The carrot and the stick: benefits and barriers in getting a diagnosis

Sodium-Glucose Cotransporter-2 Inhibitors, Dulaglutide, and Risk for Dementia : A Population-Based Cohort Study

BACKGROUND

Both sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) may have neuroprotective effects in patients with type 2 diabetes (T2D). However, their comparative effectiveness in preventing dementia remains uncertain.

OBJECTIVE

To compare the risk for dementia between SGLT2 inhibitors and dulaglutide (a GLP-1 RA).

DESIGN

Target trial emulation study.

SETTING

Nationwide health care data of South Korea obtained from the National Health Insurance Service between 2010 and 2022.

PATIENTS

Patients aged 60 years or older who have T2D and are initiating treatment with SGLT2 inhibitors or dulaglutide.

MEASUREMENTS

The primary outcome was the presumed clinical onset of dementia. The date of onset was defined as the year before the date of dementia diagnosis, assuming that the time between the onset of dementia and diagnosis was 1 year. The 5-year risk ratios and risk differences comparing SGLT2 inhibitors with dulaglutide were estimated in a 1:2 propensity score-matched cohort adjusted for confounders.

RESULTS

Overall, 12 489 patients initiating SGLT2 inhibitor treatment (51.9% dapagliflozin and 48.1% empagliflozin) and 1075 patients initiating dulaglutide treatment were included. In the matched cohort, over a median follow-up of 4.4 years, the primary outcome event occurred in 69 participants in the SGLT2 inhibitor group and 43 in the dulaglutide group. The estimated risk difference was -0.91 percentage point (95% CI, -2.45 to 0.63 percentage point), and the estimated risk ratio was 0.81 (CI, 0.56 to 1.16).

LIMITATION

Residual confounding is possible; there was no adjustment for hemoglobin A1c levels or duration of diabetes; the study is not representative of newer drugs, including more effective GLP-1 RAs; and the onset of dementia was not measured directly.

CONCLUSION

Under conventional statistical criteria, a risk for dementia between 2.5 percentage points lower and 0.6 percentage point greater for SGLT2 inhibitors than for dulaglutide was estimated to be highly compatible with the data from this study. However, whether these findings generalize to newer GLP-1 RAs is uncertain. Thus, further studies incorporating newer drugs within these drug classes and better addressing residual confounding are required.

PRIMARY FUNDING SOURCE

Ministry of Food and Drug Safety of South Korea.

Prevalence and Determinants of Diagnosed Dementia: A Registry Linkage Study Linking Diagnosis of Dementia in the Population-Based HUNT Study to Registry Diagnosis of Dementia in Primary Care and Hospitals in Norway

Background

A timely diagnosis of dementia can be beneficial for providing good support, treatment, and care, but the diagnostic rate remains unknown and is probably low.

Objective

To determine the dementia diagnostic rate and to describe factors associated with diagnosed dementia.

Methods

This registry linkage study linked information on research-based study diagnoses of all-cause dementia and subtypes of dementias, Alzheimer's disease, and related dementias, in 1,525 participants from a cross-sectional population-based study (HUNT4 70+) to dementia registry diagnoses in both primary-care and hospital registries. Factors associated with dementia were analyzed with multiple logistic regression.

Results

Among those with research-based dementia study diagnoses in HUNT4 70+, 35.6% had a dementia registry diagnosis in the health registries. The diagnostic rate in registry diagnoses was 19.8% among home-dwellers and 66.0% among nursing home residents. Of those with a study diagnosis of Alzheimer's disease, 35.8% (95% confidence interval (CI) 32.6-39.0) had a registry diagnosis; for those with a study diagnosis of vascular dementia, the rate was 25.8% (95% CI 19.2-33.3) and for Lewy body dementias and frontotemporal dementia, the diagnosis rate was 63.0% (95% CI 48.7-75.7) and 60.0% (95% CI 43.3-75.1), respectively. Factors associated with having a registry diagnosis included dementia in the family, not being in the youngest or oldest age group, higher education, more severe cognitive decline, and greater need for help with activities of daily living.

Conclusions

Undiagnosed dementia is common, as only one-third of those with dementia are diagnosed. Diagnoses appear to be made at a late stage of dementia.

Rural and urban differences in quality of dementia care of persons with dementia and caregivers across all domains: a systematic review

BACKGROUND

There are challenges in healthcare service delivery in rural areas, and this may be especially true for persons with dementia, who have higher needs to access to the healthcare system, and may have difficulties to commute easily and safely to these services. There is a growing body of literature regarding geographical disparities, but there is no comprehensive systematic review of geographical differences in persons with dementia across all domains of care quality. Therefore, the objective of this study is to conduct a systematic review of the literature on rural and urban differences in quality of dementia care outcomes of persons with dementia across all quality-of-care domains.

METHODS

We performed a digital search in Ovid MEDLINE on July 16, 2019, updated on May 3, 2021, for French or English records. We selected studies that reported outcome from at least one domain of quality of dementia care (Access, Integration, Effective Care, Efficient Care, Population Health, Safety, and Patient-Centered) in both rural and urban persons with dementia or caregivers. We used rigorous, systematic methods for screening, selection, data extraction and we analyzed outcomes reported by at least two studies using vote counting and appraised the certainty of evidence. Finally, we explored sources of heterogeneity.

