Inequalities in dementia care across Europe: key findings of the Facing Dementia Survey

Clinical and genetic factors affecting diagnostic timeline of amyotrophic lateral sclerosis: a 15-year retrospective study

OBJECTIVES

Amyotrophic Lateral Sclerosis (ALS) diagnosis can take 10-16 months from symptom onset, leading to delays in treatment and patient counselling. We studied the impact of clinical and genetic risk factors on the diagnostic timeline of ALS.

METHODS

Baseline characteristics, family history, gene testing, onset location, time from symptom onset to diagnosis, and time from first doctor visit to suspected ALS was collected. We used multiple regression to assess the interaction of these factors on ALS diagnostic timeline. We analysed a subgroup of patients with genetic testing and compared positive or negative tests, sporadic or familial and ALS-related genes to time for diagnosis.

RESULTS

Four hundred and forty-eight patients diagnosed with ALS at the University of Massachusetts Chan Medical Center between January 2007 and December 2021 were analysed. The median time to ALS diagnosis was 12 months and remained unchanged from 2007 to 2021 (p = 0.20). Diagnosis was delayed in patients with sporadic compared with familial ALS (mean months [standard deviation], 16.5[13.5] and 11.2[8.5], p < 0.001); cognitive onset (41[21.26]) had longer time to diagnosis than bulbar (11.9[8.2]), limb (15.9[13.2]), respiratory (19.7[13.9]) and ALS with multiple onset locations (20.77[15.71], p < 0.001). One hundred and thirty-four patients had gene testing and 32 tested positive (23.8%). Gene testing (p = 0.23), a positive genetic test (p = 0.16), different ALS genes (p = 0.25) and sporadic (p = 0.92) or familial (p = 0.85) ALS testing positive for ALS genes did not influence time to diagnosis.

DISCUSSION

Time for ALS diagnosis remained unchanged from 2007 to 2021, bulbar-onset and familial ALS made for faster diagnosis.

Performance of probable dementia classification in a European multi-country survey

Feasibility constraints limit availability of validated cognitive assessments in observational studies. Algorithm-based identification of 'probable dementia' is thus needed, but no algorithm developed so far has been applied in the European context. The present study sought to explore the usefulness of the Langa-Weir (LW) algorithm to detect 'probable dementia' while accounting for country-level variation in prevalence and potential underreporting of dementia. Data from 56 622 respondents of the Survey of Health, Ageing and Retirement in Europe (SHARE, 2017) aged 60 years and older with non-missing data were analyzed. Performance of LW was compared to a logistic regression, random forest and XGBoost classifier. Population-level 'probable dementia' prevalence was compared to estimates based on data from the Organisation for Economic Co-operation and Development. As such, application of the prevalence-specific LW algorithm, based on recall and limitations in instrumental activities of daily living, reduced underreporting from 61.0 (95% CI, 53.3-68.7%) to 30.4% (95% CI, 19.3-41.4%), outperforming tested machine learning algorithms. Performance in other domains of health and cognitive function was similar for participants classified 'probable dementia' and those self-reporting physician-diagnosis of dementia. Dementia classification algorithms can be adapted to cross-national cohort surveys such as SHARE and help reduce underreporting of dementia with a minimal predictor set.

Prevalence of treated patients with Alzheimer's disease: current trends and COVID-19 impact

BACKGROUND

There are few updated studies on the prevalence and management of Alzheimer's disease (AD), which could be underdiagnosed or undertreated. The COVID-19 pandemic may have worsened the deficiencies in the diagnosis and treatment of these patients. Electronic medical records (EMR) offer an opportunity to assess the impact and management of medical processes and contingencies in the population.

OBJECTIVE

To estimate AD prevalence in Spain over a 6-year period, based on treated patients, according to usual clinical practice. Additionally, to describe the management of AD-treated patients and the evolution of that treatment during the 2020 COVID-19 pandemic.

METHODS

Retrospective study using the Spanish IQVIA EMR database. Patients treated with donepezil, galantamine, rivastigmine, and/or memantine were included in the study. Annual AD prevalence (2015-2020) was estimated and extrapolated to the national population level. Most frequent treatments and involved specialties were described. To assess the effect of COVID-19, the incidence of new AD cases in 2020 was calculated and compared with newly diagnosed cases in 2019.

RESULTS

Crude AD prevalence (2015-2020) was estimated at 760.5 per 100,000 inhabitants, and age-standardized prevalence (2020) was 664.6 (male 595.7, female 711.0). Monotherapy was the most frequent way to treat AD (86.2%), in comparison with dual therapy (13.8%); rivastigmine was the most prescribed treatment (37.3%), followed by memantine (36.4%) and donepezil (33.0%). Rivastigmine was also the most utilized medication in newly treated patients (46.7%), followed by donepezil (29.8%), although donepezil persistence was longer (22.5 vs. 20.6 months). Overall, donepezil 10 mg, rivastigmine 9.5 mg, and memantine 20 mg were the most prescribed presentations. The incidence rate of AD decreased from 148.1/100,000 (95% confidence interval [CI] 147.0-149.2) in 2019 to 118.4/100,000 (95% CI 117.5-119.4) in 2020.

CONCLUSIONS

The obtained prevalence of AD-treated patients was consistent with previous face-to-face studies. In contrast with previous studies, rivastigmine, rather than donepezil, was the most frequent treatment. A decrease in the incidence of AD-treated patients was observed during 2020 in comparison with 2019, presumably due to the significant impact of the COVID-19 pandemic on both diagnosis and treatment. EMR databases emerge as valuable tools to monitor in real time the incidence and management of medical conditions in the population, as well as to assess the health impact of global contingencies and interventions.

Dementia is (not) a natural part of ageing: a cross-sectional study on dementia knowledge and misconceptions in Swiss and Italian young adults, adults, and older adults

BACKGROUND

Increasing public awareness and understanding of dementia is the second key action area of the 2017 WHO Global action plan on a public health response to dementia. To achieve this aim, the first indispensable step is to understand the average level of dementia knowledge and to identify areas of low dementia knowledge. We aimed to quantify dementia knowledge in the general population, and to explore the extent to which it differs by age, sex, education, and indirect experience with dementia.

