The Effects and Meanings of Receiving a Diagnosis of Mild Cognitive Impairment or Alzheimer's Disease When One Lives Alone

"How do You Take that Much Time for One Person's Life?" Experiences of Dementia Caregivers Who are Not Immediate Family

One in three people with Alzheimer's or other dementias lives alone, without a spouse/partner or nearby children (i.e., is aging solo), yet most dementia caregiving research has focused solely on spouses or children. This study examined the experiences of friends, neighbors, siblings, and others providing unpaid care for someone with dementia. We conducted semi-structured interviews with 14 caregivers (100% female; age 54-85, mean 71; 93% white, 7% black; 29% friend, 29% sibling or in-law, 21% neighbor, 21% church congregant). Participants balanced three priorities: the person living with dementia's quality of life, the person's safety and well-being, and the caregiver's resources. Caregivers described tensions when these priorities conflicted, such as the person with dementia's goal to live alone versus risks to their physical safety. These findings and future research can inform policies and programs to support non-family dementia caregiving.

Proactive Care-Seeking Strategies Among Adults Aging Solo With Early Dementia: A Qualitative Study

OBJECTIVES

People living with dementia need increasing care over time, but 1 in 3 adults with cognitive impairment lives alone. The goal of this study was to explore the self-identified strengths and resources for future care needs of adults aging solo with early dementia.

METHODS

Semistructured interviews with 15 adults not living with a partner and with no children in the same state, who self-identified as having early dementia or mild cognitive impairment; hybrid inductive/deductive reflexive thematic analysis using a successful aging framework.

RESULTS

Participants placed a high value on maintaining independence and expressed concerns about preserving selfhood and becoming a burden to others. These values influenced how participants appraised financial and social resources available to address future care needs and strategies to preempt or respond to needs such as transportation, help with finances, or activities of daily living.

DISCUSSION

Adults without close family are heterogeneous and have variable resources available to address care needs associated with dementia progression. Common values of retaining independence and minimizing burden to others may be helpful in motivating adults aging solo to undertake planning and help-seeking early.

Exploring the lived experience: impact of dementia diagnosis on individuals with cognitive impairment - a qualitative study

OBJECTIVE

Although knowledge about the experience of being diagnosed with dementia is limited, with the expected rise in dementia's prevalence in the coming decades, such knowledge is pivotal for the people diagnosed, their families, and healthcare planners. Thus, the aim of our study was to explore the experience of living with cognitive impairment and dementia and the impact of being diagnosed with dementia.

METHOD

A qualitative design was applied. Participants were recruited based on age-adjusted values below ​​threshold values on the Montreal Cognitive Assessment Scale (i.e. 70-79 years, < 22; 80-89 years, < 21; 90 + years, < 20), and the sample ultimately included 15 participants: six with and nine without a documented dementia diagnosis. Qualitative content analysis was performed on the transcribed interviews in four steps to identify codes, categories, and the overall theme.

RESULTS

Three major categories emerged from the interviews: (1) experiences with changes, (2) experiences with being diagnosed with dementia, and (3) existential experience. All participants with and most participants without a dementia diagnosis experienced changes in cognition.

CONCLUSION

Our findings imply that being diagnosed with dementia is a relief because it explains observed cognitive and functional decreases and reduces confusion, shame and stigma. However, it also raises concerns about an unknown future. Most participants not diagnosed with dementia reported having little or no difficulty with everyday living and leading a fulfilling life. Those findings emphasise the significance of timely versus early diagnosis.

Perceptions of the Role of Living Alone in Providing Services to Patients With Cognitive Impairment

Importance

The potential role of living alone in either facilitating or hampering access to and use of services for older adults with cognitive impairment is largely unknown. Specifically, it is critical to understand directly from health care and social services professionals how living alone creates barriers to the access and use of supportive health care and social services for racially and ethnically diverse patients with cognitive impairment.

Objective

To identify the potential role of living alone in the access and use of health care and social services for diverse patients with cognitive impairment by investigating professionals' perceptions of caring for such patients who live alone in comparison with counterparts living with others.

Design, Setting, and Participants

This qualitative study of 76 clinicians, social workers, and other professionals used semistructured interviews conducted between February 8, 2021, and June 8, 2022, with purposively sampled professionals providing services to diverse patients with cognitive impairment in Michigan, California, and Texas.

Main Outcomes and Measures

Clinicians, social workers, and other professionals compared serving patients with cognitive impairment and living alone vs counterparts living with others. An inductive content analysis was used to analyze the interview transcripts.

