Threat to valued elements of life: the experience of dementia across three ethnic groups

The MINDSET Study: Co-Designing Training for Interpreters in Dementia and Cognitive Assessments

There is a growing demand for interpreter-mediated cognitive assessments for dementia. However, most interpreters lack specialist knowledge of dementia and cognitive assessment tools. This can negatively affect the way instructions and responses are conveyed between clinicians and patients, undermining clinicians' ability to accurately assess for cognitive impairment. This article reports on the co-design of an online dementia training package, MINDSET, which aims to address this gap. Two iterative online co-design workshops were conducted in October and November 2021, using a World Café approach. Sixteen clinicians, interpreters, and multilingual family carers of a person with dementia participated. Based on these workshops, training and assessment materials were developed and tested with 12 interpreters from April to June 2022. The training package comprises online modules: 1) Knowledge of Dementia and Australia's Aged Care System, 2) Briefings and Introductions, 3) Interpreting Skills, 4) Interpreting Ethics, and 5) Cross-cultural Communication. The codesign process highlighted divergent perspectives between clinicians and interpreters on an interpreter's role during a cognitive assessment, but it also facilitated negotiation and consensus building, which enriched the training content. The training is now developed and will be evaluated in a randomized control trial and subsequent implementation study.

The shadow of dementia: Listening to undecidability in ethnographic interviews with persons suspecting possible dementia

Even before a diagnosis of dementia, people may negotiate in their everyday lives the fears and suspicions about the possibility of a future with dementia. My field of research involves JewishIsraeli older adult individuals who suspect that they are beginning to lose their memory, but before seeking out a formal diagnosis-and when not seeking a diagnosis at all is an equal possibility. By distinguishing their experience of suspecting possible dementia from this of living with dementia, I attempt to illuminate the social, bio-diagnostic and cultural shadows of dementia hovering in the background of their everyday experience. I begin by shedding light on the ethical and methodological context of my specific field in Israel. I next reflect upon the concept of "shadow," that is constituted within and reflecting the assemblages of lurking presences accompanying my interlocutors' daily negotiations of the possibility of dementia. I then situate their lived experiences, as well as my ethnographic engagement with them, in the context of the prevailing cultural and social moralities surrounding this possibility. Finally, I show how a negotiation of the place that this shadow occupies in their lives arises in the encounter with the ethnographer. This first account of people before diagnosis and not through the diagnostic event, while keeping the space for deciding about a possible future of diagnosis open, can contribute to the understanding of undecidability as an ethical stance in ethnography, incorporating the suspension of the need to order realities through the imperatives of a diagnosis of dementia. Further, understanding these mundane negotiations with these shadows can help us allow more space for uncertainty and unpredictability as legitimate forms of living 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.

Experiences of older immigrants living with dementia and their carers: a systematic review and meta-synthesis

OBJECTIVE

To systematically review and synthesise evidence on the experiences of older immigrants living with dementia and their carers.

DESIGN

A systematic review and meta-synthesis of qualitative studies.

METHODS

Studies exploring the experiences of older immigrants living with dementia and their carers were eligible. Databases were searched including CINAHL, MEDLINE, PsycINFO, PubMed, Embase, Web of Science and Cochrane Library from January 2000 to April 2021. Quality assessment was undertaken using the Critical Appraisal Skills Programme checklist for qualitative studies. Data were then synthesised using the thematic synthesis approach.

RESULTS

The results of this meta-synthesis were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and Enhancing transparency in reporting the synthesis of qualitative research statement. A total of 3857 studies were returned from the database search. Eighteen studies were included for meta-synthesis. Five synthesised findings were identified: living with dementia and caregiving; family relationships; barriers to dementia care services; stigma and discrimination; and legal and financial issues. The experiences of living with dementia and caregiving presented multiple challenges for older immigrants living with dementia and their families. However, there seems to be very little difference between the experiences of those who have migrated to a new country and those who were born and aged in the same country, but the ability to access and use the available services is different.

CONCLUSION

A lack of culturally appropriate dementia services, language barriers and dementia stigma can impede access to dementia care for older immigrants. Strategies to mitigate these barriers are urgently needed to ensure people from culturally and linguistically diverse backgrounds with dementia and their families have the information, education and support to access dementia services, in addition to research that explores the experiences of culturally and linguistically diverse populations.

PROSPERO REGISTRATION NUMBER

CRD42021277913.

Acceptability of the voice your values, an advance care planning intervention in persons living with mild dementia using videoconferencing technology

Advance care planning (ACP) can improve outcomes for persons living with dementia (PLwD). Clinicians see the lack of acceptability of these conversations as a barrier to ACP in individuals with mild dementia. COVID-19 pandemic has magnified the need for ACP discussions in older adults, particularly for those living with dementia. In light of the pandemic, much of the healthcare is provided virtually, but little evidence exists on how to best implement ACP virtually. We designed Voice Your Values (VYV), a tailored ACP intervention for persons living with mild dementia and their trusted individuals such as friends or family. Purpose Determine the acceptability of the VYV intervention, in terms of its content and the potential utility of videoconferencing to deliver it. Methods For this pilot study, we recruited 21 dyads of older adults with mild dementia and their trusted individuals from five geriatric clinics in Ontario, Canada. The tailored VYV intervention was delivered to dyads over two sessions over videoconferencing. Acceptability was assessed using scores on a modified Treatment Evaluation Inventory. The interventionist diary and Researcher Virtual Experience Questionnaire were used to examine facilitators and barriers, whereas Participant Virtual Experience Questionnaire was used to understand their experience. Qualitative data was analyzed using inductive content analysis. Results 100% of the participants rated VYV as acceptable. Participants and researcher rated video and sound quality highly. PLwD who lived with their trusted individuals were more likely to find the intervention acceptable (t = 3.559, p = 0.001, β = 0.323). Five interrelated themes were established that describe the acceptability of the virtually delivered VYV intervention. All PLwD were able to articulate their values and wishes related to being in a terminal and vegetative states and had them documented. Conclusion The virtual VYV intervention was an acceptable approach to ACP in older adults with mild dementia and their trusted individuals.

Accessibility of health care experienced by persons with dementia from ethnic minority groups and formal and informal caregivers: A scoping review of European literature

The number of persons with dementia from ethnic minority backgrounds is increasing. However, ethnic minority groups use health care services less frequently compared to the general population. We conducted a scoping review and used the theoretical framework developed by Levesque to provide an overview of the literature concerning access to health care for ethnic minority people with dementia and (in)formal caregivers. Studies mentioned barriers in (1) the ability to perceive a need for care in terms of health literacy, health beliefs and trust, and expectations; (2) the ability to seek care because of personal and social values and the lack of knowledge regarding health care options; and (3) lack of person-centered care as barrier to continue with professional health care. Studies also mentioned barriers experienced by professionals in (1) communication with ethnic minorities and knowledge about available resources for professionals; (2) cultural and social factors influencing the professionals’ attitudes towards ethnic minorities; and (3) the appropriateness of care and lacking competencies to work with people with dementia from ethnic minority groups and informal caregivers. By addressing health literacy including knowledge about the causes of dementia, people with dementia from ethnic minorities and their informal caregivers may improve their abilities to access health care. Health care professionals need to strengthen their competencies in order to facilitate access to health care for this group.

