Black African and Caribbean British Communities' Perceptions of Memory Problems: "We Don't Do Dementia."

Improving Conversations about Parkinson's Dementia

BACKGROUND

People with Parkinson's disease (PD) have an increased risk of dementia, yet patients and clinicians frequently avoid talking about it due to associated stigma, and the perception that "nothing can be done about it". However, open conversations about PD dementia may allow people with the condition to access treatment and support, and may increase participation in research aimed at understanding PD dementia.

OBJECTIVES

To co-produce information resources for patients and healthcare professionals to improve conversations about PD dementia.

METHODS

We worked with people with PD, engagement experts, artists, and a PD charity to open up these conversations. 34 participants (16 PD; 6 PD dementia; 1 Parkinsonism, 11 caregivers) attended creative workshops to examine fears about PD dementia and develop information resources. 25 PD experts contributed to the resources.

RESULTS

While most people with PD (70%) and caregivers (81%) shared worries about cognitive changes prior to the workshops, only 38% and 30%, respectively, had raised these concerns with a healthcare professional. 91% of people with PD and 73% of caregivers agreed that PD clinicians should ask about cognitive changes routinely through direct questions and perform cognitive tests at clinic appointments. We used insights from the creative workshops, and input from a network of PD experts to co-develop two open-access resources: one for people with PD and their families, and one for healthcare professionals.

CONCLUSION

Using artistic and creative workshops, co-learning and striving for diverse voices, we co-produced relevant resources for a wider audience to improve conversations about PD dementia.

Religious participation is associated with fewer dementia diagnoses among Black people in the United States

INTRODUCTION

Black people had the highest prevalence of Alzheimer's disease and related dementias (ADRD) of any racial/ethnic group in the United States (US) as of 2020. As racial disparities in the prevalence of ADRD are being investigated, more evidence is necessary to determine the pathways and mechanisms that either slow ADRD progression or improve quality of life for those affected. Religion/spirituality (R/S) has been shown to affect health outcomes but has rarely been studied as a possible pathway for reducing ADRD risk. Crucially, Black people also report higher levels of R/S than other racial/ethnic groups in the United States. This research asks if R/S affects ADRD risk among Black adults and if any effects persist after controlling for hypertension.

METHODS

We conducted a secondary data analysis drawing from the Health and Retirement Study (HRS), a nationally representative longitudinal dataset with an oversampling of Black adults.

RESULTS

We used logistic regression analysis to demonstrate how R/S has an ameliorating impact on ADRD risk among Black people, even after controlling for hypertension. Those who never attended religious services had 2.37 higher odds of being diagnosed with ADRD than those who attended more than once a week. Further, as R/S attendance increased, ADRD risk decreased linearly.

CONCLUSION

These findings demonstrate the importance that existing cultural networks (e.g., R/S) can have for reducing ADRD burden for Black people and has important implications for the role of R/S in shaping ADRD symptomatology.

Subjective cognitive complaints in White and African American older adults: associations with demographic, mood, cognitive, and neuroimaging features

Subjective cognitive complaints (SCC) in cognitively intact older adults have been investigated as a clinically important symptom that may portend the onset of a neurodegenerative disorder such as Alzheimer's disease. Few studies have concurrently incorporated demographic features, depressive symptoms, neuropsychological status, and neuroimaging correlates of SCC and evaluated whether these differ in White and African American older adults. In the current study, 131 (77 White, 54 African American) healthy participants ≥50 years old completed the Cognitive Function Instrument (CFI) to assess SCC, and they underwent objective cognitive testing, assessment of mood, and brain magnetic resonance imaging. Pearson Product Moment correlations were performed to evaluate associations of the CFI self-ratings with the above measures for the combined group and separately for White and African American participants. SCC were associated with greater depressive symptoms in both White and African American participants in adjusted models controlling for overall cognitive status, education, and hypertension. Greater white matter hyperintensities, lower cortical thickness, older age, and slower set shifting speed were associated with increased SCC in White participants. Although the correlations were not significant for African Americans, the strength of the associations were comparable to White participants. Hippocampal volume was not associated with either total SCC or items specific to memory functioning in the entire group. Longitudinal studies are needed to further evaluate the clinical significance of these associations with risk of conversion to mild cognitive impairment and dementia.

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.