METHODS

We conducted an online cross-sectional survey in two Italian-speaking sites, south Switzerland (Ticino) and northern Italy (Piedmont). The survey was distributed between September and December 2019. We registered socio-demographic characteristics including whether the participant had contact with a person living with dementia, and measured dementia knowledge with the Dementia Knowledge Assessment Survey (DKAS).

RESULTS

Misconceptions about dementia were common among respondents, and lack of knowledge has been identified in dementia causes, characteristics, risk factors, and health promotion. Our results point out the lack of knowledge about how to communicate and relate with, and take care of a person living with dementia. The overall DKAS score was significantly and positively associated with female sex (β = 0.21; p < 0.001), educational level (β = 0.15; p < 0.001) and contact with a person living with dementia (β = 0.17; p < 0.001), but not with age (β = -0.01; p = 0.57).

CONCLUSION

Our results confirmed that general population's knowledge of dementia is thin. Interventional studies that rely on participatory action research methods are warranted to co-design interventions aimed at improving dementia knowledge and understanding in the public.

On becoming a dementia-friendly community: An empirical study of the individual factors that predict openness towards dementia-friendly communities

BACKGROUND AND OBJECTIVES

Evidence suggests that limited public awareness and dementia-related stigma can create barriers to community inclusiveness. This study explored the relation between public knowledge of dementia, attitudes towards people with dementia, experience with dementia and openness towards dementia-friendly communities.

RESEARCH DESIGN AND METHODS

Two-hundred and twenty-nine members of the public completed a cross-sectional online survey with three established measures [Alzheimer's Disease Knowledge Test, Attitudes Towards People with Dementia scale and Understanding of Health Problems survey] and one exploratory scale [Openness Towards Dementia-Friendly Communities]. An existing 'mild' dementia vignette was used to evaluate dementia recognition. Factors contributing to correct dementia recognition (knowledge, exposure to dementia, education and gender), worry about developing dementia (knowledge, exposure and respondent age), and openness towards dementia-friendly communities (knowledge, exposure and attitudes) were examined through group comparisons and a multiple linear regression.

RESULTS

Consistent with the literature, the respondents had poor knowledge, reasonably good dementia recognition, and mostly positive attitudes towards people with dementia. None of the proposed factors were significantly associated with correct dementia recognition, and only gender was significantly associated with dementia worry. Knowledge and attitudes towards people with dementia (not exposure) were significant independent predictors of openness towards dementia-friendly communities.

DISCUSSION AND IMPLICATIONS

The expansion of dementia-friendly communities will require further investment in awareness-raising initiatives to improve dementia knowledge and attitudes in the community. This study shows the importance of these factors in the broader community's openness towards dementia-friendly communities.

A Cost-Consequence Analysis of Different Screening Procedures in Alzheimer's Disease: Results from the MOPEAD Project

Background:

For care planning and support, under-detection and late diagnosis of Alzheimer’s disease (AD) is a great challenge. Models of Patient-Engagement for Alzheimer’s Disease (MOPEAD) is an EU-funded project aiming at testing different strategies to improve this situation.

Objective:

To make a cost-consequence analysis of MOPEAD.

Methods:

Four screening strategies were tested in five countries (Germany, the Netherlands, Slovenia, Spain, and Sweden): 1) a web-approach; 2) Open-House initiative; 3) in primary care; and 4) by diabetes specialists. Persons-at-risk of AD in all strategies were offered referral to a hospital-based specialist. The primary health-economic outcome was the cost per true-positive case (TP) of AD from the screened population.

Results:

Of 2,847 screened persons, 1,121 screened positive (39%), 402 were evaluated at memory clinics (14%), and 236 got an AD diagnosis (8%). The cost per TP of those screened was €3,115 with the web-approach, €2,722 with the Open-House, €1,530 in primary care, and €1,190 by diabetes specialists. Sensitivity analyses that more likely reflect the real-world situation confirmed the results. The number-needed-to-screen was 30 with the web-approach, 8 with the Open-House and primary care, and 6 with the diabetes specialists.

There were country differences in terms of screening rates, referrals to memory clinics, staff-types involved, and costs per TP.

Conclusion:

In primary care and by the diabetes specialist, the costs per TP/screened population were lowest, but the capacity of such settings to identify cases with AD-risk must be discussed. Hence new diagnostic strategies such as web-solutions and Open-House initiatives may be valuable after modifications.

[General practitioners' views on cognitive disorders diagnosis: a qualitative study]

Diagnosis of cognitive disorders is at medical and ethical stake. The aim of an qualitative study based on interviews was to explore the views of general practitioners on this diagnosis. General practitioners are ambivalent about the relevance and temporality of the diagnosis of cognitive disorders, which could be resolved by a shared decision making at each stage of the diagnostic approach.

Crossing the “Cookie Theft” Corpus Chasm: Applying What BERT Learns From Outside Data to the ADReSS Challenge Dementia Detection Task

Large amounts of labeled data are a prerequisite to training accurate and reliable machine learning models. However, in the medical domain in particular, this is also a stumbling block as accurately labeled data are hard to obtain. DementiaBank, a publicly available corpus of spontaneous speech samples from a picture description task widely used to study Alzheimer's disease (AD) patients' language characteristics and for training classification models to distinguish patients with AD from healthy controls, is relatively small—a limitation that is further exacerbated when restricting to the balanced subset used in the Alzheimer's Dementia Recognition through Spontaneous Speech (ADReSS) challenge. We build on previous work showing that the performance of traditional machine learning models on DementiaBank can be improved by the addition of normative data from other sources, evaluating the utility of such extrinsic data to further improve the performance of state-of-the-art deep learning based methods on the ADReSS challenge dementia detection task. To this end, we developed a new corpus of professionally transcribed recordings from the Wisconsin Longitudinal Study (WLS), resulting in 1366 additional Cookie Theft Task transcripts, increasing the available training data by an order of magnitude. Using these data in conjunction with DementiaBank is challenging because the WLS metadata corresponding to these transcripts do not contain dementia diagnoses. However, cognitive status of WLS participants can be inferred from results of several cognitive tests including semantic verbal fluency available in WLS data. In this work, we evaluate the utility of using the WLS ‘controls’ (participants without indications of abnormal cognitive status), and these data in conjunction with inferred ‘cases’ (participants with such indications) for training deep learning models to discriminate between language produced by patients with dementia and healthy controls. We find that incorporating WLS data during training a BERT model on ADReSS data improves its performance on the ADReSS dementia detection task, supporting the hypothesis that incorporating WLS data adds value in this context. We also demonstrate that weighted cost functions and additional prediction targets may be effective ways to address issues arising from class imbalance and confounding effects due to data provenance.

