Diagnosis of mental illness in elderly people from ethnic minorities

Bilingualism Is Associated with a Delayed Onset of Dementia but Not with a Lower Risk of Developing it: a Systematic Review with Meta-Analyses

Some studies have linked bilingualism with a later onset of dementia, Alzheimer's disease (AD), and mild cognitive impairment (MCI). Not all studies have observed such relationships, however. Differences in study outcomes may be due to methodological limitations and the presence of confounding factors within studies such as immigration status and level of education. We conducted the first systematic review with meta-analysis combining cross-sectional studies to explore if bilingualism might delay symptom onset and diagnosis of dementia, AD, and MCI. Primary outcomes included the age of symptom onset, the age at diagnosis of MCI or dementia, and the risk of developing MCI or dementia. A secondary outcome included the degree of disease severity at dementia diagnosis. There was no difference in the age of MCI diagnosis between monolinguals and bilinguals [mean difference: 3.2; 95% confidence intervals (CI): -3.4, 9.7]. Bilinguals vs. monolinguals reported experiencing AD symptoms 4.7 years (95% CI: 3.3, 6.1) later. Bilinguals vs. monolinguals were diagnosed with dementia 3.3 years (95% CI: 1.7, 4.9) later. Here, 95% prediction intervals showed a large dispersion of effect sizes (-1.9 to 8.5). We investigated this dispersion with a subgroup meta-analysis comparing studies that had recruited participants with dementia to studies that had recruited participants with AD on the age of dementia and AD diagnosis between mono- and bilinguals. Results showed that bilinguals vs. monolinguals were 1.9 years (95% CI: -0.9, 4.7) and 4.2 (95% CI: 2.0, 6.4) older than monolinguals at the time of dementia and AD diagnosis, respectively. The mean difference between the two subgroups was not significant. There was no significant risk reduction (odds ratio: 0.89; 95% CI: 0.68-1.16) in developing dementia among bilinguals vs. monolinguals. Also, there was no significant difference (Hedges' g = 0.05; 95% CI: -0.13, 0.24) in disease severity at dementia diagnosis between bilinguals and monolinguals, despite bilinguals being significantly older. The majority of studies had adjusted for level of education suggesting that education might not have played a role in the observed delay in dementia among bilinguals vs. monolinguals. Although findings indicated that bilingualism was on average related to a delayed onset of dementia, the magnitude of this relationship varied across different settings. This variation may be due to unexplained heterogeneity and different sources of bias in the included studies. Registration: PROSPERO CRD42015019100.

Validation of a brief Multicultural Cognitive Examination (MCE) for evaluation of dementia

BACKGROUND

The aims of this study were to present the psychometric properties of a newly designed cognitive screening instrument, the Multicultural Cognitive Examination (MCE), and to compare it with the Rowland Universal Dementia Assessment Scale (RUDAS) in a multicultural population.

METHODS

The study was a Western European cross-sectional multicenter study. The MCE consists of four components evaluating separate cognitive functions and was constructed by adding measures of memory, verbal fluency, and visuospatial function to the RUDAS to create a scale with 0 to 100 points.

RESULTS

A total of 66 patients with dementia and 123 cognitively intact participants were included across six memory clinics; 96 had minority ethnic background, and 93 had majority ethnic background. Moderate to large differences were present between patients with dementia and control participants on all MCE components. The MCE significantly improved diagnostic accuracy compared with using the RUDAS alone, with area under the curves of .918, .984, and .991 for the RUDAS, MCE composite, and demographically corrected composite scores, respectively. Diagnostic accuracy of the MCE did not significantly differ between minority and majority ethnic groups. Across MCE subcomponents, patients with Alzheimer's disease (AD) dementia performed significantly poorer on the memory component compared with those with non-AD dementia.

CONCLUSIONS

The MCE is a brief cross-cultural cognitive screening instrument that expands evaluation of the cognitive functions covered by the RUDAS, does not require any specialized training, and may be useful for classification of mild dementia or dementia subtypes.

Validation of a European Cross-Cultural Neuropsychological Test Battery (CNTB) for evaluation of dementia

BACKGROUND

The aims of this study were to establish the diagnostic accuracy of the European Cross-Cultural Neuropsychological Test Battery (CNTB) for dementia in different ethnic populations in Western Europe, to examine its ability to differentiate cognitive impairment profiles for dementia subtypes, and to assess the impact of demographic variables on diagnostic properties.