Promotors and barriers to the implementation and adoption of assistive technology and telecare for people with dementia and their caregivers: a systematic review of the literature

BACKGROUND

One of the most pressing issues in our society is the provision of proper care and treatment for the growing global health challenge of ageing. Assistive Technology and Telecare (ATT) is a key component in facilitation of safer, longer, and independent living for people with dementia (PwD) and has the potential to extend valuable care and support for caregivers globally. The objective of this study was to identify promotors and barriers to implementation and adoption of ATT for PwD and their informal (family and friends) and formal (healthcare professionals) caregivers.

METHODS

Five databases Medline (Ovid), CINAHL, Web of Science, APA PsycINFO and EMBASE were searched. PRISMA guidelines have been used to guide all processes and results. Retrieved studies were qualitative, mixed-method and quantitative, screened using Rayyan and overall quality assessed using Critical Appraisal Skills Programme (CASP) and Mixed Methods Assessment Tool (MMAT). Certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria and assigned within categories of high, moderate, or low. NVivo was used for synthesis and analysis of article content. A narrative synthesis combines the study findings.

RESULTS

Thirty studies (7 quantitative, 19 qualitative and 4 mixed methods) met the inclusion criteria. Identified primary promotors for the implementation and adoption of ATT were: personalized training and co-designed solutions, safety for the PwD, involvement of all relevant stakeholders, ease of use and support, and cultural relevance. Main barriers for the implementation and adoption of ATT included: unintended adverse consequences, timing and disease progress, technology anxiety, system failures, digital divide, and lack of access to or knowledge of available ATT.

CONCLUSION

The most crucial elements for the adoption of ATT in the future will be a focus on co-design, improved involvement of relevant stakeholders, and the adaptability (tailoring related to context) of ATT solutions over time (disease process).

Knowledge of dementia and dementia care in a cross-sectional sample of individuals living in rural and urban areas in KwaZulu-Natal, South Africa

Knowledge of dementia is considered one of the facilitators of dementia risk reduction because it has been linked to early detection, diagnosis, and help-seeking in people with dementia. This study explored knowledge of dementia symptoms, causes, and care in a community sample of individuals living in rural and urban areas in KwaZulu-Natal, South Africa. A cross-sectional household study of 300 participants, ⩾ 18 years old, using semi-structured individual interviews was conducted. Of the 300 participants, 94% recognised the presence of the cognitive decline symptoms, and 12.4% identified the symptoms as dementia. Participants emphasised biological and medical risk factors over socio-cultural factors. Although the participants primarily adopted a biomedical understanding of dementia, with a small number acknowledging a traditional understanding, they preferred a multi-disciplinary approach to care. Participants advocated for a multidisciplinary care approach that included medical, family, social work, mental health services, and spiritual and traditional care for people with dementia and their families. Therefore, policy and care services for African people with dementia and their families need to holistically integrate multiple care approaches. This will maximise the benefit of public health interventions while also building capacity in our understaffed and burdened healthcare systems.

The meaning and experience of hope by people living with dementia as expressed through poetry

Background

Narratives of dementia can undermine the ability of people to live well. Positive psychology, concerned with the cultivation of personal strengths, is a model through which people’s capacity to have positive experiences can be researched. This study explored the meanings and experiences of hope, a positive psychological construct found to facilitate well-being, in people with dementia.

Methods

People with dementia submitted poems about the meanings and their experiences of hope through an online platform. The submitted poems ( n = 29) underwent thematic analysis.

Findings

There were three main themes: (1) “ hope is light in the darkness” encapsulated the meaning ascribed to hope as a resource that spotlights what is still possible, (2) “ poetry gives voice to experiences of hope” captured the role of poetry in communicating the otherwise elusive concept of hope, and (3 )“peers uphold hope and cast away the darkness” captured that participants’ hope was blocked by stigmatising views held and expressed by others but facilitated through positive social interactions.

Conclusions

People are capable of having hope in the context of dementia, with hope being a uniquely functional strength that supports wellbeing. Health professionals, family and society have a clear role in supporting people with dementia to maintain their hope.