Barriers in access to dementia care in minority ethnic groups in Denmark: a qualitative study

OBJECTIVES

To explore barriers in access to dementia care in Turkish, Pakistani and Arabic speaking minority ethnic groups in Denmark.

METHOD

Semi-structured qualitative individual- and group interviews with minority ethnic family carers, primary care dementia coordinators, staff in elderly daycare, and multicultural link workers. Hermeneutic phenomenology was used as theoretical framework.

RESULTS

A total of 21 individual- and 6 group interviews were conducted, including a total of 35 participants. On the service user side, barriers in access to dementia care were related to lacking language proficiency and strong cultural norms, including familial responsibility for the care of older family members and stigma associated with mental illness and dementia. On the care provider side, the available formal services were rarely tailored to the specific needs of minority ethnic service users and were often considered inadequate or unacceptable.

CONCLUSION

Care practices and perceived consequences of dementia in minority ethnic communities were heavily influenced by cultural factors leading to a number of persisting barriers to accessing dementia care services. There is a simultaneous need to raise awareness about dementia and the existence of dementia care services in minority ethnic groups, to reduce stigma, and to develop culturally appropriate dementia care options.

A Review of Qualitative Research of Perception and Experiences of Dementia Among Adults From Black, African, and Caribbean Background: What and Whom Are We Researching?

BACKGROUND AND OBJECTIVES

Black, African, and Caribbean (BAC) families are disproportionately affected by dementia but engage less with services. Studies reporting their experiences of dementia have tended to aggregate people from diverse backgrounds, without considering the impact of this diversity, or researchers' ethnicities. We investigated participants' and researchers' ethnic identities, exploring how this relates to findings.

RESEARCH DESIGN AND METHODS

We searched electronic databases in September 2018, for qualitative studies exploring how participants of Black ethnicity understand and experience dementia and dementia care. We reported participants' and researchers' ethnicities, and meta-synthesized qualitative findings regarding how ethnicity influences experiences and understanding of dementia.

RESULTS

Twenty-eight papers reported 25 studies; in United States (n = 17), United Kingdom (n = 7), and Netherlands (n = 1). 350/492 (71%) of participants were in U.S. studies and described as African American; participants in U.K. studies as Caribbean (n = 45), African/Caribbean (n = 44), African (n = 28), Black British (n = 7), or Indo-Caribbean (n = 1); and in Netherlands as Surinamese Creole (n = 17). 6/25 (24%) of studies reported involving recruiters/interviewers matching participants' ethnicity; and 14/25 (56%) involved an author/advisor from a BAC background during analysis/procedures. We identified four themes: Dementia does not relate to me; Inappropriate and disrespectful services; Kinship and responsibility; Importance of religion.

DISCUSSION AND IMPLICATIONS

Studies were mostly from a U.S. African American perspective, by researchers who were not of BAC background. Themes of dementia diagnosis and services feeling less relevant to participants than the majority population resonated across studies. We caution against the racialization of these findings, which can apply to many differing minority groups.

Exploring Dementia Care Systems Across the African Caribbean Diaspora: A Scoping Review and Consultation Exercise

BACKGROUND AND OBJECTIVES

Understanding the influences of marginalized cultural and social identities as experienced by the African Caribbean diaspora within the context of dementia care is essential to minimize the gaps in current practice and policy in the health care setting. This study explores the impact of marginalized identities upon the meaning-making process, access to services and experience of care provisions through a scoping review and consultancy exercises with key stakeholders.

RESEARCH DESIGN

Fourteen databases were searched using key terms. Primary studies in English, any year, study design, and country of origin were eligible. Titles, abstracts, and full texts were screened for inclusion and data were extracted in stages. Thematic analysis was performed and the findings were discussed in a series of consultation meetings with people with dementia, carers, and health care professionals in Manchester (United Kingdom) and Jamaica.

RESULTS

The scoping review retrieved n = 1,989 research articles. Nineteen were included, most were qualitative (n = 14), 3 quantitative, and 2 mixed-method. The findings revealed limited insight into cultural and multiple individual identities in explaining conceptualization and service access. Consultation meetings confirmed these findings and highlighted differences in health care services and systems in the United Kingdom and Jamaica.

DISCUSSION AND IMPLICATIONS

This study suggests there is a complex interaction of sociocultural processes that marginalize African Caribbean persons in and across various national settings within the context of dementia care. The study highlights the importance of acknowledging and addressing how prevalent racialized- and class-based divides and related marginalized social locations are reflected in inequities in access to and use of dementia services.

Participation as means for adaptation in dementia: a conceptual model

OBJECTIVES

There are a number of conceptual models of dementia, capturing a range of biopsychosocial factors. Few integrate the lived experience of dementia. The aim of this study was to develop a conceptualisation grounded in the first-hand accounts of living with the condition and reflecting its complexity.

METHOD

The study was conducted within an explanatory, critical realist paradigm. An overarching narrative approach, informed by a previously completed systematic review and metasynthesis of research on the lived experience of dementia and the assumptions of complexity theory, was used to guide data collection and analysis. Data were contributed by 31 adults, including 12 people living with dementia and 19 family caregivers.

RESULTS

The experience of living with dementia was conceptualised as a process of adaptation through participation, emerging from ongoing, dynamic and nonlinear interactions between the adaptive capacity of a person with dementia and the adaptive capacity within the environment. The proposed conceptual model describes contexts and mechanisms which shape this capacity. It identifies a range of potential outcomes in dementia. These outcomes reflect interactions and the degree of match between the adaptive capacity of a person and the adaptive capacity within the environment.

CONCLUSION

By recognising and exploring the potential for adaptation and enduring participation in dementia, findings of this research can support practitioners in facilitating positive outcomes for people affected by the condition.

Adapting and Optimizing Problem Adaptation Therapy (PATH) for People With Mild-Moderate Dementia and Depression

OBJECTIVE

To adapt and optimize problem adaptation therapy for depression in dementia by grounding it in the lives of people with dementia, caregivers and clinicians.

METHODS

A person-centered qualitative approach was taken to elicit the unique cognitive, psychological and social needs of people with dementia relevant to the adaptation of the intervention. A two-stage design was used: the first involved interviews and focus groups to identify priorities and concerns surrounding depression in dementia, the second trialling of the adapted intervention.

PARTICIPANTS

Ten people with dementia and nine caregivers participated in individual interviews, 35 healthcare practitioners and clinical academics with experience of working with dementia participated in focus groups.