METHODS

The study was a Western European cross-sectional multi-center study. A total of 66 patients with dementia and 118 cognitively intact participants were included across six memory clinics; 93 had ethnic minority background and 91 had ethnic majority background. Tests in the CNTB cover global cognitive function, memory, language, executive functions, and visuospatial functions.

RESULTS

Significant differences with moderate to large effect sizes were present between patients with dementia and control participants on all CNTB measures. Area under the curves (AUC) ranged from .62 to .99 with a mean AUC across all measures of .83. Comparison of ethnic minority and majority groups generally revealed higher sensitivity in the minority group but no significant difference in the mean AUC's across all measures (.84 vs78, P = .42). Comparison of impairment profiles for patients with Alzheimer's disease (AD) and non-AD dementia revealed that AD patients were significantly more impaired on the memory domain, whereas patients with non-AD dementia were more impaired on the executive functions domain.

CONCLUSIONS

The CNTB was found to have promising cross-cultural diagnostic properties for evaluation of dementia in the targeted minority and majority populations and could represent a valid cross-cultural alternative to other well-established neuropsychological test batteries when assessing patients from these populations.

Mental health of the ageing immigrant population

About 6% of older people in the UK are immigrants. Concentrated in deprived inner-city areas, their numbers are rising rapidly, with the ageing of those arriving after the Second World War. Cultural, language and educational differences cause problems in studying this group's mental health. Idioms of distress may affect presentation, help-seeking behaviour and acceptability of treatment. Ethnic elders may be considered vulnerable to depression because of socio-economic deprivation, immigrant status and old age but studies are contradictory and may use inappropriate screening instruments. Relatively few consider immigrant status and dementia. Uncontrolled hypertension could relate to higher dementia rates in Black immigrants which are not reflected in the country of origin. No genetic risk has been found. There is potential for prevention in this population.

Clinical effectiveness of interventions for treatment-resistant anxiety in older people: a systematic review

BACKGROUND

Anxiety and related disorders include generalised anxiety disorder, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder and phobic disorders (intense fear of an object or situation). These disorders share the psychological and physical symptoms of anxiety, but each disorder has its own set of characteristic symptoms. Anxiety disorders can be difficult to recognise, particularly in older people (those aged over 65 years). Older people tend to be more reluctant to discuss mental health issues and there is the perception that older people are generally more worried than younger adults. It is estimated that between 3 and 14 out of every 100 older people have an anxiety disorder. Despite treatment, some people will continue to have symptoms of anxiety. People are generally considered to be 'resistant' or 'refractory' to treatment if they have an inadequate response or do not respond to their first treatment. Older adults with an anxiety disorder find it difficult to manage their day-to-day lives and are at an increased risk of comorbid depression, falls, physical and functional disability, and loneliness.

OBJECTIVE

To evaluate the effectiveness of pharmacological, psychological and alternative therapies in older adults with an anxiety disorder who have not responded, or have responded inadequately, to treatment.

DATA SOURCES

Electronic databases (MEDLINE, MEDLINE In-Process and Other Non-Indexed citations, EMBASE, The Cochrane Library databases, PsycINFO and Web of Science) were searched from inception to September 2013. Bibliographies of relevant systematic reviews were hand-searched to identify additional potentially relevant studies. ClinicalTrials.gov was searched for ongoing and planned studies.

REVIEW METHODS

A systematic review of the clinical effectiveness of treatments for treatment-resistant anxiety in older adults was carried out.

RESULTS

No randomised controlled trial or prospective comparative observational study was identified meeting the prespecified inclusion criteria. Therefore, it was not possible to draw any conclusions on clinical effectiveness.

LIMITATIONS

As no study was identified in older adults, there is uncertainty as to which treatments are clinically effective for older adults with an anxiety disorder who have not responded to prior treatment. The comprehensive methods implemented to carry out this review are a key strength of the research presented. However, this review highlights the extreme lack of research in this area, identifying no comparative studies, which is a marked limitation.

CONCLUSIONS

Specific studies evaluating interventions in older adults with an anxiety disorder who have not responded to first-line treatment are needed to address the lack of evidence. The lack of evidence in this area means that older adults are perhaps receiving inappropriate treatment or are not receiving a particular treatment because there is limited evidence to support its use. At this time there is scope to develop guidance on service provision and, as a consequence, to advance the standard of care received by older adults with a treatment-resistant anxiety disorder in primary and secondary care. Evaluation of the relative clinical effectiveness and acceptability of pharmacological and psychological treatment in older adults with an anxiety disorder that has not responded to first-line treatment is key future research to inform decision-making of clinicians and patients. An important consideration would be the enrolment of older adults who would be representative of older adults in general, i.e. those with multiple comorbid physical and mental disorders who might require polypharmacy.