RESULTS

From the 38 included studies, we found differences in many dementia care domains. Rural persons with dementia had higher mortality rates (Population Health), lower visits to any physicians (Access), more hospitalizations but shorter stays (Integration), higher antipsychotic medications (Safety), lower use of home care services and higher use of nursing home (Patient-Centered Care) compared to urban persons with dementia.

CONCLUSIONS

This comprehensive portrait of rural-urban differences in dementia care highlights possible geographically based inequities and can be used by researchers and decision makers to guide development of more equitable dementia care policies.

The Bubble of Normalisation: A Qualitative Study of Carers of People With Dementia Who Do Not Seek Help for a Diagnosis

OBJECTIVE

Improving dementia diagnosis rates are a key feature of dementia strategy and policy worldwide. This study aimed to explore the experience of carers of people diagnosed with dementia during or following a hospital admission in order to identify factors that had prevented them from seeking help beforehand. Semi-structured interviews were conducted with 12 informal carers including adults caring for a parent, a friend or a spouse diagnosed with dementia between 2010-2019, following an acute hospital admission for a physical health problem, having not sought help previously.

MAIN FINDINGS

Carers created a 'bubble of normalisation' around themselves and the person living with dementia (PLWD) to reject the label of dementia and protect the PLWD from a loss of independence, discrimination and prejudice they felt would be the result of a diagnosis. Carers struggled to talk to the PLWD about dementia reinforcing denial and stigma. Post-diagnosis carers felt unsupported and questioned the value of diagnosis.

PRINCIPAL CONCLUSIONS

Stigma related to images of dementia as a disease that takes away independence and identity prevented discussion about dementia between carers and the PLWD. A lack of open discussion about memory concerns between health care professionals and carers also served to delay diagnosis.

Self-Administered Gerocognitive Examination: longitudinal cohort testing for the early detection of dementia conversion

Background

Significant cognitive changes as individuals’ age are not being identified in a timely manner, delaying diagnosis and treatments. Use of brief, multi-domain, self-administered, objective cognitive assessment tools may remove some barriers in assessing and identifying cognitive changes. We compared longitudinal Self-Administered Gerocognitive Examination (SAGE) test scores to non-self-administered Mini-Mental State Examination (MMSE) scores in 5 different diagnostic subgroups.

Methods

A cohort study evaluating annual rates of change was performed on 665 consecutive patients from Ohio State University Memory Disorders Clinic. Patients with at least two visits 6 months apart evaluated with SAGE and MMSE and classified according to standard clinical criteria as subjective cognitive decline (SCD), mild cognitive impairment (MCI), or Alzheimer’s disease (AD) dementia were included. The pattern of change in SAGE scores was compared to MMSE. One way and repeated measures ANOVA and linear regression models were used.

Results

Four hundred twenty-four individuals (40 SCD, 94 MCI non-converters to dementia, 70 MCI converters to dementia (49 to AD dementia and 21 to non-AD dementia), 220 AD dementia) met inclusion criteria. SAGE and MMSE scores declined respectively at annual rates of 1.91 points/year (p < 0.0001) and 1.68 points/year (p < 0.0001) for MCI converters to AD dementia, and 1.82 points/year (p < 0.0001) and 2.38 points/year (p < 0.0001) for AD dementia subjects. SAGE and MMSE scores remained stable for SCD and MCI non-converters. Statistically significant decline from baseline scores in SAGE occurred at least 6 months earlier than MMSE for MCI converters to AD dementia (14.4 vs. 20.4 months), MCI converters to non-AD dementia (14.4 vs. 32.9 months), and AD dementia individuals (8.3 vs. 14.4 months).

Conclusions

SAGE detects MCI conversion to dementia at least 6 months sooner than MMSE. Being self-administered, SAGE also addresses a critical need of removing some barriers in performing cognitive assessments. Limitations of our single-site cohort study include potential referral and sampling biases. Repetitively administering SAGE and identifying stability or decline may provide clinicians with an objective cognitive biomarker impacting evaluation and management choices.

‘We're happy as we are’: the experience of living with possible undiagnosed dementia

It is estimated that a third of people in the United Kingdom with signs of dementia are living without a formal diagnosis. In Wales, the proportion is nearly half. Some explanations for the gap between prevalence of dementia and number of diagnoses include living with a long-term partner/spouse and systemic barriers to diagnosis. This study recruited participants from the Cognitive Function and Ageing Studies-Wales (CFAS-Wales) cohort, randomly selected from people aged over 65 living in two areas of Wales, who met study criteria for a diagnosis of dementia and did not have a record of a formal diagnosis in general practice records. We aimed to understand more about the contexts and circumstances of people who live with and cope with cognitive difficulties without having a formal diagnosis of dementia. We conducted qualitative interviews with six participants and their spouses, and additionally with four family members of three invited people who were unable to take part. Themes were generated using thematic analysis. We present the argument that there is an adaptive response to low service levels and a complex interaction between the expectations of levels of service, perceptions of the legitimacy of cognitive problems and the right to make demands on services. This paper concludes that more could be done to address barriers to diagnosis and treatment services for those living with symptoms of dementia, but that the value placed on diagnosis by some individuals might be lower than anticipated by government policy.