The Development and Validation of the Threat of Dementia Scale

Dementia represents a substantial threat to the self. However, to date, there is no reliable way to measure how threatened people feel by dementia. This article reports on two online studies. In Study 1, 248 participants rated statements about dementia according to their threat to well-being. In Study 2, 99 participants (all students at the University of the West of England) completed the emerging scale (the Threat of Dementia Scale or ToDS). We validated this by examining its associations with conceptually related measures, including the revised Fraboni Scale of Ageism and the Fear of Alzheimer's Disease Scale. Study 1 yielded 13 statements that were highly intercorrelated and comprised a single factor. In Study 2, the ToDS demonstrated good construct validity and acceptable test-retest reliability. Higher levels of distancing predicted lower scores on the ToDS. The ToDS is a reliable and valid instrument that is the first statistically validated method of examining the extent to which dementia threatens well-being.

Experience of UK Latin Americans caring for a relative living with dementia: A qualitative study of family carers

INTRODUCTION

Most studies of the Latin American immigrant experience and care for relatives living with dementia have been in the United States (US). In the United Kingdom (UK), unlike the US, most Latin Americans are first generation immigrants and are a rapidly increasing population. Therefore, we aimed to explore the UK experiences of Latin Americans caring for a relative with dementia.

METHODS

We purposively recruited UK-based Latin American family carers of people with dementia ensuring maximum diversity. We conducted semi-structured qualitative interviews (in English or Spanish) with 11 family carers, stopping recruiting when we reached thematic saturation. We took an inductive thematic analytic approach.

FINDINGS

Four main themes were identified: (1) Family comes first, particularly older people, leading to an obligation to care; (2) dementia as an illness that is accepted and talked about, which is regarded as positive with close networks but not wider society; (3) difficult behaviours are not the responsibility of the person with dementia, who is often conceptualised as a child; and (4) caring expectations lead to incompatibility with formal services, and a reluctance to leave people with dementia alone.

CONCLUSIONS

Familial obligation is the driver for family carers and acceptance of the illness helped despite adversities. Openness to talk about dementia with close networks was distinctive and helpful, contrasting with wider society, where greater awareness of dementia is needed. Considering the person with dementia as a child did not seem to undermine personhood and enabled maintenance of compassion. The relative with dementia was a priority. There was a lack of culturally and linguistically appropriate services, thus restricting family carers' ability to fulfil other roles, such as parental.

Understanding help-seeking decisions in people with subjective cognitive decline: A systematic review of qualitative studies

OBJECTIVE

To synthesize the findings of qualitative research on help-seeking in people with subjective cognitive decline.

METHODS

Relevant qualitative studies were identified by searching the PubMed, CINAHL, Ovid Medline, PsycInfo, Embase, and Web of Science databases. Studies that investigated help-seeking behavior in older adults with subjective cognitive decline were retrieved. The systematic review was conducted in line with JBI methodology for systematic reviews of qualitative evidence.

RESULTS

11 studies were included and three themes related to the process of help-seeking for cognitive problems emerged. These themes included: detected changes, challenges in identifying the need for help and decision to seek professional help.

CONCLUSION

Making decisions to seek help for people with subjective cognitive decline is a multi-stage process. A better understanding of the complex psychological responses to subjective cognitive decline among older adults may help health care professionals to develop strategies to improve help-seeking in clinical practice.

Socio-Economic Disparities in Access to Diagnostic Neuroimaging Services in the United Kingdom: A Systematic Review

Socio-economic factors affecting health care can lead to delays in diagnosis of neurological conditions, consequentially affecting treatment and morbidity rates. This inequality in health care can leave patients from lower socio-economic backgrounds more vulnerable to a poorer quality of care from health care providers in the United Kingdom (U.K.). Aims: In this systematic review, we assess the impact of socio-economic status on the use of diagnostic neuroimaging in the U.K., measured by the timeliness, accessibility and appropriate use of computed tomography (CT), magnetic resonance imaging (MRI), ultrasonography, electroencephalography (EEG) and single-photon emission computed tomography (SPECT). We specifically evaluate the non-surgical use of neuroimaging techniques as this relies on the judgment of primary care-givers (e.g., doctors and radiologists), where health disparities are most common. This study includes the analysis of diagnostic imaging used for dementia, minor head injury, stroke, cancer, epilepsy, chronic inflammatory demyelinating polyneuropathy and Parkinson’s disease. With this study, we aim to assess the health inequalities at disease diagnosis. Methods: Using Medline (via Ovid), PubMed and Web of Science databases as sources of information, we critically appraise existing studies on neuroimaging use in the U.K. health care system, published between January 2010 and February 2021. Findings: A total of 18 studies were included in this research, revealing that there was an increase in patients of Black and Asian communities diagnosed with dementia and at an earlier age. There was little evidence to suggest that a lack of access to diagnostic imaging is associated with socio-economic status. However, there are data to suggest that people of a lower socio-economic background require more specialist services with diagnostic neuroimaging tools. In addition, there is evidence to suggest that diagnostic neuroimaging techniques could be utilised more effectively by health care workers to prevent unnecessary delays in diagnosis for patients in lower socio-economic areas.