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.

Negative stereotypes, fear and social distance: a systematic review of depictions of dementia in popular culture in the context of stigma

BACKGROUND

Literature, film and news media reflect and shape social perceptions of dementia which in turn impact on dementia stigma. The aim of this paper is to systematically review papers on the depiction and frames for dementia in literature, film, mass media and social media in order to better understand cultural stigma related to dementia.

METHODS

A systematic search of electronic databases was undertaken combining phrases relating to dementia, popular culture and representations, and phrases relating to dementia and stigma. We searched for scientific English language papers which included original analysis on the representation or depiction of dementia in popular culture (i.e. in film and television, literature, news, social media and language). Articles published between 1989-2018 were included. The search was conducted in December 2017 and updated in January 2019. Inductive thematic synthesis was undertaken.

RESULTS

A total of 60 articles were included from an initial sample of 37022. Dementia was almost always depicted in conjunction with ageing, and often equated with Alzheimer's disease. Common frames for dementia were biomedical - dementia involves the deterioration of the brain for which there is no current cure; natural disaster or epidemic - dementia is a force of nature which will overwhelm mankind; and living dead - people with dementia lose their brains, memories, minds and consequently their personhood and human rights. There were examples of more positive depictions of dementia including expressing love and individual agency and experiencing personal growth. Feelings commonly associated with dementia were fear, shame, compassion and guilt, and depictions often resulted in a sense of social distance.

CONCLUSIONS

Depictions of dementia in popular culture are associated with negative images and feelings, and social distance between people with dementia and those without. These correspond to dementia stigma in the public and as experienced by people with dementia. Further research is needed into the impact of literature, news and social media on dementia stigma and these cultural mediums might be used to reduce stigma.

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.

Challenges in the provision of digital technologies to elderly with dementia to support ageing in place: a case study of a Swedish municipality

PURPOSE

The aim of this paper is to identify structural problems and challenges for the delivery of digital technologies for ageing in place to elderly with dementia.

METHODS

To that end, I conducted a case study in a Swedish municipality.

RESULTS

The results showed that elderly with dementia are not exploiting their full potential of receiving help in the form of technology, since the four conditions of the Consumer Direction (Control and Direct services - Variety of digital technologies for ageing in place options - Information and Support - Participation in systems design) were met to a very low degree.

CONCLUSIONS

I propose that the municipality in question creates a proper knowledge-sharing platform so that occupational therapists are well informed about digital technologies for ageing in place, to allow them to provide accurate information and support to elderly with dementia, resulting in a possible increase in use of technology and subsequently support the empowerment goal of Consumer Direction. I also believe, according to the findings of this study, that the module of Information and Support should be treated as the most important condition for achieving increased Consumer Direction.Implications for rehabilitationElderly with dementia and their relatives do not receive sufficient information about digital technologies for ageing in place (DTAP). There is not enough information regarding the available options and their use. This often denies elderly with dementia and their relatives the services they are entitled.Occupational therapists knowledge about DTAP affects the variety of options presented to elderly with dementia and their subsequent use.Once a person is diagnosed with dementia, physicians tend to suggest medicinal solutions, overlooking the dissemination of DTAP information. Thus hindering their early access to DTAP.

Implementing dementia risk reduction in primary care: a preliminary conceptual model based on a scoping review of practitioners' views

Primary care practitioners (PCPs) do not routinely promote dementia risk reduction. The purpose of this study was to map the published literature on the views of PCPs about dementia risk reduction, in order to identify implementation constructs and strategies crucial to the development of an implementation intervention to support dementia risk reduction in primary care. We undertook a scoping review of the PCPs' views about promoting brain health for reducing dementia risk. We searched MEDLINE, PsycINFO, CINAHL, and Embase for English-language articles published between 1995 and December 2017. We then applied the Consolidated Framework for Implementation Research (CFIR) and matched Expert Recommendations for Implementing Change to the scoping review findings in order to develop a preliminary implementation model. Eight articles reported views of PCPs about dementia prevention. Study findings were mapped to 5 of the 39 CFIR constructs: (i) knowledge and beliefs about dementia risk reduction, (ii) evidence strength and quality, (iii) relative priority, (iv) available resources, and (v) external policy and incentives. The findings suggest implementation strategies to consider in our preliminary model include (i) educational meetings, (ii) identifying and preparing champions, (iii) conducting local consensus discussions, (iv) altering incentive structures, and (v) capturing and sharing local knowledge. There have been few studies about the views of PCPs about dementia risk reduction. Implementation in the primary care setting is fundamental to early identification of risk and supporting preventive practices, but it needs to focus on more than just education for PCPs. We need more up-to-date and in-depth data on the views of PCPs about dementia risk reduction and context-specific analyses of implementation needs. Further research into effective primary care interventions to reduce dementia risk is expected to support implementation efforts.

Clinical 18F-FDG and amyloid brain positron emission tomography/CT in the investigation of cognitive impairment: where are we now?

The number of people living with dementia is increasing, but as yet there remains no cure or disease-modifying treatment. This review aims to help readers understand the role of 18F-FDG PET/CT imaging in the investigation of cognitive impairment and how the advent of amyloid PET/CT imaging may hold the key to radically changing management of the most common form of dementia - Alzheimer's disease. The indications for 18F-FDG PET/CT and amyloid PET/CT imaging in cognitive impairment are outlined. Additionally, the mechanisms of action, technique, patient preparation and acquisition parameters for both are detailed. We conclude by providing a framework for interpreting 18F-FDG PET/CT and amyloid PET/CT imaging in the more common conditions that lead to cognitive impairment conditions with tips on avoiding pitfalls in interpretation.

