Developing the Canadian Indigenous Cognitive Assessment for Use With Indigenous Older Anishinaabe Adults in Ontario, Canada

Dementia among Minority Populations: A Scoping Review of Meaning, Language, and Translation

BACKGROUND

Dementia as a neurocognitive disorder is becoming increasingly common worldwide, and minority groups are more vulnerable than the general population. Many factors may contribute to their vulnerability such as misconceptions, language barriers, cultural factors, invalid assessment tools, lack of knowledge, or assigning spiritual beliefs to dementia symptoms. Therefore, this scoping literature review aimed to clarify how empirical studies reflect the meaning of dementia, language, and translation among minority ethnic groups.

SUMMARY

The PRISMA extension for the scoping review protocol was used. Thirty-eight studies published in English were reviewed and analysed. The findings revealed that lack of knowledge about dementia and attributing the disease to the normal ageing process were frequent among minority groups. Furthermore, their cultural-specific perspectives and worldviews of wellness and well-being can impact the way dementia is perceived, consequent help-seeking behaviours, or caregiving. Facilitating educational programs to enhance the knowledge and experiences of ethnic communities might be beneficial. Moreover, language is shown to be an important aspect in dementia assessment and participants' educational level could significantly impact their functional capacity when responding to cognitive measures. Even though there are some useful screening tests, diagnosis barriers might be eased by assessment tool development, modifications, and accurate translations for ethnic communities.

KEY MESSAGES

A promising pathway to support ethnically diverse communities regarding dementia can be raising awareness, providing ethnic-specific services, developing cultural-specific tools to assess dementia or any cognitive impairment by considering perceptions, language, and culture among ethnic groups. Cultural and spiritual considerations could also encourage engagement during assessment.

Culturally adapted cognitive assessment tool for Indigenous communities in Brazil: Content, construct, and criterion validity

INTRODUCTION

Initial dementia prevalence estimates have revealed a significant burden of the disease in Indigenous communities in Amazonas, Brazil. However, the need for culturally adapted cognitive tools poses a critical challenge when assessing cognitive performance in these communities. This study addressed this issue by culturally adapting and providing validity indicators for the Brazilian Indigenous Cognitive Assessment (BRICA) tool in Manaus, Brazil's urban multiethnic Indigenous community.

METHODS

Using a three-stage process and a stakeholder-engaged approach, the BRICA tool was culturally adapted in an urban multiethnic Indigenous community from Manaus, Brazil. The content validity index (CVI) examined inter-rater concordance between experts, while criterion and concurrent validity were performed using diagnostic consensus criteria in 141 Indigenous participants aged ≥ 50 years.

RESULTS

Findings showed evidence of content validity in terms of equivalence aspects (scale CVI [S-CVI] 0.93) and relevance ratings (S-CVI 0.85) between expert panels. The identified cut-off score of ≤ 33/39 on the BRICA demonstrated a sensitivity of 94.4%, specificity of 99.2%, positive predictive value of 94.4%, and negative predictive value of 99.2% for dementia diagnosis.

DISCUSSION

Using a stakeholder-engaged approach, we culturally adapted the BRICA tool for a Brazilian urban multiethnic Indigenous community. This comprehensive adaptation process resulted in favorable indicators of content, construct, and criteria validity for the BRICA tool. By addressing the existing bias in cognitive assessment within Indigenous communities, the BRICA tool represents a noteworthy breakthrough. Its implementation exhibits potential for improving the early detection and management of dementia among Indigenous groups.

Highlights

Culturally sensitive tools are essential to assess cognition in Indigenous populations.An expert panel and stakeholders' perspectives were incorporated to design the Brazilian Indigenous Cognitive Assessment (BRICA) tool.A cognitive screening tool was adapted and validated using a stakeholder approach.BRICA is the first culturally sensitive cognitive tool for urban Brazilian Indigenous individuals.

Validation of the Kimberley Cognitive Assessment (KICA-Cog) for Torres Strait Islander Peoples

OBJECTIVES

The aim of this study was to validate the Kimberley Indigenous Cognitive Assessment-Cognitive Component (KICA-Cog) adapted for dementia screening in Torres Strait Islander Peoples.

