A Systematic Review on the Evidence of Misdiagnosis in Dementia and Its Impact on Accessing Dementia Care

BACKGROUND

Whilst there is a drive to increase diagnosis rates in dementia, there is a lack of attention on getting a correct and timely subtype diagnosis. For people with a rarer subtype of dementia, getting the correct diagnosis, and subsequent care, might be more difficult than for people aged 65+ presenting with the more common symptoms of Alzheimer's disease dementia. Thus, the aim of this mixed-method systematic review was to synthesise the evidence base on misdiagnosis of dementia.

METHODS

Misdiagnosis in dementia was defined as either receiving an initial incorrect dementia subtype diagnosis or receiving an incorrect non-dementia diagnosis. Post-mortem assessments of subtype diagnosis were excluded. Nine databases were searched in June 2023, with screening of titles and abstracts and consequent full texts completed independently by two researchers. Findings were synthesised using narrative synthesis.

RESULTS

Twenty studies were included. Studies were categorised into four themes: (i) Factors associated with delayed diagnosis or misdiagnosis; (ii) Difficulties related to the diagnostic process; (iii) Economic consequences of misdiagnosis; and (iv) Experiences of delayed diagnosis or help-seeking. People with Lewy Body dementia or behavioural variant fronto-temporal dementia were found to experience longer diagnosis times and often incorrect initial diagnoses. Whilst evidence is limited regarding the economic impacts, evidence from the US points towards increased economic costs of misdiagnosis.

CONCLUSIONS

There is an urgent need to investigate the rates and emotional and economic impacts of misdiagnosis on people with dementia, their carers, and the health and social care system. Advancing the evidence base is crucial to reduce misdiagnosis and inform clinical practice.

Survey on the current situation for early diagnosis of dementia and contributing factors in Japan

BACKGROUND

Early diagnosis of dementia is important for both initiation of non-pharmacological activities to slow cognitive decline as well as the development of disease-modifying drugs; however, it appears there may be a tendency for formal diagnosis to be delayed. Since the current status of diagnosis in Japan is unclear, we conducted a survey with family caregivers of patients with dementia using questionnaires and interviews to investigate the factors regarding the dementia diagnosis process in Japan.

METHODS

We distributed questionnaires to family caregivers of people with dementia and conducted additional follow-up interviews with approximately half of them. We calculated odds ratios for the time to diagnosis using logistic regression analysis for each characteristic from the questionnaire data. We also created co-occurrence networks from the interview data in order to provide qualitative context to the questionnaire data.

RESULTS

We collected 68 questionnaires and conducted 32 interviews. The median time to diagnosis was 12 months, and logistic regression analysis showed a significant trend toward shorter time to diagnosis in the absence of other caregivers. In addition, there were significant differences in age, relationship with patients and the time from the first visit to the final diagnosis between groups with and without other caregivers.

CONCLUSIONS

The results of this study suggest that the presence or absence of other caregivers may affect caregivers' behaviour and the time taken to receive a diagnosis of dementia. These findings indicate it may be beneficial to predict inhibiting factors and change approaches based on caregivers' and patients' background to promote early diagnosis.

Virtual Assessment as a Way to Reduce Help-seeking Barriers in Older Adults With Subjective Cognitive Decline

Subjective cognitive decline (SCD), a potential early marker for neurodegenerative disease such as Alzheimer's disease, is common among older adults. Although it is often regarded as a personal health concern, most individuals with SCD do not seek help from a health care professional. Help-seeking (HS) is a complex, individualized process with significant life-course implications, and older adults often face several barriers to HS across personal, socioeconomic, and cultural domains. The pandemic exacerbated these barriers by imposing additional limitations on in-person care. In response, virtual assessment became a popular method to conduct remote care. We provide a narrative review of the challenges and triumphs that came with the transition from in-person, pen-paper cognitive assessments to virtual cognitive assessments. In addition, we address the impact virtual assessment had in tackling barriers that previously limited individuals with SCD from formal HS. We argue that virtual cognitive assessment helps alleviate health access barriers to HS (e.g., cost, transportation, and physician availability) and allows individuals with different coping styles to undergo assessment within more convenient environments. We hope the findings presented in this review inform health care practice, public education, and future research targeted towards the use of virtual assessment to facilitate HS in older adults with SCD.