RESULTS

The findings highlight the importance of addressing key themes that typified the experience of depression among people with dementia including: a profound sense of isolation and role loss, the feeling of being both a burden and poorly understood, polarized thinking, interpersonal tensions, diverging views among carers and people with dementia about their capabilities, and changeability in cognitive ability and mood. These themes were used to inform adaptation of the intervention manual, ensuring that its content and delivery addressed the concerns of both people with depression and dementia and those who support them.

CONCLUSION

Implications for PATH included a focus on facilitating open communication, supporting the continuation of valued roles, and improving confidence.

Barriers to access and ways to improve dementia services for a minority ethnic group in England

RATIONALE, AIMS, AND OBJECTIVES

There is a general lack of awareness and understanding of dementia within ethnic minority groups in the United Kingdom. There is also a dearth of research involving ethnic minority caregivers about reducing barriers to accessing services and optimizing engagements with religiously tailored interventions. This paper reports findings from a qualitative study that examined the barriers to health care service use in the Bangladeshi community living in the United Kingdom.

METHODS

The research draws on findings from a doctoral level research study on understanding dementia among the Bangladeshi community in England. The data for the doctoral research were gathered in two ways: (a) focus group discussions and (b) semi-structured interviews. All data were audio-recorded and analysed using thematic analysis. NVivo software was used to aid transcribing, coding, and interpretation of emergent themes.

RESULTS

The data showed that there were some barriers experienced by participants due to their religious and cultural beliefs and practices with other barriers related to the complexity of the UK health care system. Gender-based caregiving also appeared to interfere with religious ideologies while religiously appropriate health care services were deemed of great importance for successfully accessing those services.

CONCLUSIONS

The findings provide an understanding of the experiences of the Bangladeshi community when seeking to access mainstream UK health care services and may help to provide useful directions for future research.

Access to Health Services in Older Minority Ethnic Groups with Dementia: A Systematic Review

BACKGROUND/OBJECTIVES

While it is acknowledged that minority ethnic (ME) groups across international settings face barriers to accessing care for dementia, it is not clear whether ME groups access services less frequently as a result. The objective of this review is to examine whether ME groups have longer delays before accessing dementia/memory services, higher use of acute care and crisis services and lower use of routine care services based on existing literature. We also examined whether ME groups had higher dementia severity or lower cognition when presenting to memory services.

DESIGN

Systematic review with narrative synthesis.

SETTING

Nonresidential medical, psychiatric, memory, and emergency services.

PARTICIPANTS

Twenty studies totaling 94,431 older adults with dementia or mild cognitive impairment.

MEASUREMENTS

We searched Embase, Ovid MEDLINE, Global Health, and PsycINFO from inception to November 2018 for peer-reviewed observational studies which quantified ethnic minority differences in nonresidential health service use in people with dementia. Narrative synthesis was used to analyze findings.

RESULTS

Twenty studies were included, mostly from the U.S. (n = 13), as well as the UK (n = 4), Australia (n = 1), Belgium (n = 1), and the Netherlands (n = 1). There was little evidence that ME groups in any country accessed routine care at different rates than comparison groups, although studies may have been underpowered. There was strong evidence that African American/Black groups had higher use of hospital inpatient services versus U.S. comparison groups. Primary care and emergency services were less well studied. Study quality was mixed, and there was a large amount of variability in the way ethnicity and service use outcomes were ascertained and defined.

CONCLUSION

There is evidence that some ME groups, such as Black/African American groups in the U.S., may use more acute care services than comparison populations, but less evidence for differences in routine care use. Research is sparse, especially outside the U.S.

"In the Bengali Vocabulary, There Is No Such Word as Care Home": Caring Experiences of UK Bangladeshi and Indian Family Carers of People Living With Dementia at Home

BACKGROUND AND OBJECTIVES

We aimed to explore experiences of South Asian carers of people with dementia receiving health or social care in the United Kingdom, purposively recruited to encompass a range of migration, economic and cultural experiences. While previous work in this area has reported carers' understanding of, and attitudes to dementia, we explored how carers' cultural identities and values influenced their experiences, negotiation of the caring role and relationship with services.

RESEARCH DESIGN AND METHODS

We conducted semi-structured interviews with 10 Bangladeshi and Indian family carers of people living with dementia at home. We recruited participants from community settings in London and Bradford, UK. Interviews were audio recorded, transcribed and thematically analyzed.

RESULTS

We identified 4 themes: an expectation and duty to care, expectation and duty as a barrier to accessing formal care (family carer reluctance, care recipient reluctance, and service organization), culturally (in)sensitive care, and the importance of support from informal care networks.

DISCUSSION AND IMPLICATIONS

Interviewees described tensions between generations with different understandings of familial care obligations. Expectations to manage led to burden and guilt, and the cost of caring, in terms of lost employment and relationships was striking. Unlike in previous studies, interviewees wanted to engage and be supported by services, but were frequently offered care models they could not accept. There was a tension between a state-provided care system obliged to provide care when there are no alternatives, and family carers who feel a duty to always provide alternatives. Informal social networks often provided valued support.

Dementia Knowledge and Attitudes of the General Public among the Bangladeshi Community in England: A Focus Group Study

BACKGROUND

Increasing life expectancy worldwide means more people will develop dementia. Despite the rapid growth in older Bangladeshi immigrants living in the UK, there is little evidence of how community members understand and view the process of ageing and dementia. However, Bangladeshis have a higher risk of developing type 2 diabetes and heart disease, both of which are important indicators of dementia development in old age. This study aimed to explore and analyse the perception and knowledge of, and attitudes towards, ageing and dementia among the Bangladeshi community.

METHODS

A qualitative research approach guided two separate focus group discussions held with Bangladeshi adults in Portsmouth, UK. A topic guide was used alongside two vignettes depicting either early- or late-stage dementia to stimulate discussion. The data were recorded, transcribed, and analysed thematically using NVivo qualitative software.

RESULTS

Three main themes emerged: (1) knowledge and perceptions of dementia; (2) perceived causes of dementia; and (3) perceptions of stigma about dementia. Lack of knowledge and understanding of dementia was evident, but the stigma about dementia was non-existent. This study fills a research gap by providing qualitative research examining knowledge about and attitudes towards dementia among a Bangladeshi community in England.

CONCLUSION

Future research must highlight the importance of raising dementia awareness among, and providing information about dementia caregiving to, Bangladeshi community members, as well as providing religiously sensitive healthcare services.

Ethnic disparity in access to the memory assessment service between South Asian and white British older adults in the United Kingdom: A cohort study

BACKGROUND

Equality of access to memory assessment services by older adults from ethnic minorities is both an ethical imperative and a public health priority.

OBJECTIVE

To investigate whether timeliness of access to memory assessment service differs between older people of white British and South Asian ethnicity.

DESIGN

Longitudinal cohort.

SETTING

Nottingham Memory Study; outpatient secondary mental healthcare.

SUBJECTS

Our cohort comprised 3654 white British and 32 South Asian older outpatients.

