Complexity in cognitive assessment of elderly British minority ethnic groups: Cultural perspective

Understanding and Awareness of Dementia in the Pakistani-Origin Community of Stoke-on-Trent, UK: A Scenario-Based Interview Study

The aim of this project was to explore the understanding and awareness of dementia in the Pakistani-origin community in a deprived urban region of the UK. The study was unique in accessing and interviewing Pothwari speakers, some of whom could not read or understand spoken English. Data generated from an earlier study were used to construct five scenarios, which were used as the basis for face-to-face semi-structured interviews with 11 male and female participants from the Pakistani-origin community spanning two generations. Braun and Clarke's six phases of thematic analysis were used to analyse the data to answer the research questions. Themes constructed from these interviews indicated a lack of awareness and understanding of dementia, a range of attitudes and assumptions, reluctance to seek external support, and a significant role for the cultural background in shaping the individuals' responses. The study found that poor understanding, cultural differences, and language issues presented barriers to accessing services in the British Pakistani community, particularly among those who had been born in Pakistan and/or spoke Pothwari in preference to English. Services and information may need to be offered by Pothwari speakers in order to reach this neglected sector of the population.

A new tool for assessing the cultural adaptation of cognitive tests: demonstrating the utility of the Manchester Translation Evaluation Checklist (MTEC) through the Mini-Mental State Examination Urdu

BACKGROUND

Low- and middle-income countries contribute to the majority of dementia and mild cognitive impairment cases worldwide, yet cognitive tests for diagnosis are designed for Western cultures. Language and cultural discrepancies mean that translated tests are not always reliable or valid. We propose a model for culturally adapting cognitive tests, one step of which is to assess the quality of any translation and cultural adaptation undertaken. We developed the Manchester Translation Evaluation Checklist (MTEC) to act as a tool for quality assessment and demonstrated its use by assessing a popular cognitive test that had been adapted.

AIMS

Assess quality of the translation and cultural adaptation of the Urdu Mini-Mental State Examination developed for a Pakistani population.

METHOD

Two raters completed the MTEC for the Mini-Mental State Examination (MMSE) Urdu and compared feedback. All authors were fluent in English and Urdu and familiar with Pakistani culture.

RESULTS

Raters had 78.5% agreement across the MTEC. The MMSE Urdu was appropriately translated and retained grammar and verb tense, but three questions had spelling errors. Across 20 MMSE questions, 5 required further cultural adaptation because the questions were not understandable in daily use, comfortable to answer, relevant to the language and culture, and relevant to original concepts.

CONCLUSIONS

The MTEC highlighted errors in the MMSE Urdu and demonstrated how this tool can be used to improve it. Future studies could employ the MTEC to improve existing translated measures of health assessment, particularly cognitive tests, and act as a quality check when developing new adaptations of tests and before psychometric validation.

Developing guidelines for the translation and cultural adaptation of the Montreal Cognitive Assessment: scoping review and qualitative synthesis

BACKGROUND

Ethnic minorities in countries such as the UK are at increased risk of dementia or minor cognitive impairment. Despite this, cognitive tests used to provide a timely diagnosis for these conditions demonstrate performance bias in these groups, because of cultural context. They require adaptation that accounts for language and culture beyond translation. The Montreal Cognitive Assessment (MoCA) is one such test that has been adapted for multiple cultures.

AIMS

We followed previously used methodology for culturally adapting cognitive tests to develop guidelines for translating and culturally adapting the MoCA.

METHOD

We conducted a scoping review of publications on different versions of the MoCA. We extracted their translation and cultural adaptation procedures. We also distributed questionnaires to adaptors of the MoCA for data on the procedures they undertook to culturally adapt their respective versions.

RESULTS

Our scoping review found 52 publications and highlighted seven steps for translating the MoCA. We received 17 responses from adaptors on their cultural adaptation procedures, with rationale justifying them. We combined data from the scoping review and the adaptors' feedback to form the guidelines that state how each question of the MoCA has been previously adapted for different cultural contexts and the reasoning behind it.

CONCLUSIONS

This paper details our development of cultural adaptation guidelines for the MoCA that future adaptors can use to adapt the MoCA for their own languages or cultures. It also replicates methods previously used and demonstrates how these methods can be used for the cultural adaptation of other cognitive tests.

