Integrated care for adults with dementia and other cognitive disorders

Management Practice and Clinical Outcomes of Dementia in Sub-Saharan Africa: A Systematic Review

Background

Dementia is a severe neurodegenerative disorder and it is a group of acquired symptoms associated with impaired cognitive functions. In low-income settings particularly in Sub-Saharan Africa (SSA), it is often seen as part of normal aging. Environmental, behavioral, and lifestyle interventions have the potential to alter the disease course of dementia.

Objective

This study is aimed to synthesize the literature/evidence(s) on the management practice and treatment outcomes of dementia in SSA.

Method

Comprehensive literature was searched in PubMed database, Cochrane Library, and Google Scholar. Eligibility has been set, and based on the criteria, initially, a total of 442 results were obtained, and from those around 183 articles were duplicated. After examining titles and abstracts of records 26 articles were identified. Finally, five randomized clinical trials (RCT) and three prospective cohort studies that were reported on the management practice and treatment outcome of dementia in SSA were eligible for analysis. RCT and prospective cohort studies were used to strengthen the quality of evidence. The quality of the included RCT studies was assessed by using the Cochrane Risk of Bias Tool.

Result

A total of 2781 patient data were included in the final analysis. Of these, 2354 patients were obtained from 5 RCTs and 427 patients from 3 prospective cohort studies, which were conducted in SSA countries. RCT studies were done on the feasibility and clinical effectiveness of cognitive stimulation therapy (CST) showed improvements in language memory domains and physical health. In addition, studies that focus on the management of human immunodeficiency virus-associated dementia (HIVAD) were reported to improve neurocognitively.

Conclusion

CST is applicable in low-resource settings and it shows improvements in cognitive function and quality of life. Early initiation of combination antiretroviral therapy in resource-limited settings has been associated with improvement in the cognitive function of HIVAD.

Cross-sector learning collaboratives can improve post-diagnosis care integration for people with young onset dementia

Post-diagnosis young onset dementia (YOD) care is often fragmented, with services delivered across aged care, healthcare, and social care sectors. The aim of this project was to test the feasibility and potential effectiveness of a learning collaborative implementation strategy for improving the cross-sector integration of care for people with YOD and to generate data to refine the implementation strategy for scaleup. We conducted a longitudinal mixed methods process evaluation and recruited one representative from three Australian aged care organisations, three disability care organisations and three organisations (n = 9) contracted to deliver care navigation services. One representative from each organisation joined a learning collaborative within their local area and completed a six-module online education package incorporating written resources, webinars, collaboration and expert mentoring. Participants identified gaps in services in their region and barriers to care integration and developed a shared plan to implement change. Normalisation Process Theory was applied to understand the acceptability, penetration and sustainability of the implementation strategy as well as barriers and enabling factors. Dementia knowledge measured by the Dementia Knowledge and Awareness Scale was high among the professionals at the start of the implementation period (mean = 39.67, SD = 9.84) and did not change by the end (mean = 39.67, SD = 8.23). Quantitative data demonstrated that clinicians dedicated on average half of the recommended time commitment to the project. However, qualitative data identified that the learning collaborative strategy enhanced commitment to implementing integrated care and promoted action towards integrating previously disparate care services. Participant commitment to the project was influenced by their sense of obligation to their team, and teams that established clear expectations and communication strategies early were able to collaborate and use the implementation plan more effectively (demonstrating collective action). Teams were less likely to engage in the collective action or reflexive monitoring required to improve care integration if they did not feel engaged with their learning collaborative. Learning collaboratives hold promise as a strategy to improve cross-sector service collaboration for people with YOD and their families but must maximise group cohesion and shared commitment to change.

Intermediate care in caring for dementia, the point of view of general practitioners: A key informant survey across Europe

Background

Intermediate care is often defined as healthcare occurring somewhere between traditional primary (community) and secondary (hospital) care settings. High quality intermediate care is important in dementia, may prevent caregiver burnout and also lead to optimal care for people with dementia. However, very little is known about the point of intermediate care for persons with dementia in Europe.