Prevalence of dementia diagnoses not otherwise specified in eight European countries: a cross-sectional cohort study

Background

Dementia is a syndrome, with a wide range of symptoms. It is important to have a timely diagnosis during the disease course to reduce the risk of medication errors, enable future care planning for the patient and their relatives thereby optimizing quality of life (QoL). For this reason, it is important to avoid a diagnosis of dementia not otherwise specified (DNOS) and instead obtain a diagnosis that reflects the underlying pathology. The aim of this study was to investigate the prevalence and associated factors of DNOS in persons with dementia living at home or in a nursing home.

Methods

This is a cross-sectional cohort study performed in eight European countries. Persons with dementia aged ≥65 years living at home (n = 1223) or in a nursing home (n = 790) were included. Data were collected through personal interviews with questionnaires based on standardised instruments. Specific factors investigated were sociodemographic factors, cognitive function, and mental health, physical health, QoL, resource utilization and medication. Bivariate and backward stepwise multivariate regression analyses were performed.

Results

The prevalence of DNOS in the eight participating European countries was 16% (range 1–30%) in persons living at home and 21% (range 1–43%) in persons living in a nursing home. These people are more often older compared to those with a specific dementia diagnosis. In both persons living at home and persons living in a nursing home, DNOS was associated with more severe neuropsychiatric symptoms and less use of anti-dementia medication. In addition, persons with DNOS living at home had more symptoms of depression and less use of antidepressant medication.

Conclusions

The prevalence of DNOS diagnosis is common and seems to vary between European countries. People with DNOS are more often older with more severe neuropsychiatric symptoms and receive fewer anti-dementia medication, anxiolytics and antidepressants. This would support the suggestion that a proper and specific diagnosis of dementia could help the management of their disease.

Diagnosis and treatment of cognitive impairment

As a result of the aging population dementia is a growing challenge, especially in healthcare. Nevertheless, cognitive disorders are often not systematically evaluated, especially during hospital stays for other reasons; however, cognitive impairment is associated with a number of geriatric syndromes, including falls, delirium, dysphagia and lack of adherence to treatment plans. This article considers the current state of diagnosis and treatment of dementia. Non-pharmacological therapeutic approaches as well as current and future pharmacological treatment options are discussed. The drugs of choice for the symptomatic treatment of cognitive deficits in Alzheimer's disease and Parkinson-associated dementia are cholinesterase inhibitors and memantine; there is no specific pharmacological treatment for other types of dementia. Prevention and treatment of cardiovascular risk factors can potentially retard the progression of possibly all forms of dementia.

Influences on the access to and use of formal community care by people with dementia and their informal caregivers: a scoping review

BACKGROUND

The literature describes the obstacles to sufficient care faced by people with dementia and their informal caregivers. Although factors influencing access and utilisation are frequently studied, the body of knowledge lacks an overview of aspects related to influence. The frequently used Behavioural Model of Health Care Use (BM) could be used to structure and explain these aspects. An adaptation of the BM emphasises psychosocial influences and appears to enrich the understanding of the use of long-term care for dementia.

METHODS

We conducted a scoping review with the aim of providing an overview of the aspects influencing the access to and utilisation of formal community care in dementia. Our search covered the PubMed, CINAHL, Social Science Citation Index and PsychInfo databases, as well as grey literature. Two researchers assessed the full texts for eligibility. A data extraction form was developed and tested. We analysed the main topics investigated by the studies and mapped and described the investigated psychosocial aspects according to the BM after narratively summarising the findings. We used the Mixed Method Appraisal Tool (MMAT) to critically appraise the included studies.

RESULTS

A total of 94 studies were included: n = 55 with quantitative designs, 35 with qualitative designs and four with mixed methods. The studies investigated different services, mainly focusing on health care services. One third of the studies provided information regarding the severity of dementia. The most frequently investigated main topics were ethnicity and attitudes towards services. Psychosocial aspects were frequently investigated, although few studies considered the perspectives of people with dementia. Approximately half of the studies reported a theoretical framework. The adapted BM facilitated the structuring and description of psychosocial aspects. However, this instrument did not address topics beyond the scope of psychosocial aspects, such as sociodemographic characteristics.

CONCLUSIONS

The access to and utilisation of formal community care for dementia can only be partly explained by individual influencing aspects. Therefore, a theoretical framework would likely help to describe this complex subject. Our findings indicate that the psychosocial categories of the adapted BM enriched the original BM, and that people with dementia should more often be included in healthcare service research to ensure a better understanding of the barriers to accessing formal community care.

A scoping review of gaps and priorities in dementia care in Europe

Dementia is a widely recognized public health priority due to the increasing number of people living with the condition and its attendant health, social, and economic costs. Delivering appropriate care is a challenge in many countries in Europe contributing to unmet needs of people living with dementia. Acute hospital settings are often the default route in pursuit for dementia care due to the lack of or limited knowledge of local service provisions. The care environment and the skillsets in acute hospitals do not fully embrace the personhood necessary in dementia care. Predictions of an exponential increase in people living with dementia in the coming 30 years require evidence-based strategies for advancing dementia care and maximizing independent living. However, the evidence required to inform priorities for enabling improvements in dementia care is rarely presented in a way that stimulates and sustains political interests. This scoping review of the literature drew on principles of meta-ethnography to clarify the gaps and priorities in dementia care in Europe. The review constituted eight papers (n = 8) and a stakeholder consultation involving three organizations implementing dementia care programs in Europe comprising Emmaus Elderly Care in Belgium, Residential Care Holy Heart in Belgium, and ZorgSaam in the Netherlands. Overarching concepts of gaps identified include fragmented non-person-centered care pathways, the culture of dementia care, limited knowledge and skills, poor communication and information sharing, and ineffective healthcare policies. Key areas distinguished from the literature for narrowing the gaps to improve care experiences and the support for people living with dementia care encompass person-centered care, integrated care pathways, and healthcare workforce development. Action for advancing care and maximizing independent living needs to go beyond mere inclusions on political agendas to incorporate a shift in health and social care policies to address the needs of people living with dementia.

