Dementia in a Black and minority ethnic population: characteristics of presentation to an inner London memory service

A retrospective analysis of the ethnicity of individuals referred to a tertiary neuropsychology service in the United Kingdom

Objective: Ethnic minorities comprise approximately 18% of the UK population and are at high risk of developing neurological conditions. Despite this, there is little information regarding their access to neuropsychology services. This study evaluated whether ethnic minorities were proportionally represented in a tertiary neuropsychology department in the UK in accordance with census data for the region. We also aimed to highlight which ethnic groups were over- and underrepresented. Method: Anonymised demographic data of 3429 outpatient and 3304 inpatient referrals to an adult UK neuropsychology department was collected. These data were compared to the 2021 UK census data for the region. Results: Ethnicities in both the outpatient referrals (χ2(15) = 24066.55, p < .001) and inpatient referrals (χ2(15) = 35940924.75, p < .001) are significantly different from the Census. All ethnic minorities were underrepresented in adult neuropsychology referral data for both outpatient settings (-0.06% to -4.66%) and inpatient settings (-0.01% to -4.99%). Pakistani individuals were the most underrepresented across all settings, followed by individuals from an African background. Conversely, individuals of White British ethnicity were overrepresented in both outpatient settings (+10.73%) and inpatient settings (+15.68%). Conclusions: The UK ethnic minorities were not referred to a neuropsychology service relative to regional population prevalence. This contradicts their increased susceptibility for risk of neurological conditions but may also indicate the inaccessibility of neuroscience services for ethnic minorities. Replicating this study across different regions and gathering data on prevalence rates for different neurological conditions across ethnicity is recommended. Additionally, improving accessibility of neuropsychology services for British ethnic minorities should be prioritised.

"At least we finally found out what it was": Dementia diagnosis in minoritized populations

BACKGROUND

Disparities in diagnosis persist among persons living with dementia (PLWD); most research on delayed diagnosis relies on medical records or administrative claims. This study aimed to identify factors that delay or facilitate dementia diagnoses in racial or ethnic minoritized PLWD and elicit care partner perspectives on timing and effects of diagnosis.

METHODS

Maryland-based participants cared for a PLWD age 60 or older, self-identified as Black/African/African-American, Asian, or Hispanic/Latino, and spoke English. Nineteen care partner in-depth, semi-structured interviews were conducted and analyzed using conventional qualitative content analysis methods.

RESULTS

Biological, sociocultural, and environmental factors delayed dementia diagnosis. Memory loss was the most common early symptom, but the onset was often subtle or perceived as normal aging. Stigma and secrecy surrounding dementia influenced recognition and discussion of dementia among families and communities. Diagnoses were family-initiated and started in primary care. Care partners were divided in their perceptions of diagnosis timeliness and whether earlier diagnosis would have changed outcomes. Family reactions to dementia diagnoses varied; most participants expressed a strong sentiment of service and duty to care for older family members. Participants overwhelmingly felt the benefits of obtaining a dementia diagnosis outweighed harms.

CONCLUSIONS

Numerous factors affect dementia diagnosis in racial and ethnic minoritized PLWD. Normalization of brain health discussions and systematic, proactive discussion and detection of dementia in primary care may address multilevel barriers and facilitators to diagnosis. Systems-level and community-led public health interventions may also help address disparities in brain health education and dementia diagnosis.

Tailoring STrAtegies for RelaTives for Black and South Asian dementia family carers in the United Kingdom: A mixed methods study

OBJECTIVES

We culturally adapted STrAtegies for RelaTives (START), a clinically and cost-effective intervention for dementia family carers, for Black and South Asian families. It had previously been delivered to family carers around the time of diagnosis, when most people with dementia had very mild, mild or moderate dementia.