Research questions

What intermediate care services exist and how are they utilized in the care of people with dementia in Europe?

Objective

This study aims at describing the point of view of General Practitioners on intermediate care services for people with dementia across Europe.

Methods

Key informant survey was sent to GPs via a self-developed questionnaire with space for open ended comments. 16 European countries participated to this cross-sectional mixed method study. Given the volunteer nature of the study, no minimum sample size requirements were applied to participation. Convenience sampling technique was used to address variations due to regional variations and regulations within the same country. Descriptive analyses of all intermediate care facilities groups by countries were performed. Qualitative analyses approach was used for the optional-free text to exemplify and/or complete the reasons contained in the closed response categories.

Results

The questionnaire was sent to 16 European countries. 583 questionnaires were analyzed. The responding physicians were 48 (± 11) years old on average and they had been in practice for an average of 18 (+ /11) years. The types of intermediate care considered were integrated at-home services, respite and relief services, day care centers and nursing homes. Their availability was considered very inhomogeneous by the majority of respondents. The main benefits of intermediate care cited were better medical care for the patient (78%), better quality of life for the caregiver (67%), prevention of the caregiver burden (73%) and a break for the caregiver (59%). The reported difficulties were: accessing these facilities due to limited financial support (76%) and cumbersome administrative procedures (67%). Many other facets of our findings were captured in the qualitative themes that emerged.

Conclusion

Intermediate care in Europe is diverse and heterogeneous. Major concerns of GPs are about the cost issues and the cumbersome administrative procedures to access them.

Characterising Australian memory clinics: current practice and service needs informing national service guidelines

Background

Memory clinics (MCs) play a key role in accurate and timely diagnoses and treatment of dementia and mild cognitive impairment. However, within Australia, there are little data available on current practices in MCs, which hinder international comparisons for best practice, harmonisation efforts and national coordination. Here, we aimed to characterise current service profiles of Australian MCs.

Methods

The ‘Australian Dementia Network Survey of Expert Opinion on Best Practice and the Current Clinical Landscape’ was conducted between August-September 2020 as part of a larger-scale Delphi process deployed to develop national MC guidelines. In this study, we report on the subset of questions pertaining to current practice including wait-times and post-diagnostic care.

Results

Responses were received from 100 health professionals representing 60 separate clinics (45 public, 11 private, and 4 university/research clinics). The majority of participants were from clinics in metropolitan areas (79%) and in general were from high socioeconomic areas. While wait-times varied, only 28.3% of clinics were able to offer an appointment within 1-2 weeks for urgent referrals, with significantly more private clinics (58.3%) compared to public clinics (19.5%) being able to do so. Wait-times were less than 8 weeks for 34.5% of non-urgent referrals. Only 20.0 and 30.9% of clinics provided cognitive interventions or post-diagnostic support respectively, with 7.3% offering home-based reablement programs, and only 12.7% offering access to group-based education. Metropolitan clinics utilised neuropsychological assessments for a broader range of cases and were more likely to offer clinical trials and access to research opportunities.

Conclusions

In comparison to similar countries with comprehensive government-funded public healthcare systems (i.e., United Kingdom, Ireland and Canada), wait-times for Australian MCs are long, and post-diagnostic support or evidence-based strategies targeting cognition are not common practice. The timely and important results of this study highlight a need for Australian MCs to adopt a more holistic service of multidisciplinary assessment and post-diagnostic support, as well as the need for the number of Australian MCs to be increased to match the rising number of dementia cases.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03253-7.

The use of formal care for dementia from a professional perspective: a scoping review

Background and objectives

The progressive character of dementia usually leads to a continuously increasing need for support. There is some evidence of late use of professional support during the disease course. We aim to provide an overview of aspects influencing access and use of formal care in dementia from the perspective of health and social care professionals. Additionally, the perspectives of professionals and people with dementia/informal carers will be compared.

