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

Testing the 'Faith Moves Mountains model' to increase Alzheimer's disease awareness, detection, and diagnosis among rural, racially, and ethnically diverse older adults

OBJECTIVES

Racially and ethnically diverse populations have recently contributed to the majority of rural and small-town growth. Consequently, the disproportionately high risk and prevalence of Alzheimer's disease and related dementias (ADRD) among rural and minoritized older residents will likely increase. To address this threat, we tested the hypotheses that (1) a faith-based, resident-led approach would increase basic ADRD knowledge and diagnosis, and (2) older age, female gender, lower educational levels, and more years lived rural would predict number of referrals, new dementia diagnoses, and treatment.

METHODS

An adaptation of Schoenberg's Faith Moves Mountains model, previously successful in detection and management of other chronic illnesses in rural settings, guided this community-based participatory research. Local faith community members were trained as research assistants to recruit, administer surveys, conduct brief memory assessments, teach brain health strategies, and follow-up with residents. Outreaches were offered virtually during the pandemic, then in-person monthly at rotating church sites, and repeated ∼1 year later.

RESULTS

This rural sample was racially and ethnically diverse (74.5% non-White), with 28% reporting eight or less years of formal education. Findings included that referrals and years lived rural were significant and positive predictors of new ADRD treatments [(b = 3.74, χ2(1, n = 235) = 13.01, p < 0.001); (b = 0.02, χ2(1, n = 235 = 3.93, p = 0.048)], respectively, regardless of participant characteristics.

CONCLUSION

Resident-led action research in rural, diverse, faith communities is a successful approach to increasing ADRD disease knowledge, detection, diagnosis, and treatment.

Documentation of cognitive impairment screening amongst older hospitalised Australians: a prospective clinical record audit

BACKGROUND

Failure to detect cognitive impairment (CI) in hospitalised older inpatients has serious medical and legal implications, including for the implementation of care planning. This mixed methods study aimed to determine amongst hospital in-patients aged ≥ 65 years: (1) Rates of documentation of screening for CI, including the factors associated with completion of screening; (2) Rates of undocumented CI amongst patients who had not received screening during their admission; (3) Healthcare provider practices and barriers related to CI screening.

METHODS

A mixed methods study incorporating a clinical audit and interviews with healthcare providers was conducted at one Australian public hospital. Patients were eligible for inclusion if they were aged 65 years and older and were admitted to a participating ward for a minimum of 48 h. Patient characteristics, whether CI screening had been documented, were extracted using a template. Patients who had not been screened for CI completed the Montreal Cognitive Assessment (MoCA) to determine cognitive status. Interviews were conducted with healthcare providers to understand practices and barriers to screening for CI.

RESULTS

Of the 165 patients included, 34.5% (n = 57) had screening for CI documented for their current admission. Patients aged > 85 years and those with two or more admissions had greater odds of having CI screening documented. Among patients without CI screening documented, 72% (n = 78) were identified as cognitively impaired. While healthcare providers agreed CI screening was beneficial, they identified lack of time and poor knowledge as barriers to undertaking screening.

CONCLUSIONS

CI is frequently unrecognised in the hospital setting which is a missed opportunity for the provision of appropriate care. Future research should identify feasible and effective strategies to increase implementation of CI screening in hospitals.

Economic hardships of Korean American family caregivers of persons with dementia: a mixed-methods study

Objectives. This study examined the relationships between economic hardships (i.e. perceived financial hardship and job interference) and caregiver burden among Korean American family caregivers of persons with dementia and explored their lived experience caring for their loved ones.Methods. Using a mixed-methods research design, we first conducted a survey with 36 Korean American family caregivers. We also conducted semi-structured, in-depth, individual interviews (n = 33) and subsequently compared the results.Results. Cohabiting with their loved ones, the total duration of caregiving, and financial hardship were statistically significant predictors of higher levels of caregiver burden. Our thematic analysis resulted in four themes: (1) financial hardship, (2) early retirement, (3) dual responsibilities contributing to physical and emotional challenges, and (4) a lack of caregiver support.Conclusion. Our findings suggest the importance of developing culturally appropriate interventions that are affordable and accessible to Korean American family caregivers of persons with dementia.