Results

A total of 76 professionals were interviewed (mean [SD] age, 49.3 [12.7] years); 59 were female (77.6%), 8 were Black or African American (11%), and 35 were White (46%). Participants included physicians, nurses, social workers, and home-care aides, for a total of 20 professions. Participants elucidated specific factors that made serving older adults living alone with cognitive impairment more challenging than serving counterparts living with others (eg, lacking an advocate, incomplete medical history, requiring difficult interventions), as well as factors associated with increased concerns when caring for older adults living alone with cognitive impairment, such as isolation and a crisis-dominated health care system. Participants also identified reasons for systematic unmet needs of older adults living alone with cognitive impairment for essential health care and social services, including policies limiting access and use to public home-care aides.

Conclusions and Relevance

In this qualitative study of professionals' perspectives, findings suggest that living alone is a social determinant of health among patients with cognitive impairment owing to substantial barriers in access to services. Results raised considerable concerns about safety because the US health care system is not well equipped to address the unique needs of older adults living alone with cognitive impairment.

'Redeemed' or 'isolated': A systematic review of the experiences of older adults receiving a mild cognitive impairment diagnosis

BACKGROUND

Understanding the experiences of older adults living with MCI can benefit healthcare professionals in diagnosing and implementing early interventions to delay cognitive decline.

OBJECTIVE

To assess and synthesize qualitative research exploring the experience of older adults diagnosed with MCI.

METHODS

PubMed, Embase, CINAHL, Web of Science, and PsycINFO databases were searched. Studies involving the experience of being diagnosed with MCI in older adults were included. Thomas and Harden's methodology of synthesizing qualitative studies was used.

RESULTS

Eleven studies were included. Three themes were identified: perceived reality of the MCI diagnosis; emotional and psychological responses to the MCI label; coping engaged in parallel processing. Older adults had confusing perspectives on the MCI diagnosis, leading to complicated and diverse emotional reactions and coping measures.

CONCLUSIONS

The relationship between perspectives, emotional reactions, and coping methods might be the key for healthcare professionals to break through the early diagnosis and intervention of MCI.

A synthesis of qualitative studies on patient and caregiver experiences with cognitive impairment screening and diagnosis

OBJECTIVES

To understand patient and caregiver perspectives on the experience of being screened or diagnosed with cognitive impairment to inform preventive clinical care.

METHODS

Systematic review and synthesis of qualitative studies with searches in Ovid MEDLINE ALL, EBSCOHost CINAHL, and Scopus in February 2021. Included studies were assessed for quality and coded with descriptive, deductive, and inductive codes and findings were rated using GRADE-CER-qual.

RESULTS

We included 15 qualitative studies representing 153 patients and 179 caregivers. Most studies involved in-depth interviews. No studies examined screening experiences for older adults presenting without cognitive function concerns; nearly all patients received a diagnosis of cognitive impairment. Seven themes emerged with moderate to high confidence. Findings showed the role of caregivers in pursuing assessment and its benefits in validating concerns and for future planning. Patients were less inclined to be evaluated, fearing judgements or social consequences from the diagnostic label. Caregivers and patients were at times frustrated with the assessment process yet believed it might result in treatments to cure or slow disease progression.

CONCLUSION

Clinicians and care systems can support caregivers and patients by providing timely and informative resources to support their shared and separate motivations, needs, and concerns.

The Living Alone with Cognitive Impairment Project's Policy Advisory Group on Long-Term Services and Supports: Setting a Research Equity Agenda

(1) Background: A United States national policy advisory group (PAG) was convened to identify barriers and facilitators to expand formal long-term services and support (LTSS) for people living alone with cognitive impairment (PLACI), with a focus on equitable access among diverse older adults. The PAG's insights will inform the research activities of the Living Alone with Cognitive Impairment Project, which is aimed at ensuring the equitable treatment of PLACI. (2) Methods: The PAG identified barriers and facilitators of providing effective and culturally relevant LTSS to PLACI via one-on-one meetings with researchers, followed by professionally facilitated discussions among themselves. (3) Results: The PAG identified three factors that were relevant to providing effective and culturally relevant LTSS to PLACI: (i) better characterization of PLACI, (ii) leveraging the diagnosis of cognitive impairment, and (iii) expanding and enhancing services. For each factor, the PAG identified barriers and facilitators, as well as directions for future research. (4) Conclusions: The barriers and facilitators the PAG identified inform an equity research agenda that will help inform policy change.