METHODS

Data were obtained from a broader dementia prevalence study completed in the Torres Strait and Northern Peninsula Area between 2015 and 2018. Modifications were made to items from the original KICA-Cog to ensure they were culturally appropriate for the Torres Strait. All participants completed a KICA-Cog and had a comprehensive dementia assessment with a geriatrician experienced in cross-cultural assessment.

RESULTS

A total of 255 Torres Strait residents aged 45 years and over completed a KICA-Cog and underwent geriatric assessment. The adapted KICA-Cog showed good validity for dementia diagnosis with a cut point of 33/34 associated with a sensitivity of 81% and specificity of 92% with an area under the ROC curve of 0.91.

CONCLUSIONS

The KICA-Cog, when modified for the Torres Strait, is a valid cognitive screening tool for dementia. Caution is required when interpreting test scores, as the adapted KICA-Cog had slightly lower sensitivity (ability to detect people with dementia) than the original KICA-Cog. As with all short cognitive tests, individuals with a low KICA-Cog scores should undergo further medical investigations before a dementia diagnosis is considered.

Characteristics of Recurrent Visions of the Nonphysical World Among Cognitively Unimpaired Elders of the Ojibwe Tribal Nation

Importance

Visual hallucinations are a core feature of dementia with Lewy bodies and primary psychiatric disease, yet identification of a hallucination vs normal spiritual experience depends on cultural context. Almost no information exists in the medical literature regarding normal spiritual experiences in American Indian participants in the context of a neurocognitive evaluation.

Objective

To assess the characteristics of a normal spiritual experience in an Ojibwe Tribal Nation.

Design, Setting, and Participants

This prospective, cross-sectional study was conducted between August 1, 2021, and August 31, 2022, among an Ojibwe Tribal Nation in northern Minnesota. Participants were evaluated at their tribal nation clinic. Cognitively unimpaired tribal Elders who were enrolled members of the tribal nation and aged 55 years or older were invited to participate via fliers, radio advertisements, and health fair presentations. Thirty-seven tribal Elders volunteered.

Main Outcomes and Measures

Each participant was asked whether they experienced hallucinations or visions of people, animals, or objects that are not part of the physical world. This was an a priori formulated question and part of a comprehensive neurocognitive evaluation consisting of history and physical examination (including cognitive screening with a subspecialty-trained behavioral neurologist); blood tests for metabolic, nutritional, and thyroid conditions; and noncontrast magnetic resonance imaging brain scan. Four patients were excluded from the present analysis due to having mild cognitive impairment or dementia.

Results

Thirty-three cognitively unimpaired tribal Elders (mean [SD] age, 66.0 [7.5] years; 22 women [67%]) were included. Sixteen (48%) answered affirmatively, reporting recurrent visions of the nonphysical world. Generally, these visions were well formed, benevolent in nature, and transient; started in preadolescence; involved spirits or ancestors; and were congruent with cultural and spiritual beliefs of the Ojibwe people. No patients had accompanying dream enactment behavior, dysautonomia, parkinsonism, sleep transition-related hallucinations, or moderate to severe depression to suggest a prodrome of an α-synucleinopathy, hypnopompic or hypnagogic hallucinations, or psychosis.

Conclusions and Relevance

Although based on only 1 Ojibwe Tribal Nation, this study suggests that formed visions of the nonphysical world are common among cognitively healthy Ojibwe individuals and can represent normal spiritual experiences. Clinicians would benefit from careful consideration of cultural or spiritual context to avoid misdiagnosis of neuropsychiatric disease.

Innovation in Rural Health Services Requires Local Actors and Local Action

Objectives: We examine the role of “local actors” and “local action” (LALA) in health service innovation in high-resource small rural settings and aim to inform debates about the extent to which communities can be empowered to drive change in service design and delivery.

Methods: Using an adapted roles and activities framework we analyzed 32 studies of innovation projects in public health, clinical interventions, and service models.

Results: Rural communities can investigate, lead, own and sustain innovation projects. However, there is a paucity of research reflecting limited reporting capacity and/or understanding of LALA. Highlighting this lack of evidence strengthens the need for study designs that enable an analysis of LALA.