Societal and equity challenges for Brain Health Services. A user manual for Brain Health Services-part 6 of 6

Brain Health Services are a novel approach to the personalized prevention of dementia. In this paper, we consider how such services can best reflect their social, cultural, and economic context and, in doing so, deliver fair and equitable access to risk reduction. We present specific areas of challenge associated with the social context for dementia prevention. The first concentrates on how Brain Health Services engage with the "at-risk" individual, recognizing the range of factors that shape an individual's risk of dementia and the efficacy of risk reduction measures. The second emphasizes the social context of Brain Health Services themselves and their ability to provide equitable access to risk reduction. We then elaborate proposals for meeting or mitigating these challenges. We suggest that considering these challenges will enable Brain Health Services to address two fundamental questions: the balance between an individualized "high-risk" and population focus for public health prevention and the ability of services to meet ethical standards of justice and health equity.

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.

Challenges for Diagnostic Clarity for Post-stroke Cognitive Impairment and Behavioural Issues in Middle-Income Countries: Case Studies From Malaysia

Following stroke, individuals require ongoing screening, diagnosis and monitoring for cognitive impairment. Services and policies around these vary widely between settings, and reports from many countries highlight persistent under-diagnosis of cognitive impairment in the months and years after stroke. Missed and delayed diagnosis of post-stroke cognitive impairment, including dementia, are important factors in shaping the experiences of people so affected and their family members, especially in low- and middle-income countries. Drawing upon ethnographic research conducted in Malaysia, this article draws upon three case studies to examine the continued health-seeking behaviour after the appearance of salient cognitive and behavioural symptoms that occurred after stroke. Findings highlight the challenges in getting formal diagnostic clarity for cognitive and behavioural symptoms in a rural setting within a middle-income country. No study participants sought help for memory or cognitive problems, partly due to limited lay awareness of cognitive impairment but more significantly due to health service factors. Despite their elevated risk for dementia, participants were not monitored for cognitive impairment during any follow-up care in various health facilities. Furthermore, caregivers' attempts to seek help when behavioural issues became untenable were met with multiple health system barriers. The journey was complicated by the meanings attached to the reactions towards cognitive symptoms at the community level. We suggest that strategies seek to increase the awareness of post-stroke cognitive and behavioural symptoms, and incorporate clear treatment pathways into the long-term care plans of community-dwelling stroke survivors.

The use of Twitter by people with young-onset dementia: A qualitative analysis of narratives and identity formation in the age of social media

A diagnosis of dementia in midlife can be challenging, causing losses or changes in a person’s identity. Narrative provides a means of reconstructing identity and can be communicated on social media. There has been initial evidence on the value of Twitter for people with dementia, but researchers have not yet directly engaged with users’ perspectives. We employed a narrative model of identity to examine why people with dementia use Twitter and what challenges they face. Interviews were conducted with 11 younger people with dementia and analysed thematically. Participants used Twitter to counter a loss of identity through community membership and by regaining a sense of purpose. They sought to redefine dementia identities by challenging stigma and campaigning for social change. The character limit of tweets facilitated narrative through which participants preserved their identities. These findings suggest that Twitter could be an important source of post-diagnostic support for people with young-onset dementia. However, there are some risks as Twitter was sometimes a hostile environment for individuals who did not present in a ‘typical’ manner, or faced technical difficulties because of their symptoms. In the future, platform developers could work with people with dementia to make Twitter more accessible for this group.

Unpacking the Complexity of Migrated Older Adults' Lives in the UK through an Intersectional Lens: A Qualitative Systematic Review

BACKGROUND AND OBJECTIVES

The intersection of population ageing and international migration increases the ethnic and cultural diversity of the UK's older population, which has significant implications for health and care services and requires social inclusion and equal access to welfare. This review aimed to explore the complexity of migrated older adults' lives and analyse how their multiple identity markers interweave and affect their lived experiences.

