Younger people in dementia care: a review of service needs, service provision and models of good practice

Sources and perceptions of hope: A qualitative study involving younger people with dementia

Hope is an important but overlooked phenomenon in dementia studies. Few studies have examined how people with dementia experience or perceive hope, possibly because it is seen as a diagnosis without hope. In this article, we report on a doctoral study, the aim of which was to examine the phenomenon of hope from the perspective of younger people with dementia to generate new understanding and enable community-based healthcare professionals to support well-being. The study was conducted in the Midlands, England, and used a modified diary-interview method. Six participants were given a camera and asked to take pictures of whatever made them feel hopeful. During a post-diary semi-structured interview, a conversation about hope took place. Interviews were transcribed and interpreted using the 'Voice-Centred Relational Method'. Findings show that hope is important to younger people with dementia. Sources of hope were the surrounding environment, keeping connected, taking action, and drawing on internal resources. An over-arching theme was 'defying dementia' and participants demonstrated resistance to negative stereotypes. Living with dementia did not curtail hope, although it could be weakened when participants felt 'cast adrift' by services. The In vivo codes generated were fear of dementia, threats to identity, disconnection from others, and frustrations and restrictions. It is concluded that hope should be a more central part of practice-based conversations with people with dementia.

Religious Influences on the Experience of Family Carers of People with Dementia in a British Pakistani Muslim Community

This paper reports on a study that begins to address the paucity of research around the religious motivations of Muslim carers of family members with dementia. Seven carers were recruited for interviews from the British Pakistani Muslim community concentrated in the Midlands and North of England. Interview transcripts were analysed thematically using an iterative collaborative methodology. The findings suggested that the Muslim faith plays a pivotal role as a support mechanism for individual carers and their families, but the wider faith community and its leaders did not typically offer support and could impede access to external care. This was a result of cultural pressure and lack of awareness both among religious leaders and the community as a whole. The study concluded that the inequality in access to dementia services may be constructively addressed if service providers engage with these faith concerns in the community and religious leaders to meet the needs of Muslims of British Pakistani origin.

Enhanced temporal complexity of EEG signals in older individuals with high cognitive functions

Recent studies suggest that the maintenance of cognitive function in the later life of older people is an essential factor contributing to mental wellbeing and physical health. Particularly, the risk of depression, sleep disorders, and Alzheimer's disease significantly increases in patients with mild cognitive impairment. To develop early treatment and prevention strategies for cognitive decline, it is necessary to individually identify the current state of cognitive function since the progression of cognitive decline varies among individuals. Therefore, the development of biomarkers that allow easier measurement of cognitive function in older individuals is relevant for hyperaged societies. One of the methods used to estimate cognitive function focuses on the temporal complexity of electroencephalography (EEG) signals. The characteristics of temporal complexity depend on the time scale, which reflects the range of neuron functional interactions. To capture the dynamics, composed of multiple time scales, multiscale entropy (MSE) analysis is effective for comprehensively assessing the neural activity underlying cognitive function in the brain. Thus, we hypothesized that EEG complexity analysis could serve to assess a wide range of cognitive functions in older adults. To validate our hypothesis, we divided older participants into two groups based on their cognitive function test scores: a high cognitive function group and a low cognitive function group, and applied MSE analysis to the measured EEG data of all participants. The results of the repeated-measures analysis of covariance using age and sex as a covariate in the MSE profile showed a significant difference between the high and low cognitive function groups (F = 10.18, p = 0.003) and the interaction of the group × electrodes (F = 3.93, p = 0.002). Subsequently, the results of the post-hoct-test showed high complexity on a slower time scale in the frontal, parietal, and temporal lobes in the high cognitive function group. This high complexity on a slow time scale reflects the activation of long-distance neural interactions among various brain regions to achieve high cognitive functions. This finding could facilitate the development of a tool for diagnosis of cognitive decline in older individuals.

Behavioural and psychological symptoms of early-onset and late-onset Alzheimer's disease among Chinese adults: analysis of modifiable factors

BACKGROUND

To conduct a comprehensive comparison of behavioural and psychological symptoms of dementia (BPSD) in Chinese people with early-onset Alzheimer's disease (EOAD) and late-onset Alzheimer's disease (LOAD) and analyse the factors of differences.

METHODS

A cross-sectional survey of 93 EOAD and100 LOAD and their caregivers in China from November 2018 to May 2019.

RESULTS

The total Neuropsychiatric Inventory score was significantly higher in LOAD. A higher level of agitation in EOAD was related to a lower quality of life of caregivers and the emotional expression of ignoring people with dementia. Higher euphoria scores in LOAD were associated with reduced negative coping by caregivers and reduced stability and predictability at home.

CONCLUSION

The early identification and management of specific BPSD of EOAD and LOAD by family members and health professionals may improve the quality of care and life for people with dementia and that of caregivers.

Determinants of Caregiver Burden in Early-Onset Dementia

Introduction

Caregivers of patients with early-onset dementia (EOD) experience high levels of burden, which is known to be affected by caregivers' psychological features as well as by patients' and caregivers' demographical and social variables. Although potential clinical, demographical, and social determinants have been separately examined, it is not known how they reciprocally interact.

Methods

Ninety-two consecutive patient-caregiver dyads were recruited from the Cognitive Neurology Clinics of Modena, Northern Italy. Caregivers were asked to fill in questionnaires regarding their burden, psychological distress, and family economic status. Data were analyzed with multivariable regression models and then entered in a mediation model.

Results

Caregiver burden was positively related to female caregiver sex, spousal relationship to the patient, severity of patient's behavioral symptoms, diagnostic delay, and financial distress of the family. It was negatively related to disease duration, patient's education, region of birth, caregiver age, number of caregiver's days off work, number of offspring, and caregiver perception of patient's quality of life. While the effect of caregiver age, diagnostic delay, and of proxies of family or social network directly impacted on caregiver's burden, the effect of patient's disease duration, being a wife caregiver, financial distress, and number of caregiver's days off work was entirely mediated by the level of caregiver psychological distress.

Conclusions

Both direct actions (such as increasing social networks and shortening diagnostic delay) and indirect actions aimed at reducing psychological distress (such as increasing the number of caregiver's days off work and financial support) should be planned to reduce caregiver's burden.