Urbanicity and cognitive functioning in later life

Introduction

Prior research has shown disparities in cognitive functioning across the rural-urban continuum. We examine individual- and contextual-level factors to understand how and why urbanicity shapes cognitive functioning across older adulthood.

Methods

Using a nationally representative sample from 1996 to 2016 waves of the Health and Retirement Study (HRS) and growth curve models, we assess urban-suburban-exurban differences in older adult cognitive functioning.

Results

Results demonstrate that older adult men and women living in exurban areas, and older adult men in suburban areas, have lower cognitive functioning scores compared to their urban peers. Educational attainment and marital status contribute to but do not fully explain these differences. There were no differences in the trajectory over age, suggesting that urbanicity disparities in cognition occur earlier in life, with average differences remaining the same across older adulthood.

Discussion

Differences in cognitive functioning across urbanicity are likely due to factors accumulating prior to older adulthood.

Differentiation of Subjective Cognitive Decline, Mild Cognitive Impairment, and Dementia Using qEEG/ERP-Based Cognitive Testing and Volumetric MRI in an Outpatient Specialty Memory Clinic

BACKGROUND

Distinguishing between subjective cognitive decline (SCD), mild cognitive impairment (MCI), and dementia in a scalable, accessible way is important to promote earlier detection and intervention.

OBJECTIVE

We investigated diagnostic categorization using an FDA-cleared quantitative electroencephalographic/event-related potential (qEEG/ERP)-based cognitive testing system (eVox® by Evoke Neuroscience) combined with an automated volumetric magnetic resonance imaging (vMRI) tool (Neuroreader® by Brainreader).

METHODS

Patients who self-presented with memory complaints were assigned to a diagnostic category by dementia specialists based on clinical history, neurologic exam, neuropsychological testing, and laboratory results. In addition, qEEG/ERP (n = 161) and quantitative vMRI (n = 111) data were obtained. A multinomial logistic regression model was used to determine significant predictors of cognitive diagnostic category (SCD, MCI, or dementia) using all available qEEG/ERP features and MRI volumes as the independent variables and controlling for demographic variables. Area under the Receiver Operating Characteristic curve (AUC) was used to evaluate the diagnostic accuracy of the prediction models.

RESULTS

The qEEG/ERP measures of Reaction Time, Commission Errors, and P300b Amplitude were significant predictors (AUC = 0.79) of cognitive category. Diagnostic accuracy increased when volumetric MRI measures, specifically left temporal lobe volume, were added to the model (AUC = 0.87).

CONCLUSION

This study demonstrates the potential of a primarily physiological diagnostic model for differentiating SCD, MCI, and dementia using qEEG/ERP-based cognitive testing, especially when combined with volumetric brain MRI. The accessibility of qEEG/ERP and vMRI means that these tools can be used as adjuncts to clinical assessments to help increase the diagnostic certainty of SCD, MCI, and dementia.

Diagnostic challenges for dementia in Australia: are blood-based biomarkers the solution?

The burden of dementia will increase as the Australian population ages and grows in coming decades. Early and accurate diagnosis remains challenging, and disproportionately so for particular groups, including rural communities. Recent advances in technology, however, now allow reliable measurement of blood biomarkers that could improve diagnosis in a range of settings. We discuss the most promising biomarker candidates for translation into clinical practice and research in the near future.

Depressive Symptoms and Cognitive Decline Among Chinese Rural Elderly Individuals: A Longitudinal Study With 2-Year Follow-Up

Background

Depressive symptoms and mild cognitive impairment (MCI) are highly prevalent in rural China. The study aimed to investigate the longitudinal associations between changes in depressive symptoms and cognitive decline and MCI incidence among Chinese rural elderly individuals.