METHODS

We interviewed a maximum variation sample of family carers (phase one; n = 15 South Asian; n = 11 Black) about what aspect of START, required cultural adaptation, then analysed it thematically using the Cultural Treatment Adaptation Framework then adapted it in English and into Urdu. Facilitators then delivered START individually to carers (phase two; n = 13 South Asian; n = 8 Black). We assessed acceptability and feasibility through the number of sessions attended, score for fidelity to the intervention and interviewing family carers about their experiences. We used the Hospital Anxiety and Depression Scale. to examine whether immediate changes in family carers' mental health were in line with previous studies.

RESULTS

In phase one we made adaptations to peripheral elements of START, clarifying language, increasing illustrative vignettes numbers, emphasising privacy and the facilitator's cultural competence and making images ethnically diverse. In phase two 21 family carers consented to receive the adapted intervention; 12 completed ≥5/8 sessions; four completed fewer sessions and five never started. Baseline HADS score (n = 21) was 14.4 (SD = 9.8) but for those who we were able to follow up was 12.3 (SD 8.1) and immediately post-intervention was 11.3 (n = 10; SD = 6.1). Family carers were positive about the adapted START and continued to use elements after the intervention.

CONCLUSIONS

Culturally adapted START was acceptable and feasible in South Asian and Black UK-based family carers and changes in mental health were in line with those in the original clinical trial. Our study shows that culturally inclusive START was also acceptable. Changes made in adaptations were relevant to all populations. We now use the adapted version for all family carers irrespective of ethnicity.

Ethnic Variations in Patient Outcomes in a Memory Clinic Setting Between 2013 and 2021

BACKGROUND

The incidence of dementia in Black and Asian populations in the UK is set to rise. There is concern surrounding differences in services provided for different ethnic groups.

OBJECTIVE

This study aimed to examine ethnic variations in survival, services accessed, and medication use across White, Black, and Asian groups in routine memory clinic setting.

METHODS

We retrospectively examined referrals to a memory service between 2013 and 2021. A random sample of 104 White, 99 Asian, and 74 Black patients were analyzed for differences in support services, voluntary services, medication use, and survival rate.

RESULTS

There were statistically significant differences in survival of the Asian compared to the White group (Hazard ratio (HR = 2.17,95% confidence interval (CI) 1.23-3.85, p = 0.008)) following adjustment for age, gender, diagnosis, cognitive impairment, severity, access to support and voluntary services, and use of cholinesterase inhibitors, N-methyl-D-aspartate antagonists, and antipsychotics. The Asian group showed a statistically significantly reduction in access to support services compared to the White group (HR = 0.05, 95% CI 0.01-0.37, p = 0.003). In contrast, the survival rate was similar between the White and Black dementia patients.

CONCLUSION

We found significantly reduced survival and reduced access to support services in Asian compared to White patients with dementia. Further research is needed to investigate the generalizability of our results, and determine the cause, and consequent remedies of these associations in ethnic minority groups.

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.

The Immigrant Memory Collaborative: A Community-University Partnership to Assess African Immigrant Families' Experiences with Dementia

Research suggests a disparity in the prevalence of dementia, with Black older adults having double the risk compared to their White counterparts. African immigrants are a fast-growing segment of the U.S. Black population, but the dementia care needs and resources of this population are not fully understood. In this paper, we describe the process of working collaboratively with a community partner and project advisory board to conduct a culturally informed project. Specifically, we describe the process of developing culturally informed instruments to collect data on dementia care needs and resources among African immigrants. Working together with a diverse project advisory board, a guide was developed and used to conduct community conversations about experiences with dementia/memory loss. Transcripts from six conversations with 24 total participants were transcribed and analyzed thematically by two independent coders in Nvivo. These qualitative findings were used to inform the development of a survey for quantitative data collection that is currently ongoing. Themes (e.g., cultural attitudes, challenges, and current resources) from the community conversations that informed the survey are described briefly. Despite the challenges of conducting research during a global pandemic, having trusting relationships with a partnering community organization and project advisory board facilitated the successful development of instruments to conduct preliminary dementia care research in an underserved population. We anticipate that survey results will inform interventions that increase education, outreach, and access to dementia care and caregiving resources for this population. It may serve as a model for community–university partnerships for similar public health efforts in dementia as well as other chronic disease contexts.