Methods

We conducted a scoping review with a systematic literature search in Medline via Ovid in January 2019 and updated this in April 2020 and in May 2021. Publications were considered eligible when focusing on influencing aspects of the use of formal care or support for people with dementia in an outpatient setting from the perspective of health professionals. Included publications were critically appraised using the Mixed Method Appraisal Tool. We identified aspects of access to and use of formal care and support services. A consultation exercise with three specialised trained dementia care nurses was conducted to validate our results.

Results

We included 29 studies: n = 20 qualitative, n = 6 quantitative-descriptive, n = 3 mixed-methods. Various support services were identified, but a focus was on services for diagnostic and treatment of dementia. A wide range of influencing aspects (n = 15) describe the access to and use of formal care services. Aspects related to the complexity and structure of the healthcare system and the competence of professionals were frequently addressed. Second, attitudes and expectations of professionals, and experiences with people with dementia and their informal carers were identified. The dementia care nurses highlighted the importance of coordinated care to enhance dementia-specific competencies.

Conclusions

Health and social care professionals still describe barriers in accessing and using formal care due to various influences. Ways to improve access to and use of professional support in dementia should consider individual and system-level activities, as well as overarching aspects. Important topics are therefore education and training of professionals and coordinated dementia-specific care to provide adequate support for people with dementia and their relatives. Several professions may be involved in this increasingly important field, e.g., nurses with a dementia-specific training like dementia care nurses.

Collaboration between general practitioners and social workers: a scoping review

OBJECTIVES

Aim of the study is to present an overview of collaboration structures and processes between general practitioners and social workers, the target groups addressed as well the quality of available scientific literature.

DESIGN

A scoping review following the guidelines of the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews).

INCLUDED SOURCES AND ARTICLES

According to a pre-published protocol, three databases (PubMed, Web of Science, DZI SoLit) were searched using the participant-concept-context framework. The searches were performed on 21 January 2021 and on 10 August 2021. Literature written in English and German since the year 2000 was included. Two independent researchers screened all abstracts for collaboration between general practitioners and social workers. Articles selected were analysed regarding structures, processes, outcomes, effectiveness and patient target groups.

RESULTS

A total of 72 articles from 17 countries were identified. Collaborative structures and their routine differ markedly between healthcare systems: 36 publications present collaboration structures and 33 articles allow an insight into the processual routines. For all quantitative studies, a level of evidence was assigned. Various measurements are used to determine the effectiveness of collaborations, for example, hospital admissions and professionals' job satisfaction. Case management as person-centred care for defined patient groups is a central aspect of all identified collaborations between general practitioners and social workers.

CONCLUSION

This scoping review showed evidence for benefits on behalf of patients, professionals and healthcare systems by collaborations between general practitioners and social workers, yet more rigorous research is needed to better understand the impact of these collaborations.

TRIAL REGISTRATION NUMBER

www.osf.io/w673q.

Dementia-related continuing education for rural interprofessional primary health care in Saskatchewan, Canada: perceptions and needs of webinar participants

Dementia-related continuing education opportunities are important for rural primary health care (PHC) professionals given scarce specialized resources. This report explores the initial perceptions and continuing education needs of rural interprofessional memory clinic team members and other PHC professionals related to a short series of dementia-related education webinars. Three webinars on separate topics were delivered over an 8-month period in 2020 in Saskatchewan, Canada. The research design involved analysis of webinar comments and post-webinar survey data. Sixty-eight individuals participated in at least one webinar, and 46 surveys were completed. Rural memory clinic team members accounted for a minority of webinar participants and a majority of survey respondents. Initial perceptions were positive, with webinar topics and interactivity identified as the most effective aspects. Continuing education needs were mainly aligned with professional roles; however, some overlap of interests occurred. Future webinars will further explore learning needs within an interprofessional environment.

Post-diagnosis young-onset dementia care in the National Disability Insurance Scheme

OBJECTIVE

Post-diagnosis service delivery for young-onset dementia (with onset prior to 65 years) recently moved to the disability system in an attempt to address systemic barriers to best practice in aged care. The objective of this study was to examine experiences and satisfaction with disability services so far among people with young-onset dementia and their care partners and identify strategies for service and system improvement.