Methods

A 2-year follow-up study was conducted among 1,477 participants from the Anhui Healthy Longevity Survey (AHLS). Depressive symptoms were assessed by the 9-item Patient Health Questionnaire (PHQ-9), and cognitive status was evaluated by the Mini Mental State Examination (MMSE). Multivariable linear regression and logistic regression were employed.

Results

Every 1-unit PHQ-9 score increase was significantly associated with more cognitive decline (β = 0.157, 95% CI: 0.092, 0.221, p &lt; 0.001) and a higher risk of MCI incidence (OR = 1.063, 95% CI: 1.025, 1.103, p = 0.001). The participants who experienced worsening of depression symptoms had a larger decline in the 2-year MMSE score (β = 0.650, 95% CI: 0.039, 1.261, p = 0.037) and elevated risks of incident MCI (OR = 1.573, 95% CI: 1.113, 2.223, p = 0.010).

Limitations

Screening tools rather than standard diagnostic procedures were used in the study. Moreover, the long-term associations still need further exploration since the follow-up time was short.

Conclusions

Increased depressive symptoms were associated with more cognitive decline and higher risks of incident MCI among Chinese rural residents.

Predicting daily functioning with the modified Telephone Interview for Cognitive Status

Background

The modified Telephone Interview for Cognitive Status (mTICS) is a frequently used telephone-based cognitive screening measure that can distinguish between normal aging, mild cognitive impairment (MCI), and dementia. Although it has been used to predict current and future cognitive function in older adults, no studies have examined if the mTICS can predict daily functioning.

Aims

The current study sought to examine the relationship between the mTICS and a performance-based measure of daily functioning.

Methods

The mTICS and demographic information (age, sex, education) were collected during a telephone screening visit for 149 older adults (65–91 years in age) with amnestic MCI. Three subscales of the Independent Living Scales (ILS; Managing Money, Managing Home and Transportation, Health and Safety) were collected during a baseline visit and during a 16 month follow-up visit in a subsample of 93 individuals.

Results

Using simple hierarchical regression, baseline mTICS total score combined with demographic variables significantly predicted 19–22% of baseline ILS subscale scores. Similarly, in a subsample of 93 participants with 16 month follow-up data, baseline mTICS and demographic information predicted 9–31% of ILS subscale scores at follow-up.

Conclusions

The mTICS appears able to predict daily functioning in older individuals with MCI. Remote tracking of cognition and daily functioning in this at-risk group seems particularly beneficial to geriatricians and other providers, especially during COVID-19.

Barriers and Facilitators to Screening for Cognitive Impairment in Australian Rural Health Services: A Pilot Study

Australian National standards recommend routine screening for all adults over 65 years by health organisations that provide care for patients with cognitive impairment. Despite this, screening rates are low and, when implemented, screening is often not done well. This qualitative pilot study investigates barriers and facilitators to cognitive screening for older people in rural and regional Victoria, Australia. Focus groups and interviews were undertaken with staff across two health services. Data were analysed via thematic analysis and contextualized within the i-PARIHS framework. Key facilitators of screening included legislation, staff buy-in, clinical experience, appropriate training, and interorganisational relationships. Collaborative implementation processes, time, and workloads were considerations in a recently accredited tertiary care setting. Lack of specialist services, familiarity with patients, and infrastructural issues may be barriers exacerbated in rural settings. In lieu of rural specialist services, interorganisational relationships should be leveraged to facilitate referring ‘outwards’ rather than ‘upwards’.

Factors affecting cognitive dysfunction screening for Latinx adults with type 2 diabetes

Aim

To examine influences on screening of Latinx adults with type 2 diabetes for cognitive problems by identifying patient-, clinician-, and clinic-level factors.