Construct validity and reliability of the Test Your Memory Chinese version in older neurology outpatient attendees

BACKGROUND

Early distinguishing the cognitive impairment from healthy population is crucial to delay the progression of mild cognitive impairment (MCI) and Alzheimer disease (AD). Test Your Memory (TYM) has been proved to be a valid and reliable screening instrument for AD and MCI. This study aimed to develop a culturally appropriate and functional Standard Mandarin Chinese translation of the TYM, and to evaluate its reliability and validity in detecting AD and MCI in Chinese.

METHODS

182 subjects with AD/MCI and 55 healthy controls were recruited to participate in this study, and everyone undergo the test of Standard Mandarin Chinese version of the TYM (TYM-CN), Mini-mental State Examination (MMSE), Montreal cognitive assessment (MoCA-BJ), and Clinical Dementia Rating (CDR) Scale. Concurrently, all the subjects with AD/MCI received the general physical and neurologic examinations, extensive laboratory tests, and brain computed tomography/magnetic resonance imaging (MRI). Of which, 90 subjects were asked to complete the re-test of TYM-CN at 3 weeks after the initial visit. Intra-class correlation coefficient (ICC) and Cronbach's alpha was used to assess the test-retest reliability and the internal consistency. The validity, sensitivity and specificity were also analyzed. One-way analysis of variance, χ2 test, correlation analysis, and receiver operating characteristic curve (ROC) analysis were employed, as needed.

RESULTS

The total scores of TYM-CN was 43.89 ± 3.44, 40.88 ± 4.38, and 29.12 ± 7.44 (p < 0.01) for healthy controls group, MCI group, and AD group, respectively. The ICC for 11 items of TYM-CN ranged from 0.863 (copying) to 0.994 (anterograde), and that of the total scale was 0.993, suggesting an excellent reliability. Furthermore, the significant correlation was also found between TYM-CN and MMSE (r = 0.76), MoCA-BJ (r = 0.74), and CDR scores (r = 0.76), indicating a good validity. A TYM-CN scores ≤ 39.5 had 95% sensitivity and 95% specificity in differentiating AD from healthy controls, and that ≤ 43.5 had 75% sensitivity and 91% specificity in distinguishing MCI from healthy controls, respectively.

CONCLUSION

The reliability and validity of the TYM-CN are statistically acceptable for the evaluation of cognitive impairment, which may contribute to neuropsychological tests for the diagnosis of AD and MCI from healthy controls in China.

Public knowledge of late-life cognitive decline and dementia in an international sample

BACKGROUND AND OBJECTIVES

One method of mitigating global increases in dementia prevalence involves assessing public knowledge and then educating laypeople. We measured knowledge of late-life pathological cognitive decline in a diverse, international sample using a standardized, validated instrument.Research design and methods: We assessed 3619 international respondents recruited through Amazon's Mechanical Turk with a 44-item dementia knowledge survey and 18 sociodemographic items.

RESULTS

Results suggested that the following sociodemographic variables are associated with less overall knowledge: young age, male gender, low educational attainment, born in a developing nation, of ethnic minority status, not married, and less prior dementia experience. Specific knowledge gaps emerged in cerebrovascular disease, delirium versus dementia, treatment of behavioral dementia symptoms, Alzheimer's disease genetics, Parkinson's disease symptoms, and characteristics of chronic traumatic encephalopathy and subjective cognitive decline.Discussion and implications: Findings may facilitate effective multinational dementia education initiatives by providing specific recommendations as to which sociodemographic populations and content knowledge domains will benefit the most from limited resources.

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.

Barriers and facilitators to the access to and use of formal dementia care: findings of a focus group study with people with dementia, informal carers and health and social care professionals in eight European countries

BACKGROUND

People with dementia and informal carers often access formal care late in the process of dementia. The barriers and facilitators to service use from the perspectives of different stakeholders involved are not well understood. Thus, we aimed to explore the barriers and facilitators of access to and utilisation of formal care from the perspectives of people with dementia, their informal carers and health and social care professionals.

METHOD

Focus groups with people with dementia, informal carers and professionals were conducted in eight European countries. Recruitment targeted people with dementia, informal carers with experience of formal care and professionals involved in providing (access to) formal care. Qualitative content analysis using open coding was used on a national level. Cross-national synthesis was based on the translated national reports.

RESULTS

Overall, 55 focus groups with 261 participants were conducted, involving 51 people with dementia, 96 informal carers and 114 professionals. Sixteen categories describing barriers and facilitators were identified, referring to three global themes: Aspects related to 1) individuals involved, 2) the system or 3) overarching aspects. The attitudes and beliefs of people with dementia and their carers may have a major impact, and they often serve as barriers. Formal care was perceived as a threat to the individual independence of people with dementia and was thus avoided as long as possible. A healthcare professional serving as a constant key contact person could be an essential facilitator to overcome these barriers. Contact should be initiated proactively, as early as possible, and a trusting and consistent relationship needs to be established. Beyond that, the findings largely confirm former research and show that barriers to accessing and using formal care still exist across Europe despite a number of national and European initiatives.

CONCLUSION

Further investigations are needed to elaborate how the concept of a key contact person could be integrated with existing case management approaches and how the independence and autonomy of people with dementia can be strengthened when formal care needs to be accessed and used. These may be meaningful facilitators regarding enhanced access to formal care for people with dementia and their families.

Pre-clinical pharmacokinetic-pharmacodynamic modelling and biodistribution studies of donepezil hydrochloride by a validated HPLC method

A simple, sensitive and robust HPLC–PDA assay was developed and validated for rapid determination of donepezil hydrochloride (DNP), a potent acetylcholinesterase inhibitor in rat plasma and tissues. All biological samples were prepared by the solid-phase extraction method using loratadine as an internal standard. Separation of the analytes was achieved on a Waters Nova-Pak C18 column (3.9 × 150 mm, 4 μm) using an isocratic mobile phase of acetonitrile and ammonium formate (pH 6.4; 0.01 M) (62 : 38% v/v) at a flow rate of 1 mL min⁻¹. All validation parameter results were within the acceptable range described in the guidelines for bioanalytical method validation. The method showed linearity in the concentration range of 50–5000 ng mL⁻¹ with LOD of 20 ng mL⁻¹ and LLOQ of 50 ng mL⁻¹. Moreover, the advantage of this method over previously published methods is the short analysis run time of 6 min in HPLC itself, alongside its application not only for plasma samples but also in tissues, with low LLOQ. The method was successfully applied for studying the compartmental pharmacokinetics, tissue distribution and pharmacodynamics. A two-compartmental micro model was statistically fitted for the assessment of pharmacokinetic parameters. The tissue distribution studies suggest that the kidneys, lungs and liver are the primarily responsible organs for metabolism and elimination of DNP. Pharmacodynamic studies were performed by measuring acetylcholinesterase inhibitory activity of DNP, which indicated that the pharmacokinetic and pharmacodynamic data are in correlation with each other.