Comorbidity Trajectories Associated With Alzheimer's Disease: A Matched Case-Control Study in a United States Claims Database

Background: Trajectories of comorbidities among individuals at risk of Alzheimer's disease (AD) may differ from those aging without AD clinical syndrome. Therefore, characterizing the comorbidity burden and pattern associated with AD risk may facilitate earlier detection, enable timely intervention, and help slow the rate of cognitive and functional decline in AD. This case-control study was performed to compare the prevalence of comorbidities between AD cases and controls during the 5 years prior to diagnosis (or index date for controls); and to identify comorbidities with a differential time-dependent prevalence trajectory during the 5 years prior to AD diagnosis. Methods: Incident AD cases and individually matched controls were identified in a United States claims database between January 1, 2000 and December 31, 2016. AD status and comorbidities were defined based on the presence of diagnosis codes in administrative claims records. Generalized estimating equations were used to assess evidence of changes over time and between AD and controls. A principal component analysis and hierarchical clustering was performed to identify groups of AD-related comorbidities with respect to prevalence changes over time (or trajectory), and differences between AD and controls. Results: Data from 186,064 individuals in the IBM MarketScan Commercial Claims and Medicare Supplementary databases were analyzed (93,032 AD cases and 93,032 non-AD controls). In total, there were 177 comorbidities with a ≥ 5% prevalence. Five main clusters of comorbidities were identified. Clusters differed between AD cases and controls in the overall magnitude of association with AD, in their diverging time trajectories, and in comorbidity prevalence. Three clusters contained comorbidities that notably increased in frequency over time in AD cases but not in controls during the 5-year period before AD diagnosis. Comorbidities in these clusters were related to the early signs and/or symptoms of AD, psychiatric and mood disorders, cerebrovascular disease, history of hazard and injuries, and metabolic, cardiovascular, and respiratory complaints. Conclusion: We demonstrated a greater comorbidity burden among those who later developed AD vs. controls, and identified comorbidity clusters that could distinguish these two groups. Further investigation of comorbidity burden is warranted to facilitate early detection of individuals at risk of developing AD.

Perceived Help-Seeking Difficulty, Barriers, Delay, and Burden in Carers of People with Suspected Dementia

Because of an often complicated and difficult-to-access care system, help-seeking for people with suspected dementia can be stressful. Difficulty in help-seeking may contribute to carer burden, in addition to other known stressors in dementia care. This study examined the relationship between perceived help-seeking difficulty and carer burden, and the barriers contributing to perceived difficulty. We interviewed 110 carers accessing a community-based dementia assessment service for suspected dementia of a family member for their perceived difficulty, delays, and barriers in help-seeking, and carers burden in terms of role strain, self-criticism, and negative emotions. Linear regression models showed that perceived help-seeking difficulty is associated with carer self-criticism, while carer role strain and negative emotions are associated with symptom severity of the person with dementia but not help-seeking difficulty. Inadequate knowledge about symptoms, service accessibility, and affordability together explained more than half of the variance in perceived help-seeking difficulty (Nagelkerke R² = 0.56). Public awareness about symptoms, support in navigating service, and financial support may reduce perceived difficulty in help-seeking, which in turn may reduce carer self-criticism during the early course of illness.

Persistent barriers and facilitators to seeking help for a dementia diagnosis: a systematic review of 30 years of the perspectives of carers and people with dementia

OBJECTIVE

To identify barriers and facilitators to help seeking for a dementia diagnosis from the perspective of carers and people with dementia.

DESIGN

A systematic review of the literature was conducted according to the PRISMA guidelines (PROSPERO protocol registration CRD42018092524). Nine electronic databases were searched for qualitative, quantitative, and mixed methods primary research studies. Two independent reviewers screened titles and abstracts, full texts of eligible studies, and conducted quality appraisal of included articles. A convergent qualitative synthesis approach was used.

RESULTS

From 7496 articles, 35 papers representing 32 studies from 1986 to 2017 were included. Studies originated from 13 countries across 4 continents. Barriers and facilitators were reported predominantly by carers. A small number of studies included people with dementia. Barriers included denial, stigma and fear, lack of knowledge, normalization of symptoms, preserving autonomy, lack of perceived need, unaware of changes, lack of informal network support, carer difficulties, and problems accessing help. Facilitators included recognition of symptoms as a problem, prior knowledge and contacts, and support from informal network.

CONCLUSIONS

Studies from a 30-year period demonstrated that barriers to help seeking persist globally, despite increasing numbers of national dementia policies. Barriers and facilitators rarely existed independently demonstrating the complexity of help seeking for a diagnosis of dementia. Multiple barriers compounded the decision-making process and more than one facilitator was often required to overcome them. Multi-faceted interventions to reduce barriers are needed, one approach would be a focus on the development of dementia friendly communities to reduce stigma and empower people with dementia and carers.

Discussion of memory during primary care visits of older adults with cognitive impairment and accompanying family

OBJECTIVES

Cognitive impairment is underdiagnosed in primary care. Understanding factors that precipitate memory-related discussion could inform strategies to improve diagnosis and counseling. We assessed whether: 1) having a cognitive impairment or dementia diagnosis, 2) ratings of cognition by clinicians, or 3) ratings of cognition by family companions were associated with memory-related discussion during primary care visits.