METHODS

The criterion for timely access to memory assessment service was set at 90 days from referral. Relationships between ethnicity and likelihood of timely access to memory assessment service were analysed using binary logistic regression. Analyses were adjusted for socio-demographic factors, deprivation and previous access to rapid response mental health services.

RESULTS

Among white British outpatients, 2272 people (62.2%) achieved timely access to memory assessment service. Among South Asian outpatients, fourteen people (43.8%) achieved timely access to memory assessment service. After full adjustment, South Asian outpatients had a 0.47-fold reduced likelihood of timely access, compared to white British outpatients (odds ratio 0.47, 95% confidence interval 0.23-0.95, P value = .035). The difference became non-significant when restricting analyses to outpatients reporting British nationality or English as first language. Older age, lower index of deprivation and previous access to rapid response mental health services were associated with reduced likelihood of timely access, while gender was not.

CONCLUSIONS

In a UK mental healthcare service, older South Asian outpatients are less likely to access dementia diagnostic services in a timely way, compared to white British outpatients.

Patients' and Family Members' Subjective Experiences of a Diagnostic Evaluation of Mild Cognitive Impairment

Background:

People with a diagnosis of mild cognitive impairment (MCI) often struggle with uncertainty and fear when learning of and coping with their diagnosis. However, little is known about their experiences and perspectives, and those of their care partners, when seeking out and undergoing a diagnostic evaluation for their cognitive symptoms.

Method:

This study is a secondary analysis of a focus group discussion that was initially conducted to learn the perspectives and experiences of participants and their care partners during a mock disclosure session of brain scan results. Participant’s broader views on their experience of completing a cognitive evaluation resulting in an MCI diagnosis were evaluated in this study. Analysis used qualitative content methodology and line-by-line coding which generated categories and themes.

Results:

The (1) “presence of a threat” and (2) attempts to “minimize the threat” emerged as overarching themes driving the process of seeking out a diagnostic evaluation for cognitive symptoms. Subthemes that highlight the complexity of the presence of a threat included the “fear of stigma,” and the “emotional reactions” related to an MCI diagnosis. Three additional subthemes represented approaches that participants and their care partners used to minimize threat of MCI: “use of language” to minimize the threat; “information sharing and withholding”; and the “use of social support to legitimize personal experiences.”

Conclusion:

These findings add to the literature by elucidating the uncertainty, fears, and coping strategies that accompany a diagnostic evaluation of MCI.

Age, memory loss and perceptions of dementia in South Asian ethnic minorities

BACKGROUND

South Asian older adults are represented less frequently in mainstream mental health services or those for people with dementia. This study aimed to explore in detail the perceptions of dementia (symptoms, causes, consequences, treatments) held by South Asians and to discern how these understandings vary by age and by the self-recognition of memory problems, as these influence help-seeking behaviour.

METHODS

Participants were allocated to three groups: younger adults; older adults; and older adults with subjective memory problems. They completed the semi-structured Barts Explanatory Model Inventory for Dementia schedule, whilst older adults also completed measures of cognition (MMSE), and depression (GDS). Interviews were conducted in English, Gujarati or Urdu.

RESULTS

Groups were similar in identifying unusual forgetting and confusion as the most frequent symptoms; stress and age as the most frequent causes; and talking to your GP/nurse, taking medication, and talking to family and friends as the most frequent treatments. Younger adults more often knew about risk factors and reported practical consequences more than older adults. Older adults with subjective memory problems were more likely to describe sleep related problems or symptoms commonly associated with depression. They more often cited as causes of dementia lack of sleep, side effects of medication and medical reasons, and mentioned religion as a means to cope.

CONCLUSIONS

Findings highlight variability in perceptions of dementia across the South Asian Community and identify specific areas where dementia awareness could be raised in South Asian sub-groups to improve timely diagnosis, treatment outcomes and service access.

Living With Dementia: A Meta-synthesis of Qualitative Research on the Lived Experience

Purpose of the Study

To identify and examine the published qualitative research evidence relative to the experience of living with dementia.

Design and Methods

Metasynthesis was used as the methodological framework to guide data collection and analysis.

Results

Three themes were identified. The first theme considered the main condition-related changes experienced by people with dementia (PWD) and showed how these are interlinked and impact upon various areas of people’s lives. The second theme indicated that amidst these changes, PWD strive to maintain continuity in their lives by employing various resources and coping strategies. The third theme underlined the role of contextual factors. The reviewed evidence indicates that, the emerging experience of PWD and their potential to adjust to the continuous changes is influenced by access to and quality of both personal and contextual resources which remain in a constant, transactional relationship to each other.

Implications

The findings were interpreted and discussed in the context of relevant theoretical frameworks and research evidence. It was considered that current evidence and findings presented in this review can be further explored and expanded upon in a more systematic way through research conducted within the theoretical framework of dynamic systems theory. Further research would be also beneficial to explore the subjective experience of dementia from a participatory perspective. Exploring the application of these theoretical standpoints would contribute to the current state of knowledge and offer both PWD and carers fresh perspective on the nature of change and potential for adaptability in dementia.

Awareness and understanding of dementia in South Asians: A synthesis of qualitative evidence

Background

Despite a growing elderly South Asian population, little is known about the experience of diagnosis and care for those living with dementia. There have been a number of individual qualitative studies exploring the experiences of South Asian people living with dementia and their carers across different contexts. There has also been a growing interest in synthesizing qualitative research to systematically integrate qualitative evidence from multiple studies to tell us more about a topic at a more abstract level than single studies alone. The aim of this qualitative synthesis was to clearly identify the gaps in the literature and produce new insights regarding the knowledge and understanding of the attitudes, perceptions, and beliefs of the South Asian community about dementia.

Methods

Following a systematic search of the literature, included qualitative studies were assessed by two independent reviewers for methodological quality. Data were extracted and pooled using the Joanna Briggs Institute Qualitative Assessment and Review Instrument (QARI). Findings were synthesized using the Joanna Briggs Institute approach to qualitative synthesis by meta-aggregation.

Results

Seventeen papers were critically appraised, with 13 meeting the inclusion criteria. Participants were mostly of South Asians of Indian background; followed by Pakistani with a few Sri Lankans. Missing South Asian countries from the current evidence base included those from Bangladesh, Bhutan, Maldives, and Nepal. Three meta-synthesis themes emerged from the analysis: (1) a poor awareness and understanding of dementia, (2) the experience of caregiving, and (3) the attitudes toward dementia care provision.

Conclusions

A consistent message from this qualitative synthesis was the limited knowledge and understanding of dementia amongst the South Asians. Whilst symptoms of dementia such as ‘memory loss’ were believed to be a part of a normal ageing process, some South Asian carers viewed dementia as demons or God’s punishments. Most studies reported that many South Asians were explicit in associating stigmas with dementia.