Transcending inequities in dementia care in Black communities: Lessons from the maximizing independence at home care coordination program

Purpose

We examine care partners’ experience of the Maximizing Independence at Home (MIND) intervention, a multicomponent, home-based dementia care coordination program designed to provide high quality, wholistic care coordination for people and families living with dementia. The goal of the study was to understand 1. the unique dementia-related needs of Black care partners and barriers and challenges to caregiving experienced within the Black community, 2. perceived benefits of the MIND program, and 3. ways to improve the program and make it more culturally responsive to the Black community.

Method

We conducted three focus groups totaling 20 care partners of people living with dementia; who participated in the MIND intervention (2014–2019); all Black/African American and English speaking. Verbatim transcriptions were independently analyzed line-by-line by two coders using inductive approaches.

Findings

Participants noted three overarching themes related to dementia care needs and challenges in the Black community: difficulty finding and accessing dementia information and relevant services and supports; familial conflict/lack of sibling and familial support; and lack of effective communication about dementia within Black Communities. Regarding MIND at home program benefits, four themes emerged: 1. perceived to help locate resources (formal and informal); 2. provided care partners an opportunity for socialization and interaction; 3. included comprehensive assessments and helpful linked information; and 4. resulted in a “much needed break for care partners.” Increased diversity of the MIND program personnel, greater clarity and consistency in MIND program promotion, and better communications were themes for how the program could be improved.

Conclusion

Care partners participating in the MIND program perceived common benefits in aspects related to care for the persons living with dementia as well as benefits to themselves, believed the program addressed important challenges and gaps in education, services, and social support, and could be enhanced in its delivery and cultural responsiveness.

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

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

"Making Sense of a Disease That Makes No Sense": Understanding Alzheimer's Disease and Related Disorders Among Caregivers and Providers Within Alaska Native Communities

BACKGROUND AND OBJECTIVES

With the rate of Alzheimer's disease and related dementias (ADRD) increasing among Alaska Indian/Alaska Native (AI/AN) people, the Alaska Native Health system is ill-prepared to meet the challenges associated with the growing population at risk of ADRD. The high cost of care, inadequate training of health care providers, and lack of supportive services for caregivers are especially concerning.

RESEARCH DESIGN AND METHODS

Interviews were conducted with 22 AN caregivers for ANs with ADRD and 12 ANs and non-Native health care providers in communities across Alaska. Interviews lasted approximately 60 min and were transcribed verbatim. We employed directed content analysis to examine the major agreements and disagreements between the participants' understandings of ADRD in each of the domains of Kleinman's Explanatory Model of Illness.

RESULTS

Caregivers and health care providers expressed concerns about the lack of understanding, resources, and awareness of ADRD among ANs in rural and urban communities. Both caregivers and providers recognized the need to obtain an early diagnosis, blend Western and traditional medicines, promote lifestyle and dietary changes, and foster training for caregivers. Health care providers acknowledged their limited exposure to AN understanding of ADRD and wish to receive culturally relevant training to better serve AN.

DISCUSSION AND IMPLICATIONS

As the older AN adult population grows, the need for culturally responsive training and support services will continue to increase. We recommend establishing rural outreach and support groups for caregivers, developing an understanding of how ANs view ADRD to train and educate health care providers, and implement screening early for memory loss during routine medical examinations.

Positioning ethnicity in dementia awareness research: does the use of senility risk ascribing racialised knowledge deficits to minority groups?

Over recent decades, the importance of increasing dementia awareness has been promoted by charities, researchers and governments. In response, a large body of research has emerged that evaluates the awareness of different populations. One such population are minority ethnic communities. Associated studies typically conclude that minority ethnic groups have a poor awareness of dementia and that interventions should be developed to better educate them. Operationalisations of awareness almost always reference senility - the traditional notion that dementia is a natural outcome of ageing - a widely held belief among many populations. Senility is considered incorrect knowledge in the research literature, and those participants who identify with it are deemed to have poor awareness. Despite the researchers' claims that senility is false, the scientific evidence is inconclusive, and the concept is contested. As such, a large body of research repeatedly positions minority ethnic communities as inferior and in need of re-education based on researchers' questionable assumptions. This issue is bound up with a racialised deficit-model of science communication and wider critiques of psychiatric colonialism. In response, researchers of dementia and ethnicity should reflect on their own awareness and the ways in which they position others in relation to it.