METHODS

We examined audio-recorded primary care visits of cognitively impaired patients aged 65 years and older, family companions (n = 93 dyads), and clinicians (n = 14). Cognitive impairment and dementia diagnoses were extracted from the electronic health record. Clinicians and family rated patient cognition on a 10-point scale in postvisit surveys. We measured memory-related discussion using a ratio of memory-related discussion episodes to total visit statements.

RESULTS

We observed more memory-related discussion during primary care visits of patients with a diagnosis of mild cognitive impairment (+7.8% episodes; P < .001) or dementia (+26.3% episodes; P < .001) than no diagnosis. Clinician and family ratings of cognition varied by diagnosis: among patients with no diagnosis, family rated worse impairment than clinicians (average: 2.4 versus 1.3; P = .004) while for patients with a dementia diagnosis, clinicians rated worse impairment than family (average: 7.1 versus 5.5; P = .006). Each unit increase in clinician-rated severity of cognitive impairment was associated with more memory-related discussion (+2.6% episodes; P < .001); this association was attenuated for family (+0.7% episodes; P = .095).

CONCLUSIONS

Discussion of cognitive impairment appears largely driven by clinician ratings of cognition and presence of an established diagnosis. Findings suggest potential benefit of engaging family to improve cognitive impairment detection in primary care.

The Lost Years: Delay Between the Onset of Cognitive Symptoms and Clinical Assessment at a Memory Clinic

Background

Early assessment of cognitive symptoms is an issue in geriatrics. This study investigated the delay from the onset of cognitive symptoms to initial clinical assessment and its associations with patients’ sociodemographic and clinical characteristics.

Methods

This is a cross-sectional retrospective study using medical chart review of 316 patients referred for assessment to a university-affiliated memory clinic. Symptom duration was self-reported by patients/carers. Severity of symptoms assessed by the MoCA and FAST instruments was compared according to delay duration (≥3 years vs. <3 years) using chi-squared tests. Logistic regression was used to determine the association between patients’ characteristics and long symptom duration (≥3 years).

Results

At the initial assessment, 29.4% of patients reported experiencing cognitive symptoms for ≥3 years. They were more likely to have MoCA scores ≤17 (47.8 vs. 34.1%; p=.023) and FAST scores ≥5 (21.5 vs. 10.8%; p=.012). They were also significantly older than 75 years (75–84 yr: OR=2.22 [95%CI: 1.11–4.41]; ≥85 yr: 4.36 [2.08–9.11]), presented more depressive symptoms (2.37 [1.40–4.02]), and were less likely to live alone (0.55 [0.31–0.96]).

Conclusions

A significant proportion of patients had cognitive symptoms for years when initially assessed, which delayed diagnosis and management. Stigma, depression, and compensatory help from carers may contribute to this delay.

Differences in Dementia Beliefs between Non-Demented Public Screeners and In-Home Screeners and Their Potential Impact on Future Dementia Screening Intention: The Nakajima Study

In many cohort studies of dementia, while differences in sociodemographic characters between responders and non-responders of dementia screening have been reported, differences in dementia beliefs have been relatively less known. The aims of this study were to clarify dementia beliefs and to explore potential impacts on an intention to attend a future dementia screening in public screeners and in-home screeners, respectively. We performed a cross-sectional population-based study using a question about an intention to attend a future dementia screening and a questionnaire on dementia beliefs. Subjects were all residents aged 65 years or older in the north area of Nakajima, Japan (n = 385). All subjects were asked to attend a public dementia screening first. An in-home dementia screening was subsequently conducted in subjects with non-responders to a public screening. The questionnaire consisted of four dementia beliefs: "perceived susceptibility," "perceived severity," "perceived barriers," and "perceived benefits." Public screeners significantly expressed an intention to attend a future dementia screening more than in-home screeners (p = 0.002). In in-home screeners, low "perceived severity" were significantly associated with an intention to attend a future dementia screening [adjusted OR (95% CI) = 0.51 (0.32-0.80)]. In both public and in-home screeners, high "perceived benefits" were significantly associated with an intention to attend a future dementia screening [adjusted OR (95% CI) = 2.13 (1.46-3.10); adjusted OR (95% CI) = 2.56 (1.22-5.35), respectively]. It is necessary to reduce "perceived severity" among in-home screeners to increase dementia screening participants.

Time from Symptom Debut to Dementia Assessment by the Specialist Healthcare Service in Norway

Objectives

We described the duration from symptom debut to assessment at specialist healthcare outpatient clinics for dementia in Norway and explored whether educational level was associated with time from symptom debut to dementia assessment.

Methods

The study comprised 835 persons from a register for individuals with cognitive symptoms (NorCog). The outcome variable was time in months from symptom debut to assessment. The main independent variable was the number of years of education. Also age, gender, marital status, cognitive function, neuropsychiatric symptoms, assistance and location were assessed.

Results

In an adjusted linear mixed model, a higher educational level was associated with a longer duration from symptom debut to assessment, where 5 additional years of education increased the time from symptom debut to consultation by 10%.