Caring and Uncaring Encounters between Assistant Nurses and Immigrants with Dementia Symptoms in Two Group Homes in Sweden-an Observational Study

BACKGROUND

The total number of people with dementia symptoms is expected to double every 20 years and there will also be an increase in the number of older immigrants in several countries. There are considerable deficiencies in the present knowledge of how to conduct well-functioning health care for immigrants with dementia symptoms. The aim of this study was to explore caring and uncaring encounters between assistant nurses and immigrants in two group homes for persons with dementia symptoms in Sweden: a Finnish-speaking as well as a Swedish-speaking context. In addition, this study aims to describe how caring and uncaring encounters are manifested in these two contexts according to Halldórsdóttir's theory of "Caring and Uncaring encounters".

METHOD

Descriptive field notes from 30 separate observations were analyzed using qualitative deductive content analysis.

RESULTS

The main category "caring encounters" focused on reaching out to initiate connection through communication, removing masks of anonymity by acknowledging the unique person, acknowledgment of connection by being personal. Reaching a level of truthfulness by being present and showing respect, raising the level of solidarity by equality and true negotiation of care, based on the residents' needs. The main category, uncaring encounters, focused on disinterest in and insensitivity towards the other, coldness in the connection and lack of humanity in care situations. The observations showed that caring encounters occurred more in the Finnish-speaking context and uncaring encounters more often in the Swedish context.

CONCLUSION

Encounters could be caring, uncaring, and carried out using a person-centered approach. Communication and relationships could be facilitated using the same language but also through learning to interpret residents' needs and desires.

Dementia in UK South Asians: a scoping review of the literature

OBJECTIVE

Over 850 000 people live with dementia in the UK. A proportion of these people are South Asians, who make up over 5% of the total UK population. Little is known about the prevalence, experience and treatment of dementia in the UK South Asian population. The aim of this scoping review is to identify dementia studies conducted in the UK South Asian population to highlight gaps in the literature which need to be addressed in future research.

METHOD

Databases were systematically searched using a comprehensive search strategy to identify studies. A methodological framework for conducting scoping reviews was followed. An extraction form was developed to chart data and collate study characteristics and findings. Studies were then grouped into six categories: prevalence and characteristics; diagnosis validation and screening; knowledge, understanding and attitudes; help-seeking; experience of dementia; service organisation and delivery.

RESULTS

A total of 6483 studies were identified, 27 studies were eligible for inclusion in the scoping review. We found that studies of prevalence, diagnosis and service organisation and delivery in UK South Asians are limited. We did not find any clinical trials of culturally appropriate interventions for South Asians with dementia in the UK. The existing evidence comes from small-scale service evaluations and case studies.

CONCLUSIONS

This is the first scoping review of the literature to identify priority areas for research to improve care for UK South Asians with dementia. Future research should first focus on developing and validating culturally appropriate diagnostic tools for the UK South Asians and then conducting high-quality epidemiological studies in order to accurately identify the prevalence of dementia in this group. The cultural adaptation of interventions for dementia and testing in randomised controlled trials is also vital to ensure that there are appropriate treatments available for the UK South Asians to access.

The experience of lived space in persons with dementia: a systematic meta-synthesis

BACKGROUND

Identifying how persons with dementia experience lived space is important for enabling supportive living environments and creating communities that compensate for the fading capabilities of these persons. Several single studies have explored this topic; however, few studies have attempted to explicitly review and synthesize this research literature. The aim of this systematic meta-synthesis was therefore to interpret and synthesize knowledge regarding persons with dementia's experience of space.

METHODS

A systematic, computerized search of AgeLine, CINAHL Complete, Embase, Medline and PsycINFO was conducted using a search strategy that combined MeSH terms and text words for different types of dementia with different descriptions of experience. Studies with 1) a sample of persons with dementia, 2) qualitative interviews as a research method and 3) a description of experiences of lived space were included. The search resulted in 1386 articles, of which 136 were identified as eligible and were read and assessed using the CASP criteria. The analysis was inspired by qualitative content analyses.

RESULTS

This interpretative qualitative meta-synthesis included 45 articles encompassing interviews with 672 persons with dementia. The analysis showed that living in one's own home and living in long-term care established different settings and posed diverse challenges for the experience of lived space in persons with dementia. The material revealed four main categories that described the experience of lived space: (1) belonging; (2) meaningfulness; (3) safety and security; and (4) autonomy. It showed how persons with dementia experienced a reduction in their lived space due to the progression of dementia. A comprehensive understanding of the categories led to the latent theme: "Living with dementia is like living in a space where the walls keep closing in".

CONCLUSION

This meta-synthesis reveals a process whereby lived space gradually becomes smaller for persons with dementia. This underscores the importance of being aware of the experiences of persons with dementia and the spatial dimensions of their life-world. To sustain person-centred care and support the preservation of continuity and identity, one must acknowledge not only the physical and social environment but also space as an existential experience for persons with dementia.

Person-centred care: experiences of older people with dementia

AIM

To explore the views, perceptions and experiences of older people with dementia of person-centred care, and how these might affect practice.

METHOD

This was a qualitative literature review. A literature search was undertaken, which involved searching databases, reference-checking, and hand-searching of academic journals, national policies and nursing organisation websites, from 1999 to 2017. The author undertook data extraction and a meta-synthesis independently to identify themes from the articles.

FINDINGS

A total of 12 articles were included in the literature review. Few articles pertaining to the views, perceptions and experiences of older people with dementia receiving person-centred care were identified, with most of the literature based in settings outside the UK. Four main themes were identified: shared decision-making; promoting individuality, independence and autonomy; person-centred care; and communication and giving voice to people with dementia.

CONCLUSION

Knowledge of the lived experience of people with dementia is important to ensure they receive care that enhances their quality of life. It is essential to consider the views and experiences of older people with dementia to provide effective person-centred care and undertake appropriate research. Further research is required to evaluate the experiences of older people with dementia receiving care to inform practice.

Barriers and facilitators in accessing dementia care by ethnic minority groups: a meta-synthesis of qualitative studies

BACKGROUND

It is estimated that there are about 25,000 people from UK ethnic minority groups with dementia. It is clear that there is an increasing need to improve access to dementia services for all ethnic groups to ensure that everyone has access to the same potential health benefits. The aim was to systematically review qualitative studies and to perform a meta-synthesis around barriers and facilitators to accessing care for dementia in ethnic minorities.

METHODS

Databases were searched to capture studies on barriers and facilitators to accessing care for dementia in ethnic minorities. Analysis followed the guidelines for meta-ethnography. All interpretations of data as presented by the authors of the included papers were extracted and grouped into new themes.

RESULTS

Six hundred and eighty four papers were identified and screened. Twenty eight studies were included in the meta-synthesis. The analysis developed a number of themes and these were incorporated into two overarching themes: 'inadequacies' and 'cultural habitus'.

CONCLUSIONS

The two overarching themes lend themselves to interventions at a service level and a community level which need to happen in synergy.

TRIAL REGISTRATION

The review was registered with PROSPERO: CRD42016049326 .