A National Memory Clinic Survey to Assess Provision for People from Diverse Ethnic Backgrounds in England and Wales

English national guidelines regarding dementia assessment and management recommend consideration of cultural and linguistic diversity when assessing people with cognitive complaints. To date there has been no assessment of adherence to these guidelines. We aimed to assess whether current services provided in memory assessment services (MAS) adhere to national policy, in their approach to the assessment and management of individuals with memory problems from minority ethnic backgrounds. We sent a survey to 213 memory services in England and Wales. Twenty MAS from seven regions responded to the survey. We found that 80% (16) provided translated resources, 70% (14) used cognitive assessment tools that are culturally sensitive and appropriate, and 65% (13) showed good use of sufficiently skilled and knowledgeable interpreters. Communication barriers, particularly language, were raised as a potential obstacle to diagnosing minority ethnic patients. Memory clinics appear to reflect national policy for the assessment and management of memory problems in minority ethnic patients. However, only a minority of services responded and they may be more engaged in considering these populations. We need wider knowledge of practice to explore how guidelines support healthcare professional’s assessment of patients from minority ethnic groups in memory service diagnostic procedures.

Developing and implementing guidelines on culturally adapting the Addenbrooke's cognitive examination version III (ACE-III): a qualitative illustration

BACKGROUND

Cognitive tests currently used in healthcare and research settings do not account for bias in performance that arises due to cultural context. At present there are no universally accepted steps or minimum criteria for culturally adapting cognitive tests. We propose a methodology for developing specific guidelines to culturally adapt a specific cognitive test and used this to develop guidelines for the ACE-III. We then demonstrated their implementation by using them to produce an ACE-III Urdu for a British South Asian population.

METHODS

This was a several stage qualitative study. We combined information from our systematic review on the translation and cultural adaptation of the ACE-III with feedback from previous ACE-III adaptors. This identified steps for cultural adaptation. We formatted these into question-by-question guidelines. These guidelines, along with feedback from focus groups with potential users were used to develop ACE-III Urdu questions. Clinical experts reviewed these questions to finalise an ACE-III Urdu.

RESULTS

Our systematic review found 32 adaptations and we received feedback from seven adaptors to develop the guidelines. With these guidelines and two focus groups with 12 participants a sample ACE-III Urdu was developed. A consensus meeting of two psychiatrists with a South Asian background and familiarity with cognitive tests and cultural adaptation finalised the ACE-III Urdu.

CONCLUSIONS

We developed a set of guidelines for culturally adapting the ACE-III that can be used by future adaptors for their own language or cultural context. We demonstrated how guidelines on cultural adaptation can be developed for any cognitive test and how they can be used to adapt it.

Recruitment and methodological issues in conducting dementia research in British ethnic minorities: A qualitative systematic review

OBJECTIVE

Identifying existing recruitment and methodological issues within dementia research conducted in UK studies that included ethnic minorities.

METHODS

We searched for and included any publication detailing dementia research in the UK that included any ethnic minority. The search results and all titles and abstracts were screened according to the inclusion criteria followed by screening of the full texts. We extracted data regarding the recruitment and methodological issues faced by the researchers. This data was combined and listed, and related issues were grouped into overarching themes and subthemes.

RESULTS

Of 52 publications suitable for analysis, 33 provided data collated into six themes: attitudes and beliefs about dementia in ethnic minority communities, recruitment process, data collection issues, practical issues, researcher characteristics, and lack of published research and normative data. These themes allowed us to identify three areas responsible for addressing these recruitment and methodological issues: community and patient education, health services, and researchers' training.

CONCLUSIONS

This is the first review identifying recruitment and methodological issues within UK dementia research that included ethnic minorities. We now have a compilation of reported existing issues and a framework of areas responsible for addressing them and devising solutions.

Cultural validation of the Addenbrooke's Cognitive Examination Version III Urdu for the British Urdu-speaking population: a qualitative assessment using cognitive interviewing

OBJECTIVES

Our research determined whether the Addenbrooke's Cognitive Examination Version III (ACE-III) Urdu eliminated cultural bias through a qualitative assessment of its understanding and acceptability within the British Urdu-speaking population, employing cognitive interviews.

METHOD

We aimed to recruit 25 participants fluent in speaking and writing Urdu, over the age of 60 years, able to give informed consent and who did not have a history of cognitive impairment. Participants were administered the ACE-III Urdu, and cognitive interviews were conducted, which involve obtaining verbal data on the individual's perception of the assessment overall, their understanding of the mental processes behind how they interpreted questions within the assessment and how they produced appropriate responses. This allows us to gauge the participants' overall thoughts on the Urdu ACE-III before applying question-formatted prompts to every ACE-III Urdu item.

RESULTS

We recruited 25 participants, 12 women (48%), ranging from ages 60 years to 85 years (M=69.12, SD=6.57), all from Greater Manchester. Participants came from varied socioeconomic backgrounds, with 22 identifying as Pakistani, one as British Pakistani and two as East African. Across 19 ACE-III Urdu items, 7 required changes based on participant feedback: item 5a: fluency; items 6, 18 and 19: memory; items 12 and 13: language; and item 17: visuospatial abilities.The need for some of these changes was realised after 21 participants, due to persistently reoccurring issues, and these were applied before the last four participants. Overall, the ACE-III Urdu was considered easy and straightforward by all 25 participants, who understood items and felt the ACE-III Urdu was appropriate, not just for them, but for British Urdu speakers in general.

