Mild Dementia: Perceptions and Problems

Make it Easy on Yourself!

In this article we draw on personal experiences to discuss the use of the interview as a research method from the perspective of someone with dementia. Despite the increased emphasis on including people with dementia themselves in research, the perspective of the person with dementia on the interview situation is so far missing. In this article we hope to add to the established understanding that people with dementia can be included in research, by outlining the reflections of a person with dementia about how it felt and what was useful in taking part in an interview. In particular, we want to highlight the importance of the relationship created in an interview, the role of the social setting, and some basic practical strategies to make the situation easier.

`Making mistakes'

This paper outlines the use of a new qualitative research approach, Co-Constructed Inquiry, to develop a personal theory of the experience of living and adjusting to an early diagnosis of Alzheimer's disease. The personal theory was developed over a 21-month period (March 2004—December 2005) between Sarah, a person with Alzheimer's disease, and a clinical nurse specialist at a memory clinic in North Wales, John Hughes-Roberts. The resulting work suggested that Sarah co-constructed her experience of living with the onset of Alzheimer's disease as a process of `making mistakes' and that her life story was a powerful influence in mediating and enhancing her coping behaviour. Moreover, a sequence of `balancing' acts, i.e. losing balance — finding balance — keeping balance, which Sarah visualised as the `up and down' motion of a see-saw, both conceptualised and diagrammed her early adjustment experience. Sarah's personal theory has implications for practice and research development.

Awareness context theory and the dynamics of dementia

This article presents the initial results of an ongoing constructivist grounded theory study (Charmaz, 2000) exploring the impact of dementia on the everyday life and relationships of older spousal couples. Using a process of ‘emergent fit’ (Glaser, 1978) and drawing upon data from 74 interviews with 20 spouse couples living with dementia, it considers the relevance of ‘awareness context theory’ (Glaser & Strauss, 1965) and the ‘dynamics of dementia’ (Keady, 1999) to an understanding of interpersonal relationships among spouses. The combination of existing literature and new data provide further insights into how couples actively work to ‘construct’ awareness in a way that, for the majority, maintains both a sense of ‘self’ for the person with dementia (PWD) and the integrity of the relationship between couples. It is suggested that a ‘mutual acknowledgement’ of the diagnosis and a subsequent focus on maintaining a meaningful life in the present combine to create a ‘nurturative relational context’ in which living with dementia unfolds.

Agreement on diagnosis among patients, companions, and professionals after a dementia evaluation

A diagnosis of dementia is challenging to deliver and to hear; yet, agreement on diagnosis is essential for effective treatment for dementia. We examined consensus on the results of an evaluation of dementia in 90 patients assessed at an Alzheimer's Disease Research Center. Diagnostic impressions were obtained from 5 sources: (1) the physician's chart; (2) the patient who was evaluated; (3) a companion present at the evaluation; (4) a diagnostic summary written by a nurse present during the evaluation; and (5) raters who watched a video of the diagnostic disclosure conversation. Overall, diagnostic consensus was only moderate. Patients and companions exhibited just fair agreement with one another. Agreement was better between physicians and companions compared with that between physicians and patients, although it was imperfect between physicians and video raters and the written summary. Agreement among sources varied by dementia severity, with the lowest agreement occurring in instances of very mild dementia. This study documents discrepancies that can arise in diagnostic communication, which could influence adjustment to a diagnosis of dementia and decisions regarding future planning and care.

Psychosocial factors that shape patient and carer experiences of dementia diagnosis and treatment: a systematic review of qualitative studies

BACKGROUND

Early diagnosis and intervention for people with dementia is increasingly considered a priority, but practitioners are concerned with the effects of earlier diagnosis and interventions on patients and caregivers. This systematic review evaluates the qualitative evidence about how people accommodate and adapt to the diagnosis of dementia and its immediate consequences, to guide practice.

METHODS AND FINDINGS

We systematically reviewed qualitative studies exploring experiences of community-dwelling individuals with dementia, and their carers, around diagnosis and the transition to becoming a person with dementia. We searched PubMed, PsychINFO, Embase, CINAHL, and the British Nursing Index (all searched in May 2010 with no date restrictions; PubMed search updated in February 2012), checked reference lists, and undertook citation searches in PubMed and Google Scholar (ongoing to September 2011). We used thematic synthesis to identify key themes, commonalities, barriers to earlier diagnosis, and support identified as helpful. We identified 126 papers reporting 102 studies including a total of 3,095 participants. Three overarching themes emerged from our analysis: (1) pathways through diagnosis, including its impact on identity, roles, and relationships; (2) resolving conflicts to accommodate a diagnosis, including the acceptability of support, focusing on the present or the future, and the use or avoidance of knowledge; and (3) strategies and support to minimise the impact of dementia. Consistent barriers to diagnosis include stigma, normalisation of symptoms, and lack of knowledge. Studies report a lack of specialist support particularly post-diagnosis.