Caring for Ethnic Older People Living with Dementia - Experiences of Nursing Staff

The total number of persons living with dementia is estimated to double every 20 years and ageing migrant populations are growing in several countries. There are gaps in the health and social care of people from other countries, regardless of the efforts made when someone has a dementia diagnosis; similarly, receiving care in sheltered accommodation is less common. The aim of this study was to explore and describe the nursing staff's experiences of caring for non-Swedish speaking persons living with dementia in a Finnish speaking group home in relation to a Swedish speaking group home in Sweden. 27 qualitative semi-structured interviews were analysed using qualitative content analyses. The first main category, "communication", concentrated on language abilities and deficiencies, non-verbal language, highlighting the consequences of not understanding and the benefits of a common language. The second main category, "culturally oriented activities", focused on being served traditional food, celebrating holidays at the group home, the importance of traditions and the importance of familiar music as cultural elements. The Swedish speaking nursing staff could provide qualitative and equitable care, but the challenge was greater for them than for the bilingual nursing staff who spoke the same language as the residents.

Adaptation of the Barts Explanatory Model Inventory to dementia understanding in South Asian ethnic minorities

OBJECTIVE

Studies indicate a limited understanding of dementia and its associated symptoms, causes and consequences among South Asian older adults. As a consequence, fewer people from this ethnic group receive a diagnosis of dementia. The aim of this study was to adapt the previously designed Barts Explanatory Model Inventory Checklist (BEMI-C), a tool designed to elicit perceptions of mental illness from people with different cultural backgrounds, for use with people with dementia in the South Asian population.

METHOD

Both a literature review and 25 qualitative interviews were conducted to find themes and perceptions that are relevant to the South Asian culture in recognising and dealing with symptoms of dementia. The emergent themes and perceptions were then added to the BEMI-C through synthesis of findings.

RESULTS

The initial four checklists of symptoms, causes, consequences and treatments from the BEMI-C were retained in the new BEMI-Dementia (BEMI-D) and expanded with six additional themes, including 123 new perceptions relevant to the understanding of dementia. All new themes emerged from the qualitative interviews, some of which were also found in the literature.

CONCLUSION

Given the national priority of improving dementia awareness and timely diagnosis, the BEMI-D can serve as a useful tool, in research and perhaps practice, to assess the barriers to dementia service uptake in this population and their understandings of dementia. Based on the detailed methodological description of the adaptation of the BEMI-C, this paper further suggests how this tool can be adapted to suit other ethnic minority groups.

Subjective Cognitive Decline from a Phenomenological Perspective: A Review of the Qualitative Literature

BACKGROUND

Subjective cognitive decline is related to greater risk of dementia and biological markers of Alzheimer's disease (AD), but researchers are yet to characterize the phenomenological perspective of cognitive decline in those with and without a diagnosis of AD.

OBJECTIVE

To collate and synthesize studies measuring the subjective experience of cognitive change or decline in healthy older adults and those with mild cognitive impairment and AD.

METHODS

We reviewed 58 peer-reviewed articles that were found to directly or indirectly refer to the subjective experience of cognitive decline.

RESULTS

We extracted eight central themes, dealing with cognitive changes experienced by each diagnostic group, and also related to issues of changing self-identity, the causal attribution of cognitive decline, the anxiety and concern related to perceived decline, the negative perceptions attached to a diagnosis of dementia, changing levels of insight, and perception of well-being in aging.

CONCLUSION

This review is the first step toward characterizing phenomenological profiles of cognitive change in both non-demented and demented older adults. Developing a clearer understanding of subjective cognitive decline, particularly at the earliest stages of AD, will augment the sensitivity of detection of individuals at greater risk of future dementia.

Black African and Caribbean British Communities' Perceptions of Memory Problems: "We Don't Do Dementia."

Objectives

We aimed to identify and explore the barriers to help-seeking for memory problems, specifically within UK Black African and Caribbean communities.

Method

We purposively recruited participants from community groups and subsequent snowball sampling, to achieve a maximum variation sample and employed thematic analysis. Our qualitative semi-structured interviews used a vignette portraying a person with symptoms of dementia, and we asked what they or their family should do. We stopped recruiting when no new themes were arising.

Results and significance

We recruited 50 people from a range of age groups, country of origin, time in the UK, religion and socio-economic background. Some of the barriers to presentation with dementia have been reported before, but others were specific to this group and newly identified. Many people recognised forgetfulness but neither that it could be indicative of dementia, nor the concept of dementia as applying to them. Dementia was viewed as a white person’s illness. Participants felt there was little point in consulting a doctor for forgetfulness. Many thought that seeing a GP was only for severe problems. Some said that their culture was secretive and highly valued privacy of personal affairs and therefore did not want to discuss what they regarded as a private and stigmatising problem with a GP. Participants did not appreciate their GP could refer to memory services who have more time and expertise. They were concerned about harm from medication and compulsory institutionalisation. Care should be from the family. Any intervention should emphasise the legitimacy of seeing a doctor early for memory concerns, that dementia is a physical illness which also occurs in the Black community, that help and time are available from memory services whose role is to prolong independence and support families in caring.

Perceptions of self-defined memory problems vary in south Asian minority older people who consult a GP and those who do not: a mixed-method pilot study

OBJECTIVE

South Asian older adults access services for mental health problems and dementia less than other older people in the UK, unlike for physical health problems. This pilot study investigated how South Asians with self-defined memory problems, with and without GP consultation, construe the symptoms, causes, consequences and treatment of the condition.

METHODS

Participants were recruited through community centres, their networks and memory clinics in Greater Manchester. The newly developed Barts Explanatory Model Inventory for Dementia (BEMI-D) was administered to 33 (18 M, 15 F) older South Asians aged 65 or above with memory problems in English, Gujarati or Urdu. Furthermore, cognition, executive function and depression were assessed.

RESULTS

Perceptions of dementia varied by GP consultation for memory problems. A greater proportion of older adults without a consultation considered memory problems to be given by God, saw acceptance of fate as an alternative treatment and did not identify medical support as appropriate. Forgetfulness and loss of social meaning were identified as symptoms of dementia more by those with a consultation. Higher levels of diabetes, heart disease and depression were found in those without a consultation.

CONCLUSIONS

Differences in perceptions may influence the decision about consulting a GP. Similarly, consultation for memory problems appears linked to extent physical health problems and mental health consultation (depression). These variations reported on a small scale in this pilot study suggest the need to explore the impact of perceptions on rates of GP consultation, so as to improve timely diagnosis and access to appropriate services.

Perspectives of People with Dementia About Meaningful Activities: A Synthesis

Qualitative studies were synthesized to describe perspectives of people with dementia regarding meaningful activities. Themes of connectedness were identified using a meta-ethnography approach. The theme of being connected with self encompasses engagement for continuity, health promotion, and personal time. The theme of being connected with others includes being with others not to feel alone, doing an activity with others, and meaningful relationships. The theme of being connected with the environment encompasses being connected to one’s familiar environment, community, and nature. This synthesis suggests that connectedness is an important motivation for engagement in daily activities. Findings indicate that identifying the underlying motivation for an individual with dementia to engage in different activities is important for matching a person with activities that will be satisfying. This review may inform the development of interventions for engaging people with dementia in meaningful, daily activities and creating connectedness to self, others, and the environment.