A qualitative meta-synthesis of common and unique preferences for supportive services among persons with young onset dementia and their caregivers

BACKGROUND AND OBJECTIVES

Young onset dementias (young onset dementia) produce a myriad of stressors for persons with young onset dementia and their caregivers, yet there is a critical shortage of supportive services that address their needs. To develop such services, it is necessary to first comprehensively understand persons' with young onset dementia and their caregivers' service preferences. Therefore, we conducted a meta-synthesis to integrate and summarize qualitative data on persons' with young onset dementia and caregivers' preferences for supportive services for young onset dementia, defined as support provided by medical providers, psychosocial interventions, and any other resources/services provided to promote positive adjustment in persons with young onset dementia and their caregivers.

RESEARCH DESIGN AND METHODS

We searched five electronic databases for qualitative articles from inception to January 2020. We extracted and synthesized data from eligible articles using thematic analysis. After removal of duplicates, we screened 219 articles identified through database and hand searches.

FINDINGS

Forty-three studies met our inclusion criteria. We extracted findings from these 43 studies on preferences within three a priori defined domains: 1) general characteristics of supportive services, 2) format and modality of supportive services, and 3) content for supportive services. Persons with young onset dementia and caregivers predominantly expressed common preferences, with some unique preferences based on their specific roles within the partnership.

DISCUSSION AND IMPLICATIONS

Persons with young onset dementia and their caregivers endorsed largely overlapping preferences, including having direct contact with providers and the ability to participate together in programs that have content and skills relevant to their specific needs and challenges. Findings can directly inform the format, content, and procedures of supportive services for persons with young onset dementia and their caregivers.

The nature of positive post-diagnostic support as experienced by people with young onset dementia

OBJECTIVES

Studies on service needs of people with young onset dementia have taken a problem-oriented approach with resulting recommendations focusing on reducing service shortcomings. This study aimed to build on 'what works' in real-life practice by exploring the nature of post-diagnostic support services that were perceived positively by younger people with dementia and carers.

METHOD

Positive examples of support were gathered between August 2017 and September 2018, via a national survey. Inductive thematic analysis was employed to explore the nature of positively experienced services provided for younger people with dementia, including analysis of what was provided by positively experienced services.

RESULTS

Two hundred and thirty-three respondents reported 856 positive experiences of support. Data analysis yielded eight themes regarding the objectives of positive services: Specialist Advice and Information on Young Onset Dementia, Access to Age-appropriate Services, Interventions for Physical and Mental Health, Opportunities for Social Participation, Opportunities to Have a Voice, Enablement of Independence while Managing Risk, Enablement of Financial Stability, and Support Interventions for Family Relationships.

CONCLUSION

The study findings (a) suggest that positive services may collectively create an enabling-protective circle that supports YPD to re-establish and maintain a positive identity in the face of young onset dementia, and (b) provide a basis from which future good practice can be developed.

Alcohol Use, Mental Health, and Functional Capacity as Predictors of Workplace Disability in a Cohort With Manifest Huntington's Disease

OBJECTIVE

Huntington's disease (HD) is an inherited neurodegenerative disease involving motor, cognitive, psychiatric, and behavioral impairments that eventually affect work-role functioning. There is limited research regarding predictors of workplace disability in HD. The authors examined predictors of work impairment and disability in a cross-sectional cohort of employed persons with symptomatic HD participating in the worldwide Enroll-HD study.

METHODS

The study sample (N=316) comprised individuals with manifest HD and a CAG repeat length range between 39 and 60 and were currently engaged in paid full- or part-time employment. Univariate and multivariate logistic regression analyses identified predictors and the effect of all predictors in a fully adjusted model.

RESULTS

Of the sample, 20.3% reported missing work due to HD, 60.1% reported experiencing impairment while working due to HD, 79.1% reported having work-related activity impairment due to HD, and 60.8% reported impairment in overall work productivity due to HD. Individuals had 25% higher odds of missing work time if they had a higher level of functional impairment (odds ratio=0.76, 95% CI=0.64, 0.91) and had three times greater odds of missing work if they were current alcohol drinkers, compared with nondrinkers (odds ratio=2.86, 95% CI=1.62, 5.03). Individuals with lower self-perceived mental health were also 5% more likely to experience impairment at work due to HD. Motor impairment was not a strong predictor of workplace disability.

CONCLUSIONS

These findings provide important new knowledge that can inform the development of strategies or targeted intervention trials to support persons with symptomatic HD to maintain their work roles.

Needs-appropriate services for people with young onset dementia: The perspectives of healthcare professionals

Young onset dementia has become a growing challenge in national healthcare systems. Concerns about the situation have already been expressed; however, they mostly report the views of services end-users. Aimed at finding out useful further improvement, interviews documenting the working experiences of professionals addressing healthcare services to people with young onset dementia (YOD) were analysed qualitatively. The interviews resulted in four themes and twelve categories. The themes regarded services' complexity and responsiveness, the levels of education and knowledge on YOD, the impact that serving people with YOD reflects on staff working experience and quality of life, and a series of proposals aimed at improving services by giving people with YOD and families the provision of care they deserve. Although some of the themes recapped the ones reported in the previous literature, the mixture of internally and externally driven instances represented in the themes depict the complexity of care delivery in the services. Findings are discussed in the light of a pragmatical framework capable of suggesting what changes services should implement to be timely responsive.

Risk of rhabdomyolysis with donepezil compared with rivastigmine or galantamine: a population-based cohort study

BACKGROUND

Donepezil, rivastigmine and galantamine are popular cholinesterase inhibitors used to manage the symptoms of Alzheimer disease and other dementias; regulatory agencies in several countries warn about a possible risk of rhabdomyolysis with donepezil, based on information from case reports. Our goal was to investigate the 30-day risk of admission to hospital with rhabdomyolysis associated with initiating donepezil versus other cholinesterase inhibitors.

METHODS

We conducted a retrospective cohort study in Ontario, Canada, from 2002 to 2017. Participants were adults aged 66 years or older with a newly dispensed prescription for donepezil compared with rivastigmine or galantamine. The primary outcome was hospital admission with rhabdomyolysis (assessed using hospital diagnostic codes) within 30 days of a new prescription of a cholinesterase inhibitor. Odds ratios were estimated using logistic regression, with inverse probability of treatment weights calculated from propensity scores.