CONCLUSIONS

There is an extensive body of qualitative literature on the experiences of community-dwelling individuals with dementia on receiving and adapting to a diagnosis of dementia. We present a thematic analysis that could be useful to professionals working with people with dementia. We suggest that research emphasis should shift towards the development and evaluation of interventions, particularly those providing support after diagnosis.

The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) is associated with informant stress

OBJECTIVE

To study the association between informant stress and appraisal of patients' cognitive functioning as reported by the Informant Questionnaire on Cognitive Decline in the Elderly--IQCODE.

METHODS

Routinely collected data from a geriatric outpatient department (207 dyads) during the years 1995-1998 were analysed. Relative stress scale (RSS) has been categorised for possible low, intermediate and high risk of psychiatric morbidity and caregivers were combined to four groups (female and male spouses and female and male non-spouses, respectively). The relationship between IQCODE (dependent) and categorised RSS and informant groups and patient age was further studied by means of the general linear model (GLM-UNIANOVA).

RESULTS

In general, spouses reported better cognitive functioning than non-spouses. There was a significant association between IQCODE and RSS (p < 0.001), and the composite variable informant group and informant gender (p < 0.001). The main effect of the interaction term RSS x informant group + informant gender was not significant. Post hoc test, however, revealed a significant effect of the interaction term RSS x female spouses (p < 0.001) on IQCODE.

CONCLUSION

IQCODE is associated with informant stress. Categorisation of RSS score into groups of low, intermediate and high risk for psychiatric morbidity can be a valuable contribution to a more meaningful application of RSS in general practice.

Community mental health nursing and early intervention in dementia: developing practice through a single case history

People Nursing in association with Journal of Clinical Nursing 13, 6b, 57-67 Community mental health nursing and early intervention in dementia: developing practice through a single case history This paper reports on a single case history taken from the 'Dementia Action Research and Education' project, a 15-month primary care intervention study that was undertaken in North Wales in the early part of 2000. The study sought to address the meaning, context and diversity of early intervention in dementia care and employed a community mental health nurse and a psychiatric social worker to undertake early and psychosocial interventions with older people with dementia (aged 75 years and over) and their families. The workers tape-recorded, documented and analysed their interventions with 27 older people with dementia and their families over the 15-month duration of the study. Clinical supervision was also undertaken during the intervention phase. One case history is presented in this paper to illustrate the work of the community mental health nurse and to identify areas of practice development. Greater role transparency, collaborative working and improvement in educational preparation for practice are called for.

Disclosing a Dementia Diagnosis: A Review of Opinion and Practice, and a Proposed Research Agenda

PURPOSE

The ethical and practical issues in disclosing a dementia diagnosis remain subjects of some debate. In this review of the literature we document previous opinion and practice in the area of diagnostic disclosure.

DESIGN AND METHODS

We identified sources for this review with a MEDLINE and PsycINFO database search, followed by collection of additional articles from reference lists.

RESULTS

Across sources we were able to identify a broad list of arguments both for and against diagnostic disclosure. We briefly discuss some of the ethical principles that undergird those reasons.

IMPLICATIONS

Practice guidelines and professional opinion regarding disclosure appear to depart from the actual experience reported by clinicians, patients, and family members. At a more detailed level, process issues in disclosure, such as who is told, how and what they are told, and the impact of disclosure, are poorly understood. Sensitivity to individual differences may promote an optimal approach to disclosure. Research in this area is sparse and often contradictory, and throughout the review we propose research questions that, when answered, could clarify issues in disclosure that are essential to sound dementia care.