Informal carer experiences of UK dementia services-A systematic review

WHAT IS KNOWN ON THE SUBJECT?: Dementia affects an increasing number of people and a person with dementia requires significant levels of care. Dementia care is often delivered by family members. Caring for someone with dementia places significant demand on the carer and support for the carer is often needed. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Research has been conducted into caregivers' experiences of caring for someone with dementia, but a synthesis of findings for studies from the UK is needed to collate the research evidence and provide an account of the common trends within the existing research. This paper adds to existing knowledge by highlighting the key difficulties experienced by carers of a person with dementia in their caring role and their experiences with support services across the existing research evidence. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Improvements to the process of dementia assessment and the process of receiving a dementia diagnosis are needed. Information and support needs to be more accessible for the carer of a person with dementia Cultural differences need to be acknowledged in the support and information offered to carers of a person with dementia. ABSTRACT: Aim To understand the experiences of informal carers' of individuals with dementia in the UK when engaging with services for support in their caring role. Methods Following the PRISMA guidelines, a qualitative systematic literature review was carried out. Six Internet databases were searched. Results were screened, and eligible studies were appraised using Critical Appraisal Skills Programme (CASP, 2019) and data synthesized using Evan & Pearson (2001) and Evans (2002). Results The search returned 231 records, 11 were selected for critical appraisal and data synthesis. Four main themes (information for carers, process of diagnosing dementia, difficulties accessing support and cultural differences of experiences of services) were extracted. Discussion Carers experience services as providing inadequate support for the Person with Dementia (PwD) and themselves for support relating to dementia. Difficulties in receiving information and support were experienced from before diagnosis to end-of-life (EoL) care. Additionally, cultural differences were found in carers' experiences. Implications for practice The provision of and access to dementia support should be improved; more information for carers about dementia and dementia services is needed; cultural differences need to be appreciated in the support and information offered.

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 Review of Qualitative Research of Perception and Experiences of Dementia Among Adults From Black, African, and Caribbean Background: What and Whom Are We Researching?

BACKGROUND AND OBJECTIVES

Black, African, and Caribbean (BAC) families are disproportionately affected by dementia but engage less with services. Studies reporting their experiences of dementia have tended to aggregate people from diverse backgrounds, without considering the impact of this diversity, or researchers' ethnicities. We investigated participants' and researchers' ethnic identities, exploring how this relates to findings.

RESEARCH DESIGN AND METHODS

We searched electronic databases in September 2018, for qualitative studies exploring how participants of Black ethnicity understand and experience dementia and dementia care. We reported participants' and researchers' ethnicities, and meta-synthesized qualitative findings regarding how ethnicity influences experiences and understanding of dementia.

RESULTS

Twenty-eight papers reported 25 studies; in United States (n = 17), United Kingdom (n = 7), and Netherlands (n = 1). 350/492 (71%) of participants were in U.S. studies and described as African American; participants in U.K. studies as Caribbean (n = 45), African/Caribbean (n = 44), African (n = 28), Black British (n = 7), or Indo-Caribbean (n = 1); and in Netherlands as Surinamese Creole (n = 17). 6/25 (24%) of studies reported involving recruiters/interviewers matching participants' ethnicity; and 14/25 (56%) involved an author/advisor from a BAC background during analysis/procedures. We identified four themes: Dementia does not relate to me; Inappropriate and disrespectful services; Kinship and responsibility; Importance of religion.

DISCUSSION AND IMPLICATIONS

Studies were mostly from a U.S. African American perspective, by researchers who were not of BAC background. Themes of dementia diagnosis and services feeling less relevant to participants than the majority population resonated across studies. We caution against the racialization of these findings, which can apply to many differing minority groups.