RESULTS

The average age in our 2 groups was 81.1 years, and 61.4% of our population was female. Donepezil was associated with a higher risk of hospital admission with rhabdomyolysis compared with rivastigmine or galantamine (88 events in 152 300 patients [0.06%] v. 16 events in 68 053 patients [0.02%]; weighted odds ratio of 2.21, 95% confidence interval [CI] 1.52-3.22). Most hospital admissions with rhabdomyolysis after donepezil use were not severe, and no patient was treated with acute dialysis or mechanical ventilation.

INTERPRETATION

Initiating donepezil is associated with a higher 30-day risk of admission to hospital with rhabdomyolysis compared with initiating rivastigmine or galantamine. The proportion of patients who develop severe rhabdomyolysis within 30 days of initiating donepezil is very low.

Resilience in Carers of People With Young-Onset Alzheimer Disease

Young-onset Alzheimer disease (YOAD) causes psychological and emotional difficulties for carers. However, even in the face of considerable caregiving demands and burden, some carers are resistant to stress, which may be a sign of resilience. This study investigated whether the clinical symptoms of the person with YOAD might be associated with resilience in their carers. A consecutive series of 43 persons with YOAD and their 43 family caregivers were assessed. The carers showed moderate to high level of resilience, low level of anxiety and depressive symptoms, and moderate level of burden. No relationship was found between resilience and sociodemographic characteristics of both carers and care recipient and with clinical characteristics of persons with YOAD. A linear regression analysis showed that resilience was inversely associated with carers' depressive symptoms. The findings suggest that resilience may mainly be related to carers' mental health.

Co-creation of a family-focused service model living with younger onset dementia

Families living with younger onset dementia face unique social challenges, which services do not currently address. There is a gap in understanding the experiences of families affected by younger onset dementia, including the interactions and relationships within the family units, and with existing services and supports. In this qualitative research study, semi-structured interviews were conducted across Australia with seven health and social care providers, five persons living with younger onset dementia, six spouse/carers, and 17 children. A thematic analysis was conducted using a theoretical lens drawn from the combined perspectives of the social model of disability and family systems-illness model. Two central themes emerged in the data: (1) Understanding the social demands on the family – lifecycle challenges living with younger onset dementia from a social and family context; and (2) Interactions of health and social care providers with families living with younger onset dementia – opportunities and challenges in providing support and services geared to a whole family approach. In order to provide families for those living with younger onset dementia with optimal assistance and support, co-creation of a family-focused services model is proposed. Its purpose is to support effective therapeutic interactions and service development among service users, service providers, and stakeholders.

Age-appropriate services for people diagnosed with young onset dementia (YOD): a systematic review

BACKGROUND

Literature agrees that post-diagnostic services for people living with young onset dementia (YOD) need to be age-appropriate, but there is insufficient evidence of 'what works' to inform service design and delivery.

OBJECTIVE

To provide an evidence base of age-appropriate services and to review the perceived effectiveness of current interventions.

METHODS

We undertook a systematic review including all types of research relating to interventions for YOD. We searched PubMed, CINHAL Plus, SCOPUS, EBSCO Host EJS, Social Care Online and Google Scholar, hand-searched journals and carried out lateral searches (July-October 2016). Included papers were synthesised qualitatively. Primary studies were critically appraised.

RESULTS

Twenty articles (peer-reviewed [n = 10], descriptive accounts [n = 10]) discussing 195 participants (persons diagnosed with YOD [n = 94], caregivers [n = 91] and other [n = 10]) were identified for inclusion. Services enabled people with YOD to remain living at home for longer. However, service continuity was compromised by short-term project-based commissioning and ad-hoc service delivery.

CONCLUSION

The evidence on the experience of living with YOD is not matched by research and the innovation needed to mitigate the impact of YOD. The inclusion of people with YOD and their caregivers in service design is critical when planning support in order to delay institutional care.

The impact of younger-onset dementia on relationships, intimacy, and sexuality in midlife couples: a systematic review

BACKGROUND

The impact of dementia on relationships, intimacy, and sexuality has been documented in later life couples. However, little is known about the experiences of couples living with younger-onset dementia. The aim of this systematic review was to analyze the literature describing the impact of younger-onset dementia on relationships, intimacy, and sexuality in midlife couples.

METHODS

A systematic literature search was conducted in July 2016 for relevant research papers. Five databases were searched: Web of Science, PsycINFO, MedLine, Scopus, and CINAHL. A quality appraisal checklist was used to assess the methodological quality of included studies.

RESULTS

Eleven studies were identified that explored relationships, intimacy, and sexuality from the perspective of the spouse, the person with dementia or both members of the dyad. Several themes were identified including shifts in roles and responsibilities, declines in relationship quality, changes in identity, and self-esteem, increasing social isolation and loneliness, shifts in intimacy, and changes in sexual activity.

CONCLUSIONS

Many of the reviewed studies were subject to a range of methodological issues including small sample sizes, small number of studies, and a reliance on the perspective of only one member of the dyad. Future research should follow couples longitudinally to gain a clearer picture of the impact of younger-onset dementia on the couple relationship over time. The inclusion of people living with younger-onset dementia in research will assist in developing a deeper understanding of the experiences of the individual and dyad.

Do spouse caregivers of young and older persons with dementia have different needs? A comparative study

AIM

The aim of this study was to explore the needs of spouse caregivers of persons with dementia (PWD) and then to compare them based on the PWD's age at disease onset. This data could be used to adapt support programmes to address differences between the two groups.

METHOD

Thirty-eight spouse caregivers of persons with late-onset dementia and 40 spouse caregivers of persons with early-onset dementia (PEOD) agreed to participate in the study. The mean ± SD age of the PEOD was 57.6 ± 4.0 years, whereas it was 80.9 ± 5.3 years for the persons with late-onset dementia. Interviews were conducted in the spouse caregivers' homes with only the spouse caregiver. The semi-structured interviews were based on the French version of the Carers Outcome Agreement Tool. The interviews were analyzed in two steps. The first step was qualitative to identify needs. The data were thematically analyzed using QSR NVivo 10. The second step was quantitative to compare the needs depending on the PWD's age at onset. The comparison between the two groups was performed using the χ² test.