METHODS

The 151 participating Australians living with young-onset dementia or providing informal care to a person with young-onset dementia were recruited via social media, advocacy bodies and specialist medical clinics. A cross-sectional online survey asked participants to provide a timeline of their interactions with the disability system so far and rate their satisfaction with the disability system, aged care and disability services.

RESULTS

Participants reported a mean age at symptom onset of 55 years. In all, 53% were diagnosed with Alzheimer's disease and 25% were diagnosed with frontotemporal dementia. Sixty percent had received an approved plan from the National Disability Insurance Scheme, although 3% were rejected. More than 27% waited longer than 6 months to receive their plan, and half waited at least a month post-approval to access services. Less than 30% agreed that the National Disability Insurance Scheme understands dementia, and fewer than half felt that the process of accessing National Disability Insurance Scheme funding is easy and fast enough. Nonetheless, respondents remained overwhelmingly in favour of young-onset dementia services remaining in the disability system rather than in aged care.

CONCLUSIONS

While people with young-onset dementia and their care partners strongly agree with their inclusion in the National Disability Insurance Scheme, a relatively low level of experience with dementia in the disability workforce and a lack of integration with the healthcare and aged care systems continue to create important barriers for accessing the services they need.

Care Integration in Primary Dementia Care Networks: A Longitudinal Mixed-Methods Study

Introduction:

Currently, care integration for community-dwelling persons with dementia is poor and knowledge on how to effectively facilitate development of integrated dementia care is lacking. The DementiaNet program aims to overcome this with a focus on interprofessional collaboration. The objective of this study is to investigate how care integration in interprofessional primary dementia care networks matures and to identify factors associated with (un)successfully maturation.

Theory and methods:

A longitudinal mixed-methods study, including 17 primary care networks participating in the DementiaNet study, was performed. Semi-structured interviews based on the Rainbow Model of Integrated Care were conducted at start, at 12- and 24 months. Network maturity scores (range 1–4) were derived from the interviews and qualitative data was used to explain the observed patterns.

Results:

Networks consisted on average of 9 professionals (range 4–22) covering medical, care and social disciplines. Network maturity yearly increased with 0.29 (95%-CI: 0.20–0.38). Important factors for improvement included getting to know each other’s expertise, having a capable network leader(s), stable network composition and participation of a general practitioner.

Conclusions:

The DementiaNet approach enables a transition towards more mature networks. Identified success factors provide better understanding of how network maturity can be achieved and gives guidance to future care integration strategies.

The effect of the 2018 Japan Floods on cognitive decline among long-term care insurance users in Japan: a retrospective cohort study

BACKGROUND

The July 2018 Japan Floods caused enormous damage to western Japan. Such disasters can especially impact elderly persons. Research has shown that natural disasters exacerbated a decline in cognitive function, but to date, there have been no studies examining the effects of this disaster on the elderly. The object of this study was to reveal the effect of this disaster in terms of cognitive decline among the elderly.

METHODS

Study participants were certified users of the long-term care insurance (LTCI) system in Hiroshima, Okayama, and Ehime prefectures from May 2018 to June 2018. The observation period was from July 2018 to December 2018. Our primary outcome was cognitive decline after the disaster using a dementia symptomatology assessment. In addition to a crude model, a multivariate Cox proportional hazards model was used to assess the cognitive decline of victims, adjusting for age classification, gender, the level of dementia scale before the disaster occurred, residential environment, whether a participant used facilities shut down after the disaster, and population density. After we confirmed that the interaction term between victims and residential environment was statistically significant, we stratified them for the analysis.

RESULTS

The total number of participants was 264,614. Victims accounted for 1.10% of the total participants (n = 2,908). For the Cox proportional hazards model, the hazard ratio of the victims was 1.18 (95% confidential interval (CI): 1.05-1.32) in the crude model and 1.12 (95% CI: 1.00-1.26) in the adjusted model. After being stratified by residential environment, the hazard ratio of home victims was 1.20 (95% CI: 1.06-1.36) and the hazard ratio of facility victims was 0.89 (95% CI: 0.67-1.17).