Exploring Dementia Care Systems Across the African Caribbean Diaspora: A Scoping Review and Consultation Exercise

BACKGROUND AND OBJECTIVES

Understanding the influences of marginalized cultural and social identities as experienced by the African Caribbean diaspora within the context of dementia care is essential to minimize the gaps in current practice and policy in the health care setting. This study explores the impact of marginalized identities upon the meaning-making process, access to services and experience of care provisions through a scoping review and consultancy exercises with key stakeholders.

RESEARCH DESIGN

Fourteen databases were searched using key terms. Primary studies in English, any year, study design, and country of origin were eligible. Titles, abstracts, and full texts were screened for inclusion and data were extracted in stages. Thematic analysis was performed and the findings were discussed in a series of consultation meetings with people with dementia, carers, and health care professionals in Manchester (United Kingdom) and Jamaica.

RESULTS

The scoping review retrieved n = 1,989 research articles. Nineteen were included, most were qualitative (n = 14), 3 quantitative, and 2 mixed-method. The findings revealed limited insight into cultural and multiple individual identities in explaining conceptualization and service access. Consultation meetings confirmed these findings and highlighted differences in health care services and systems in the United Kingdom and Jamaica.

DISCUSSION AND IMPLICATIONS

This study suggests there is a complex interaction of sociocultural processes that marginalize African Caribbean persons in and across various national settings within the context of dementia care. The study highlights the importance of acknowledging and addressing how prevalent racialized- and class-based divides and related marginalized social locations are reflected in inequities in access to and use of dementia services.

Access to Health Services in Older Minority Ethnic Groups with Dementia: A Systematic Review

BACKGROUND/OBJECTIVES

While it is acknowledged that minority ethnic (ME) groups across international settings face barriers to accessing care for dementia, it is not clear whether ME groups access services less frequently as a result. The objective of this review is to examine whether ME groups have longer delays before accessing dementia/memory services, higher use of acute care and crisis services and lower use of routine care services based on existing literature. We also examined whether ME groups had higher dementia severity or lower cognition when presenting to memory services.

DESIGN

Systematic review with narrative synthesis.

SETTING

Nonresidential medical, psychiatric, memory, and emergency services.

PARTICIPANTS

Twenty studies totaling 94,431 older adults with dementia or mild cognitive impairment.

MEASUREMENTS

We searched Embase, Ovid MEDLINE, Global Health, and PsycINFO from inception to November 2018 for peer-reviewed observational studies which quantified ethnic minority differences in nonresidential health service use in people with dementia. Narrative synthesis was used to analyze findings.

RESULTS

Twenty studies were included, mostly from the U.S. (n = 13), as well as the UK (n = 4), Australia (n = 1), Belgium (n = 1), and the Netherlands (n = 1). There was little evidence that ME groups in any country accessed routine care at different rates than comparison groups, although studies may have been underpowered. There was strong evidence that African American/Black groups had higher use of hospital inpatient services versus U.S. comparison groups. Primary care and emergency services were less well studied. Study quality was mixed, and there was a large amount of variability in the way ethnicity and service use outcomes were ascertained and defined.

CONCLUSION

There is evidence that some ME groups, such as Black/African American groups in the U.S., may use more acute care services than comparison populations, but less evidence for differences in routine care use. Research is sparse, especially outside the U.S.

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.

Ethnic variations in referrals to the Leicester memory and dementia assessment service, 2010 to 2017

BACKGROUND

The incidence of dementia in Black, Asian and minority ethnic (BAME) groups is increasing in the UK, with concern about underdiagnosis and late presentation.

AIMS

By reviewing referrals to memory clinics from Leicester City we examined whether the following differed by ethnicity: the proportion with a diagnosis of dementia, type of dementia and severity at presentation.