A simple, sensitive and robust HPLC–PDA assay was developed and validated for rapid determination of donepezil hydrochloride (DNP), a potent acetylcholinesterase inhibitor in rat plasma and tissues.

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.

Patient Characteristics and Outcomes Associated with Receiving an Earlier Versus Later Diagnosis of Probable Alzheimer's Disease

BACKGROUND

Effectiveness of Alzheimer's disease (AD) treatments may depend critically on the timeliness of intervention.

OBJECTIVE

To compare characteristics and outcomes of patients diagnosed with probable AD (prAD) based on time elapsed from first onset of cognitive decline.

METHODS

Patients with ≥1 prAD diagnosis and ≥1 follow-up visit were selected from the National Alzheimer's Coordinating Center (NACC) Uniform Data Set (UDS; 9/2005-6/2015) and stratified based on the time between the perceived onset of cognitive decline at baseline and first prAD diagnosis (i.e., earlier versus later diagnosis). Characteristics at baseline and prAD diagnosis, clinically meaningful progression, and medication use following prAD diagnosis were compared.

RESULTS

Median time from perceived onset of cognitive decline to prAD diagnosis was 4.5 years (earlier diagnosis: ≤3.46; later diagnosis: >5.71). Earlier-diagnosed patients (n = 1,476) were younger at baseline (74.3 versus 76.3 years) and had better cognitive and functional scores than later-diagnosed patients (n = 1,474). At first prAD diagnosis, earlier-diagnosed patients had lower mean global Clinical Dementia Rating (CDR) score (0.8 versus 1.1), higher mean Mini-Mental State Examination (MMSE) (22.6 versus 20.0), and lower mean Functional Activities Questionnaire (11.6 versus 17.3). Earlier- and later-diagnosed patients experienced similar time to a decrease of ≥3 points in MMSE (median 23.2 versus 23.1 months, p = 0.83), but earlier-diagnosed patients had longer time to a CDR score of ≥2 points, and longer times to initiation of AD medication and antipsychotic agents (all p < 0.01).

CONCLUSION

Earlier prAD diagnosis in NACC data is associated with higher cognitive function and lower functional impairment at diagnosis.

Síntomas neuropsiquiátricos como factor de confusión en la detección de la demencia

OBJECTIVE

The aim of the study was to evaluate whether the neuropsychiatric symptoms interfere with cognitive impairment detection in primary care and to describe which of them generate more confusion.

DESIGN

Descriptive and observational study.

LOCATION

Mobile psychiatric unit in collaboration with primary healthcare centers in Barcelona.

PARTICIPANTS

A total of 104 patients over 65years referred to mobile psychiatric unit from primary healthcare clinicians suspecting mental disease.

MAIN MEASUREMENTS

All patients received a DSM-IV-TR diagnosis. We included in the study the Mini Mental State Examination (MMSE), Neuropsichiatric Inventory, Severe Psychiatric Illness scale, Global Assessment of Functioning, Clinical Global Impression and Word Health Organisation Dissability Assessment Schedule.

RESULTS

55.8% of patients referred from primary care had altered MMSE score. Neuropsychiatric symptoms more frequently associated with suspected cognitive impairment were delusions, hallucinations, agitation, disinhibition, irritability and purposeless motor behavior.

CONCLUSIONS

When psychiatric symptoms of Severe Mental Disorder (SMD) are detected in elderly individuals with no history of SMD, cognitive impairment should be suspected and a screening test be done.

General practitioners' perceptions of the barriers and solutions to good-quality palliative care in dementia

The general practitioner (GP) is in a pivotal position to initiate and adapt care for their patients living with dementia. This study aimed to elicit GPs' perceptions of the potential barriers and solutions to the provision of good-quality palliative care in dementia in their practices. A postal survey of GPs across Northern Ireland was conducted with open-ended items soliciting for barriers in their practices and possible solutions; 40.6% (138/340) were returned completed. Barriers to palliative care in dementia were perceived to be a dementia knowledge deficit for healthcare staff and the public, a resource shortfall within the GP practice and community, poor team coordination alongside inappropriate dementia care provision, and disagreements from and within families. These findings have significant implications for educators and clinicians as enhanced dementia education and training were highlighted as a strong agenda for GPs with the suggestions of dementia awareness programmes for the public.

Negotiating access to a diagnosis of dementia: Implications for policies in health and social care

The ‘Pathways to Diagnosis’ study captured the experience of the prediagnosis period of Alzheimer’s disease and related dementias through indepth interviews with 29 persons with dementia and 34 of their family caregivers across four sites: anglophones in Calgary, francophones in Ottawa, Chinese-Canadians in Greater Vancouver and Indo-Canadians in Toronto. In this cross-site analysis, we use the ‘Candidacy’ framework to comprehensively explore the challenges to securing a diagnosis of dementia in Canada and to develop relevant health and social policy. Candidacy views eligibility for appropriate medical care as a process of joint negotiation between individuals and health services, which can be understood relative to seven dimensions: identification of need, navigation, appearances at services, adjudication by providers, acceptance of/resistance to offers, permeability of services and local conditions. Interviewees experienced challenges relative to each of the seven dimensions and these varied in form and emphasis across the four ethno-linguistic groups.

Examination of level of knowledge in Italian general practitioners attending an education session on diagnosis and management of the early stage of Alzheimer's disease: pass or fail?

BACKGROUND

We detected the general level of knowledge about the early diagnosis of Alzheimer's disease (AD) and subsequent care in general practitioners (GPs) from Southern Italy. We explored also the GP perception about their knowledge and training on diagnosis and management of AD.