CONCLUSIONS

This study showed that elderly living at home during the 2018 Japan Floods were at risk for cognitive decline. Medical providers, care providers, and local governments should establish a system to check on the cognitive function of elderly victims and provide necessary care support.

Use of medical services by older Australian women with dementia: a longitudinal cohort study

OBJECTIVE

To assess the use of Medicare-subsidised health services by women with and without dementia.

METHODS

Data from women of the 1921-26 birth cohort of the Australian Longitudinal Study on Women's Health were linked to various administrative datasets to ascertain dementia diagnosis. The use of subsidised general practitioner (GP) services (75+ health assessments [HAs], chronic disease management meetings [CDMs], multidisciplinary case conferences [MCCs]) and specialist and allied health services between 2000 and 2013 for these women was analysed using longitudinal GEE models.

RESULTS

A total of 9,683 women were included with 1,444 (15%) women identified as having dementia. Compared to women with no dementia indication, women with dementia had more yearly non-emergency GP attendances (short [<30 minutes] IRR=1.11 [1.07, 1.13]; long [>30 minutes] IRR=1.11 [1.04, 1.19]) and fewer specialist attendances (IRR=0.91 [0.85, 0.97]) and were more likely to have an emergency GP attendance (OR=2.29 [2.05, 2.57]). There were no significant differences in the odds of having either a HA or CDM or using allied health services for women with and without dementia indicators.

CONCLUSIONS

The overall use of services designed to improve the prevention and coordination of the care of older people with chronic conditions was low. Women with dementia were no more likely to access these services. Implications for public health: There is underuse of some primary and allied healthcare services designed for people with complex chronic conditions. These could be better used by women with dementia to improve the management of complex comorbidities (e.g. CDMs), to prevent the onset of disability (e.g. physiotherapy), and enhance needs assessment and service access (e.g. HAs).

Integrated dementia care: A qualitative evidence synthesis of the experiences of people living with dementia, informal carers and healthcare professionals

BACKGROUND

In order to provide improved care provision, integrated care services are being developed. However, little is known about how people living with dementia, their families and healthcare professionals experience integrated care. Therefore, the purpose of this review of the qualitative literature was to examine the experiences and perceptions of integrated dementia care.

METHODS

This qualitative review synthesised findings from included studies identified from a comprehensive literature search. Searches included: five electronic databases, journal handsearching, and reference list searching of relevant literature reviews and the final included studies.

FINDINGS

Three overarching themes were identified: 1) Ways of working which facilitate the delivery of integrated dementia care; 2) Informal carers as equal partners in care provision and decision making; and 3) Challenges leading to fragmented and disjointed integrated dementia care. For integrated care to be successful, communication and collaboration between healthcare professionals, and the involvement of informal carers is needed. Multidisciplinary teams and employing case managers to coordinate care provision can improve communication and collaboration. However, distrust between healthcare professionals and a lack of a central database to access and share information often hinders the development of integrated dementia care service provision.

CONCLUSION

Integrated dementia care can be successful and well received by people living with dementia and their families when certain conditions are met. However, given the negative consequences fragmented and disjointed care can have on people living with dementia and their families, action is needed to further support the development of integrated dementia care services.

The influence of TCM constitutions and neurocognitive function in elderly Macau individuals

BACKGROUND

Traditional Chinese medicine (TCM) constitution contributes to predicating disease occurrence and pathological progress. In this study, we investigate the correlation between TCM constitution and neurocognitive function in elderly Macau individuals.

METHODS

A total of 313 older adults from elderly healthcare centers were recruited at random. The data of gender, age, education, sleeping hours, physical activities were collected, and the Geriatric Depression Scale, Hong Kong version of the Montreal Cognitive Assessment (MoCA) and categories of TCM constitution were administered.