STUDY REGISTRATION

The protocol for the systematic review is registered on PROSPERO (registration number CRD42013005612).

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Validation of the Rowland Universal Dementia Assessment Scale for multicultural screening in Danish memory clinics

BACKGROUND/AIMS

The Rowland Universal Dementia Assessment Scale (RUDAS) is a brief cognitive screening test that was developed to detect dementia in multicultural populations. The RUDAS has not previously been validated in multicultural populations outside of Australia. The aim of this study was to evaluate the diagnostic accuracy of the RUDAS in a multicultural sample of patients referred to Danish memory clinics.

METHODS

Data were collected from 137 consecutive patients (34 with an immigrant background) in three Danish memory clinics. All patients were given the RUDAS as a supplement to the standard diagnostic workup.

RESULTS

Diagnostic accuracy for the RUDAS [area under the curve (AUC) = 0.838] was similar to that of the Mini-Mental State Examination (MMSE; AUC = 0.840). The cutoff score with the best balance of sensitivity, specificity and accuracy was <24/30 for the RUDAS (sensitivity 0.69, specificity 0.80) and <25/30 for the MMSE (sensitivity 0.76, specificity 0.83). In contrast to the MMSE, regression analyses revealed that the RUDAS was unaffected by factors related to the patients' immigrant backgrounds.

CONCLUSION

The RUDAS showed high specificity and proved to be less affected by cultural and linguistic factors than the MMSE, making it a particularly valuable tool when screening for cognitive impairment in elderly multicultural patient populations.

Comparison of performance on three neuropsychological tests in healthy Turkish immigrants and Danish elderly

BACKGROUND

Appropriate neuropsychological tests for cross-cultural assessment of dementia in elderly ethnic and linguistic minorities are generally lacking in Europe. The aim of this study was to investigate the cross-cultural applicability of the Recall of Pictures Test (RPT), Clock Reading Test (CRT), and supermarket fluency (SF) in samples of Turkish immigrants and Danish elderly.

METHODS

Samples of Turkish immigrants and Danish elderly were recruited from the Greater Copenhagen area. All participants were screened for factors known to affect cognitive test performance. Those who were included in the study underwent an approximately two-hour assessment, where the RPT, CRT, and SF were applied as a part of a comprehensive battery of neuropsychological tests.

RESULTS

A total of 109 elderly participants were included in the study: 73 Turkish and 36 Danish. Significant differences were found between the Turkish and Danish samples in CRT and SF performances, but not in any of the RPT measures. Age and acculturation level were the only demographic variables with significant impact on test performances. Performance data for the three tests are presented as percentiles.

CONCLUSIONS

Although small differences were observed between the Turkish and Danish samples on the CRT and SF, we consider the three tests to be important neuropsychological tests for assessment of dementia in elderly patients from ethnic minority migrant populations.

Quality of dementia diagnostic evaluation for ethnic minority patients: a nationwide study

BACKGROUND/AIMS

Diagnostic evaluation of dementia for ethnic minority patients may be challenging. This study aimed to evaluate the quality of diagnostic evaluation of dementia for patients from ethnic minorities in Denmark.

METHODS

The Danish national hospital registers were used to identify patients from the main ethnic minority groups in Denmark, who were diagnosed with dementia in the period 2005-2007. Three raters independently reviewed the patients' medical records. Data were compared to data from a previous similar study in the general Danish population.

RESULTS

Fifty-seven medical records were reviewed. An acceptable diagnostic workup was documented in only 23% of the patients. Dementia diagnosis was confirmed in 35%. Significant differences in the quality of the diagnostic evaluation were found between patients from ethnic minorities and the general population.

CONCLUSION

There are significant ethnic disparities in the quality of diagnostic evaluations and outcome of dementia in the secondary healthcare sector.

Over- and under-diagnosis of dementia in ethnic minorities: a nationwide register-based study

OBJECTIVE

Among dementia professionals in several European countries, it is believed that dementia is under-diagnosed and under-treated to a greater extent among ethnic minorities than in the native population. It is unknown whether this belief holds true. The objective of this study was to compare the prevalence of register-based dementia diagnoses in the largest ethnic minority groups in Denmark with the prevalence of register-based dementia diagnoses in the general Danish population.