Comorbidity and dementia: a mixed-method study on improving health care for people with dementia (CoDem)

Background

Among people living with dementia (PLWD) there is a high prevalence of comorbid medical conditions but little is known about the effects of comorbidity on processes and quality of care and patient needs or how services are adapting to address the particular needs of this population.

Objectives

To explore the impact of dementia on access to non-dementia services and identify ways of improving the integration of services for this population.

Design

We undertook a scoping review, cross-sectional analysis of a population cohort database, interviews with PLWD and comorbidity and their family carers and focus groups or interviews with health-care professionals (HCPs). We focused specifically on three conditions: diabetes, stroke and vision impairment (VI). The analysis was informed by theories of continuity of care and access to care.

Participants

The study included 28 community-dwelling PLWD with one of our target comorbidities, 33 family carers and 56 HCPs specialising in diabetes, stroke, VI or primary care.

Results

The scoping review (n = 76 studies or reports) found a lack of continuity in health-care systems for PLWD and comorbidity, with little integration or communication between different teams and specialities. PLWD had poorer access to services than those without dementia. Analysis of a population cohort database found that 17% of PLWD had diabetes, 18% had had a stroke and 17% had some form of VI. There has been an increase in the use of unpaid care for PLWD and comorbidity over the last decade. Our qualitative data supported the findings of the scoping review: communication was often poor, with an absence of a standardised approach to sharing information about a person’s dementia and how it might affect the management of other conditions. Although HCPs acknowledged the vital role that family carers play in managing health-care conditions of PLWD and facilitating continuity and access to care, this recognition did not translate into their routine involvement in appointments or decision-making about their family member. Although we found examples of good practice, these tended to be about the behaviour of individual practitioners rather than system-based approaches; current systems may unintentionally block access to care for PLWD. Pathways and guidelines for our three target conditions do not address the possibility of a dementia diagnosis or provide decision-making support for practitioners trying to weigh up the risks and benefits of treatment for PLWD.

Conclusions

Significant numbers of PLWD have comorbid conditions such as stroke, diabetes and VI. The presence of dementia complicates the delivery of health and social care and magnifies the difficulties that people with long-term conditions experience. Key elements of good care for PLWD and comorbidity include having the PLWD and family carer at the centre, flexibility around processes and good communication which ensures that all services are aware when someone has a diagnosis of dementia. The impact of a diagnosis of dementia on pre-existing conditions should be incorporated into guidelines and care planning. Future work needs to focus on the development and evaluation of interventions to improve continuity of care and access to services for PLWD with comorbidity.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Dementia in a Black and minority ethnic population: characteristics of presentation to an inner London memory service

Aims and method To examine data on referrals to an inner-city London memory service to explore any differences in referral rates, cognitive assessments and stages of dementia at presentation between ethnic groups. Results African-Caribbean patients were well represented in the memory service. They were diagnosed with dementia on average 4.5 years younger than their White British counterparts and were more likely to be diagnosed with a vascular or mixed type dementia. However, scores on initial cognitive testing were significantly lower in the African-Caribbean group, possibly representing more advanced disease at presentation. Clinical implications Initiatives to access Black and minority ethnic populations earlier in the course of their illness should be considered. Professionals need to consider the potential for cultural bias in memory testing and diagnosing dementia in these populations, and the importance of cultural competency in assessments.

South Asian older adults with memory impairment: improving assessment and access to dementia care

OBJECTIVE

With increasing international migration, mental health care of migrants and ethnic minorities is a public health priority. South Asian older adults experience difficulties in accessing services for memory impairment, dementia and mental illness. This review examines barriers and facilitators in the pathway to culturally appropriate mental health care.

METHODS

Web of Knowledge, Pubmed and Ovid databases were searched for literature on South Asian older adults or their family carers, their understandings of mental illness and dementia and their pattern of service use. Dates were from 1984 to 2012. Abstracts were assessed for relevance, followed by detailed reading of salient papers. Three researchers rated the quality of each included study. A narrative synthesis was undertaken of extracted and charted data.

RESULTS

Eighteen studies met the eligibility criteria for the review. South Asians and health professionals highlighted several difficulties which deterred help seeking and access to care: a lack of knowledge of dementia and mental illness, and of local services; stigma; culturally preferred coping strategies; and linguistic and cultural barriers in communication and decision making.

CONCLUSIONS

To improve access for these groups, service users and providers need to be better informed; services need to be more culturally tailored, sometimes employing staff with similar cultural backgrounds; and health professionals can benefit from dementia education and knowledge of local services. These factors are key to the delivery of the National Dementia Strategy in England.

Expanding the gerontological imagination on ethnicity: conceptual and theoretical perspectives

The globalisation of international migration has increased the ethnic diversity of most ageing populations across the Western world. This has implications for gerontological research, policy and practice, and puts our understandings of ethnicity to the test. This paper presents the different perspectives that inform ethnicity scholarship (the essentialist/primordial perspective, the structuralist/circumstantialist perspective and social constructionism) and suggests that the way in which we regard ethnicity has implications for how gerontological research is designed, how policies for old age are formulated and how gerontological practice is shaped. Through a review of contemporary gerontological research on ethnicity published in some of gerontology's main journals, the paper discusses some of the trends observed and concludes that most research seems to be informed by essentialism and structuralism. This suggests that the gerontological imagination on ethnicity has yet to be informed by the latest developments in ethnicity scholarship. The paper therefore urges gerontologists to broaden their understanding of ethnicity and suggests that much could be gained if we were to let the social constructionist perspective on ethnicity and the notion of intersectionality be sources of inspiration for the gerontological imagination on ethnicity.

Care pathways for dementia: current perspectives

Uncertainty appears to typify the experience of living with dementia. With an uncertain illness trajectory and unpredictable levels of deterioration and stability in symptoms, people with a diagnosis of dementia may live with uncertainty and anxiety and find it hard to make plans or decisions for their future. People with memory problems and caregivers seeking a diagnosis of dementia may also potentially find themselves navigating a labyrinth-like maze of services, practitioners, assessments, and memory tests, with limited understanding of test scores and little information about what support is available. In this context of uncertainty, the apparent clarity and certainty of a “dementia care pathway” may be attractive. However, the term “dementia care pathway” has multiple and overlapping meanings, which can potentially give rise to further confusion if these are ill-defined or a false consensus is presumed. This review distinguishes four meanings: 1) a mechanism for the management and containment of uncertainty and confusion, useful for the professional as well as the person with dementia; 2) a manual for sequencing care activities; 3) a guide to consumers, indicating eligibility for care activities, or a guide to self-management for dementia dyads, indicating the appropriateness of care activities; and 4) a manual for “walking with” the person. Examples of these approaches are presented from UK dementia services with illustrations of existing care pathways and associated time points, specifically focusing on: 1) early symptom identification and first service encounters, 2) assessment process, 3) diagnostic disclosure, 4) postdiagnostic support, and 5) appropriate interventions. We review the evidence around these themes, as well as discuss service pathways and referral routes used by some services in England and internationally. We conclude that the attraction of the term “care pathway” is seductive, but caution is needed in taking shared understandings for granted.

