What Correlates With the Intention to be Tested for Mild Cognitive Impairment (MCI) in Healthy Older Adults?

Intention to Be Screened for Alzheimer's Disease in Nondemented Older Adults: Integrated Behavioral Model and Self-Efficacy as Mediation Effect

The study explored factors associated with intention to be screened for Alzheimer's disease (AD). The study also examined whether self-efficacy mediates the relationship between knowledge about screening and the intention to be screened for AD. A population-based, random-digit dialing survey was performed and 1,043 responses were collected from a sample of nondemented persons (50 years or older) living in urban, suburban, and rural areas in a Midwestern state. The findings showed that participants who were younger and who had higher levels of (a) perceived benefits and barriers, (b) social support, and (c) self-efficacy reported higher levels of intention to be screened for AD. Older adults with positive life orientation reported greater intention to be screened for AD, whereas depressed participants were more likely to report a plan to be screened for AD. Self-efficacy mediated the relationship between knowledge about screening and intention to be screened. Older adults were more likely to report intention to be screened when they had positive attitudes about the screen and believed that they could receive the screen. The intention to be screened for AD could serve public awareness by defining effective ways to assist older adults to seek a cognitive screen.

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.

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.

Amyloid-β Imaging in Older Adults Presenting to a Memory Clinic with Subjective Cognitive Decline: A Pilot Study

BACKGROUND

Subjective cognitive decline (SCD) in otherwise normal aging may be identified via symptom inventories in a research setting ('questionnaire-discovered complaints') or via patients seeking evaluation/services in a clinical setting ('presenting complainers'). Most studies of SCD and amyloid-β (Aβ) imaging to date have used the former approach, with inconsistent results.

OBJECTIVE

To test whether 'presenting SCD' participants in an academic memory clinic setting show increased brain Aβ deposition on imaging.

METHODS

Fourteen patients (mean age 68.1, SD 4.0 years) diagnosed with subjective cognitive complaints with normal neuropsychological testing were recruited into a Pittsburgh compound B (PiB)-PET study. Detailed self-report inventories and additional cognitive tests were administered. Results were compared to a reference cohort of cognitively normal volunteers (NC) from an independent neuroimaging study (mean age 73.6, SD 5.8 years).

RESULTS

57% (8/14) of SCD participants were PiB-positive by a sensitive, regionally-based definition, compared to 31% (26/84) of the NC cohort. SCD participants had significantly higher PiB retention (SUVR) than NC in three of six regions of interest: frontal cortex (p = 0.02), lateral temporal cortex (p = 0.02), and parietal cortex (p = 0.04). SCD participants showed measurable deviations on questionnaires reflecting high negative affect (i.e., depressive symptoms and neuroticism). Findings were suggestive that deficits on verbal associative binding may be specific to Aβ-positive versus Aβ-negative SCD.

CONCLUSION

Older participants with SCD presenting to a memory clinic in this pilot study sample have higher brain Aβ deposition compared to normal aging study volunteers unselected on complaints. Further study of presenting SCD are warranted to determine the prognostic significance of Aβ deposition in this context.

Attitudes and preferences towards screening for dementia: a systematic review of the literature

BACKGROUND

Population screening might provide a mechanism to enable early detection of dementia. Yet the potential benefits, harms or acceptability of such a large-scale intervention are not well understood. This research aims to examine the attitudes and preferences of the general public, health care professionals, people with dementia and their carers towards population screening for dementia.

METHODS

A systematic review of the international literature was undertaken. A search of fifteen bibliographic databases was conducted (up to 12 July 2012; no language restriction) using terms related to dementia, screening, specific screening tools, case finding, and attitudes and preferences; genetic screening and biomarkers were excluded. All study designs were included except opinion-based papers. Included papers were doubly quality assessed and thematically analysed using NVivo.

RESULTS

29,910 papers were identified of which 29 met the inclusion criteria. We identified seventeen themes relating to the 3 phases of the screening process (pre-, in- and post-screen) - none emerged as more of a facilitator than a barrier to the acceptance of dementia screening. Seven themes emerged in relation to the patient, carer and general population: existing health state; lifestyle and life view; awareness of dementia; role of clinician; communication; benefit; and role of the family. Ten themes emerged in relation to the clinician and healthcare professional: patient's existing health and comorbidities; awareness of dementia; confidence; duration of patient contact; suitability of screening tool; cost; disclosure; time; treatment and prognosis; and stigma.