METHOD

We examined referrals between 2010 and 2017: all those whose ethnicity was recorded as Black (n = 131) and a random sample of 260 Asian and 259 White British referrals. Severity of dementia was assessed by record review. Odds ratios (ORs) were adjusted for general practice, age, gender and year of referral.

RESULTS

A diagnosis of dementia was recorded in 193 (74.5%) White British, 96 (73.3%) Black and 160 (61.5%) Asian referrals. Compared with Asians, White British had twice the adjusted odds of a dementia diagnosis (OR = 1.99 (1.23-3.22). Of those with dementia, Alzheimer's disease was more common in White British (57.0%) than in Asian (43.8%) and Black referrals (51.0%): adjusted OR White British versus Asian 1.76 (1.11-2.77). Of those with dementia, the proportion with moderate/severe disease was highest in White British (66.8%), compared with 61.9% in Asian and 45.8% in Black groups. The adjusted OR for the White versus Black groups was 2.03 (1.10-3.72), with no significant difference between Asian and White British groups.

CONCLUSIONS

Differences in confirmed dementia suggest general practitioners have a lower threshold for referral for possible dementia in some BAME groups. Unlike other centres, we found no evidence of greater severity at presentation in Asian and Black groups.

Representation of Black, Asian and minority ethnic patients in secondary care mental health services: analysis of 7-year access to memory services in Leicester and Leicestershire

AIMS AND METHOD

We aimed to explore access by Black, Asian and minority ethnic (BAME) elders to the memory services in Leicester and Leicestershire, examining any trends over time. We then compared the odds of referral by ethnicity, using observed versus expected referrals for the city of Leicester. We gathered data on a comprehensive county-wide memory clinic used by people with suspected dementia and memory problems from the Trust electronic record system during the period 2011-2017. For Leicester city, we compared referral rates for 2011-2017 and compared observed and expected referral rates with demographics from the UK Census 2011.

RESULTS

In Leicester, there was a significant underrepresentation of referrals from the BAME population as compared with the White population in 2011, 2012 and 2013, when compared with population estimates of those aged ≥60 years from the 2011 UK Census Leicester city data. Data for the Black population were too small for comparisons. The odds of being referred to a memory clinic for the White group was double that of the Asian group in 2011 (odds ratio 2.15, 95% CI 1.52-3.02) and nearly 1.5 times in 2012 (odds ratio 1.40, 95% CI 1.01-1.93). This difference did not persist after 2014. However, this differential odds of referral changes when the age difference between the groups is accounted for. After adjusting for age, there were no differences between the two groups in their odds of referral to the memory clinic from 2011 to 2013, but from 2014 to 2017, members of the Asian group had higher odds of being referred.

CLINICAL IMPLICATIONS

The relationship between BAME and access to memory services is complex. The relative lower prevalence of Asian people among referrals to memory services in Leicester from 2011 to 2013 may partly be explained by the lower ages of the Asian population at referral. The higher prevalence of Asian people in 2014-2017 may be owing to use of denominators from the 2011 UK Census, which are likely to be disproportionately low for this group. Further studies are needed to explore any potential barriers to the access of services by BAME communities.

Ethnic disparity in access to the memory assessment service between South Asian and white British older adults in the United Kingdom: A cohort study

BACKGROUND

Equality of access to memory assessment services by older adults from ethnic minorities is both an ethical imperative and a public health priority.

OBJECTIVE

To investigate whether timeliness of access to memory assessment service differs between older people of white British and South Asian ethnicity.

DESIGN

Longitudinal cohort.

SETTING

Nottingham Memory Study; outpatient secondary mental healthcare.

SUBJECTS

Our cohort comprised 3654 white British and 32 South Asian older outpatients.

METHODS

The criterion for timely access to memory assessment service was set at 90 days from referral. Relationships between ethnicity and likelihood of timely access to memory assessment service were analysed using binary logistic regression. Analyses were adjusted for socio-demographic factors, deprivation and previous access to rapid response mental health services.