Disparities in Nursing Home Use and Quality Among African American, Hispanic, and White Medicare Residents With Alzheimer's Disease and Related Dementias

Objective: This article examines differences in nursing home use and quality among Medicare beneficiaries, in both Medicare Advantage and fee-for-service, newly admitted to nursing homes with Alzheimer's disease and related dementias (ADRD). Method: Retrospective, national, population-based study of Medicare residents newly admitted to nursing homes with ADRD by race and ethnic group. Our analytic sample included 1,302,099 nursing home residents-268,181 with a diagnosis of ADRD-in 13,532 nursing homes from 2014. Results: We found that a larger share of Hispanic Medicare residents that are admitted to nursing homes have ADRD compared with African American and White beneficiaries. Both Hispanics and African Americans with ADRD received care in segregated nursing homes with fewer resources and lower quality of care compared with White residents. Discussion: These results have implications for targeted efforts to achieve health care equity and quality improvement efforts among nursing homes that serve minority patients.

The Potential of Information Technology to Navigate Caregiving Systems: Perspectives from Dementia Caregivers

Technologies designed to support caregivers of adults with Alzheimer's disease and related dementias (AD/RD) have been developing at an increasingly rapid pace. However, little remains known about caregivers' perspectives on how technologies can and should help them navigate larger service systems they interact with to engage in caregiving. This study involved in-depth interviews and a beta test of an AD/RD caregiver app to learn more about how they currently use technologies and how potential technological features and functions can best meet their needs. Thematic findings suggest a conceptual model for designing AD/RD caregiver technologies. The findings suggest that eHealth and individual technologies may not fully meet the needs of caregivers as they navigate the larger systems within which they provide care. Findings highlight the need to develop technologies for caregivers that are effective, easy to use, and more widely disseminated - especially for caregivers from disadvantaged backgrounds.

Scaffolding and working together: a qualitative exploration of strategies for everyday life with dementia

Background

living with dementia has been described as a process of continual change and adjustment, with people with dementia and their families adopting informal strategies to help manage everyday life. As dementia progresses, families increasingly rely on help from the wider community and formal support.

Methods

this article reports on a secondary analysis of qualitative data from focus groups and individual interviews with people with dementia and their carers in the North of England. In total, 65 people with dementia and 82 carers took part in the research: 26 in interviews and 121 in focus groups. Focus group and interview audio recordings were transcribed verbatim. A qualitative, inductive, thematic approach was taken for data analysis.

Findings

the article applies the metaphor of scaffolding to deepen understanding of the strategies used by families. Processes of scaffolding were evident across the data where families, communities, professionals and services worked together to support everyday life for people with dementia. Within this broad theme of scaffolding were three sub-themes characterising the experiences of families living with dementia: doing things together; evolving strategies; and fragility and fear of the future.

Conclusions

families with dementia are resourceful but do need increasing support (scaffolding) to continue to live as well as possible as dementia progresses. More integrated, proactive work is required from services that recognises existing scaffolds and provides appropriate support before informal strategies become unsustainable; thus enabling people with dementia to live well for longer.

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

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

Help-seeking for dementia: a systematic review of the literature

BACKGROUND

Help-seeking (HS) for dementia presents a great challenge, especially because a timely and appropriate HS process might be associated with better outcomes for the person with dementia, their caregivers, and society. A clear understanding of the HS concept and its measurement in the area of dementia might improve the effectiveness of the process.

AIMS

The aims of our systematic review were: (1) to systematically obtain and evaluate the relevant literature on HS and dementia; and (2) to summarize current research findings and draw conclusions for future research and clinical care in this area.

METHOD

A systematic review of the literature on HS and dementia was conducted up till June 2013.

RESULTS

From the 478 retrieved articles, 48 were included in the review. Conceptually, the studies examined professional and nonprofessional sources of help; showed preference for seeking help from close relatives followed by primary health caregivers; and identified inadequate knowledge and stigmatic beliefs as the main barriers to HS. The majority of the studies did not rely on a theoretical framework.

CONCLUSIONS

Although the body of literature in the area of HS and dementia is growing, several conceptual and methodological limitations still have to be resolved to advance knowledge in the area.

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

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