CONCLUSIONS

As for all screening programmes, screening for dementia raises complex issues around preference and choice for clinicians and the public, and it is unclear what specific factors promote or reduce screening acceptance the most. Overall, the level of evidence is low, few large scale studies have been undertaken and none were conducted in representative samples, all affecting the generalizability of identified themes across healthcare contexts. Nevertheless, our findings suggest that population screening for dementia may not be acceptable to either the general public or health care professionals, and highlight where focused efforts are needed to gain insights into dementia specific issues.

Decision-making in older people with dementia

Dementia is a syndrome characterized by a progressive impairment in cognition, function and behaviour, with a considerable burden in terms of health and social care, and economic costs. As Alzheimer's disease and other dementias advance, the patient's capacity, competence and possibility of participation in decision-making decrease. Key points in managing people with dementia include screening of cognitive impairment, neuropsychological assessment, laboratory tests and neuroimaging, genetic tests, informed consent, inclusion in clinical trials and discussion of advance directives, driving, managing finances and testamentary capacity, pharmolocogical and non-pharmacological treatment and also palliative and end-of-life care. In this article we review these crucial points in decision-making for people with dementia and their families and caregivers.

Feasibility and validity of dementia assessment by trained community health workers based on Clinical Dementia Rating

OBJECTIVES

To determine the level of agreement between dementia rating by trained community health workers (CHWs) based on the Clinical Dementia Rating (CDR) and the criterion standard: physician diagnosis.

DESIGN

Cross-sectional validation study.

SETTING

Community gathering places such as ethnic churches, senior centers, low-income elderly apartments, and ethnic groceries in the Baltimore-Washington metropolitan area.

PARTICIPANTS

Ninety community-dwelling Korean-American individuals aged 60 and older.

MEASUREMENTS

The CDR is a standardized clinical dementia staging instrument used to assess cognitive and functional performance using a semistructured interview protocol. Six CHWs trained and certified as CDR raters interviewed and rated study participants. A bilingual geriatric psychiatrist evaluated participants independently for dementia status.

RESULTS

CHWs rated 61.1% of the participants as having mild cognitive impairment (MCI; CDR = 0.5) or dementia (CDR≥1), versus 56.7% diagnosed by the clinician. A receiver operating characteristic (ROC) curve analysis demonstrated good predictive ability of CDR rating by trained CHWs (area under the ROC curve = 0.86, 95% confidence interval = 0.78-0.93, sensitivity = 85.5%, specificity = 88.6%) in detecting MCI and dementia.

CONCLUSION

The findings provide preliminary evidence that trained CHWs can effectively identify community-dwelling elderly Korean adults with MCI and dementia for early follow-up assessment and care in a community with scarce bilingual caregivers and programs.

Illness representations in older adults with mild cognitive impairment

Little is known about patients' understanding of a diagnosis of mild cognitive impairment (MCI). The purpose of this cross-sectional descriptive study was to describe beliefs about MCI in people diagnosed with the condition and examine correlates (demographic and health) of those beliefs. Thirty individuals diagnosed with MCI completed the Illness Perception Questionnaire-MCI (IPQ-MCI), measuring eight domains of beliefs about MCI, and one scale of emotional distress. Five of them also participated in a 15-minute cognitive interview to explore responses to the IPQ-MCI. Participants correctly identified symptoms related to MCI; generally attributed MCI to aging, heredity, and abnormal brain changes; and believed MCI to be chronic, predictable, and controllable, causing little emotional distress. However, there were no consistent beliefs regarding the negative consequences of MCI or whether MCI was understandable. There were few significant correlates of beliefs. People with MCI are able to report their beliefs about their illness, suggesting that misconceptions and gaps in knowledge can be identified and addressed with nursing interventions.