RESULTS

Of the 313 elderly individuals enrolled in this study, 86 (27.48%) were of balanced constitution. Among the other categories of TCM constitution, the most was Yin-deficiency (23.32%), followed by 53 (16.93%) with Phlegm-dampness. The average neurocognitive score of all elderly individuals was 18.01 ± 6.25. After adjusting for all possible confounds, multiple linear regression analysis showed that Qi-depressed constitution and neurocognitive scores were negatively correlated (β = - 2.66, 95%CI - 4.99 ~ - 0.33), Meanwhile, Yin-deficient constitution and neurocognitive scores were negatively correlated (β = - 2.10, 95%CI - 3.73 ~ - 0.47). Compared with balanced constitution, Qi-depressed constitution mainly affected visual-spatial ability dimension (β = - 0.91, 95%CI - 1.54 ~ - 0.28) and naming dimension (β = - 0.64, 95%CI - 1.04 ~ - 0.25), Yin-deficient constitution mainly affected visual space dimension (β = - 0.53, 95%CI - 0.97 ~ - 0.08).

CONCLUSION

Qi-depressed and Yin-deficient constitutions are associated with and contributed to the decline of neurocognitive function in senior adults, especially visual-spatial ability and naming dimensions. Further investigations into how TCM constitutions interact with neurocognitive function are needed.

Development and pilot testing of quality improvement indicators for integrated primary dementia care

Background

Implementation of integrated primary care is considered an important strategy to overcome fragmentation and improve quality of dementia care. However, current quality indicator (QI) sets, to assess and improve quality of care, do not address the interprofessional context. The aim of this research was to construct a feasible and content-wise valid minimum dataset (MDS) to measure the quality of integrated primary dementia care.

Methods

A modified Delphi method in four rounds was performed. Stakeholders (n=15) (1) developed a preliminary QI set and (2) assessed relevance and feasibility of QIs via a survey (n=84); thereafter, (3) results were discussed for content validity during a stakeholder and (4) expert consensus meeting (n=8 and n=7, respectively). The stakeholders were professionals, informal caregivers, and care organisation managers or policy officers; the experts were professionals and researchers. The final set was pilot-tested for feasibility by multidisciplinary dementia care networks.

Results

The preliminary set consisted of 40 QIs. In the survey, mean scores for relevance ranged from 5.8 (SD=2.7) to 8.5 (SD=0.7) on a 9-point Likert scale, and 25% of all QIs were considered feasible to collect. Consensus panels reduced the set to 15 QIs to be used for pilot testing: 5 quality of care, 3 well-being, 4 network-based care, and 3 cost-efficiency QIs. During pilot testing, all QIs were fully completed, except for well-being QIs.

Conclusion

A valid and feasible MDS of QIs for primary dementia care was developed, containing innovative QIs on well-being, network-based care and cost-efficiency, in addition to quality of care QIs. Application of the MDS may contribute to development and implementation of integrated care service delivery for primary dementia care.

Post-diagnostic allied health interventions for people with dementia in Australia: a spotlight on current practice

OBJECTIVE

The Clinical Practice Guidelines for Dementia in Australia provide evidence-based recommendations for the assessment, diagnosis, and care of people with dementia and their informal carers. The extent to which current Australian post-diagnosis care reflects these recommendations is not well understood. This brief report provides a snapshot of current practice related to three key recommendations from the Guidelines: occupational therapy, exercise, and informal carer support.

RESULTS

Nursing (n = 3) and allied health clinicians (n = 29) provided data about 1114 consultations with people with dementia and/or informal carers over a 9-month study period. Results showed that delivery of evidence-based dementia care remains a significant challenge in Australia. Clinicians found it difficult to tailor exercise interventions to overcome cognitive and organisational barriers to adherence during and between consultations. Occupational therapists primarily focussed on functional assessment rather than on delivering evidence-based interventions. Clinicians also found it difficult to identify and address the array of needs reported by informal carers, especially when the person with dementia is present during the consultation. Though these results are reported by a selected sample, they emphasise the need for innovative knowledge translation strategies to facilitate widespread quality improvement in post-diagnosis dementia care. Trial registration Registered with the Australian New Zealand Clinical Trials Registry 21 February 2018 (ACTRN12618000268246).