Self-identity in older persons suffering from dementia: preliminary results

In this study, we explored the role-identity of nursing home residents suffering from dementia, as well as the potential for utilizing their enduring sense of self-identity for enhancing their quality of life. Four types of role-identity were explored: professional, family-role, leisure activities, and personal attributes. The methodology included structured interviews and a case study. Participants for the interviews were 38 residents of two nursing homes in Israel. Residents, relatives, and staff members were interviewed to provide information about past roles and the degree to which those roles are maintained in the present, and about strategies for bolstering the sense of self-identity. A large range of roles were identified. All role identities deteriorated significantly, with family roles retaining the greatest prominence in the present. However, much heterogeneity was manifested in all roles. Both staff members and relatives felt that a sense of identity in residents could be enhanced in most of the residents, which would exert a beneficial effect on their well-being. Caregiving respondents anticipated that this improvement would be substantial for about half of the residents. The case study illustrates how self-identity can change throughout dementia, and how it can be utilized to improve quality of life.

The DIAL-log study 1: Profiling the experience of people with dementia

Between July 1996 and December 1997 telephone helpline staff from the Alzheimer's Disease Society (ADS) in London, and six participating ADS regions in England and one in Northern Ireland, documented calls from people with dementia who contacted the service. Each call was recorded as soon as practicable after its completion on a Dementia Information and Advice Line (DIAL) log form (DIAL-log). Sixty-four calls were recorded in this way and 62 completed DIAL-logs were included in the study findings. Analysis of the data was undertaken via SPSS 6.1 for Windows. This article, the first of two, introduces the background to the study and notes that callers reported memory loss and forgetfulness as the most frequently noticed first signs of dementia. The study aims and limitations are also outlined in this first article. The second article will detail the main findings and the challenges that the DIAL-log study may provide for future dementia care practice and research.

The Circle Model--support for relatives of people with dementia

Home care for cognitively impaired elderly puts tremendous stress and burden on their families. Therefore it is important to search for effective care models in order to provide support for this group. In this study, an intervention model--the Circle Model--was developed, tested and evaluated in six places in Sweden. The model is unique in that family caregivers and volunteers were trained together in study circles. After their training, the volunteers replaced the caregivers in the homes on a regular basis, which permitted the caregivers some relief from the demands of caregiving. Interviews were conducted with the participants to gather information about their training and relief care experiences. The caregivers reported that the study circle provided opportunity to exchange experiences with other people in similar situations. They felt a spirit of community with other relatives, and were able to increase their knowledge in care providing and coping strategies. The emphasis in temporary relief care by the volunteers was placed on providing the relatives with feelings of security and relaxation. The satisfaction among the Circle Model participants was reciprocal. The volunteers also reported high satisfaction and appreciation of the knowledge which they acquired from the caregivers. The Circle Model brings new dimensions to the home care situation and should be seen as a complement to social services support.

Dementia and help with household tasks: a comparison of cases and non-cases

This paper is based on data, relating to people aged 75+ living in the community, from the city of Liverpool and from a rural area of North Wales. It compares those suffering from cognitive brain disorders with those identified as being cognitively unimpaired. Levels of need, and sources of help with a range of domestic and home maintenance tasks are identified. Results show that most help for those who are cognitively impaired comes from relatives living in the same household, while help for those who are physically impaired comes primarily from spouses or relatives living in different households. Cases do not demonstrate a higher level of use of formal services than non-cases. Implications for policy and practice are discussed.

The experience of dementia: a review of the literature and implications for nursing practice

This paper explores the early experience of dementia when the veil of uncertainty that surrounds the diagnosis of this condition is lifted. Consideration will also be given to the impact of dementia on carers and the service demands that are created. In the UK alone there are estimated to be 636,000 people living with dementia, with this figure rising to just under 900,000 by the year 2021. In the USA the projected number of people with Alzheimer's disease is expected to be 9,000,000 by the year 2040 Despite a wealth of social and gerontological research on the impact of dementia upon family carers, service responses and policy initiatives are fragmented because dementia is excluded from some important recent initiatives, such as the Mental Health Task Force. Current services and interventions focus predominantly on the later stages of dementia, when a meaningful perspective of the person with dementia is difficult to obtain. Nursing has a relatively long history of caring for people with dementia and their family carers. The paper will also consider the contribution of nursing and nursing research to the field and explore additional avenues for service intervention and education.

Dementia in old age: an anthropological perspective

This paper examines the assumption that dementia in old age is a universal phenomenon that will vary in its prevalence and manifestation because of social and cultural factors. It finds that while researchers have been successful in demonstrating the commonality of dementia, they have been less successful in showing whether or not it varies across cultures and between social and ethnic groupings. The inconclusiveness of findings may, in part, be a function of diagnostic differences and the research methodologies employed. New instruments and measures are being devised to overcome these problems. However, the sociocultural context in which dementia occurs and the meaning of the disorder to those involved (as sufferers and caregivers) are often missing dimensions. In particular, there is little knowledge about how the disorders of old age in non-Western settings are experienced and understood. In this respect anthropology has a special contribution to make to research on dementia.