[Predementia Alzheimer's disease. Benefits of early diagnosis]

Given population aging and the rise in the number of persons with Alzheimer's disease, measures that aim not only to delay but also to prevent the development of this disease are increasingly required. Advances in the diagnosis of Alzheimer's disease support the need for a review of current clinical standards for mild cognitive impairment and provide new goals in the early treatment of this disease. The current diagnostic process should be refocussed toward the pathological substrate of this disease rather than symptoms in order to initiate therapeutic measures as soon as possible without waiting for clinical manifestations to appear. Such an approach is essential in patients with greater cognitive reserve, in whom the lesions are usually more severe at diagnosis and treatment is less effective. To identify disease-modifying therapies to delay the onset of the clinical symptoms of Alzheimer's disease in cognitively intact persons at high risk, biomarkers for this disease must be validated. A single biomarker is unlikely to provide the required diagnostic accuracy and therefore a multimodal approach, incorporating biochemical, neuropathological and anatomical and metabolic neuroimaging methods, should be employed. To optimize the results of drugs under investigation, a combination of biomarkers should be used to select appropriate participants in the earliest phases of the disease, and disease progression should be followed-up. Early diagnosis might clarify essential questions in the care of patients with Alzheimer's disease, such as the possibility of distinguishing among various subtypes, thus encouraging the development of optimal treatments for each. The ultimate goal is to develop disease-modifying treatments that could be initiated early, while patients are asymptomatic or only minimally symptomatic, to maintain their quality of life.

Clinical recognition of dementia and cognitive impairment in primary care: a meta-analysis of physician accuracy

OBJECTIVE

We aimed to examine the ability of the general practitioners (GPs) to recognize a spectrum of cognitive impairment from mild cognitive impairment (MCI) to severe dementia in routine practice using their own clinical judgment.

METHOD

Using PRISMA criteria, a meta-analysis of studies testing clinical judgment and clinical documentation was conducted against semi-structured interviews (for dementia) and cognitive tests (for cognitive impairment). We located 15 studies reporting on dementia, seven studies that examined recognition of broadly defined cognitive impairment, and eight regarding MCI.

RESULTS

By clinical judgment, clinicians were able to identify 73.4% of people with dementia and 75.5% of those without dementia but they made correct annotations in medical records in only 37.9% of cases (and 90.5% of non-cases). For cognitive impairment, detection sensitivity was 62.8% by clinician judgment but 33.1% according to medical records. Specificity was 92.6% for those without cognitive impairment by clinical judgment. Regarding MCI, GPs recognized 44.7% of people with MCI, although this was recorded in medical notes only 10.9% of the time. Their ability to identify healthy individuals without MCI was between 87.3% and 95.5% (detection specificity).

CONCLUSION

GPs have considerable difficulty identifying those with MCI and those with mild dementia and are generally poor at recording such diagnoses in medical records.

[New possibilities for automated diagnosis of dementia]

Dementia is underdiagnosed and undertreated in Germany. Automatic diagnosing of dementia based on standard magnetic resonance imaging has the capacity to reduce diagnostic uncertainties. The algorithm learns a disease specific pattern of atrophy from training samples. It is independent from radiological expertise which may be scarce outside specialised centres and can be installed on MRT-machines or desktop PCs. It can also play its part in planning and conducting treatment trials by recruiting a sample with predicted fast future decline. Extension, based e.g. on resting state functional imaging are possible but are further away from clinical routine.

Early identification and treatment of Alzheimer's disease: social and fiscal outcomes

BACKGROUND

Alzheimer's disease (AD) is a progressive neurodegenerative disease that places substantial burdens on those who provide support for family members with declining cognitive and functional abilities. Many AD patients eventually require formal long-term care services because of the absence, exhaustion, or inability of family members to provide care. The costs of long-term care, and especially nursing home care, often deplete private financial resources, placing a substantial burden on state Medicaid programs. Current evidence suggests that pharmacological treatments and caregiver interventions can delay entry into nursing homes and potentially reduce Medicaid costs. However, these cost savings are not being realized because many patients with AD are either not diagnosed or diagnosed at late stages of the disease, and have no access to Medicare-funded caregiver support programs.

METHODS AND RESULTS

A Monte Carlo cost-benefit analysis, based on estimates of parameters available in the medical literature, suggests that the early identification and treatment of AD have the potential to result in large, positive net social benefits as well as positive net savings for states and the federal government.

CONCLUSIONS

These findings indicate that the early diagnosis and treatment of AD are not only socially desirable in terms of increasing economic efficiency, but also fiscally attractive from both state and federal perspectives. These findings also suggest that failure to fund effective caregiver interventions may be fiscally unsound.