Conclusion: Innovation and community participation in health services are pressing issues in small rural settings where population size and distance from health infrastructure make service delivery challenging. Current reviews of community participation in rural health give little insight into the process of innovation nor understanding of how local actors produce improvements in innovation. This review outlines how communities and institutions can harness the essential role of LALA in supporting health innovations.

Volume, scope, and consideration of ethical issues in Indigenous cognitive impairment and dementia research: A systematic scoping review of studies published between 2000-2021

INTRODUCTION

High quality research involving Indigenous people with cognitive impairment and dementia is critical for informing evidence-based policy and practice. We examined the volume, scope and ethical considerations of research related to dementia with Indigenous populations globally from January 2000-December 2021.

METHODS

Studies were included if they were published in English from 2000 to 2021 and provided original data that focused on cognitive impairment or dementia in any Indigenous population.

RESULTS

The search yielded 13,009 papers of which, 76 met inclusion criteria. The overall number of papers increased over time. Studies were mostly conducted in Australia with Aboriginal and Torres Strait Islander people (n = 30; 39%). Twenty-six papers directly involved Indigenous participants with cognitive impairment or dementia. Of these studies, ethics approval was commonly required from two or more committees (n = 23, 88.5%). Ethical and legal governance frameworks were rarely discussed.

DISCUSSION

There is a clear need for further robust studies examining cognitive impairment and dementia with Indigenous populations. Future research should consider the ethical aspects of involving Indigenous participants with cognitive impairment in research.

Development of rehabilitation services in an Inuit sociocultural context: challenges, strategies and considerations for the future

In recent years, a new rehabilitation programme has been developed on the Hudson Bay coast of Nunavik. The purpose of this article is to reflect on the experience of an occupational and physical therapy programme development in an Inuit sociocultural context. To do so, the challenges encountered during the first years following the implementation of rehabilitation services and the strategies implemented by the professionals to overcome them were identified, examined in the light of the literature, and discussed with members of the rehabilitation team. The challenges encountered and strategies implemented were divided into 10 major themes: (1) diverse clinical needs; (2) communication issues; (3) acquisition of cross-cultural interaction and population-specific knowledge; (4) adaptation of clinical practice to Nunavimmiut; (5) client engagement in rehabilitation; (6) professional isolation; (7) lack of awareness around the objectives and scope of rehabilitation practice; (8) use of culturally safe assessment tools; (9) staff turnover; (10) large geographic area to be served. This exercise highlighted the need to adapt clinical rehabilitation practices to Nunavimmiut’s worldviews and culture, as well as to adopt a reflective practice in order to improve the quality, relevance and effectiveness of rehabilitation services.

Indigenous-specific cultural safety within health and dementia care: A scoping review of reviews

Globally, health inequities experienced by Indigenous communities are often described and documented in terms of deficits and disease. However, health disparities are complex and involve numerous underlying issues beyond the social determinants of health. Indigenous Peoples face unique barriers to accessing culturally safe and equitable healthcare, including racism, systemic injustice, and a historical legacy of colonialism. There is a paucity of knowledge on Indigenous-specific cultural safety interventions to support health and dementia care. The objective of this scoping review of reviews was to appraise the existing literature to identify key elements, conceptualizations, and interventions of cultural safety to improve health services and dementia care for Indigenous Peoples. Guided by Indigenous principles of relationality, we conducted a scoping review of reviews published between January 2010 to December 2020. We searched CINAHL, PubMed, Scopus, Web of Science, and Google Scholar. Given the limited literature focusing specifically on Indigenous people with dementia, our inclusion criteria focused broadly on Indigenous cultural safety in healthcare. A collaborative and relational rights-based approach co-led by Indigenous cisgender, Two-Spirit, and non-Indigenous cisgender health care providers was used to re-center Indigenous ways of knowing. A total of seventeen articles met our inclusion criteria. Our review identified a range of cultural safety themes from education initiatives to collaborative partnerships with Indigenous communities. Themes emerged at three levels: person-centered/individual level, health practitioner/student level, and healthcare organizational level. Few reviews described specific interventions, implementation strategies, evaluation methods, or the concept of sex and gender to improve cultural safety in healthcare delivery. Findings from this review can help to inform future research, inspire innovative collaborative methodologies, and enhance cultural safety interventions. In moving forward, there is an urgent need for anti-racism education, self-determination, and authentic partnerships to achieve Indigenous-specific cultural safety inclusive of sex and gender considerations in health and dementia care.