Methods

This was a mixed methods study consisting of semi-structured interviews with Latinx adults with type 2 diabetes (n = 30; mean age = 68; 57% Mexican American) and surveys and interviews with health care providers (n = 15) in Central Texas. Data were examined with thematic analysis (interviews) and descriptive statistics (surveys and inventories).

Results

For the interviewed patients, screening was important, but inability to work related to a possible diagnosis of dementia was a concern. Both providers and patients agreed that other health issues (e.g., hyperglycemia) took precedence over cognitive screening. Providers (96.7%) were expected to screen patients but lacked clinic support and time; they relied on patients for initial prompts. Only one clinic required staff education on cognitive screening, with an emphasis on potential cultural differences in test results and adequate resources related to dementia for Latinx adults.

Conclusions

Clinics serving Latinx adults have a responsibility to deliver appropriate care. Leadership should consider innovative practices such as the creation, with patients, of educational materials for screening—a need highlighted by most participants.

Suspected Dementia in Young Adults: Cognitive Screening Tools for Use in Primary Care

Background: Memory complaints are frequent among young adults presenting in general practice. Many of them will have reversable, functional cognitive impairment that can easily be mistaken for dementia. Its accurate and timely identification is warranted to prevent further escalation to overt dementia syndrome. Objective: To evaluate the recommended primary care screening cognitive tools for dementia for use in younger people. Methods: 2.5 years clinical data were collected during the course of ongoing patient care for all assessed face-to-face patients in a secondary care memory service for younger adults. Cognitive screening and assessment tests used in primary [General Practice Assessment of Cognition (GPCOG)] and secondary [Addenbrooke’s Cognitive Examination-III (ACE-III), Rowland Universal Dementia Assessment Scale (RUDAS), Salzburg Dementia Test Prediction (SDTP)] care were analyzed for their accuracy to identify dementia and memory complaints. Area under the curve in receiver operating characteristic curves was used to measure predictive value of tests for a clinical diagnosis of dementia. Results: 348 young adults were assessed for cognitive impairment. Following comprehensive Memory Clinic assessments, 241 (69.25%) were diagnosed with memory complaints in the absence of relevant neuropathology and 107 with dementia. GPCOG, especially the informant part, and RUDAS had low accuracy to identify dementia (AUC = 0.465 and AUC = 0.698, respectively). In contrast, ACE-III and SDTP demonstrated the highest accuracy (AUC = 0.799 and AUC = 0.809/0.817, respectively). Conclusion: Dementia screening in younger people will benefit from SDTP incorporated as part of the screening cognitive toolset. The national guidance on dementia screening tools, diagnostic pathways, and management should also refer to younger adults.

Enhancing Dementia Education and Cognitive Screening in A Haitian Population: A Faith-based Approach

Ethnically diverse Americans experience 1.8-2.5 times higher risk of developing Alzheimer's disease than Whites (Mayeda, et al., 2016), yet cognitive screening is not routinely conducted among Haitian American communities. Dementia risk awareness is beneficial for improving management of chronic illness and behaviors that impact risk of cognitive decline. A quasiexperimental paired samples t-test design was employed to test the effectiveness of an educational intervention among 50 older faith- based Haitian adults using the Basic Knowledge of Alzheimer's Disease (BKAD) scale, cognitive screening using the Cognitive State Test (COST), and referrals to a local memory/wellness center. A significant difference was seen in knowledge scores: pre-test (M = 18.5, SD = 3.12) and post-test (M = 23.1, SD = 2.42); conditions t(41.9) = -9.5, p = .000. All of those who volunteered for screening completed follow-up neuropsychological evaluations. Outreach to faith-based settings is suggested as an avenue for improving dementia knowledge and detection.