RESULTS

The results demonstrated that the majority of needs are the same for the two groups of spouse caregivers. All caregivers need to unwind, to stimulate and pay attention to the PWD, to break the isolation, and to be more prepared and confident. However, some differences emerge, with the spouse caregivers of PEOD expressing a greater number of needs. The caregivers of PEOD seem to have a greater need to interact and maintain contacts with other people (P = 0.001), have more general care-related needs (P = 0.005), require more appropriate care structures (P = 0.037), and need greater assistance with administrative procedures (P = 0.004).

CONCLUSION

To improve spouse caregivers' well-being and sense of efficiency, it would be interesting to develop a support programme with a common framework and specific modules depending on the PWD's age at disease onset.

Why aren't people with young onset dementia and their supporters using formal services? Results from the INSPIRED study

Background/Aims

Despite reporting high levels of burden, supporters of people with young onset dementia (YOD) underuse formal community services. Previous quantitative studies in YOD are of limited utility in guiding service design because they did not consider important contextual barriers to service use. The aim of this study was to identify all relevant barriers and describe the service features considered most important to improving uptake by people with YOD and their supporters.

Methods

Eighty-six people with consensus-confirmed YOD (mean onset age 55.3 years) and/or their primary supporter participated in quantitative interviews, and 50 also participated in one of seven qualitative focus groups. Interview participants reported levels of community service use and reasons for non-use, functional impairment, behavioural and psychological symptoms, supporter burden, social network, and informal care provision. Focus group participants expanded on reasons for non-use and aspects of an ideal service.

Results

Although at least one community service was recommended to most participants (96.8%), 66.7% chose not to use one or more of these. Few of the clinical or demographic factors included here were related to service use. Qualitative analyses identified that lack of perceived need, availability, and YOD-specific barriers (including ineligibility, unaffordability, lack of security, lack of childcare) were commonly reported. Five aspects of an ideal service were noted: unique, flexibile, affordable, tailored, and promoting meaningful engagement.

Conclusion

People with YOD and their families report that formal community services do not meet their personal and psychological needs. Researchers can provide ongoing assessment of program feasibility, suitability, and generalisability.

Anosognosia and Its Relation to Psychiatric Symptoms in Early-Onset Alzheimer Disease

BACKGROUND

We investigated differences in the prevalence of anosognosia and neuropsychiatric symptoms (NPSs) characteristics according to disease severity in patients with early-onset Alzheimer disease (EOAD).

METHODS

We recruited 616 patients with EOAD. We subdivided participants into 2 groups based on the presence or absence of anosognosia and then again by Clinical Dementia Rating (CDR) scale. We compared the differences in the Neuropsychiatric Inventory (NPI) scores according to anosognosia and disease severity.

RESULTS

The percentage of patients with anosognosia in each CDR group steadily increased as the CDR rating increased (CDR 0.5 8.6% vs CDR 1 13.6% vs CDR 2 26.2%). The NPI total score was significantly higher in patients with anosognosia in the CDR 0.5 and 1 groups; by contrast, it had no association in the CDR 2 group. Frontal lobe functions were associated with anosognosia only in the CDR 0.5 and 1 groups. After stratification by CDR, in the CDR 0.5 group, the prevalence of agitation ( P = .040) and appetite ( P = .013) was significantly higher in patients with anosognosia. In the CDR 1 group, patients with anosognosia had a significantly higher prevalence of delusions ( P = .032), hallucinations ( P = .048), and sleep disturbances ( P = .047). In the CDR 2 group, we found no statistical difference in the frequency of symptoms between patients with and without anosognosia.

CONCLUSION

These results confirm that the prevalence of anosognosia as well as the individual NPS and cognitive functions associated with it differ according to EOAD severity.

A younger onset dementia toolkit: Innovative practice

A diagnosis of younger onset dementia requires specific care tailored to the individual and the family. Dementia care workers often do not have the skills and experience necessary to offer this care within the residential and community environment. This article reports the development of an interactive resource to educate those employed to care for people living with younger onset dementia. Prescription for Life, a talking e-Flipbook was developed and piloted in two states of Australia. Feedback from the pilots was incorporated in the resource prior to a national rollout. The project was supported by an expert panel, including experts from national aged care providers.

Younger Onset Dementia

This literature review focused on the experience, care, and service requirements of people with younger onset dementia. Systematic searches of 10 relevant bibliographic databases and a rigorous examination of the literature from nonacademic sources were undertaken. Searches identified 304 articles assessed for relevance and level of evidence, of which 74% were academic literature. The review identified the need for (1) more timely and accurate diagnosis and increased support immediately following diagnosis; (2) more individually tailored services addressing life cycle issues; (3) examination of the service needs of those living alone; (4) more systematic evaluation of services and programs; (5) further examination of service utilization, costs of illness, and cost effectiveness; and (6) current Australian clinical surveys to estimate prevalence, incidence, and survival rates. Although previous research has identified important service issues, there is a need for further studies with stronger research designs and consideration of the control of potentially confounding factors.

Sustaining people with dementia or mild cognitive impairment in employment: A systematic review of qualitative evidence

Introduction

The World Health Organization estimates that 10% of the 35.6 million people worldwide with dementia are aged under 65 years. In an ageing workforce this has implications for employers, employees, and statutory and third sector services. Limited research has been conducted into this emerging global issue.

Method

This systematic review, employing the methodology of the Joanna Briggs Institute, aimed to identify and synthesise the best available qualitative evidence regarding the needs, experiences and perspectives of people with early onset dementia or mild cognitive impairment who were either in employment or wished to gain employment.

Results

Of 69 studies identified, eight met the inclusion criteria. From these, four themes emerged: disease progression and recognition; the emotional impact of change; the employer’s management of the worker; and changes to the worker role.

Conclusion

There are health benefits to the individual with dementia or mild cognitive impairment of continuing to engage in meaningful occupation. Retirement policy changes have resulted in an ageing workforce with concurrent risk factors for dementia. A lack of understanding of reasonable adjustments and sheltered employment opportunities was evident from the literature. This review highlights the potential for occupational therapists to engage this client group in vocational rehabilitation.

Self-management for people with early dementia

This article describes the concept of self-management and how it is being promoted. This is followed by a consideration of why dementia has been largely set aside. Illustrations of how people with early dementia might be enabled to participate are given and the requirements that will help to make this a reality are postulated. These include early disclosure of the diagnosis, support with the consequences of disclosure, a focus upon the needs of the person with dementia, identification of specific interventions that might facilitate self-management, meeting needs for professional education and support and a whole systems approach towards treatment and care. The results of a scoping review of the evidence is given, with an extra factor of meeting needs for lay and patient education being identified in addition to those elements originally postulated. The implications of policy neglect combined with a patchy evidence base and unrecognized service innovations are discussed.