Critiquing the Canadian Model of Client-Centered Enablement (CMCE) for Indigenous Contexts

Background. The Truth and Reconciliation Commission of Canada outlines the need for health care professionals to create more welcoming spaces for Indigenous Peoples. The scope of occupational therapy is continually expanding-yet the profession itself is grounded in and derived from a dominant Eurocentric worldview, and practice is designed to serve a homogenous Western populace. Purpose. To critically examine the Canadian Model of Client-Centered Enablement (CMCE) for its value within Indigenous contexts. Key Issues. The CMCE is positioned as a client-centered model, however there is a clear hierarchical client-professional relationship threaded throughout. Concepts such as enable, advocate, educate, coach, and coordinate demonstrate paternalistic authority, lacking reciprocity, knowledge-sharing, and power redistribution. Implications. Reimagining health care relationships as entrenched in social interconnectedness demands critical reflection and action. A model of practice that endorses social change and actively addresses colonial power inequities must root its paradigmatic foundations in postcolonial views of health care as a social relationship.

Culturally safe dementia care: Building nursing capacity to care for First Nation Elders with memory loss

BACKGROUND

Nursing staff require culturally relevant and dementia-specific education to care for the increasing number of First Nation Elders experiencing memory loss. The culturally safe dementia care (CSDC) research team, composed of researchers, decision makers and Secwepemc Elders, was formed to address this.

OBJECTIVES

To increase the capacity of nurses to care for First Nations Elders with memory loss in a culturally safe way.

METHODS

Our community-based research used purposive sampling and mixed methods to create, implement and evaluate an education programme for nurses. Thirty-four Elders from six Secwepemc communities participated in roundtables to share views and stories of dementia and nursing care. These data were used to create four teaching stories for the storytelling sessions and talking circles with Elders which, together with the Indigenous Cultural Competency (ICC) training, comprised the CSDC education programme. Thirty-eight nurses (healthcare aides, licensed practical nurses and registered nurses) working in Central British Columbia began the CSDC study and 15 nurses took part in the education programme, evaluated the storytelling session and completed the three pre- and post-measures (Approaches to Dementia Questionnaire (ADQ), ICC knowledge quiz and self-assessment, and Care Plans). The pre- and post-tests were scored, and the data were analysed statistically. The data from the roundtables and talking circles were analysed thematically through a collaborative process.

RESULTS

The scores for the ADQ Hope sub-scale, the ICC knowledge quiz and the Care Plans increased from pre- to post-test. All nurse participants judged the storytelling session to be effective and their learning outcomes reflected culturally safe dementia care.

CONCLUSIONS

This programme can improve the knowledge, skills and values of nurses to provide culturally safe dementia care.

Canadian Indigenous Cognitive Assessment (CICA): Inter-rater reliability and criterion validity in Anishinaabe communities on Manitoulin Island, Canada

INTRODUCTION

Despite increasing dementia rates, few culturally informed cognitive assessment tools exist for Indigenous populations. The Canadian Indigenous Cognitive Assessment (CICA) was adapted with First Nations on Manitoulin Island, Canada, and provides a brief, multi-domain cognitive assessment in English and Anishinaabemowin.

METHODS

Using community-based participatory research (CBPR) methods, we assessed the CICA for inter-rater and test-retest reliability in 15 individuals. We subsequently evaluated validity and established meaningful CICA cut-off scores in 55 individuals assessed by a geriatrician.

RESULTS

The CICA demonstrated strong reliability (intra-class coefficient = 0.95 [0.85,0.98]). The area under the curve (AUC) was 0.98 (0.94, 1.00), and the ideal cut-point to identify likely cases of dementia was a score of less than or equal to 34 with sensitivity of 100% and specificity of 85%.

DISCUSSION

When used with older First Nations men and women living in First Nations communities, the CICA offers a culturally safe, reliable, and valid assessment to support dementia case-finding.