METHODS

On a sample of 131 GPs, we administered two questionnaires: the GP-Knowledge, evaluating GPs' expertise about AD epidemiology, differential diagnosis, and available treatments, and the GP-QUestionnaire on Awareness of Dementia (GP-QUAD), assessing the GPs' attitudes, awareness, and practice regarding early diagnosis of dementia.

RESULTS

Specific screening tests or protocols to diagnose and manage dementia were not used by 53% of our GPs. The training on the recognition of early AD signs and symptoms was considered inadequate by 55% of the participants. Females were more likely to consider their training insufficient (58%) compared to males (53%). Female GPs were less likely to prescribe antipsychotic drugs to control neuropsychiatric symptoms (NPS) and suggest specialist advice in late stage of cognitive impairment. Multiple Correspondence Analysis (MCA) performed only on GP-QUAD suggested two dimensions explaining 26.1% ("GP attitude") and 20.1% ("GP knowledge") of the inertia for a total of 46.2%,

CONCLUSION

In our survey on GP clinical practice, several problems in properly recognizing early AD symptoms and subsequently screening patients to be referred to secondary/tertiary care centers for diagnosis confirmation have emerged. In the future, specific training programs and educational projects for GPs should be implemented also in Italy to improve detection rates and management of dementia in primary care.

Ethical challenges in preclinical Alzheimer's disease observational studies and trials: Results of the Barcelona summit

Alzheimer's disease (AD) is among the most significant health care burdens. Disappointing results from clinical trials in late-stage AD persons combined with hopeful results from trials in persons with early-stage suggest that research in the preclinical stage of AD is necessary to define an optimal therapeutic success window. We review the justification for conducting trials in the preclinical stage and highlight novel ethical challenges that arise and are related to determining appropriate risk-benefit ratios and disclosing individuals' biomarker status. We propose that to conduct clinical trials with these participants, we need to improve public understanding of AD using unified vocabulary, resolve the acceptable risk-benefit ratio in asymptomatic participants, and disclose or not biomarker status with attention to study type (observational studies vs clinical trials). Overcoming these challenges will justify clinical trials in preclinical AD at the societal level and aid to the development of societal and legal support for trial participants.

Performance of cognitive tests, individually and combined, for the detection of cognitive disorders amongst community-dwelling elderly people with memory complaints: the EVATEM study

BACKGROUND AND PURPOSE

Dementia is a leading cause of dependence amongst the aged population. Early identification of cognitive impairment could help to delay advanced stages of dependence. This study aimed at assessing the performance of three neuropsychological tests to detect cognitive disorders in elderly subjects with memory complaints.

METHODS

The EVATEM study is a prospective multicentre cohort with a 1-year follow-up. Subjects with memory complaints were selected during preventive health examinations, and three neuropsychological tests (five-word, cognitive disorders examination, verbal fluency) were administered. Two groups were identified in memory clinics: (i) cognitively healthy individuals (CHI) and (ii) mild cognitive impairment or demented individuals (MCI-DI). Cross-sectional analyses were performed on data at inclusion. The relationship between the diagnosis of MCI-DI/CHI and the neuropsychological tests was assessed using logistic regressions. The performance of the neuropsychological tests, individually and combined, to detect cognitive disorders was calculated.

RESULTS

Of 585 subjects, 31.11% had cognitive disorders (MCI, 176 subjects; DI, six subjects). Amongst the three tests studied, the odds ratio for MCI-DI was higher for the five-word test <10 [odds ratio 3.2 (1.81; 5.63)]. The best performance was observed when the three tests were combined: specificity 90.5% and sensitivity 42.4% compared to respectively 89.2% and 28.3% for the five-word test.

CONCLUSIONS

Despite the poor sensitivity of the five-word test, it seems to be the most adapted for the diagnosis of MCI-DI in older adults with a memory complaint, in prevention centres, taking into account its high specificity and its rapid administration compared to the other tests.

The dementia diagnosis: a literature review of information, understanding, and attributions

This review examines how people understand and make sense of a dementia diagnosis. The review explores how lay frameworks and information presented at diagnosis may inform a caregiver's understanding of dementia in a family member. Existing qualitative research exploring how caregivers understand and make sense of dementia is reviewed. A literature search was conducted, and the results indicated that family carers often receive little or unclear information about dementia, with diagnostic information often delivered in euphemistic terms. Lack of clarity regarding diagnosis and prognosis creates uncertainty for caregivers and impacts future care planning. Caregiver's understandings of the condition vary, with some symptoms often not attributed to the condition. The literature highlights significant gaps and misconceptions in public knowledge regarding dementia, which raises questions about how family caregivers understand the condition. Further research is required to explore how information is presented to family carers at the time of diagnosis and how this is used to understand the condition.

Optimizing person-centered transitions in the dementia journey: a comparison of national dementia strategies

The journey for people with Alzheimer's disease or another dementia involves the need for increasing levels of support, with transitions across care settings. Although transitional care has received increasing attention in the health care arena, no widely accepted transitions typology exists for the dementia journey. At the same time, national dementia strategies are proliferating. We developed a typology containing six transitions that cover the dementia journey from symptom recognition to end-of-life care. We then critically evaluated whether and how the national dementia strategies of Australia, England, France, the Netherlands, Norway, Scotland, and the United States addressed each transition. Adopting a person-centered perspective, we found that most or all of the national strategies adequately address earlier transitions in the journey, but fewer strategies address the later transitions. We recommend that next-generation national dementia strategies focus on later transitions, specify how care coordination and workforce training should make transitions more person centered, and use person-centered outcomes in evaluating the success of the strategies' implementation and dissemination.