The Impact of Young Onset Dementia on Informal Caregivers Compared with Late Onset Dementia: Results from the NeedYD Study

OBJECTIVES

The impact of the dementia might be more severe for caregivers of people with young onset dementia (YOD) compared with those who care for someone with late onset dementia (LOD), as a young age among caregivers has been identified as a predictor of increased burden. The present study compares well-being between LOD and YOD caregivers longitudinally because this knowledge is essential in order to develop adequate support programs.

DESIGN, SETTING, AND PARTICIPANTS

220 YOD and 108 LOD patient-caregiver dyads were included from two prospective cohorts with a 2-year follow up. To assess well-being we used the Short Sense of Competence Questionnaire, the RAND-36, the Symptom Checklist 90, and the Montgomery Asberg Depression Rating Scale. The severity and the course of the different measures used to describe caregiver burden were analyzed with linear mixed models.

RESULTS

Caregivers in both groups experienced high levels of physical and psychological complaints, mild depressive symptoms, lower health-related quality of life (HRQoL), and decreased feelings of competence. The severity and the course of most measures were similar in both groups, although HRQoL on both the physical and the mental domain was lower for the YOD caregivers.

CONCLUSIONS

The number of actual psychological and physical complaints does not differ between YOD and LOD caregivers. YOD caregivers have greater perceived difficulties in daily life because of these complaints, however.

Public advocacy and community engagement: interventions for individuals with young-onset dementia and their families

Individuals and families affected by young-onset dementia (YOD) deal with multiple difficulties related to the altered timing of the dementias. These individuals and families are overlooked by the health care and social support systems because there are few tailored services/policies for younger people affected by dementia. This article suggests how public advocacy and interventions at the clinical and community levels can support people living with YOD, in particular the spouses, who provide most of the care.

Family carers' experiences of attending a multicomponent psychosocial intervention program for carers and persons with dementia

Background

Psychosocial interventions for persons with dementia and their primary family carers are promising approaches to reducing the challenges associated with care, but, obtaining significant outcomes may be difficult. Even though carers in general are satisfied with such interventions, few studies have evaluated the interventions by means of qualitative methods.

Aim

The objective of the study reported here was to investigate family carers’ experiences of a multicomponent psychosocial intervention program, and also to offer advice on how to develop the intervention program.

Methods

Content analyses were taken from individual qualitative interviews conducted in 2012 with 20 carers (aged 50–82 years) who participated in a psychosocial intervention program that included education, individual and family counseling, and parallel group sessions for carers and persons with dementia.

Results

Two main categories emerged: 1) benefits of the intervention program, which sets out the informants’ experiences for the benefits of participation, described in the subcategories “importance of content and group organization” and “importance of social support”; and 2) missing content in the intervention program, which details the informants’ suggestions for future interventions, contained in the subcategories “need for extended content” and “need for new group organization”.

Conclusion

The carers found the interventions useful. The importance of even earlier and more flexible interventions for the family carers, the extended family, and the persons with dementia was underscored.

Unmet support needs of early-onset dementia family caregivers: a mixed-design study

BACKGROUND

Though advances in knowledge and diagnostics make it possible today to identify persons with early-onset dementia or a related cognitive disorder much sooner, little is known about the support needs of the family caregivers of these persons. The aim of this study was to document the unmet support needs of this specific group of caregivers. This knowledge is essential to open avenues for the development of innovative interventions and professional services tailored to their specific needs.

METHODS

This study was conducted using a mixed research design. Participants were 32 family caregivers in their 50s recruited through memory clinics and Alzheimer Societies in Quebec (Canada). The Family Caregivers Support Agreement (FCSA) tool, based on a partnership approach between caregiver and assessor, was used to collect data in the course of a semi-structured interview, combined with open-ended questions.

RESULTS

The unmet support needs reported by nearly 70% of the caregivers were primarily of a psycho-educational nature. Caregivers wished primarily: (1) to receive more information on available help and financial resources; (2) to have their relatives feel valued as persons and to offer them stimulating activities adjusted to their residual abilities; (3) to reduce stress stemming from their caregiver role assumed at an early age and to have the chance to enjoy more time for themselves; and (4) to receive help at the right time and for the help to be tailored to their situation of caregiver of a young person.

CONCLUSIONS

Results show numerous unmet support needs, including some specific to this group of family caregivers. Use of the FCSA tool allowed accurately assessing the needs that emerged from mutual exchanges. Avenues for professional innovative interventions are proposed.

Nobody asked me how I felt: experiences of adult children of persons with young-onset dementia

BACKGROUND

There are few studies of young persons (<65 years old) with dementia, and the situation of their children has been a neglected research field. The aim is explore how adult children of a parent with young-onset dementia have experienced the development of their parents' dementia and what needs they have for assistance.

METHOD

Qualitative interviews with 14 informants (aged 20-37 years; 12 daughters, 2 sons) during 2011 were conducted and analyzed thematically.

RESULTS

The informants experienced great burdens and felt neglected during the development of their parents' dementia, both by their family and by health and social services. They emphasized a need to be seen as individuals, with their experiences, feelings, and personal needs for assistance. The stresses experienced during the development of parental dementia seemed to increase conflicts in the family. There were variations in reactions between children, depending on age, gender, family structure and relationships, responsibilities, personal relations with both parents, and whether there was an adult primary caregiver. The length of time living together with the parent with dementia seemed to increase the stress and burden to the children. They expressed a great need for information and support.

CONCLUSION

The findings strengthen the notion of the need for family-oriented support, combined with person-centered care for the children according to their needs. In addition, group meetings and contact with other young people in the same stage of life could be of interest for some.