Conclusion

The findings may perhaps be explained by the hypothesis that highly educated people may be able to compensate better for cognitive impairment, which is in line with a hypothesis of cognitive reserve.

How people come to recognise a problem and seek medical help for a person showing early signs of dementia: A systematic review and meta-ethnography

Evidence suggests that there is usually a long delay between noticing first signs of dementia and seeking medical help. We conducted a systematic review of what people experience and how they make decisions during this time, and used a meta-ethnographic approach to synthesise the findings. Screening and quality assessment resulted in nine studies eligible for inclusion. People with dementia mainly report experiencing memory lapses, while carers focus on more subtle changes in personality. People respond to these changes in one of three ways: 1) they discount them as normal; 2) they reserve judgement as to their cause and significance, or 3) they misattribute them. Pivotal events can finally trigger help seeking. Active reflection and seeking of further evidence may lead to earlier recognition of the possibility of dementia and the need to seek help; it also reduces the risk of a pivotal event. Public education should aim to improve recognition of more subtle signs and to encourage repeated evaluation and reflection.

Hospitalizations of Children with Huntington's Disease in the United States

Background

Juvenile Huntington's disease (JHD) is a childhood-onset neurodegenerative disorder. Although it is caused by the same pathologic expansion of CGA repeats as adult-onset Huntington's disease, JHD has distinct clinical features. Most clinical research in HD focuses in the adult-onset disease; therefore, little is known about acute care outcomes for patients with JHD.

Methods

The Kids' Inpatient Database (KID) was used to examine hospitalizations of children with JHD and to determine the diagnoses and procedures associated with inpatient care for JHD. Regression models were built to examine acute care outcomes, including death, length of stay, and disposition at discharge in patients with JHD compared with patients in the general KID data.

Results

The proportion of JHD cases among hospitalized children was 1.23 per 100,000 KID inpatient stays. Seizures/convulsions (58.5%) and psychiatric conditions (26.1%) were the most common primary or secondary diagnoses among JHD patient hospitalizations. The most common procedure was percutaneous endoscopic gastrostomy tube placement (8.6%). Compared with hospitalizations of the general population, hospitalizations of patients with JHD had a lower odds of discharge to home (adjusted odds ratio [AOR], 0.23; 95% confidence interval [CI], 0.14-0.37) and an increased likelihood of death (AOR, 8.03; 95% CI, 2.98-21.60) or discharge to a short-term care facility (AOR, 4.44; 95% CI, 2.59-7.61). A diagnosis of JHD was associated with increased length of stay (7.04 vs. 3.75 days; P < 0.01).

Conclusions

Children with JHD have unique acute care patterns. Future studies are needed to determine the extent to which coordinated care may impact inpatient and disposition needs.

To what extent does diagnosis matter? Dementia diagnosis, trouble interpretation and caregiving network dynamics

Contemporary research into health and mental health treats diagnosis as a central step in understanding illness management and trajectory; consequently, in the last two decades, sociology of diagnosis has attained increasing influence within medical sociology. Deeply embedded in social constructionism, the set of research divides between those who focus on the social and historical construction of diagnoses as categories, and those who see diagnosis as a process. Regarding the latter, this approach explores the constitution of the medical production, highlighting how it constitutes a starting point for entering a 'sick role', for being labelled, for naming one's problem and by extension, for framing one's illness narrative.

Analysis of barriers to cognitive screening in rural populations in the United States

There is scant research regarding barriers to cognitive screening in rural US populations. This is surprising when there is evidence of the importance of preventative health behaviors such as memory screening that can lead to earlier diagnosis and treatment of Alzheimer's disease and decrease in associated costs. A systematic review of published research revealed modifiable barriers to screening such as lack of knowledge and lack of knowledgeable providers to screen. Recommendations for diminishing barriers include the use of storytellers to provide culturally relevant education and informing practitioners of new Medicare coverage for cognitive screening.

Social Representation of Dementia and Its Influence on the Search for Early Care by Family Member Caregivers

INTRODUCTION

Social representations (SRs) contain 3 dimensions: information, attitude, and field. These affect the recognition of the first symptoms of dementia by the patient's caregiver. This study focused on the period from the first signs of cognitive difficulties to the diagnosis of dementia.

METHODS

Eight caregivers of elderly patients with dementia were interviewed to construct their SRs regarding dementia and how this influences seeking medical treatment during the first stages of the disease. Social representations were analyzed through a structural focus, based on the content analysis.

RESULTS

Decision making is related to knowledge about dementia, attitude (emotions and sensitivity), and the concept of the caregiver about the relative with dementia. The results confirm the importance of the symbolic dimension of personal experience in managing care and seeking medical treatment.

CONCLUSION

The presence of dementia in the family creates interpersonal dilemmas that caregivers experience. The solutions are framed in the sociocultural context.