Discerning rural Appalachian stakeholder attitudes toward memory screening

OBJECTIVE

The aim of this descriptive study was to examine Appalachian stakeholder attitudes toward routine memory screening, and to compare and contrast results from a similar study conducted in an ethnically diverse rural Florida cohort. Determining perceptions about memory screening is essential prior to developing culturally relevant programs for increasing early dementia detection and management among rural underserved older adults at risk of cognitive impairment. Benefits of early detection include ruling out other causes of illness and treating accordingly, delaying onset of dementia symptoms through behavior management and medications, and improving long-term care planning (Dubois, Padovani, Scheltens, Rossi, & Dell'Agnello, 2016). These interventions can potentially help to maintain independence, decrease dementia care costs, and reduce family burdens (Frisoni, et al., 2017).

METHOD

Researchers applied a parallel mixed method design (Tashakkori & Newman, 2010) of semi-structured interviews, measurements of health literacy (REALM-SF) (Arozullah, et al., 2007), sociodemographics, and cognitive screening perceptions (PRISM-PC) (Boustani, et al., 2008), to examine beliefs and attitudes about memory screening among 22 FL and 21 WV rural stakeholders (residents, health providers, and administrators).

RESULTS

Findings included that > 90% participants across both cohorts were highly supportive of earlier dementia detection through routine screening regardless of sample characteristics. However, half of those interviewed were doubtful that provider care or assistance would be adequate for this terminal illness. Despite previous concerns of stigma associated with an Alzheimer's disease diagnosis, rural providers are encouraged to educate patients and community members regarding Alzheimer's disease and offer routine cognitive screening and follow-through.

A survey of international clinical teleneuropsychology service provision prior to and in the context of COVID-19

Objective: Despite expansion of telecommunication strategies across health services and data supporting feasibility of videoconference-based neuropsychological assessment, relatively little is known about teleneuropsychology (TeleNP) use in practice. The current COVID-19 pandemic provides an opportunity for greater use of TeleNP and understanding of neuropsychologists' experience with this unique assessment medium.Methods: During the course of a no-cost global webinar related to practical/ethical considerations of TeleNP practice, attendees were invited to engage in a 26-question survey about their TeleNP use and related COVID-19 concerns. TeleNP practices before the COVID-19 pandemic and early on during the global outbreak were queried among survey participants, along with examination of TeleNP intentions following COVID-19.Results: Multiple countries were represented across five continents, with two-thirds of respondents being from the United States. Approximately one-fourth of respondents reported using TeleNP for clinical interview, feedback, and intervention prior to the onset of the COVID-19 pandemic, and approximately one-tenth of individuals used TeleNP for testadministration. Increased use of TeleNP for clinical interview, feedback, and intervention was reported within the first few weeks of the global COVID-19 outbreak, though the use of TeleNP for testing remained relatively unchanged. Most respondents indicated an intention for future use of TeleNP.Conclusions: Our findings suggest the use of TeleNP is increasing, although use of remote TeleNP testing is still developing. Findings also illustrate increasing use of TeleNP in the context of the COVID-19 pandemic and encourage follow-up investigation in future studies to understand the changing practices and rates of TeleNP provision over time.

An updated measure for investigating basic knowledge of Alzheimer's disease in underserved rural settings

Objective: Older rural adults face a higher burden of Alzheimer's disease (AD) and delayed detection. This risk is heightened in rural populations that are ethnically diverse. Patients and providers are often hesitant to participate in screening, partially due to gaps in knowledge of the current science. The purpose of this paper is to describe the results of administering the revised version of the Basic Knowledge of Alzheimer's Disease (BKAD) measure in small rural communities in five different states.Methods: The BKAD measure was revised after first being tested in rural Appalachia. Revisions including eliminating non-discriminating items and adding questions regarding early detection, sleep, head injury, and vision changes. Reliability and validity testing included Cronbach's alpha and Rasch item analysis, test-retest, and predictive validity. Descriptive measures and independent sample t-tests were used to analyze knowledge gaps and sociodemographics.Results: Tests for reliability and validity were highly favorable, including Cronbach's alpha = .85 and overall Rasch item analysis of .94. Three-fourths of participants knew that annual cognitive screening was recommended for older adults, but only one-fourth had been previously screened. Sociodemographic findings revealed that a majority of participants (86%) would participate in annual memory screening if offered, regardless of education or health literacy level.Conclusion: The BKAD measure is a good fit for use in rural and underserved populations. BKAD results can inform the design of culturally relevant programs for raising awareness of the importance of early AD detection and treatment.