'It's nice to have something to do': early-onset dementia and maintaining purposeful activity

As the global focus on dementia care increases due to the demand on health, social, legal and financial services, it is imperative to further understand the experience of those living with a diagnosis of dementia. There is a particular lack of research focused on younger people (under the age of 65 years) with dementia and virtually none focuses on the experience of the family unit. The literature suggests that periods of transition place significant stressors on families living with dementia. One such transition is the transition out of perceived purposeful activity, be this employment or voluntary work. This transition was explored during the course of a qualitative repeated interview study with younger people with dementia and their families. Nine families (20 participants) took part in semi-structured research interviews that were transcribed and analyzed using a Framework approach to qualitative analysis. Meaningful Activity emerged as a major theme through this analysis. Two subthemes also emerged: (1) the traumatic cessation of work; and (2) the need for purposeful activity. These themes have significant clinical implications as maintaining a purposeful role through high-quality, age-specific dementia services may decrease the direct and indirect costs of dementia to global economies.

Exploring the service and support needs of families with early-onset Alzheimer's disease

Although often cast as a disease of later life, a growing number of people are being diagnosed with Alzheimer's disease in their 50s and 60s. Early-onset Alzheimer's disease (EOAD) poses special challenges and needs for individuals and their caregivers, such as employment and access to services. In this cross-sectional study, the researchers surveyed 81 (N = 81) family caregivers to individuals with EOAD to identify service and support usage and need. Descriptive analyses revealed that families utilized a range of formal services (eg, adult day) and informal support from family and friends. In terms of challenges and needs, participants indicated that they struggled most with employment, benefits, and financial issues. Although most caregivers felt that they were coping well, they also indicated that their needs were not well understood by service providers and the public. These findings highlight the need to better understand and respond to the specific issues surrounding EOAD.

Family-AiD: a family-centred assessment tool in young-onset dementia

Purpose

– Standards of care and care pathways for younger people with dementia vary greatly, making clinical development and service planning challenging. Staff working in dementia services identify that they use biographical knowledge of families to influence clinical decision making. This information is not collected or implemented in a formal manner; highlighting an important knowledge-practice gap. The paper aims to discuss these issues.

Design/methodology/approach

– The development of a family-centred assessment for use in dementia care has three core components: first, thematic development from qualitative interviews with younger people with dementia and their families; second, clinical input on a preliminary design of the tool; and third, feedback from an external panel of clinical and methodological experts and families living with young-onset dementia.

Findings

– The 12-item Family Assessment in Dementia (Family-AiD) tool was developed and presented for clinical use. These 12 questions are answered with a simple Likert-type scale to determine areas of unmet need and identify where families may need additional clinical support. Also included is a series of open-ended questions and a biographical timeline designed to assist staff with the collection and use of biographical and family functioning information.

Originality/value

– A dementia-specific clinical family assessment tool, which also collects background biographical data on family units may be a useful way to document information; inform clinical decision making; and address otherwise unmet needs. Family-AiD has potential to improve clinical care provision of people with dementia and their families. Evaluation of the feasibility and acceptability of its implementation in practice are now required.

A shifting sense of being: a secondary analysis and comparison of two qualitative studies on young-onset dementia

The aim of the present study was to investigate and interpret metaphorical expressions of the lived experiences of everyday life in people with young-onset dementia (YOD) and to compare these findings with findings from an analysis via grounded theory to see if the second analysis adds more knowledge to the topic. In this secondary analysis of data, metaphors from 20 Norwegian men and women living with YOD were investigated. Using Steger's anthropological three-step method, three categories were identified: Sliding away, leaving traces, and all alone in the world. Comprehensively, we understood the metaphors as representing the participants’ shifting sense of being. The main findings of the study show that by analysing the data by combining and using both methods, more knowledge to the topic was added. Acknowledging metaphorical expressions as a source of knowledge, this study reflects on how metaphors can be used in therapeutic dialogue. We conclude that metaphors add to the understanding of descriptions of daily life in a more existential way, beyond the results gained from the grounded theory analysis. However, the findings from the analysis via grounded theory included aspects that we did not find when analysing the metaphors.

Prevalence and covariates of elevated depressive symptoms in rural memory clinic patients with mild cognitive impairment or dementia

Background/Aims

To estimate the prevalence, severity, and covariates of depressive symptoms in rural memory clinic patients diagnosed with either mild cognitive impairment (MCI) or dementia.

Methods

In a cross-sectional study of 216 rural individuals who attended an interdisciplinary memory clinic between March 2004 and July 2012, 51 patients were diagnosed with MCI and 165 with either dementia due to Alzheimer's disease (AD) or non-AD dementia. The Center for Epidemiologic Studies of Depression Scale (CES-D) was used to estimate the severity and prevalence of clinically elevated depressive symptomatology.

Results

The prevalence of elevated depressive symptoms was 51.0% in the MCI patients and 30.9% in the dementia patients. Depressive symptoms were more severe in the MCI patients than in the dementia patients. Elevated depressive symptoms were statistically associated with younger age for the MCI group, with lower self-rated memory for the dementia group, and with increased alcohol use and lower quality of life ratings for all patients. In the logistic regression models, elevated depressive symptoms remained negatively associated with self-rated memory and quality of life for the patients with dementia, but significant bivariate associations did not persist in the MCI group.

Conclusions

The high prevalence and severity of depressive symptoms among rural memory clinic patients diagnosed with either MCI or dementia warrant continued investigation.

What are the experiences of people with dementia in employment?

Statistics show that an increase in the statutory retirement age in the UK will mean that many more people will develop a dementia while still in employment. A review of the literature confirmed that there are no existing studies in the UK which examine this issue in any detail. The aim of this study was to investigate the experiences of people who develop a dementia while still in employment and to understand how they make sense of these experiences; therefore a qualitative explorative inquiry based on an Interpretive Phenomenological Analysis methodology was used. Interviews with five people who had developed a dementia while still in employment were carried out, with ages ranging from 58 to 74 years. Interview transcripts were analysed and four super-ordinate themes were identified: the realization that something is wrong; managing the situation in the workplace; trying to make sense of change; and coming to terms with retirement or unemployment. The results showed that people who develop a dementia while still in employment do not always receive the 'reasonable adjustments' in the workplace to which they are entitled under the Equality Act (2010). Some of the participants felt that they were poorly treated by their workplace and described some distressing experiences. The study highlights the need for more effective specialized advice and support regarding employment issues and more research into the numbers of people in the UK that are affected by this issue.