Informal caregivers' hopes and expectations of a referral to a memory clinic

Although only 20-50% of individuals with dementia are diagnosed, early diagnosis enables patients and families to access interventions and services, and plan for the future. The current study explored the experiences of rural family caregivers in the period leading up to a diagnostic assessment at a Canadian memory clinic, their hopes and expectations of the assessment, and their experiences in the six months following diagnosis. Using a longitudinal, retrospective and prospective qualitative research design, caregivers of 30 patients referred to the clinic were interviewed during the diagnostic assessment process and again six months after the diagnosis. Most caregivers reported first noticing symptoms two years prior to diagnosis. The pre-diagnostic interviews revealed a prevalent 'need to know' among caregivers that drove the help-seeking process. Caregivers hoped that the diagnosis would have the benefits of 'naming it,' 'accessing treatment,' 'knowing what to expect,' and 'receiving guidance.' When asked six months later about the impact of the diagnosis, the main theme was 'acceptance and moving forward.' Caregivers reported that the diagnosis provided 'relief,' 'validation,' and 'improved access to services.' These findings can inform care practices of primary health care providers who represent the first point of contact regarding expectations and experiences of dementia-related diagnoses.

The impact of early dementia diagnosis and intervention on informal caregivers

In the absence of disease modifying therapies for dementia, the question rises what the benefits are of an early dementia diagnosis for patients and their caregivers. This paper reviews the caregiver perspective in dementia and addresses the question what the consequences are of promoting earlier dementia diagnosis. An early diagnosis offers caregivers the opportunity to advance the process of adaptation to the caregiver role. Caregivers that are better able to adapt to the changes that characterize dementia, feel more competent to care and experience less psychological problems. However, drawbacks of an early diagnosis may outweigh the benefits if people are left with a diagnosis but little support. There is convincing evidence that multicomponent caregiver interventions in the mild to moderate dementia stages are effective to improve caregiver well-being and delay institutionalization. However, there still exist a gap between the improved possibilities to diagnose people in the predementia stage versus the scarce knowledge on intervention effects in this very early stage. This stresses the urgent need for more research on early caregiver interventions that enhance role adaptation and that include long-term follow-up and cost-effectiveness evaluation. Early interventions may help caregivers in anticipating and accepting the future care role and transitions, with the increased possibility that caregivers can still involve the patient in the decision making process. As levels of stress and burden are still low in the predementia stage it provides excellent opportunities to empower the resources of caregivers.

Cross-cultural differences in dementia: the Sociocultural Health Belief Model

BACKGROUND

Many minority ethnic (ME) older adults face several culturally associated and systemic barriers to timely dementia diagnoses that may result in delays to dementia care-seeking. We aimed to develop and propose a model illustrating variables that influence dementia care-seeking among ME older adults.

METHODS

We conducted a literature review on the effects of these barriers on diagnostic delays and impairment levels at initial evaluation. We also strived to provide a basis for the Sociocultural Health Belief Model (SHBM) to guide future research and service planning pertaining to culture and dementia care-seeking.

RESULTS

There was consistent evidence that ME older adults with dementia tended to have greater diagnostic delays and higher levels of cognitive impairment and behavioral and psychological symptoms of dementia at initial evaluation than their non-Hispanic White counterparts. We also found several barriers to dementia care-seeking among ME groups. These barriers included lower levels of acculturation and accurate knowledge about dementia, more culturally associated beliefs about dementia, such as the perception of memory loss as normal aging and stigma associated with dementia, and health system barriers.

CONCLUSIONS

The SHBM provides an empirically based conceptual framework for examining cross-cultural differences in dementia care-seeking among diverse groups. We provide recommendations for future research, such as the need for research with more diverse ethnic subgroups and the examination of group-specific cultural values. We conclude with a discussion of the clinical and service implications of our review, including potential interventions aimed at facilitating timely dementia diagnoses among ME older adults.

Why don't older adults with subjective memory complaints seek help?

BACKGROUND

Subjective memory complaints (SMCs) are common among older adults, often causing significant distress and showing strong relationships to future cognitive decline. However, low rates of help-seeking for memory complaints are well documented. Little is known about the reasons behind the decision to seek or not to seek help with memory problems. The common-sense model of illness perception proposes that the beliefs people hold about their health underlie help-seeking behaviour. The present study investigated factors underlying the decision to seek help in people with SMCs within the framework of the common-sense model of illness perception.

METHODS

Cognition, illness perceptions, coping styles, depression and anxiety were assessed in 98 adults with SMCs, aged 50 years and above, including 60 attending a memory clinic and 38 non-help-seekers.

RESULTS

Objective cognitive performance did not differ between participants who had sought help and those who had not. Logistic regression revealed that illness perceptions including social comparison and causal attributions predict help-seeking behaviour. More general coping style did not predict help-seeking. Furthermore, participants who had sought help were more likely to have had a close relative with dementia.

CONCLUSIONS

The results suggest that beliefs about memory, rather than objective cognitive impairment, are associated with the decision to seek help for SMCs. The findings suggest that providing education regarding memory problems, in particular challenging causal attributions, may help to encourage help-seeking in people with SMCs and improve care in the early stages of dementia.