Rural stakeholder perceptions about cognitive screening

Objectives: The study aims were to explore stakeholder perceptions about cognitive screening in a rural, ethnically diverse, underserved setting, and to examine whether perceptions varied by years lived in a rural area, career, health literacy, willingness to be screened, ethnicity, education, or age. Methods: Twenty-one rural, ethnically diverse stakeholders completed an open-ended interview of five questions and a measure regarding perceptions about cognitive screening (PRISM-PC, Boustani, et al., 2008 ). Open coding using the in vivo process (Saldaña, 2015 ) to "derive codes from the actual participant language" (p. 77) was used to analyze the qualitative data. We used Pearson correlation to examine relationships between the PRISM-PC and sociodemographics including age, years of education, health literacy, years lived in rural areas, and willingness to participate in cognitive screening. Results: Eight codes and two themes were identified from the in vivo analysis. The eight codes were "a sentence being pronounced over the lives", "keep everybody at home", "Education is big", the trust issues is everything here", "identify support systems", "access to care", and "there is a cost to do that". The two themes were "Trust is the essential component of connecting with Community", and (2) "The Community recognizes the importance of knowledge in improving care. PRISM-PC results added new information in that persons were concerned about the emotional and financial burden on their families. Overall, regardless of age, careers, care involvement, health literacy, or education, 81% of stakeholders indicated they would seek annual cognitive screening. Discussion: It is important for rural health professionals to consider that contrary to previous stigma concerns, stakeholders may support earlier dementia detection.

Application of cognitive screening guidelines by health care providers in diabetes care: A cross-sectional descriptive study

RATIONALE, AIMS, AND OBJECTIVES

The risk of cognitive dysfunction is higher in people with diabetes than in the general population, and approximately 50% of those with diabetes will develop cognitive impairments as they age. Screening for cognitive dysfunction in people with diabetes can help identify both pathology and those who are at risk for higher health care utilization, but we do not know how health care providers implement cognitive screening recommendations in this population. In this study, we examined health care providers' knowledge of those recommendations and their application of them, as well as factors associated with guideline use.

METHODS

This study used a cross-sectional, descriptive correlational design with a convenience sample. All data were collected with a 20-question online survey sent to advanced practice nurses (APNs), medical doctors/doctor of osteopathic medicines (MDs/DOs), and physician assistants (PAs) in Central Texas.

RESULTS

One-hundred eighty-one health care providers responded. Participants most frequently said they were "moderately familiar" with guidelines for cognitive impairment screening (60.9%). Twenty-three per cent of physicians, 37.4% of APNs, and 8.3% of PAs indicated that they incorporated routine screening into daily practice. However, 64% did not use standardized tools to assess cognitive function. The most common clinical tasks related to cognitive screening were referral for more in-depth cognitive screening (44%) and education of families regarding cognitive problems (29%). Lack of time was the most common barrier to screening (57.7%).

CONCLUSIONS

Most respondents believed that there was a good rationale for assessing cognitive function in people with diabetes. However, despite some familiarity with guidelines for cognitive function screening, most respondents did not use standardized assessment tools. The results indicate variability in clinical practice regarding assessment and practices, such that there may be some variability in outcomes for patients.

Annual Cognitive Assessment for Older Adults: Update for Nurses

Alzheimer's disease is predicted to bankrupt Medicare by 2050 if current trends in disease prevalence do not change (Alzheimer's Association, 2012). Earlier diagnosis and access to health care for Alzheimer's disease result in decreased health care costs (Brosch & Matthews, 2014). Consequently, in January 2011 screening for cognitive impairment became a component of the annual wellness visit (AWV) outlined in the Patient Protection and Affordable Care Act. Many community health nurses are unaware of this benefit. This article includes a review of the updated 2011 definition of Alzheimer's disease, the components of the AWV, and tools for conducting cognitive assessment.