Knowledge and attitudes about Parkinson's disease among a diverse group of older adults

Underserved minorities are vulnerable to diagnostic delays and under-treatment of Parkinson's disease (PD). The purpose of this mixed-methods study was to understand knowledge and attitudes about PD among a racially/ethnically diverse group of community members. In the qualitative arm, ten homogeneous focus groups of 6 to 8 White, African-American and Chinese American older adults at senior centers in Philadelphia were conducted. Next, for the quantitative arm, a questionnaire of knowledge and attitudes about PD was administered among a larger group of senior center members. Themes were identified from the focus group discussions. ANOVA and chi-square tests were used to assess differences in PD knowledge and attitudes among the different racial/ethnic groups. Logistic regression analyzed for independent factors associated with barriers to treatment. Seventy-five adults participated in the focus groups (23 Whites, 36 African-Americans and 16 Chinese-Americans) and 154 completed the questionnaire (62 Whites, 47 African-Americans and 45 Chinese-Americans). One common theme about developing PD was fear of losing independence. Racial/ethnic groups identified unique barriers to care: mistrust in the healthcare system by African-Americans and language difficulties by Chinese-Americans. Eighty percent of all participants had no to some knowledge of PD. African-Americans and Chinese-Americans were more likely to perceive PD as a part of normal aging than whites. Chinese-Americans were more likely to perceive barriers to treatment than whites. A diverse sample of older adults demonstrated low levels of PD knowledge through both qualitative and quantitative methods. Many barriers to PD care were identified. Targeted community outreach and education efforts should incorporate information about PD and how to receive care.

The Agewell trial: a pilot randomised controlled trial of a behaviour change intervention to promote healthy ageing and reduce risk of dementia in later life

BACKGROUND

Lifestyle factors represent prime targets for behaviour change interventions to promote healthy ageing and reduce dementia risk. We evaluated a goal-setting intervention aimed at promoting increased cognitive and physical activity and improving mental and physical fitness, diet and health.

METHODS

This was a pilot randomised controlled trial designed to guide planning for a larger-scale investigation, provide preliminary evidence regarding efficacy, and explore feasibility and acceptability. Primary outcomes were engagement in physical and cognitive activity. Participants aged over 50 living independently in the community were recruited through a community Agewell Centre. Following baseline assessment participants were randomly allocated to one of three conditions: control (IC) had an interview in which information about activities and health was discussed; goal-setting (GS n = 24) had an interview in which they set behaviour change goals relating to physical, cognitive and social activity, health and nutrition; and goal-setting with mentoring (GM, n = 24) had the goal-setting interview followed by bi-monthly telephone mentoring. Participants and researchers were blinded to group assignment. Participants were reassessed after 12 months.

RESULTS

Seventy-five participants were randomised (IC n = 27, GS n = 24, GM n = 24). At 12-month follow-up, the two goal-setting groups, taken together (GS n = 21, GM n = 22), increased their level of physical (effect size 0.37) and cognitive (effect size 0.15) activity relative to controls (IC n = 27). In secondary outcomes, the two goal-setting groups taken together achieved additional benefits compared to control (effect sizes ≥ 0.2) in memory, executive function, cholesterol level, aerobic capacity, flexibility, balance, grip strength, and agility. Adding follow-up mentoring produced further benefits compared to goal-setting alone (effect sizes ≥ 0.2) in physical activity, body composition, global cognition and memory, but not in other domains. Implementation of the recruitment procedure, assessment and intervention was found to be feasible and the approach taken was acceptable to participants, with no adverse effects.

CONCLUSIONS

A brief, low-cost goal-setting intervention is feasible and acceptable, and has the potential to achieve increased activity engagement.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN30080637.

Heads in the sand may leave old age psychiatry looking foolish and vulnerable: Commentary on . . . A memory clinic v. traditional community mental health team service

Dementia has been recognised as a major challenge to health, social care and economies. Research by Rubinsztein and colleagues, in this issue, has compared the services provided by memory clinics with those of traditional community mental health team services. They conclude that memory clinics offer a more comprehensive and multidisciplinary service at no extra cost. Here I will question some of their findings and highlight the importance of better continuity of care between primary and secondary services.

Institutionalization in incident dementia cases in comparison to age- and sex- matched controls: a 5-year follow-up from Germany

BACKGROUND

Dementia is a main reason for nursing home admission. Information on institutionalization is often based on studies of limited methodological quality. We aimed to analyze time until nursing home admission since first coding of dementia diagnosis and factors associated with institutionalization in incident dementia patients compared to non-demented controls.

METHODS

We analyzed claims data of a German Health insurance company including a cohort of 1,440 patients with a first diagnosis of dementia and 6,988 age- and sex-matched controls aged 65 years and older. The follow-up was up to 5 years. We used Kaplan-Meier analysis for examining time until nursing home admission and cox regression for estimating crude and adjusted Hazard ratios.

RESULTS

Dementia patients and controls were on average 78 years and about 55 % were males. The mean time to nursing home admission was 4.0 years in patients with dementia and 4.6 years for controls. After the 5-years observation-period 62.7 % (95 % CI 59.0-66.1) of dementia patients still lived in the community in comparison to 86.2 % (95 % CI 85.2-87.2) of controls. Cox regression models show that the risk for institutionalization is 3.45 (95 % CI 3.05-3.90) times higher in dementia patients in comparison to controls when adjusted for sex, age, and comorbidity.

CONCLUSIONS

Our analysis shows a significant influence of dementia on institutionalization in comparison to age- and sex-matched controls, especially in the youngest age groups. Hence, the results add substantial information on the disease progression of dementia and are, therefore, of great importance for health-care as well as long-term care planning.

Use of health and social care services in a cohort of Italian dementia patients

The aim of this study, conducted in the Region of Lazio, Italy, in 2008-2010, was to describe the use, over a one-year period, of health and social care services in a cohort of 712 patients with a diagnosis of dementia. These patients had never previously used such services. We evaluated the association between the patients' sociodemographic and clinical characteristics and their use of services. Sociodemographic and clinical data were collected at baseline using validated instruments, while the use of services was investigated at the end of the one-year follow-up through a structured (questionnaire-based) interview with the caregiver. We found that 11.9% of patients used health or social care services. The most frequent diagnoses were: Alzheimer's disease (72.1%), mixed dementia (20.5%), and vascular dementia (9.7%). A higher probability of use of services was observed in patients with: more than five years of schooling (OR=1.79; 95%CI:1.08-2.96); one or more comorbidity (OR=4.87; 95%CI:2.05- 11.57); severe (OR=4.78; 95%CI:1.75-13.06) or moderate dementia (OR=2.08; 95%CI:0.98-4.40). The low health and social care service use among dementia patients in this study could be explained by a lack of availability of services. Public health authorities should plan adequate networks of services, considering both patients and caregivers' needs.