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

Community health worker training on older adults: A qualitative needs assessment

BACKGROUND

Community health workers (CHWs) are frontline public health personnel who serve as liaisons between vulnerable patient populations and the healthcare system. They are instrumental in health promotion and education for urban-dwelling older adults. However, no research exists on training that CHWs receive on age-friendly health care. This article explores CHW education on the 4Ms of an Age-Friendly Health System and identifies areas where additional training may be necessary.

METHODS

As part of a two-pronged qualitative needs assessment, four focus groups were held with a total of 17 CHWs and semistructured interviews were conducted with 10 clinicians, including both healthcare providers and social workers. Focus group and interview transcripts were then analyzed for major themes in Dedoose, a qualitative coding software.

RESULTS

Clinicians most often identified Mentation and Mobility as areas where CHWs can have the greatest impact. Correspondingly, CHWs felt under-equipped to assist patients in these areas and expressed strong interest in additional training. In general, CHWs and clinicians agreed that Medications and What Matters do not fall under CHW scope of practice.

CONCLUSIONS

Our findings confirm the critical role that CHWs can play in promoting the health and well-being of urban-dwelling older adults. However, we also demonstrate that many CHWs lack adequate training in age-friendly care. To meet the social and medical needs of a rapidly aging US population, there is a pertinent need to develop a novel community health worker training curriculum on Mentation and Mobility.

Training Community Health Workers to Address Disparities in Dementia Care: A Case Study From Oklahoma With National Implications

The projected increase of dementia in the diverse aging US population calls for a well-prepared public health workforce. Community health workers (CHWs) can address dementia in culturally appropriate ways. Collaborating with stakeholders, we developed a train-the-trainer curriculum for CHWs and used a virtual training platform to test its feasibility with 77 CHWs. Pre-/post-evaluation data demonstrated modestly increased dementia knowledge scores. Training participants valued the resources shared and interacting with peers. Disseminating this training could contribute to closing gaps in dementia care in diverse communities, along with policies supporting CHWs as a workforce that reduces age-related disparities and promotes health equity.

Diagnostic accuracy of the Clinical Dementia Rating Scale for detecting mild cognitive impairment and dementia: A bivariate meta-analysis

OBJECTIVE

The Clinical Dementia Rating (CDR) Scale comprising global score (CDR-GS) and sum of boxes scores (CDR-SB) is commonly used in staging cognitive impairment; however, its diagnostic accuracy is not well clarified. The meta-analysis aimed to investigate the diagnostic accuracy of the CDR for mild cognitive impairment (MCI) and dementia in older populations.

METHODS

Studies examining the diagnostic accuracy of the CDR for MCI or dementia against reference standards were included from seven electronic databases. The bivariate analysis with a random-effects model was adopted to calculate the pooled sensitivity and specificity of the CDR for MCI and dementia.

RESULTS

Fifteen studies investigating the diagnostic accuracy of the CDR-GS (n = 13) or CDR-SB (n = 5) for MCI or dementia were included. The pooled sensitivity and specificity of the CDR-GS for MCI were 93% and 97%, respectively. With respect to dementia, the CDR-GS had superior pooled specificity compared to the CDR-SB (99% vs. 94%), while similar sensitivities were found between the CDR-GS and CDR-SB (both 87%). Significant moderators of an old age, a high educational level, a high prevalence of MCI or dementia, being in a developing country, and a lack of informants' observations may affect the estimation of the sensitivity or specificity of the CDR.

CONCLUSIONS

Evidence supports the CDR being useful for detecting MCI and dementia; applying the CDR for staging cognitive impairment in at risk populations should be considered. Furthermore, including objective observations from relevant informants or proxies to increase the accuracy of the CDR for dementia is suggested.

Is Barthel Index Suitable for Assessing Activities of Daily Living in Patients With Dementia?

OBJECTIVES

To evaluate application of the Barthel Index (BI) in assessing basic activities of daily living (ADL) of patients with dementia using Rasch analysis.

DESIGN

A multi-country cross-sectional study.

SETTING AND PARTICIPANTS

Nineteen long-term care facilities located in China, Japan, South Korea, and Thailand. A total of 644 patients with dementia were included.