Assessment of Basic Knowledge About Alzheimer’s Disease Among Older Rural Residents: A Pilot Test of a New Measure

Background and Purpose: Underserved rural populations face a higher risk of Alzheimer’s disease (AD), yet studies investigating AD knowledge in this population are lacking. The purpose of this research was to develop an AD basic knowledge measure that is appropriate for use with underserved populations. Method: A content domain map, content validity index, and cognitive interviews were used in developing the first version of the basic knowledge of Alzheimer’s disease (BKAD; Study 1). Reliability and validity of the measure in this descriptive study were examined using Rasch modeling and tests for construct, concurrent, and discriminate validity (Study 2). Multiple regression was employed to examine AD knowledge predictors. Results: Findings included that the BKAD instrument discriminated well between persons with varied education levels. Psychometric analysis yielded important information to guide revision of the BKAD measure. Conclusion: The BKAD measure shows promise in meeting the need for a culturally relevant measure to assess basic Alzheimer’s disease knowledge in underserved rural populations.

Older Rural- and Urban-Dwelling Appalachian Adults With Mild Cognitive Impairment

PURPOSE

Mild cognitive impairment (MCI) is a well-recognized risk state for Alzheimer's disease and other dementias. MCI is rapidly increasing among older adults in general and has not yet been examined in older adults within the Appalachian region. Our objective was to compare MCI symptom severity among older rural and urban Appalachian adults with MCI at an initial neuropsychological testing visit.

METHODS

A cross-sectional, descriptive study of older Appalachian adults with MCI was conducted using data from the National Alzheimer's Coordinating Center Uniform Data Set. Symptom severity was conceptualized as neuropsychological composite scores across 4 cognitive domains and Clinical Dementia Rating-Sum of Boxes (CDR-SOB) score. For group comparisons, MANCOVA was used for cognitive domains and ANCOVA for CDR-SOB.

RESULTS

The sample (N = 289) was about half male (54.3%), predominantly white (91.7%), and living with others (83.5%), with a mean (±SD) 74.6 ± 6.2 years of age and 15.4 ± 3.0 years of education. Rural and urban groups differed significantly in years since onset of cognitive symptoms (2.98 ± 1.91 in rural and 3.89 ± 2.70 in urban adults, t[260] = -2.23, P = .03), but they did not differ across sociodemographic features or comorbid conditions. Rural and urban participants were similar across the 4 cognitive domains and CDR-SOB (P ≥ .05).

DISCUSSION

No differences were found between rural and urban Appalachian residents on MCI symptom severity. However, urban residents reported a longer time lapse from symptom identification to diagnosis than their rural counterparts. Future studies using more representative population samples of Appalachian and non-Appalachian adults will provide an important next step to identifying disparate cognitive health outcomes in this traditionally underserved region.

RemoDem: Delivering support for people with dementia in remote areas

RemoDem aimed to develop, test and evaluate services for people with dementia in remote areas of the Faroe Islands, Greenland, Sweden and Scotland. Formative and summative evaluation used a flexible research design including collection of baseline data, interviews and focus groups with key informants and data relating to service users, i.e. people with dementia and their carers. Challenges for service providers included organisational difficulties, lack of clear information about their populations with dementia and lack of knowledge in local communities. Test sites which developed services building on their particular local starting points adopted both specialist and 'off the shelf' technologies and found that these were generally helpful for people with significant support needs. The flexible research design was found to be essential in the real world conditions of the service development and evaluation. Services were more successful where more mature and less experimental technologies were used. The new services promised to address effectively challenges of remoteness including distance, communication and workforce deployment issues.