RESEARCH DESIGN AND METHODS

This review is a qualitative systematic review. Intersectionality was applied as a theoretical scaffold to inform the qualitative thematic synthesis of the data.

RESULTS

A total of 29 studies in the period 2000-2020 were included. Three themes- language barriers, racism and discrimination, negotiating cultural influences, were identified as common challenges faced by migrated older adults. However, the degree of these challenges and the resources to buffer their effects vary dramatically given the significant differences in older migrated adults' gender, socio-economic status (SES), cultural backgrounds and migration pathways.

DISCUSSION AND IMPLICATIONS

Rather than focusing on any single factor, it is required to consider the intersection of age, race, ethnicity, gender, SES, and migration status when understand and address inequality not only between migrated older adults and native older adults, among different migrated older adult groups but also within any certain group. This review calls for the acknowledgment and awareness of policymakers, care and service practitioners and academics on the heterogeneity of migrated older adults.

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.

Health Inequities in the Care Pathways for People Living with Young- and Late-Onset Dementia: From Pre-COVID-19 to Early Pandemic

Background: Little is known about how people with dementia and/or their family carers access health and social care services after a diagnosis. The aim of this study was to explore potential inequalities in care pathways for people with young-onset and late on-set dementia (YOD/LOD), including their family carers, with coronavirus disease 2019 (COVID-19) occurring throughout the course of the study and enabling a comparison between pre-pandemic and COVID-19 times. Methods: People with YOD and LOD with their family carers were recruited via local support groups in the North West Coast region of England. Semi-structured interviews explored the experiences of people with YOD and LOD and family carers on their access to both health and social care services and community-based services. Transcripts were coded by two researchers and analysed using thematic analysis. Fifteen interviews were conducted with seven people with YOD or LOD and 14 family carers between January and March 2020. Some interviews were conducted only with the person with dementia, because they did not have a family carer, and others were conducted only with the family carer, because the person with dementia was in the severe stages of the condition. Results: Four themes emerged from the interviews: (1) Getting the ball rolling: the process of diagnosis; (2) Balancing the support needs of people with dementia and carers; (3) Barriers to accessing support; and (4) Facilitators to accessing support. Inequities existed for both YOD and LOD, with emerging evidence of unequal experiences in accessing care at the beginning of the COVID-19 pandemic. Discussion: People with YOD and LOD and their carers require better support in accessing services after a diagnosis. Greater understanding of the pathways through which inequalities materialise are needed, especially those that might have been disrupted or exacerbated by the COVID-19 pandemic.

Taking the Test: A Qualitative Analysis of Cultural and Contextual Factors Impacting Neuropsychological Assessment of Xhosa-Speaking South Africans

Objective

There is an urgent need to make neuropsychological (NP) testing more acceptable, accessible, and culturally salient, particularly for culturally, educationally, and linguistically diverse individuals from countries who may have little-to-no experience with NP testing. In settings with limited resources such as South Africa, unique cultural and contextual factors (e.g., structural inequality, poverty) may impact the experience of NP evaluation. Research in this area is limited and requires further exploration. This qualitative study explores the role of cultural and contextual factors that may impact the experience of NP evaluation in a sample of Xhosa-speaking South African adults. Participant interviews explored the context from which individuals arrived at the NP assessment (e.g., quality of education, understanding of cognitive disorders), and their experience of completing NP tests.

Method

This qualitative study used data from semistructured interviews to conduct a thematic analysis exploring contextual factors and the experience of completing NP tests for the first time among Xhosa-speaking South African adults (N = 22). Results: Although no participants had prior experience with NP testing, most found testing procedures acceptable. Most participants, however, reported a limited understanding of the purpose of NP testing and cognitive problems. Additionally, some participants reported perceptions and attitudes that could affect test performance, such as misinterpreting standard testing procedures (e.g., no feedback from the examiner, being stopped mid-task) as indicative of poor performance.

Conclusions

This study provided much needed exploration into unique cultural factors that may impact the experience of NP assessment in South Africa, which could bias test performance and interpretation, and may aid the field of cross-cultural NP in better serving culturally and linguistically diverse populations. In these countries, neuropsychologists may need to actively evaluate participants’ understanding of NP testing to help foster optimal assessment conditions. They may also need to educate participants on possible causes of cognitive disorders.

