it is of prime importance to use the most optimal language for testing, usually the subject's native language.

Constructing Alzheimer's: narratives of lost identities, confusion and loneliness in old age

This paper is a qualitative study based on retrospective, unstructured, qualitative interviews with Mrs. Jones and other African-American, Chinese-American, Irish-American and Latino family caregivers in the Boston area. A narrative approach is used to show how family caregivers draw on their cultural and personal resources to create stories about the nature and meaning of illness and to ask how ethnic identity may influence the kinds of stories family caregivers tell. Three different story types are identified and described, each with a distinctive configuration of illness meanings and overarching theme, or storyline: a subset of African-American, Irish-American, and Chinese-American caregivers told us stories about Alzheimer's as a disease that erodes the core identity of a loved one and deteriorates their minds; a subset of Chinese caregivers narrated stories that emphasized how families managed confusion and disabilities, changes ultimately construed as an expected part of growing old; a subset of Puerto Rican and Dominican families, while using the biomedical label of Alzheimer's disease or dementia, placed the elder's illness in stories about tragic losses, loneliness, and family responsibility. To construct their stories, caregivers drew upon both biomedical explanations and other cultural meanings of behavioral and cognitive changes in old age. Their stories challenge us to move beyond the sharp contrast between ethnic minority and non-ethnic minority views of dementia-related changes, to local clinics and hospitals as sites where biomedical knowledge is interpreted, communicated, discussed, and adapted to the perspectives and lived realities of families.

The geography of dementia: an approach through epidemiology

Dementia is an extremely common condition among the elderly. Over 100 epidemiological surveys have now been published from many countries. Methodological differences make comparisons difficult, although meta-studies carried out in Europe provide baseline material for developed countries. Surveys within each geographical area which has been studied are discussed. Differences in the distribution of sub-types of dementia and the resultant challenges to governments and researchers are set out.

The problem of dementia in Australian aboriginal and Torres Strait Islander communities: an overview

The concept of dementia in old age in Australian Aboriginal and Torres Strait Islander communities is intrinsically paradoxical. Firstly, few indigenous people reach old age. Secondly, from some indigenous points of view, dementia is either not recognized as a condition or as a problem, or, in the case of the more disruptive manifestations of cognitive impairment, is perceived as 'madness'. Moreover, in the wider context of profound political, social and economic inequality experienced by most indigenous people, the western medical category of dementia may appear to be of relatively minor importance. However, government initiatives in aged care generally and dementia care in particular which are designed to address the ageing of the Australian population as a whole also include the nation's older indigenous people. This article-based on a review of published work, supplemented by discussions with indigenous and non-indigenous individuals involved in indigenous aged care and mental health-examines some of the issues surrounding cognitive decline in old age for Aborigines and Torres Strait Islanders. More specifically, it looks at the problems involved in assessing and diagnosing cognitive decline and dementia, especially among people who follow more traditional ways of life, and in providing services to sufferers and their carers. In doing so, it considers some of the relative meanings of "old age', "abnormal old age', "mental disorder', "sickness' and "dementia'.