CONCLUSION

Our cognitive interviews determined the ACE-III Urdu was acceptable, especially with regards to cultural context, but further changes were made to ensure understanding. Therefore, we adapted the ACE-III Urdu in accordance with feedback, resulting in our finalised version being culturally validated.

Dementia and immigrant groups: a qualitative study of challenges related to identifying, assessing, and diagnosing dementia

Background

Along with the ageing of the general population, Europe’s migrant populations are also ageing, thus posing new challenges for dementia care services, particularly if the services are to be adjusted to persons with different linguistic and cultural backgrounds. From the perspective of health professionals, this study aims to explore challenges involved in identifying, assessing and diagnosing people with cognitive impairment/dementia who have different linguistic and cultural backgrounds.

Methods

Research on health professionals experiences regarding the management of dementia among immigrants is scarce and qualitative methods was used to address the objective of the study. Using qualitative in-depth interviews and focus-group discussions, we sought to gather participants’ experiences regarding the diagnostic process for immigrants with dementia. The material was analysed and interpreted based on Kvale and Brinkmann’s descriptions of three different contexts of interpretation: self-understanding, critical common-sense understanding, and theoretical understanding.

Results

Health professionals described how families could attribute symptoms of dementia to processes of normal ageing, while others saw the symptoms as something shameful; both instances delayed or hindered help-seeking. Many clinicians had limited experience with older immigrants suffering from dementia, and general practitioners (GPs) in particular experienced difficulties assessing dementia due to language barriers and difficulties related to the involvement of the family or an interpreter. The findings illustrate challenges in assessment, such as unfamiliarity with test situations among those being assessed and lack of knowledge regarding appropriate diagnostic tools among health professionals. Lack of continuity and poor information exchange in the chain of care seem to reinforce many of these challenges.

Conclusions

Detection, treatment and care may be improved if primary care professionals strengthen their cross-cultural competences. Training in communication skills and in the use of cross-cultural assessment tools may help build competence and confidence when assessing and caring for people with different cultural and linguistic backgrounds. Closer collaboration among families, nurses in home-based services, dementia teams, and GPs may facilitate close monitoring of a patient over time. Such collaboration requires sufficient information exchange during transitions in the chain of care, continuity among health professionals, and a shared understanding of the goals for treatment and care.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3720-7) contains supplementary material, which is available to authorized users.

Trends in dementia diagnosis rates in UK ethnic groups: analysis of UK primary care data

Objectives

We compared incidence of dementia diagnosis by white, black, and Asian ethnic groups and estimated the proportion of UK white and black people developing dementia in 2015 who had a diagnosis for the first time in a UK-wide study.

Methods

We analyzed primary care electronic health records from The Health Improvement Network database between 2007 and 2015 and compared incidence of dementia diagnosis to dementia incidence from community cohort studies. The study sample comprised of 2,511,681 individuals aged 50–105 years who did not have a dementia diagnosis prior to the start of follow-up.

Results

A total of 66,083 individuals had a dementia diagnosis (4.87/1,000 person-years at risk, 95% CI 4.83–4.90); this incidence increased from 3.75 to 5.65/1,000 person-years at risk between 2007 and 2015. Compared with white women, the incidence of dementia diagnosis was 18% lower among Asian women (adjusted incidence rate ratio (IRR) 0.82, 95% CI 0.72–0.95) and 25% higher among black women (IRR 1.25, 95% CI 1.07–1.46). For men, incidence of dementia diagnosis was 28% higher in the black ethnic group (IRR 1.28, 95% CI 1.08–1.50) and 12% lower in the Asian ethnic group (IRR 0.88, 95% CI 0.76–1.01) relative to the white ethnic group. Based on diagnosis incidence in The Health Improvement Network data and projections of incidence from community cohort studies, we estimated that 42% of black men developing dementia in 2015 were diagnosed compared with 53% of white men.

Conclusion

People from the black ethnic group had a higher incidence of dementia diagnosis and those from the Asian ethnic group had lower incidence compared with the white ethnic group. We estimated that black men developing dementia were less likely than white men to have a diagnosis of dementia, indicating that the increased risk of dementia diagnosis reported in the black ethnic group might underestimate the higher risk of dementia in this group. It is unclear whether the lower incidence of dementia diagnosis in the Asian ethnic group reflects lower community incidence or underdiagnosis. A cohort study to determine this is needed.

Dementia in UK South Asians: a scoping review of the literature

OBJECTIVE

Over 850 000 people live with dementia in the UK. A proportion of these people are South Asians, who make up over 5% of the total UK population. Little is known about the prevalence, experience and treatment of dementia in the UK South Asian population. The aim of this scoping review is to identify dementia studies conducted in the UK South Asian population to highlight gaps in the literature which need to be addressed in future research.