METHODS

Unidimensionality, global and item fit, local dependence, person-item targeting, threshold disordering, and differential item functioning (DIF) were examined. Negative correlations between scores for DIF items and Neuropsychiatric Inventory Nursing Home version (NPI-NH) were evaluated.

RESULTS

Item reliability (1.0) and person reliability (.88) were acceptable. The Rasch dimension explained 72.9% of the variance (Eigenvalue = 27), while the first contrast explained 6.6% (Eigenvalue = 2.4). The "mobility" was misfitting to the Rasch model (infit mean square = 1.86). The overall difficulty of the BI exceeded patients' ability (person location = -2.27 logits). The "stairs climbing" and "mobility" showed narrow category thresholds (< 1.4 logits). The location of "controlling bladder" and "toilet use" overlapped. Removing "stairs climbing", collapsing categories with narrow threshold widths in "mobility", and combining "controlling bowel" and "controlling bladder" into one item, improved unidimensionality, and item fit of the scale. Only three items ("grooming", "dressing", and "toilet use") were free from DIF across countries. The scores for "feeding" were negatively related to scores for "disinhibition" (r = -0.46, P < 0.01), and scores for "controlling bowel" were negatively related to scores for "disinhibition" (r = -0.44, P < 0.01), "agitation" (r = -0.32, P < 0.05), and "aggression" (r = -0.27, P < 0.01) in Japanese samples.

CONCLUSIONS AND IMPLICATIONS

The performance of the BI for assessing patients with dementia might be compromised by misfit items, person-item mistargeting, measurement gaps, redundant items, narrow threshold width, and item bias. Mobility ability might not be helpful for determining capability of basic ADL in the patients. Comparisons of BI scores between countries should be undertaken with caution due to item bias. Neuropsychiatric symptoms might interact with basic ADL abilities of the patients. We will not suggest using the instrument in patients with dementia, without future refining to improve its performance.

Oral health in Alzheimer's disease: a multicenter case-control study

OBJECTIVES

The aim of this case-control study was to carry out an oral health assessment on a group of Alzheimer's patients and to establish a hypothesis regarding the implication of the characteristics of the disease and the treatment of oral health.

MATERIALS AND METHODS

A total of 70 Alzheimer's patients, residents at the Alzheimer Center Reina Sofia Foundation (Madrid, Spain) and at the Alzheimer State Reference Center (Salamanca, Spain), and 36 controls (companions/acquaintances), were studied by oral examination and saliva sampling. The oral health indices DMFT/DMFS, CPI, the prosthetic condition, oral hygiene, saliva volume, and pH, as well as the specific microbiological parameters governing the risk of developing caries were assessed.

RESULTS

Alzheimer's patients exhibited, as compared to the control group, (1) fewer teeth (10.9 ± 10.5 vs 23.7 ± 6.5), (2) fewer obturations (2.2 ± 3.4 vs 6.6 ± 5.6), (3) fewer periodontally healthy sextants (0.1 ± 0.4 vs 1.4 ± 2.2), (4) worse oral hygiene (43.1 vs 72.2% brushed), (5) greater use of removable prostheses (47.8 vs 8.4%), (6) higher incidence of candida infection (11.8 vs 0.0%) and cheilitis (15.9 vs 0.0%), (7) lower salivary flow (0.6 ± 0.6 vs 1.1 ± 0.6), and (8) lower buffering capacity (46 vs 80%).

CONCLUSIONS

After taking into account the influence of age, Alzheimer's patients had worse oral health (caries and periodontal disease), more mucosal lesions (cheilitis and candidiasis), and worse saliva quantity and quality.

CLINICAL RELEVANCE

Clinicians should be aware of the implications of Alzheimer's disease in oral health, in order to stablish the effective preventive measures and the optimal treatment plan.

A Risk Factor Analysis of Cognitive Impairment in Elderly Patients with Chronic Diseases in a Chinese Population

Background

This study analyzed the risk factors of cognitive impairment (CI) in elderly patients with chronic diseases.

Material/Methods

In total of 385 elderly patients with chronic diseases were selected and assigned into CI and normal groups. The activities of daily living (ADL), global deterioration scale (GDS), Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment Scale (MoCA), patient-generated subjective global assessment (PG-SGA), and mini nutritional assessment (MNA) were performed to analyze the differences between the 2 groups. Logistic regression analysis was conducted for risk factors of CI in elderly patients with chronic diseases.