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.

Differences in the Associations Between Memory Complaints and Depressive Symptoms Among Black and White Older Adults

OBJECTIVE

To test whether race (specifically Black or White) moderates the relationship between memory complaints and depressive symptoms in cognitively normal older adults, and if these relationships vary by memory complaint characteristics.

METHODS

Data from Black (n = 551) and White (n = 1,158) cognitively intact participants (Mage = 77.1, SD = 7.5; 76.6% female) in the Minority Aging Research Study and the Rush Memory and Aging Project were used. Participants completed annual clinical evaluations, including the Center for Epidemiologic Studies Depression scale and two memory complaint questions, over periods of up to 18 years. Ordinal mixed effects models were used to examine within-person relationships between memory complaints and depressive symptoms over time, as well as whether race moderated these associations.

RESULTS

Reports of greater memory change over time were associated with more depressive symptoms for both Black and White older adults. However, reports of greater frequency of memory problems were related to depressive symptoms for Black older adults only.

CONCLUSION

Findings suggest differential associations between memory complaints and depressive symptoms in cognitively normal Black and White older adults and call for future research to examine the influence of race and related factors on memory complaints and depressive symptoms.

Understanding public-stigma and self-stigma in the context of dementia: A systematic review of the global literature

Stigma negatively impact quality of life of people with dementia and their family members. Yet the literature in stigma and dementia remains scant. This article systematically reviews manifestations of and associated factors with public-stigma and self-stigma in the context of dementia. After searching and screening on the three major databases of PubMed, Embase, and psycINFO, 26 articles, including 17 quantitative papers and nine qualitative papers, were selected for synthesis. Results show consistently limited knowledge, as well as stereotype, prejudice, and discrimination of public toward people with dementia and their family caregivers. Demographic characteristics of general public were found to be associated with the level of their stigma against dementia. People with dementia and their family caregivers also perceived negative stereotype, prejudice, and discrimination from general public and healthcare professionals. They reported negative feelings of themselves and tended to delay help-seeking. Psychological factors rather than sociodemographic factors shaped self-stigma of people with dementia and their families. This systematic review highlights the need of future studies in both public-stigma and self-stigma in dementia research in different contexts and cultures, as well as the development of evidence-based and culturally competent interventions and mass media campaigns to reconstruct public perception of dementia.

Physical health monitoring in dementia and associations with ethnicity: a descriptive study using electronic health records

BACKGROUND

Good physical health monitoring can increase quality of life for people with dementia, but the monitoring may vary and ethnic inequalities may exist.

AIM

To investigate UK primary care routine physical health monitoring for people with dementia by: (a) ethnic groups, and (b) comorbidity status.

DESIGN & SETTING

A retrospective cohort study was undertaken using electronic primary care records in the UK.

METHOD

Physical health monitoring was compared in people with dementia from white, black, and Asian ethnic groups and compared those with ≥1 comorbidity versus no comorbidity, from 1 April 2015 to 31 March 2016. Using the Dementia : Good Care Planning framework and expert consensus, good care was defined as receiving, within 1 year: a dementia review; a blood pressure (BP) check (at least one); a GP consultation (at least one); a weight and/or body mass index (BMI) recording (at least one); and an influenza vaccination.

RESULTS

Of 20 821 people with dementia, 68% received a dementia review, 80% at least one BP recording, 97% at least one GP contact, 48% a weight and/or BMI recording, and 81% an influenza vaccination in 1 year. Compared with white people, black people were 23% less likely and Asian people 16% less likely to have weight recorded (adjusted incidence rate ratio [IRR] = 0.77, 95% confidence interval [CI] = 0.60 to 0.98/0.84, 0.71 to 1.00). People without comorbidities were less likely to have weight recorded (adjusted IRR = 0.74, 95% CI = 0.69 to 0.79) and BP monitored (adjusted IRR = 0.71, 95% CI = 0.68 to 0.75).

CONCLUSION

Ethnic group was not associated with differences in physical health monitoring, other than weight monitoring. Comorbidity status was associated with weight and BP monitoring. Physical health monitoring in dementia, in particular nutrition, requires improvement.