The unique experience of spouses in early-onset dementia

To date, few studies have examined the experience of spouse caregivers living with a person with early-onset dementia. Moreover, few support resources are offered to these family caregivers and fewer are still tailored to their unique trajectory. The aim of this qualitative study was to document the lived experience of spouse caregivers of young patients in order to inform the development of professional support tailored to their reality. A sample of 12 spouses of persons diagnosed with dementia before the age of 65 participated in semistructured interviews. Six themes emerged from their caregiver trajectories, namely, difficulty managing behavioral and psychological symptoms, long quest for diagnosis, nondisclosure to others and denial of diagnosis, grief for loss of spouse and midlife projects, difficulty juggling unexpected role and daily life responsibilities, and difficulty planning for future. Results open up innovative avenues for the development of interventions geared to facilitating role transition for these spouse caregivers.

Development of supportive services for frontotemporal dementias through community engagement

The effect of early onset frontotemporal dementias (FTD) on spouses and children is profound, requiring different types of support services from pre-existing Alzheimer's disease interventions already in place. This article explores how the needs of families living with FTD resulted in three programme initiatives developed at Baycrest (an academic health sciences centre focused on ageing, in Toronto, Canada) to meet the needs of this population. These included an Internet-based videoconferencing support group for spouses, a website that provides support and counsel for children and their parents, and an adult day programme designed for FTD patients. The strength of these interventions is that services were developed with involvement of stakeholders in FTD care from the start, to deal with gaps in services in a sustainable way.

Management of frontotemporal dementia in mental health and multidisciplinary settings

Diagnosis of frontotemporal dementia (FTD) in the mental health setting and issues pertaining to longitudinal care of this population in a specialist clinic are reviewed. FTD is often misdiagnosed as a psychiatric disorder, most commonly as a mood disorder. FTD has features that overlap with those of major depression, mania, obsessive-compulsive disorder and schizophrenia. We describe these features and how to differentiate FTD from these psychiatric disorders. This paper also describes practical issues in the management of FTD, specifically the issues that clinicians, patients and their families face in managing this disease. Areas of clinical care along the continuum are explored; FTD care involves collaborative management of symptoms and disability, and assisting patients and families in adapting to the disease.

Towards living well with young onset dementia: An exploration of coping from the perspective of those diagnosed

There is increasing recognition that dementia in people under 65 years represents a unique challenge to sufferers and services alike. However, by either ignoring this population or sampling them together with older adults, current research has failed to reflect this. This study explored the specific experience of living and coping with Alzheimer's disease in younger life from the perspective of those diagnosed. Semi-structured interviews were analysed using interpretive phenomenological analysis, and four themes were identified: 'disruption of the life-cycle', 'identity', 'social orientation' and 'agency'. The experience of living and coping with young onset Alzheimer's disease was strongly situated within an individual's social context. Most significantly, participants felt too young to develop the disease and felt out of time with age-related psychological tasks. Coping strategies that attempted to redress and normalise the life-cycle were identified. The contributions of the study are discussed in the context of the human development literature.

The needs of patients with early onset dementia

AIM

The burden of early-onset dementia (EOD) is often overshadowed by an ageing population.

METHODS

A questionnaire comprising 12 items was completed by 18 patients with EOD (15 with Alzheimer's disease [AD] and 3 with frontotemporal dementia) and 39 caregivers (20 spouses, 8 children, 7 siblings, 2 carers, and 2 health professionals). The onset of patients' symptoms was prior to the age of 65 years. Caregivers had to be supporting someone who matched these criteria.

RESULTS

Early recognition and referral was perceived as the principle area of improvement by both patients (94.4%) and carers (69.2%; P < .0002). Patients evaluated "diagnosis" as the area of most need (88.9%) compared with caregivers who rated "treatment" (69.2%) as their principle concern.

CONCLUSION

The perceived concerns of patients with EOD differ from that of the caregivers. Continued consumer involvement is essential in ensuring a tailored approach to young people with dementia.

'It's easier just to separate them': practice constructions in the mental health care and support of younger people with dementia and their families

There is no standard model of specialist care for younger people with dementia (onset before the age of 65 years) and specialist service provision varies widely throughout the UK. In order to gain a clearer picture about ways in which clinical staff work with younger people with dementia, semi-structured interviews were conducted with dementia care staff working in the north-west of England. Interviews focused on exploring daily working practices and the meaning placed on clinical decision making when involving family/carers in routine practice. Content analysis generated three core themes: (1) Maintaining Separation: how clinical staff conceptualize the meaning of 'family' in the provision of dementia care services; (2) Providing Practical Help: the focus in care provision on assisting families with aspects of daily life such as finances, education and physical care; and (3) Acknowledging the Family Context: how staff understand and interact with family members in an attempt to initiate care, utilizing biographically informed practice. By understanding how staff view their role in providing younger people with dementia with effective, high-quality dementia care, it is anticipated that a more family-centred approach can be integrated into already established patterns of working that more holistically meet the needs of this group.

Community-dwelling persons with dementia: what do they need? What do they demand? What do they do? A systematic review on the subjective experiences of persons with dementia

OBJECTIVES

Including the perspectives of persons with dementia (PwD) is essential in order to organize care structures for them. With this systematic review, we set out to screen the existing scientific evidence on self-expressions of community-dwelling individuals with dementia in order to provide a research base for developing an intervention for persons in early stages of the disease. The leading research questions for this review are: What needs do PwD living at home express? What are their subjective demands? What do they do to cope with their situation?

METHODS

We performed a systematic literature review of review publications on subjective experiences of PwD. The publications were analysed using MAXQDA 10 to perform a thematic analysis.

RESULTS

We identified 41 relevant reviews, of which 6 met our inclusion criteria. PwD experience the whole range of human emotions. Their needs and demands do not differ significantly from those of other groups of patients with chronic conditions. Coming to terms with the disease and maintaining normality appeared to be major themes. With regard to expectations from the side of professional health care, the need for accompanying, continuous support and counselling appeared to be central. Furthermore, disclosure of diagnosis represents a critical stage for PwD, but our findings indicated that they prefer to be included in this process.

CONCLUSIONS

PwD are well able to express their needs. They should be included in research since they can provide valuable findings. Furthermore, those findings should be implemented in applied dementia care.

Experiences of persons with early-onset dementia in everyday life: a qualitative study

BACKGROUND

The small number of existing studies confirms that people with early-onset dementia (EOD) need special assistance from the beginning and as the disease progresses. There is a need to develop services to respond to the specific needs of persons with EOD.