FADE: a strategy for action in the mild stage of dementia

This article introduces the Framework for Action in Dementia (FADE), a new strategy aimed at the mild stage of dementia. It suggests that empowering people with dementia from the onset of their illness is a crucial role for nurse practitioners.

Developing a typology of family care: implications for nurses and other service providers

The meanings attributed to the concept of care are considered. It is argued that whilst nursing has paid considerable attention to care in a professional (nursing) context, it has virtually ignored care as it is defined and construed by family carers. A new typology of family care is described which builds on the limited existing conceptual work in this area. It is further suggested that interventions which are intended to assist carers form a continuum ranging from services which are facilitative to those which are actually obstructive. In the light of these discussions, the implications of the new typology for nurses working with family carers are addressed briefly.

Living alone with dementia

In the UK there is estimated to be 154,000 people with dementia who live on their own. People with dementia aged over 85 years make up half of this figure. People with dementia who live on their own are more prone to the risk of self-neglect, injury and exploitation. District health authorities need to identify and monitor the number of people with dementia who live on their own. Nursing interventions need to take centre stage on assessment, relationship building and networking responsibilities.

The carer-led assessment process (CLASP): a framework for the assessment of need in dementia caregivers

The initial and on-going assessment of individuals with dementia may not always fully reflect the expert knowledge of the caring situation that carers possess. In the absence of such knowledge a comprehensive and responsive assessment is unlikely to be achieved. This paper describes the development of a carer-led assessment process (CLASP) which it is suggested provides a flexible framework for the assessment of need in carers of dementia sufferers.

A local census of dementia sufferers

The results of a census of all dementia sufferers known to institutional and community services in Angus are reported. A total of 859 sufferers were identified compared with an expected 1013 based on EURODEM prevalence rates. After allowing for cross-boundary flow to institutions, it was estimated that the true identification rate was 80% (809/1013). Of the estimated total 1063 sufferers (including cross-boundary flow): 26% were in hospital, 27% in residential or nursing homes, 27% in the community and known to services (often the GP), and 19% in the community and not known to services (or, at least, not returned by them in the census). With the co-operation of all concerned, a census approach can yield useful information at a much lower cost than a full survey.

Does early intervention reduce the number of elderly people with dementia admitted to institutions for long term care?

OBJECTIVE

To test whether early diagnosis and practical help reduce the number of elderly people with dementia admitted to institutions.

DESIGN

Controlled trial of effect of help from a multidisciplinary team on admission rates of people with dementia.

SETTING

Seven general practices in Cambridge.

SUBJECTS

2889 subjects aged 75 and over, of whom 159 were identified as having dementia with a two stage community survey. Eighty six subjects were referred for extra help if they or their supporters wished. The other 73 subjects had access to the usual services and served as controls.

INTERVENTION

Subjects and families in the action group were offered a wide range of help, including financial benefits, physical aids, home helps, respite admissions, practical advice, and psychiatric assessments.

MAIN OUTCOME MEASURE

Permanent admission to long term care within two years after diagnosis.

RESULTS

Early intervention did not affect admission rates in subjects who lived with supporters. By contrast, nine of the 14 (64%) subjects with moderate or severe dementia living alone were admitted in the action group in the study's second year compared with only one of 13 (8%) controls (p = 0.004).

CONCLUSIONS

Some people with moderate or severe dementia who lived alone and were at serious risk may have been identified earlier by the resource team. Without the team these people would not have become known to the responsible authorities until families, neighbours, and wardens became unable to cope. The study was conducted during the team's formative period, however, and greater experience might have allowed some subjects to remain at home for longer.

The progression of mild idiopathic dementia in a community population

Thirty-one subjects aged 75 years and over who were identified as suffering from mild, idiopathic dementia in a large community survey were reviewed at annual intervals for 2 years. Diagnoses and severity ratings were based on defined criteria following a mental state examination, a medical and psychiatric history, detailed cognitive testing, and an interview with relatives or other key informants. Fourteen subjects became more severely demented within 2 years. The initial cognitive test battery failed to reveal any differences between respondents whose dementia advanced and those whose condition remained unchanged, but, in the former group, subjects' symptoms had been present for longer, and a greater proportion had been recognised as demented, or possibly demented, by their general practitioners. We suggest that subjects whose dementia progressed had actually been more severely disabled at the time of identification.