"In the Bengali Vocabulary, There Is No Such Word as Care Home": Caring Experiences of UK Bangladeshi and Indian Family Carers of People Living With Dementia at Home

BACKGROUND AND OBJECTIVES

We aimed to explore experiences of South Asian carers of people with dementia receiving health or social care in the United Kingdom, purposively recruited to encompass a range of migration, economic and cultural experiences. While previous work in this area has reported carers' understanding of, and attitudes to dementia, we explored how carers' cultural identities and values influenced their experiences, negotiation of the caring role and relationship with services.

RESEARCH DESIGN AND METHODS

We conducted semi-structured interviews with 10 Bangladeshi and Indian family carers of people living with dementia at home. We recruited participants from community settings in London and Bradford, UK. Interviews were audio recorded, transcribed and thematically analyzed.

RESULTS

We identified 4 themes: an expectation and duty to care, expectation and duty as a barrier to accessing formal care (family carer reluctance, care recipient reluctance, and service organization), culturally (in)sensitive care, and the importance of support from informal care networks.

DISCUSSION AND IMPLICATIONS

Interviewees described tensions between generations with different understandings of familial care obligations. Expectations to manage led to burden and guilt, and the cost of caring, in terms of lost employment and relationships was striking. Unlike in previous studies, interviewees wanted to engage and be supported by services, but were frequently offered care models they could not accept. There was a tension between a state-provided care system obliged to provide care when there are no alternatives, and family carers who feel a duty to always provide alternatives. Informal social networks often provided valued support.

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.

Racial and Ethnic Disparities in Serious Psychological Distress Among Those With Alzheimer's Disease and Related Dementias

BACKGROUND

Alzheimer's disease and related dementias (ADRD) is a growing public health challenge. Prior research suggests that non-Hispanic whites (whites), non-Hispanic African Americans (African Americans), and Hispanics have differing risks for ADRD.

OBJECTIVE

To examine the existence of serious psychological distress (SPD) among whites, African Americans, and Hispanics; to calculate the predicted probability of ADRD in whites, African Americans, and Hispanics, and to decompose the differences among ADRD populations, quantifying the burden of higher SPD among African Americans and Hispanics, compared to whites.

DATA AND METHOD

The authors use nationally representative data from the Medical Expenditure Panel Survey (2007-2015) to estimate the association between ADRD and race, ethnicity, and SPD. Using Blinder-Oaxaca decomposition analysis, the authors estimate to what extent higher SPD among Hispanics and African Americans was associated with higher ADRD rates compared to whites.

RESULTS

After controlling for individuals' demographic and socioeconomic characteristics and co-existing medical conditions, the presence of SPD was still significantly associated with a higher likelihood of having ADRD. The model predicted significantly higher likelihood of having ADRD among African Americans (7.1%) and Hispanics (5.7%) compared to whites (4.5%). Higher rates of having SPD among African Americans explained 15% of white-black difference and 40% of the white-Hispanic difference in ADRD rates, respectively.

DISCUSSION AND CONCLUSION

Our findings suggest a significant relationship between SPD and ADRD and that the burden of SPD was greater among African Americans and Hispanics with ADRD. Efficient screening using self-reported SPD, compared to simply using diagnoses codes of mental illness, may be more helpful to reduce racial and ethnic disparities in ADRD.

Differences in Psychotropic Drug Prescribing Between Ethnic Groups of People with Dementia in the United Kingdom

Purpose

To test hypotheses that minority ethnic people with dementia in the UK receive fewer anti-dementia drugs and more psychotropic and anticholinergic drugs associated with harms.

Patients and Methods

We analyzed UK primary care electronic health records from The Health Improvement Network (THIN) database (2014–2016), comparing psychotropic drug prescribing initiation and duration between people with dementia from White, Black, and Asian ethnic groups. We repeated analyses in people (aged 50+) without dementia, to explore whether any differences found reflected prescribing patterns in the general older population, or were specific to dementia.