Comorbidity and dementia: a scoping review of the literature

BACKGROUND

Evidence suggests that amongst people with dementia there is a high prevalence of comorbid medical conditions and related complaints. The presence of dementia may complicate clinical care for other conditions and undermine a patient's ability to manage a chronic condition. The aim of this study was to scope the extent, range and nature of research activity around dementia and comorbidity.

METHODS

We undertook a scoping review including all types of research relating to the prevalence of comorbidities in people with dementia; current systems, structures and other issues relating to service organisation and delivery; patient and carer experiences; and the experiences and attitudes of service providers. We searched AMED, Cochrane Library, CINAHL, PubMed, NHS Evidence, Scopus, Google Scholar (searched 2012, Pubmed updated 2013), checked reference lists and performed citation searches on PubMed and Google Scholar (ongoing to February 2014).

RESULTS

We included 54 primary studies, eight reviews and three guidelines. Much of the available literature relates to the prevalence of comorbidities in people with dementia or issues around quality of care. Less is known about service organisation and delivery or the views and experiences of people with dementia and their family carers. There is some evidence that people with dementia did not have the same access to treatment and monitoring for conditions such as visual impairment and diabetes as those with similar comorbidities but without dementia.

CONCLUSIONS

The prevalence of comorbid conditions in people with dementia is high. Whilst current evidence suggests that people with dementia may have poorer access to services the reasons for this are not clear. There is a need for more research looking at the ways in which having dementia impacts on clinical care for other conditions and how the process of care and different services are adapting to the needs of people with dementia and comorbidity. People with dementia should be included in the debate about the management of comorbidities in older populations and there needs to be greater consideration given to including them in studies that focus on age-related healthcare issues.

Ethnic minority, young onset, rare dementia type, depression: A case study of a Muslim male accessing UK dementia health and social care services

A case study comprised of formal interviews, formal observations and informal discussions investigated the motivations and experiences accessing dementia care health and social care services for a Muslim, Pakistani male with dementia. Motivations derived from 'desperation' and an inability to access support from family or religious community. Experiences of accessing services were mostly negative. Dementia services were ill-informed about how to support persons with young onset dementia, with pre-existing mental health conditions, from an ethnic minority. Education and training to remove barriers to all dementia care services is required for persons with dementia, their families and within dementia services and religious communities.

Preserving Identity and Planning for Advance Care (PIPAC): preliminary outcomes from a patient-centered intervention for individuals with mild dementia

OBJECTIVES

The purpose of this pilot study was to conduct limited-efficacy testing of the newly developed Preserving Identity and Planning for Advance Care (PIPAC) intervention on self-reported and proxy-reported emotional and health-related outcomes of individuals in the early stages of dementia.

METHOD

A two-group comparison design was implemented. Blocked randomization was used to assign individuals with mild dementia and a family contact to either (1) the four-session, multi-component intervention group focused on reminiscence and future planning or (2) the minimal support phone contact comparison group. Of the 19 enrolled dyads, 18completed post-treatment assessments (i.e. 10 intervention and 8 comparison group). Individuals with dementia were M=82.8 (SD=6.46) years old; 31.6% were men and 68.4% were women. Participants were predominantly white/Caucasian (n=18, 94.7%) with one black/African-American (5.3%).

RESULTS

Analyses of covariance controlling for baseline differences revealed clinically meaningful differences (with medium to large effect sizes) between groups at post-treatment for depressive symptoms, quality of life, health-related quality of life indicators, and decisional conflict. Individuals in the intervention group were also observed to exhibit higher levels of coping. Feasibility data collected from participants and interventionists were encouraging.

CONCLUSION

Emotion-focused, patient-centered interventions like PIPAC hold promise for advancing treatment options in the early and mild stages of dementia. A full-scale, randomized clinical trial of this intervention is warranted to determine both short-term and long-term impacts on clinical outcomes including improved depressive symptomatology, quality of life, and health-related factors that impact daily functioning in social environments.

Experiences of living with dementia: qualitative content analysis of semi-structured interviews

AIMS AND OBJECTIVES

To describe people's experiences of living with dementia in Iran.

BACKGROUND

A knowledge gap exists regarding the experiences of living with dementia in nonWestern contexts. This gap may be especially apparent within the Iranian context, where dementia research is relatively new. Deeper understanding about context-related experiences of dementia is a prerequisite for nurses' ability to provide adequate and meaningful care.

DESIGN

Qualitative, cross-sectional design.

METHODS

Qualitative content analysis of semi-structured interviews with people living with dementia in urban Iran (six women and nine men; 60-87 years old).

RESULTS

The participants experienced their condition as a state of forgetfulness that was accompanied by losses and dependency on others. They wanted to feel good about themselves and feel important, but they continually struggled with matters such as a loss of accountability, feelings of futility and the frustration of others. Economic dependency and a lack of economic resources were sources of feelings of futility.

CONCLUSION

Experiences of living with dementia in Iran included a substantial struggle to stay connected to the social world and to deal with dramatic life changes, aspects of living with dementia that seem to be universal. However, the feelings of financial burden and the experience of being nagged for their shortfalls by family members have seldom been described in other studies and seem to represent a cultural aspect of their experience.

RELEVANCE TO CLINICAL PRACTICE

The results of the study call for further nursing efforts in supporting people living with dementia in their struggle with their altered lives and in retaining their connections to everyday life. Furthermore, their family members might benefit from specific nursing interventions including information about dementia and advice on how to help the family members with dementia to interact with others while exercising their individual strengths.

Exploring the affective dimension of the life review process: Facilitators’ interactional strategies for fostering personhood and social value among older adults with early dementia

We employed an auto-ethnography approach to explore the affective dimension of life review sessions with community-dwelling older military veterans with minor cognitive impairment (MCI) and early dementia. Using researchers’ analytic memos, we identified facilitators’ interactional strategies that fostered the participant’s sense of personal identity, dignity and social self-worth. Interaction among participant, caregiver, and facilitators evoked a range of emotional responses, offering a window into the affective world of MCI and early dementia. Positive emotional responses outnumbered negative emotional responses by a ratio of two-to-one in the life review sessions; however, negative emotions were more revelatory of current struggles with declines in health and function. Facilitators utilized two interactional strategies, in particular, to foster personhood and social value of participants: focusing on the participant and creating an empathic connection with the participant. Further work is needed to understand the role of emotions in research interactions and to examine the psychosocial mechanisms through which positive affect functions in promoting identity, personhood and social value among persons with MCI and early dementia.

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

BACKGROUND

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

METHODS AND FINDINGS

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

CONCLUSIONS

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