Very long pathways to diagnosis among African Americans and Hispanics with memory and behavioral problems associated with dementia

Research shows that African Americans and Hispanics experience longer delays in dementia diagnosis than do whites. This study focuses on the duration and direction of help-seeking pathways among individuals who had either very short (median: 1 year, 9 months) or very long (median: 9 years, 2 months) times-to-diagnosis. Participants reported the frequencies of events, actions, outcomes, and results around four key time points in the pathway: First Notice of a Problem, Recognition of a Pattern, First Doctor Visit, and Final Diagnosis. Using reported frequencies of events, actions, and outcomes around these events, we constructed the modal pathway or ‘canonical narrative’ and then used correspondence analysis of the data to model short and long pathways. Short pathways were dominated by stepwise movement toward diagnosis (84.5% of inertia or variance) and some ambivalence around symptom recognition (10%). Long pathways were marked by a shift away from movement toward diagnosis (44.5%) but toward the family's taking over key quotidian tasks (55.5%). We suggest that Hispanic and African American caregivers effectively provide a kind of ‘scaffolding’ for the patient, which may in fact be adaptive rather than dysfunctional. Thus, delayed diagnoses and non-diagnosis may reflect ‘active’ choices for dealing with the disease rather than avoidance of the problem.

Using the life course perspective to study the entry into the illness trajectory: the perspective of caregivers of people with Alzheimer's disease

The research community is showing increasing interest in the analysis of the care trajectory of people with chronic health problems, especially dementias such as Alzheimer's disease. However, despite this interest, there is little research on the initial phases of the care trajectory. The fact that the first symptoms of dementia are generally noticed by those surrounding the elderly person suggests that the recognition of the disease is intimately linked to interactions not only amongst family members but also amongst friends, neighbours and health professionals. This study focuses on the period beginning with the first manifestations of cognitive difficulties and ending with the diagnosis of Alzheimer-type dementia. Interviews with 60 caregivers in Montreal, Canada were used to reconstruct how older people with Alzheimer-type dementia enter into the care trajectory. Our methods consisted of the analysis of social networks, social dynamics and action sequences. Our findings are presented in the form of a typology comprised of 5 pathways of entries into the care trajectory that are structured around the following four principles of the Life Course Perspective: family history, linked lives, human agency and organisational effects. We believe that analyses of the initial phases of the care trajectory, such as this one, are essential for the application of effective early detection and intervention policies. They are also central to informing future studies that seek to understand the care experience in its entirety.

Learning from recruitment challenges: barriers to diagnosis, treatment, and research participation for Latinos with symptoms of Alzheimer's disease

This article discusses barriers to diagnosis and treatment of Alzheimer's disease (AD) and concomitantly to participation in AD research as elicited from 29 potential Latino participants who ultimately did not enroll in a study evaluating a caregiver intervention. Nearly half of all individuals contacting the researcher about the intervention study failed to meet criteria stipulating an existing AD diagnosis. Barriers to obtaining a diagnosis include lack of knowledge about AD, perceptions of memory loss as normal aging, and structural barriers to accessing care. A quarter of caregivers contacting the researcher felt too overwhelmed to participate. Many of these barriers have been previously identified as challenges to treatment, suggesting this is not just a methodological research problem, but inextricably tied to larger issues of AD knowledge and service accessibility. Engaging Latino communities equitably in the assessment of needs and the process of addressing them, thus ensuring the validity and applicability of the research and findings, is important both for increasing this group's participation in relevant studies and for addressing existing health disparities.

Missed and delayed diagnosis of dementia in primary care: prevalence and contributing factors

Dementia is a growing public health problem for which early detection may be beneficial. Currently, the diagnosis of dementia in primary care is dependent mostly on clinical suspicion on the basis of patient symptoms or caregivers' concerns and is prone to be missed or delayed. We conducted a systematic review of the literature to ascertain the prevalence and contributing factors for missed and delayed dementia diagnoses in primary care. Prevalence of missed and delayed diagnosis was estimated by abstracting quantitative data from studies of diagnostic sensitivity among primary care providers. Possible predictors and contributory factors were determined from the text of quantitative and qualitative studies of patient, caregiver, provider, and system-related barriers. Overall estimates of diagnostic sensitivity varied among studies and seemed to be in part a function of dementia severity, degree of patient impairment, dementia subtype, and frequency of patient-provider contact. Major contributory factors included problems with attitudes and patient-provider communication, educational deficits, and system resource constraints. The true prevalence of missed and delayed diagnoses of dementia is unknown but seems to be high. Until the case for dementia screening becomes more compelling, efforts to promote timely detection should focus on removing barriers to diagnosis.

Translating dementia research into practice

There is a gap between the knowledge obtained in dementia research and the practical use of it. This review examines the concept of knowledge translation (KT) and the process of translating research into practice in the field of dementia. KT in dementia practice involves key players including researchers, educators, clinicians, policy-makers, the general public and consumers who act within a multidimensional network, disseminating findings widely to effect changes in community awareness, clinical practice and health policy. Challenges include the volume of dementia research; difficulties in determining who is responsible for KT; the problems of premature KT; the lack of resources to perform KT; the paucity of research about effective KT strategies; and the characteristics of the dementia care workforce. Key features of effective KT include a simple compelling message; use of interpersonal contact and roles; a practical framework with an emphasis on "know-how"; and the provision of resources and support. More effective dementia KT will require a commitment by key players to engage in the process, a better understanding of effective KT strategies, adequate resources, and judicious selection of appropriate evidence-based information.