Results

We included 53,718 people with and 1,648,889 people without dementia. Among people with dementia, compared to White ethnic groups, Asian people were less likely to be prescribed anti-dementia drugs when they were potentially indicated (adjusted prevalence rate ratio 0.86 (95% Confidence Interval 0.76–0.98)), and received them for on average 15 days/year less. Compared to White groups, Asian and Black individuals with dementia were no more likely to take an antipsychotic drug, but those that had were prescribed them for 17 and 27 days/year more, respectively (190.8 (179.6–199.1) and 200.7 (191.1–206.5) days). Black people were less likely to be prescribed anxiolytics/hypnotics (0.60 (0.44–0.8)), but the duration these drugs were prescribed was similar across ethnic groups. Asian people were more likely to be prescribed anticholinergic drugs (1.43 (1.19–1.73)), in analyses unadjusted for cardiovascular comorbidities. Among people without dementia, those in the Asian and Black ethnic groups were less likely to be prescribed psychotropic drugs, relative to people from White groups.

Conclusion

Among people with dementia, Asian groups received less potentially beneficial symptomatic treatments, and Asian and Black groups were prescribed antipsychotic drugs for longer than White ethnic groups. Our findings may indicate care inequalities.

Perspectives of African American Older Adults on Brain Health: "Brains Get Tired Too"

BACKGROUND

Statistics suggest that African Americans have a disproportionately high prevalence of Alzheimer disease (AD), yet are less likely to enroll in AD clinical trials than white individuals. Although research has previously identified various barriers to participation, relatively little is known about how to overcome these barriers and engage African American individuals in AD research. The purpose of this study is to better understand how African Americans conceptualize brain health and their ability to influence healthy brain aging.

METHODS

Three African American community advocates each facilitated a small group of African American participants over 8 to 10 sessions of a photovoice process involving discussion and sharing of images focused on brain health. Sessions were audiotaped and transcribed verbatim and photographs were uploaded.

FINDINGS

Participants recognized a diversity of what brain health can mean and indicated an interconnectedness between brain health and its influences. Key factors that were identified by group members as key to brain health included lifestyle factors, activity, and engagement and nature, resiliency, and positivity.

DISCUSSION

These emic insights into perceptions of brain health may represent important foci for targeted messaging strategies to promote brain health and research engagement within the African American population.

Barriers in providing primary care for immigrant patients with dementia: GPs' perspectives

Background

Dementia rates are growing rapidly in all regions of the world. In the Netherlands, the incidence of dementia among older immigrants will increase twice as fast compared with the native older population. It, therefore, needs special attention.

Aim

To describe the barriers for providing primary care to immigrant patients (Turkish, Moroccan and Surinamese) with dementia from the perspectives of GPs.

Design & setting

A mixed-method study, consisting of an online survey and focus groups.

Method

An online survey was performed among 76 GPs working in the four biggest cities of the Netherlands. The barriers to providing primary care for immigrants with dementia were identified. Subsequently, three focus groups were carried out among 17 primary care physicians to discuss this topic further, and identify possible solutions and recommendations to improve dementia care.

Results

GPs experience many obstacles in the care for the immigrant patient with dementia, namely in the diagnostic process, early detection, and assessment of care needs. Strong collaboration between primary care, community care organisations, specialised memory clinics, and municipalities is needed to optimise healthcare information provision, the availability of culturally sensitive facilities, and the enhancement of healthcare professionals' training and education.

Conclusion

Important barriers were identified and recommendations were formulated for future healthcare policy. To be prepared and guarantee optimal care for the rising number of immigrant patients with dementia, recommendations should be implemented and effectiveness should be evaluated as soon as possible.

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.

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.

What does the general public understand about prevention and treatment of dementia? A systematic review of population-based surveys

Objectives

To synthesise results of population surveys assessing knowledge and attitudes about prevention and treatment of dementia.

Methods

MEDLINE, EMBASE, PsycINFO, and grey literature were searched for English language entries published between 2012 and May 2017. Survey questions were grouped using an inductive approach and responses were pooled.

Results

Thirty-four eligible studies and four grey literature items were identified. Surveys were conducted in Europe, the US, Eastern Asia, Israel, and Australia. Nearly half of respondents agreed that dementia is a normal and non-preventable part of ageing, but belief in the potential for prevention may be improving over time. The role of cardiovascular risk factors was poorly understood overall. Less than half of respondents reported belief in the availability of a cure for dementia. The value of seeking treatment was highly endorsed.

Conclusions

Results suggest that knowledge about the potential for dementia prevention and treatment remains poor but may be improving over time. Knowledge among those living in low- and middle-income countries are largely unknown, presenting challenges for the development of National action plans consistent with World Health Organization directives.