Patient Perspectives about Mild Cognitive Impairment: A Systematic Review

OBJECTIVES

Mild cognitive impairment (MCI) is a concept that is steeped in controversy not limited to prognostic uncertainty; it is unclear how patients interpret or attribute meaning to the label, and whether they perceive that being made aware is beneficial.

METHODS

A systematic review was conducted, searching ISI Web of Science, PubMed and PsycINFO in accordance with PRISMA guidelines. Search terms were developed to include articles concerning perceptions regarding MCI and experiences and impact of being informed. Thematic synthesis was applied to the findings.

RESULTS

Fourteen papers met criteria. Three themes emerged regarding the MCI label: 1) Individual differences relating to living circumstances, personal perceptions and experiences, and coping style affect how patients adjust to the MCI label; 2) Patients' reactions to the MCI label and their perceptions about how useful it was to receive are affected by the nebulous nature of the construct and information available regarding MCI; 3) Care partners are uncertain about what MCI means and how to address and cope with the patient's cognitive difficulties.

CONCLUSIONS

Patient and care partner perspectives were affected by the quality of information and support provided, possibly influenced by clinicians' understanding of the concept. Personal perceptions and experiences, living circumstance and coping styles also shaped experiences of being informed.

CLINICAL IMPLICATIONS

Clinicians should develop their understanding of MCI to deliver clear information to patients and consider the necessity of applying the label. Offering support tailored to patients' specific needs may improve perceptions about the label's utility, whilst aiding coping and adjustment.

Challenge of a dual burden in rapidly aging Delaware: Comorbid chronic conditions and subjective cognitive decline

BACKGROUND

Epidemiologic trends forecast a "dual burden"- increase in both physical chronic diseases and Alzheimer's disease (AD)- for Delaware. Estimating the burden and characteristics of this "dual burden" is critical. Cognizant of the unavailability of precise models to measure AD, SCD-a population-based measure- was used as an alternative. The primary objective was to delineate selected chronic conditions among Delaware adults with SCD in order to present: (i) prevalence of SCD by select sociodemographic characteristics, (ii) compare the prevalence of chronic conditions among people with and without SCD, and (iii) compare the prevalence of SCD associated functional limitations in Delawareans with and without comorbid chronic conditions.

METHODS

Combined data (2016 and 2020) for Delaware were obtained from the Behavioral Risk Factor Surveillance System. Analyses included 4,897 respondents aged 45 years or older who answered the SCD screening question as "yes" (n = 430) or "no" (n = 4,467). Descriptive statistics examined sociodemographic characteristics and chronic conditions in Delawareans with and without SCD.

RESULTS

Overall, 8.4% (CI: 7.4-9.5) of Delaware adults reported SCD. Delawareans with SCD were more likely to be in the younger age group (45-54 years), less educated, low income and living alone. Over 68 percent had not discussed cognitive decline with a health care professional. More than three in four Delawareans with SCD had a 1.5 times higher prevalence of having any one of the nine select chronic conditions as compared to those without SCD. Adults with SCD and at least one comorbid chronic condition were more likely to report SCD-related functional limitations.

CONCLUSIONS

Delaware cannot afford to postpone public policies to address the dual burden of SCD and chronic conditions. Results from this study can help public health stakeholders in Delaware to be informed and prepared for the challenges associated with cognitive decline and comorbidity.

The Effect of Receiving a Diagnosis of Alzheimer's Disease and Related Dementias on Social Relationships of Older Adults

INTRODUCTION

Although early diagnosis has been recognized as a key strategy to improve outcomes of Alzheimer's disease and related dementias (ADRD), the effect of receiving a diagnosis on patients' well-being is not well understood. This study addresses this gap by examining if receiving a dementia diagnosis influences social relationships.

METHODS

Data from the 3 waves (2012, 2014, and 2016) of the Health and Retirement Study were utilized as part of this study. This study examined whether receiving a new diagnosis of ADRD changed subsequent social relationships (social networks, social engagement, and social support). Regression analyses with inverse probability weighting were performed to estimate the impact of receiving a dementia diagnosis on changes in social relationships.

RESULTS

Receiving a new diagnosis of ADRD reduced both informal and formal social engagement. We found no statistically significant impacts of receiving a diagnosis of ADRD on social networks and social support.

CONCLUSIONS

Results suggest that receiving a new diagnosis of ADRD may have unintended impacts on social relationships. Practitioners and policymakers should be aware of these consequences and should identify strategies to alleviate the negative impact of receiving a diagnosis of ADRD and methods to mobilize support networks after receiving a diagnosis.