METHOD

Databases were systematically searched using a comprehensive search strategy to identify studies. A methodological framework for conducting scoping reviews was followed. An extraction form was developed to chart data and collate study characteristics and findings. Studies were then grouped into six categories: prevalence and characteristics; diagnosis validation and screening; knowledge, understanding and attitudes; help-seeking; experience of dementia; service organisation and delivery.

RESULTS

A total of 6483 studies were identified, 27 studies were eligible for inclusion in the scoping review. We found that studies of prevalence, diagnosis and service organisation and delivery in UK South Asians are limited. We did not find any clinical trials of culturally appropriate interventions for South Asians with dementia in the UK. The existing evidence comes from small-scale service evaluations and case studies.

CONCLUSIONS

This is the first scoping review of the literature to identify priority areas for research to improve care for UK South Asians with dementia. Future research should first focus on developing and validating culturally appropriate diagnostic tools for the UK South Asians and then conducting high-quality epidemiological studies in order to accurately identify the prevalence of dementia in this group. The cultural adaptation of interventions for dementia and testing in randomised controlled trials is also vital to ensure that there are appropriate treatments available for the UK South Asians to access.

Diagnostic accuracy of the Ottawa 3DY and Short Blessed Test to detect cognitive dysfunction in geriatric patients presenting to the emergency department

OBJECTIVES

Cognitive dysfunction (CD) is a common finding in geriatric patients presenting to the emergency department (ED). Our primary objective was to determine the diagnostic accuracy of the Ottawa 3DY (O3DY) and Short Blessed Test (SBT) as screening tools for the detection of CD in the ED. Our secondary objective was to estimate the inter-rater reliability of these instruments.

METHODS

We conducted a prospective cross-sectional comparative study at an inner-city academic medical centre (annual ED visit census 86 000). Patients aged 75 years or greater were evaluated for inclusion, 163 were screened, 150 were deemed eligible and 117 were enrolled. The research team completed the O3DY, SBT and Mini-Mental State Exam (MMSE) for each participant. Descriptive statistics were calculated. Sensitivity and specificity of the O3DY and SBT were calculated in STATA V.11.2 using the MMSE as our criterion standard.

RESULTS

We enrolled 117 patients from June to November 2016. The median ED length of stay at the time of completion of all tests was 1:40 (IQR 1:34-1:46). The sensitivity of the O3DY was 71.4% (95% CI 47.8 to 95.1), and specificity was 56.3% (46.7-65.9). Sensitivity of the SBT was 85.7% (67.4-99.9) and specificity was 58.3% (48.7-67.8). The receiver operating characteristic area under the curve was calculated for the O3DY (0.51; 95% CI 0.42 to 0.61) and SBT (0.52; 95% CI 0.43 to 0.61) relative to the MMSE. Inter-rater reliability for the O3DY (k=0.64) and SBT (k=0.63) were good.

CONCLUSION

In a cohort of geriatric patients presenting to an inner-city academic ED, the O3DY and SBT tools demonstrate moderate sensitivity and specificity for the detection of CD. Inter-rater reliability for the O3DY and SBT were good. Future research on this topic should attempt to derive and validate ED-specific screening tools, which will hopefully result in more robust likelihood ratios for the screening of CD in ED geriatric patients.

Mild cognitive decline. A position statement of the Cognitive Decline Group of the European Innovation Partnership for Active and Healthy Ageing (EIPAHA)

INTRODUCTION

Mild cognitive impairment (MCI) is a term used to describe a level of decline in cognition which is seen as an intermediate stage between normal ageing and dementia, and which many consider to be a prodromal stage of neurodegeneration that may become dementia. That is, it is perceived as a high risk level of cognitive change. The increasing burden of dementia in our society, but also our increasing understanding of its risk factors and potential interventions, require diligent management of MCI in order to find strategies that produce effective prevention of dementia.

AIM

To update knowledge regarding mild cognitive impairment, and to bring together and appraise evidence about the main features of clinical interest: definitions, prevalence and stability, risk factors, screening, and management and intervention.

METHODS

Literature review and consensus of expert opinion.

RESULTS AND CONCLUSION

MCI describes a level of impairment in which deteriorating cognitive functions still allow for reasonable independent living, including some compensatory strategies. While there is evidence for some early risk factors, there is still a need to more precisely delineate and distinguish early manifestations of frank dementia from cognitive impairment that is less likely to progress to dementia, and furthermore to develop improved prospective evidence for positive response to intervention. An important limitation derives from the scarcity of studies that take MCI as an endpoint. Strategies for effective management suffer from the same limitation, since most studies have focused on dementia. Behavioural changes may represent the most cost-effective approach.