Results

There were differences in age, education level, type 2 diabetes mellitus, multifocal cerebral infarction, hearing, and eyesight between CI and normal groups. Patients in the CI group showed more CD4⁺ cells, more admission times, and higher GDS scores than the normal group. Also, MMSE and MoCA scores revealed differences in total score, directive force, attention and calculating ability, language, delayed memory, reading comprehension, writing, and visual-spatial ability between the 2 groups. The number of B and CD8⁺ cells, ADL, and MNA scores were protective factors, while cerebral infarction history, number of CD4+ cells, admission times, GDS score, and age were risk factors of CI in elderly patients with chronic diseases.

Conclusions

Our study provides evidence that cerebral infarction history, number of CD4+ cells, admission times, GDS score, and age are risk factors of CI in elderly patients with chronic diseases.

Promotion, prevention and protection: interventions at the population- and community-levels for mental, neurological and substance use disorders in low- and middle-income countries

BACKGROUND

In addition to services within the health system, interventions at the population and community levels are also important for the promotion of mental health, primary prevention of mental, neurological and substance use (MNS) disorders, identification and case detection of MNS disorders; and to a lesser degree treatment, care and rehabilitation. This study aims to identify "best practice" and "good practice" interventions that can feasibly be delivered at these population- and community-levels in low- and middle-income countries (LMICs), to aid the identification of resource efficiencies and allocation in LMICs.

METHODS

A narrative review was conducted given the wide range of relevant interventions. Expert consensus was used to identify "best practice" at the population-level on the basis of existing quasi-experimental natural experiments and cost effectiveness, with small scale emerging and promising evidence comprising "good practice". At the community-level, using expert consensus, the ACE (Assessing Cost-Effectiveness in Prevention Project) grading system was used to differentiate "best practice" interventions with sufficient evidence from "good practice" interventions with limited but promising evidence.

RESULTS

At the population-level, laws and regulations to control alcohol demand and restrict access to lethal means of suicide were considered "best practice". Child protection laws, improved control of neurocysticercosis and mass awareness campaigns were identified as "good practice". At the community level, socio-emotional learning programmes in schools and parenting programmes during infancy were identified as "best practice". The following were all identified as "good practice": Integrating mental health promotion strategies into workplace occupational health and safety policies; mental health information and awareness programmes as well as detection of MNS disorders in schools; early child enrichment/preschool educational programs and parenting programs for children aged 2-14 years; gender equity and/or economic empowerment programs for vulnerable groups; training of gatekeepers to identify people with MNS disorders in the community; and training non-specialist community members at a neighbourhood level to assist with community-based support and rehabilitation of people with mental disorders.

CONCLUSION

Interventions provided at the population- and community-levels have an important role to play in promoting mental health, preventing the onset, and protecting those with MNS disorders. The importance of inter-sectoral engagement and the need for further research on interventions at these levels in LMICs is highlighted.

Community Health Workers Versus Nurses as Counselors or Case Managers in a Self-Help Diabetes Management Program

OBJECTIVES

To confirm the effectiveness of community health workers' involvement as counselors or case managers in a self-help diabetes management program in 2009 to 2014.

METHODS

Our open-label, randomized controlled trial determined the effectiveness of a self-help intervention among Korean Americans aged 35 to 80 years in the Baltimore-Washington metropolitan area with uncontrolled type 2 diabetes. We measured and analyzed physiological and psychobehavioral health outcomes of the community health worker-counseled (n = 54) and registered nurse (RN)-counseled (n = 51) intervention groups in comparison with the control group (n = 104).

RESULTS

The community health workers' performance was comparable to that of the RNs for both psychobehavioral outcomes (e.g., self-efficacy, quality of life) and physiological outcomes. The community health worker-counseled group showed hemoglobin A1C reductions from baseline (-1.2%, -1.5%, -1.3%, and -1.6%, at months 3, 6, 9, and 12, respectively), all of which were greater than reductions in the RN-counseled (-0.7%, -0.9%, -0.9%, and -1.0%) or the control (-0.5%, -0.5%, -0.6%, and -0.7%) groups.

CONCLUSIONS

Community health workers performed as well as or better than nurses as counselors or case managers in a self-help diabetes management program in a Korean American community.