Improving access to dementia care: development and evaluation of a rural and remote memory clinic

The availability, accessibility and acceptability of services are critical factors in rural health service delivery. In Canada, the aging population and the consequent increase in prevalence of dementia challenge the ability of many rural communities to provide specialized dementia care. This paper describes the development, operation and evaluation of an interdisciplinary memory clinic designed to improve access to diagnosis and management of early stage dementia for older persons living in rural and remote areas in the Canadian province of Saskatchewan. We describe the clinic structure, processes and clinical assessment, as well as the evaluation research design and instruments. Finally, we report the demographic characteristics and geographic distribution of individuals referred during the first three years.

Social Representations of Barriers to Care Early in the Careers of Caregivers of Persons With Alzheimer's Disease

The first signs of cognitive impairment in the elderly generally elicit much concern among family members. Reactions run from denial to the active search for information. Some families manage to set up relatively well-organized networks of informal support to help both caregivers and elderly relatives. However, little is known about the processes underlying the different pathways that families follow at the onset of Alzheimer-type dementia in elderly relatives. To gain a better understanding of barriers to care early in the caregiving career, from the first signs of illness to diagnosis, the authors conducted interviews with 52 caregivers recruited at two cognition clinics. Barriers to help resources were analyzed from the viewpoint of social representations. This approach allowed the consideration of a broad range of individual and group phenomena capable of fashioning caregivers' representations of this period. The results confirmed the importance of the symbolic dimension of experience in steering social practice.

The transition to caregiving: the experience of family members embarking on the dementia caregiving career

Although there is an extensive literature on dementia caregiving, research on family members' adjustment to the onset of dementia and on the early stage of caregiving is limited. This article describes a phenomenological study based on twenty semi-structured interviews with spouses and adult daughters of someone with early/mild dementia or mild cognitive impairment (MCI). Participants were asked to describe the earliest changes in the parent or spouse and the changes to their everyday lives and in their relationships brought by cognitive impairment. These family members reported taking on many new responsibilities in a highly interactive caregiving process consisting primarily of decision-making and supervision. Many participants reported experiencing frustration, resentment, grief, and relational deprivation, along with increased protectiveness and tenderness towards the person with dementia. Most of the participants were ambivalent about seeking or accepting help from others and seemed to want to maintain the status quo as long as possible. Social workers meeting with families in the context of disclosure of a dementia diagnosis or the early adjustment period may help by identifying their losses, normalizing negative feelings, and helping families envision ways they could use outside help.

African American, Chinese, and Latino family caregivers' impressions of the onset and diagnosis of dementia: cross-cultural similarities and differences

PURPOSE

We explored cross-cultural similarities and differences in minority family caregivers' perceptions of the onset and diagnosis of Alzheimer's disease in their relatives, with specific attention to clinical encounters.

DESIGN AND METHODS

We performed a meta-synthesis of three qualitative studies conducted in Massachusetts with 22 African American, Latino, and Chinese caregivers.

RESULTS

All participants conveyed striking similarities of thought about normalization of cognitive symptoms until one critical event, usually relocation, precipitated family awareness that an elder's behavior was not the result of "normal aging." A lack of knowledge about Alzheimer's disease, rather than culturally influenced beliefs, was the major deterrent to having an elder's memory assessed. Community physicians' failure to recognize Alzheimer's disease or refer to specialists was more problematic than language or ethnic differences. Physicians' disrespect for caregivers' concerns about memory loss was particularly noted by African Americans, stigmatization of persons with Alzheimer's disease was noted by Chinese, and fears that acculturation would end family home care was noted by Latinos.

IMPLICATIONS

Amid ethnocultural differences, there are many similarities in needs that offer providers the possibility to unify quality improvements in Alzheimer's disease outreach, education, and physicians' services. Suggestions include providing the public with more confidential access to Alzheimer's disease information, increasing dementia awareness among community physicians, motivating clinicians to adopt culturally sensitive communication patterns, and providing community education to reduce normalization by families and stigmatization of persons with Alzheimer's disease.

Diagnosis-seeking at subspecialty memory clinics: trigger events

BACKGROUND

Research has shown that dementia often goes unrecognized, and diagnostic assessment is often further delayed. Understanding families' decision to seek care at memory clinics is relevant to efforts to facilitate early diagnosis.

OBJECTIVE

To examine the population seeking care at two memory clinics and the triggers causing caregivers to seek diagnostic assessment for a family member.

METHOD

We surveyed a consecutive sample of caregivers who accompanied a patient to an assessment at two university memory disorders clinics. Caregivers (n=416) described events that led them to seek a memory assessment for the patient, as well as who first suggested an assessment and diagnosis received.

RESULTS

Changes in the patient (cognitive, personality/behavioral, physical, or unspecified) accounted for 81% of 903 trigger events reported. Nearly half of the caregivers noting specific patient changes recorded some combination, rather than cognitive changes alone. Of the 338 respondents who noted a change in the patient as a trigger, 85% specified at least one cognitive change, while 40% specified at least one personality/behavioral change. Memory loss was most frequent trigger reported, followed by disorientation and recommendations (lay or professional). Caregivers themselves and non-specialist physicians were the most frequent sources of recommendations noted by all respondents.

CONCLUSION

A broad range of trigger events, beyond cognitive or symptomatic changes, caused caregivers to seek diagnosis at a memory clinic. Awareness of triggers significant to families may help physicians reduce the number and severity of events needed to convince caregivers a memory assessment is indicated.