AIM

To find out how people experience living with early-onset dementia, and to assess the implications for practice and the development of further services.

METHOD

Grounded theory, a qualitative method, with interviews of 20 informants (aged 54-67 years; 12 of them men) during 2010-2011.

FINDINGS

One category, the process toward a dementia diagnosis, covered two subcategories; describing changes and being diagnosed. Another category fighting for dignity describes how the informants try to maintain their quality of life, covering two subcategories; intrapsychic challenges and social challenges.

CONCLUSION

Health services should give persons with EOD the ability to maintain contact with society and their voices should not be overlooked.

‘That’s me, the Goother’: Evaluation of a program for individuals with early-onset dementia

We conducted face-to-face, semi-structured interviews with six white men with early-onset dementia (EOD) and supplemented the interviews with a focus group with six wives of the men to document perceptions of a weekly, supervised volunteer program for the men at the local zoo. The program, ‘Get Out of the House,’ is designed to provide individuals with EOD a weekly opportunity to participate in meaningful, supervised volunteer work in the community. Interviews with participants revealed that they strongly identify with the program and are eager to share their experiences, about which they show some depth of insight. The focus group revealed that the program represents a break in the day-to-day routine for spouses and families, as well as participants, and has benefits that extend beyond the program time itself. Challenges with the development and implementation of such programs and implications for research and practice are discussed.

[Early onset dementia]

BACKGROUND

It is estimated that 1,200 people under the age of 65 have been diagnosed with dementia in Norway. This article provides an overview of the types of dementia frequently seen in younger patients.

MATERIAL AND METHODS

The article is based on a non-systematic search in PubMed, as well as the authors' own clinical and research experience.

RESULTS

Alzheimer's disease, frontotemporal dementia, vascular dementia and dementia with Lewy bodies, are the most common types of dementia occurring more often in younger than in older patients. The cognitive symptoms are more variable in younger patients than in older. Only a small percentage of early onset dementia is caused by genetic factors. There are few diagnostic tools available for this age group and it takes considerable time to reach a correct diagnosis. Early diagnosis allows the patient and carer to plan for the future.

INTERPRETATION

Physicians should be aware that dementia can occur in younger people, and more diagnostic assessments should be developed for this patient group. Better coordination from the public health authority and municipalities is needed to provide respite care for early onset dementia patients and their carers.

Quality of life and depression in carers of patients with early onset dementia

OBJECTIVE

To investigate the quality of life (QoL) and depression and its correlates in carers living with early onset dementia (EOD) patients.

METHOD

The subjects were 49 carers, either married to or cohabiting with EOD patients, 38 with Alzheimer's disease and 11 with other types of dementia. The Quality of Life - Alzheimer Disease scale (QoL-AD) and Geriatric Depression Scale-15 items (GDS-15) were used.

RESULTS

The mean QoL score for the carers was 37.9 (SD 5.5) and the mean GDS-15 score 5.1 (SD 2.9). Linear regression analyses with QoL and GDS-15 score as dependent variables were performed. Increased age of the carer (B = 0.32) and greater insight of the patients (B = -0.186) were significantly associated with a better QoL for the carer. Being married (B = 2.10), having children together with the patient (B = 1.61) and being the carer of a patient with cardiovascular disease (B = 2.28) were associated significantly with a higher GDS-15 score, whereas being the carer of a patient who received domiciliary nursing care (B = -2.29) was significantly associated with a lower GDS-15 score.

CONCLUSION

The QoL for carers of EOD patients corresponds positively with the increased age of carers and with patients' insight into their condition. Increased depressive symptomatology in carers was associated with being married, having offspring and caring for a patient with dementia and a co-morbid cardiovascular disease. A reduction in depression was seen in carers when the patients received domiciliary nursing care.

Occurrence of depression and its correlates in early onset dementia patients

OBJECTIVE

We wanted to investigate the occurrence of depression in early onset dementia (EOD) patients and which characteristics were associated with depressive symptoms.

METHODS

We included 221 patients who were diagnosed with dementia before the age of 65. Depression in these patients was measured by the Montgomery Asberg depression scale (MADRS). Measurements of cognition, behavioural and psychological symptoms and activities of daily life were along with hypothyroidism, diabetes and stroke included in the analysis. History of depression, current psychiatric co-morbidity and usage of antidepressants were recorded.

RESULTS

Mean age of patients was 58.6 years (SD = 5.2); 50.6% were women. Of them 123 patients (55.6%) had a mild degree of depression (MADRS total score 7-19), 21 patients (9.5%) had a moderate degree of depression (MADRS total score 20-34) and only 1 patient had a severe degree of depression (MADRS total score >or=35). A factor analysis produced two factors; the first factor described dysphoria: lack of concentration, pessimistic thoughts, inner tension, suicidal thoughts lassitude and lack of sleep. The second factor denoted sadness: observed sadness, reported sadness, lack of appetite and inability to feel. In an adjusted linear regression analysis history of depression was the only significantly variable associated with the MADRS total score and both factors 1 and 2.

CONCLUSION

We found a high occurrence of depressive symptoms in EOD patients; 65.7% of all our patients had some degree of depression. A history of depression was the most important correlate of depression in these patients.

Identifying needs, burden, and distress of carers of people with Frontotemporal dementia compared to Alzheimer’s disease

The literature on carers of people with Frontotemporal dementia (FTD) is negligible compared to the vast literature on carers of people with Alzheimer’s disease (AD), and little research has compared the two groups. Research has mainly focused on identifying the behavioural characteristics of people with FTD or AD. The impact of these behaviours on the psychological well-being of carers of people with FTD is relatively unexplored. This study investigated the needs, burden, and extent of depression and anxiety in carers of people with FTD ( n = 30) compared to carers of people with AD ( n = 30). Findings indicated that needs of carers of people with FTD were significantly higher than those of the carers of people with AD. The elevated needs were related to the younger onset of FTD, financial dissatisfaction, typical FTD characteristics, and access to appropriate services, information and support. Results also suggested that female carers were more likely to report a greater severity and impact of disruptive symptoms associated with FTD. No significant differences were found between the two groups on carers’ levels of burden, depression or anxiety. In order to address the needs of carers of people with FTD, we recommend specific educational and support programs, raising community awareness and understanding, and tailoring existing domiciliary services and activities for people with FTD.