RESULTS

Among white British outpatients, 2272 people (62.2%) achieved timely access to memory assessment service. Among South Asian outpatients, fourteen people (43.8%) achieved timely access to memory assessment service. After full adjustment, South Asian outpatients had a 0.47-fold reduced likelihood of timely access, compared to white British outpatients (odds ratio 0.47, 95% confidence interval 0.23-0.95, P value = .035). The difference became non-significant when restricting analyses to outpatients reporting British nationality or English as first language. Older age, lower index of deprivation and previous access to rapid response mental health services were associated with reduced likelihood of timely access, while gender was not.

CONCLUSIONS

In a UK mental healthcare service, older South Asian outpatients are less likely to access dementia diagnostic services in a timely way, compared to white British outpatients.

Ethnic differences in cognition and age in people diagnosed with dementia: A study of electronic health records in two large mental healthcare providers

OBJECTIVES

Qualitative studies suggest that people from UK minority ethnic groups with dementia access health services later in the illness than white UK-born elders, but there are no large quantitative studies investigating this. We aimed to investigate interethnic differences in cognitive scores and age at dementia diagnosis.

METHODS

We used the Clinical Record Interactive Search (CRIS) applied to the electronic health records of two London mental health trusts to identify patients diagnosed with dementia between 2008 and 2016. We meta-analysed mean Mini Mental State Examination (MMSE) and mean age at the time of diagnosis across trusts for the most common ethnic groups, and used linear regression models to test these associations before and after adjustment for age, sex, index of multiple deprivation, and marital status. We also compared percentage of referrals for each ethnic group with catchment census distributions.

RESULTS

Compared with white patients (N = 9380), unadjusted mean MMSE scores were lower in Asian (-1.25; 95% CI -1.79, -0.71; N = 642) and black patients (-1.82, 95% CI -2.13, -1.52; N = 2008) as was mean age at diagnosis (Asian patients: -4.27 (-4.92, -3.61); black patients -3.70 (-4.13, -3.27) years). These differences persisted after adjustment. In general, ethnic group distributions in referrals did not differ substantially from those expected in the catchments.

CONCLUSIONS

People from black and Asian groups were younger at dementia diagnosis and had lower MMSE scores than white referrals.

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.

The IDEMCare Study-Improving Dementia Care in Black African and Caribbean Groups: A feasibility cluster randomised controlled trial

OBJECTIVE

We evaluated the feasibility and acceptability of a tailored evidence-based intervention, consisting of a leaflet and a letter, to encourage timely help-seeking for dementia in Black elders.

METHODS

Participating GP surgeries were randomised to send either the intervention or a control leaflet about ageing well to Black patients aged ≥50 years old without known dementia. We interviewed patients 2 weeks later about the intervention's acceptability using closed and open-ended questions, and they completed a Theory-of-Planned-behaviour questionnaire about what they would do if they developed memory problems, which they also completed 4 months later.

RESULTS

Five of 26 surgeries approached agreed to invite patients. Sixty-five patients responded, of whom 61 (93.8%) agreed to participate. At 2 weeks, we consented and interviewed 47/61 (77%), of whom 24 received the intervention, and at 4 months we followed up 43/47 (91.5%). At 2 weeks, 44/47 (93.6%) found either intervention acceptable to receive by post, including 23/24 of the intervention. Nineteen of 24 (79.2%) reported reading the intervention leaflet compared with 13/23 (56.5%) controls. The intervention leaflet made 16/24 (66.7%) think about visiting their doctor for memory problems and led 4 to help-seeking behaviour. We calculated that 191 patients and 24 surgeries are required for an efficacy trial.

CONCLUSIONS

Given the intervention is acceptable, inexpensive, and unlikely to cause harm, we judge it appropriate to disseminate it without a full-scale trial. Recruitment attainment, retention, and projected sample size calculation indicated feasibility for a larger trial.