METHODS

By linking the Danish hospital registers with the Danish Civil Registration System, nationwide dementia cases for three main ethnic minorities were identified. Age- and gender-specific prevalence rates for dementia were calculated and compared to previously published data for the general population.

RESULTS

The study population consisted of 68 219 persons aged 20 and older. A total of 174 dementia cases were identified. The mean age at diagnosis was 57.7 years (SD = 16.2). Compared to the general population, there was a higher prevalence of dementia among those younger than 60 years, and a markedly lower prevalence of dementia among those 60 years and older.

CONCLUSIONS

Dementia is under-diagnosed to a greater extent among ethnic minorities in the age group 60 years and older but is over-diagnosed in the age group younger than 60 years. Several factors may contribute to this pattern, including cultural differences in help-seeking behaviour, and problems in navigating the health-care system. Furthermore, cross-cultural assessment of dementia can be difficult because of language barriers and cultural differences.

Assessment of dementia in ethnic minority patients in Europe: a European Alzheimer's Disease Consortium survey

BACKGROUND

In most European countries the ethnic minority migrant populations are currently reaching an age where dementia becomes an increasingly important issue. There is no European consensus on good clinical practice with these patient groups, who often have special needs and expectations with regard to dementia services.

METHODS

A survey was conducted in clinical dementia centers in 15 European countries. Questionnaires focusing on different points in the clinical assessment of dementia in ethnic minority patients were mailed to leading dementia experts of the European Alzheimer's Disease Consortium.

RESULTS

Thirty-six centers from 15 countries responded to the survey. Ethnic minority patients were seen on a regular basis in 69% of these centers. The diagnostic evaluation was in accordance with evidence-based clinical guidelines in 84-100% of the centers, but most centers performed cognitive assessment with instruments that are only validated in Western cultures and frequently relied on family members for interpretation. Diagnostic evaluation of the patients was considered to be challenging in 64% of the centers, mainly because of communication problems and lack of adequate assessment tools. In general, there were few indicators of culturally sensitive dementia services in the centers.

CONCLUSIONS

Ethnic minority patients are seen on a regular basis in European dementia clinics. Assessment of such patients is difficult for a number of reasons. Results from this study show that the most challenging issues are communication problems and assessment of cognitive function where there is a need to develop specific tests for ethnic minority patients.

Psychiatry of old age and ethnic minority older people in the United Kingdom

This review examines the demographic changes, the epidemiology of mental disorders and suicides, the potential risk and protective factors, access to secondary care old age psychiatry services (OAPSs) and the policy context pertaining to older people from ethnic minority groups in the United Kingdom. The number of older people from ethnic minority groups is increasing. The prevalence of mental disorders in older people from ethnic minority groups is either similar to or higher than that in the indigenous population. Therefore, the number of older people from ethnic minority groups with psychiatric morbidity is also increasing. Ethnic minority older people also have inequity of access to secondary care OAPSs. There is an urgent need to develop and implement practical strategies to improve access by older people from ethnic minority groups to OAPSs.

Mental health of migrant elders--the Islington study

BACKGROUND

In the UK, 6% of those aged 65 years and over were born abroad, most of whom now live in inner-city areas. It has been suggested that ethnic elders are particularly vulnerable to mental illness.

AIMS

To compare the prevalence of dementia and depression in older migrants with those born in the UK.

METHOD

A cross-sectional community study of 1085 people aged 65 years or older in an inner-London borough.

RESULTS

Compared with those born in the UK, the prevalence of dementia was raised in African-Caribbeans (17.3%, relative risk=1.72, Cl=1.06-2.81) and lower for the Irish-born (3.6%, relative risk=0.36, Cl=0.17-0.87). All those of African-Caribbean country of birth were significantly younger (P=0.000) but no more likely to be taking antihypertensive drugs. They were no more likely to report having cardiovascular problems but had increased rates of diabetes (P<0.0000). The overall prevalence of depression was 18.3% (95% Cl=16.1-20.7). The highest prevalence rate was found among those born in Greece and Turkey (27.2%, Cl=17.9-39.6). Migration per se does not appear to be a risk for depression and dementia in this population.

CONCLUSIONS

The excess of dementia may be of vascular aetiology. There is the potential for primary or secondary prevention.