Examining the Validity of the Financial Exploitation Vulnerability Scale

Objectives: Objectives: Lichtenberg, Campbell, Hall, and Gross used a contextual framework for financial decision-making to create and provide evidence for a new scale to assess risk for financial exploitation, the Financial Exploitation Vulnerability Scale (FEVS). This study examined the criterion validity of self-reported memory complaints and living alone on FEVS risk scores.Methods: Participants were the first 258 individuals reporting as 60 years or older and who completed the FEVS on the https://olderadultnestegg.com website between December 2020 and February 2021. Correlations, multiple regression, analysis of variance, and chi-square analyses were conducted to compare groups based on risk scores.Results: FEVS risk scores were significantly correlated with years of education, self-reported memory complaints, and living alone; 18% of unique variance was accounted for by these measures in a regression analysis. The ANOVA indicated that while there was an interaction effect for memory complaints by living alone, the majority of variance accounted for was attributed to the self-reported memory complaints measure. Conclusions: Older adults with memory complaints are in need of perceived financial vulnerability assessment.Clinical Implications: The Financial Exploitation Vulnerability Scale is a valuable self-report tool that clinical gerontologists can use in their intake assessments and follow-ups.

Do perceptions of cognitive changes matter in self-management behaviors among persons with mild cognitive impairment?

BACKGROUND AND OBJECTIVES

This secondary analysis examined 1) the association between illness perceptions (perceived understanding and cause of mild cognitive impairment [MCI]) and self-management behaviors for cognitive health, and 2) whether sociodemographic and clinical factors moderate such relationships among persons with MCI.

RESEARCH DESIGN AND METHODS

We conducted a cross-sectional study of 85 participants using baseline data from the Return of Amyloid Imaging Scan Results (RAISR) Study. The coherence and causality subscales of the Revised Illness Perceptions Questionnaires were used. Self-management behaviors (dietary changes, physical activity, mental activities, dietary supplements) were assessed using the Risk Evaluation and Education for ALzheimer's disease health behavior measure. Sociodemographic and clinical information was extracted from patients' medical records. We performed hierarchical linear regression and binary logistic regression.

RESULTS

We found no main effects for illness perceptions and self-management of cognitive health. Interaction effects were detected, including: 1) coherence and age on the total number of self-management behaviors (b = 0.01, p = 0.04) and on physical activity (p = 0.04, OR = 1.02, 95% CI = [1.00, 1.03]), 2) causality and age on dietary supplements (p = 0.03, OR = 1.31, 95% CI = [1.02, 1.67]), and 3) causality and education on mental activities (p = 0.02, OR = 0.44, 95% CI = [0.22, 0.88]).

IMPLICATION AND DISCUSSIONS

Findings suggest that age and education moderate the relationship between illness perceptions and self-management behaviors. Healthcare professionals should consider subjective perceptions about MCI in light of sociodemographic and clinical factors when discussing cognitive health self-management.

SARS-CoV-2 Susceptibility and COVID-19 Mortality Among Older Adults With Cognitive Impairment: Cross-Sectional Analysis From Hospital Records in a Diverse US Metropolitan Area

Introduction: Persistent knowledge gaps exist as to the extent that preexisting cognitive impairment is a risk factor for susceptibility to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and mortality from the coronavirus disease 2019 (COVID-19). Methods: We conducted a cross-sectional analysis of adults tested for SARS-CoV-2 at a tertiary healthcare system. Cognitive impairment was identified utilizing diagnosis codes (mild cognitive impairment, Alzheimer's disease, vascular, and other dementias) or cognitive impairment-specific medication use. Propensity score (PS) matched analyses were utilized to report odds ratios (OR) and 95% confidence intervals (CI) for association of cognitive impairment with SARS-CoV-2 susceptibility and COVID-19 mortality. Results: Between March-3rd and December-11th, 2020, 179,979 adults were tested, of whom 21,607 (12.0%) tested positive. We identified 6,364 individuals with preexisting cognitive impairment (mean age: 78.5 years, 56.8% females), among whom 843 (13.2%) tested positive and 139 (19.5%) of those hospitalized died. In the pre-PS matched cohort, cognitive impairment was significantly associated with increased SARS-CoV-2 susceptibility (OR, CI: 1.12, 1.04-1.21) and COVID-19 mortality (OR, CI: 2.54, 2.07-3.12). One-to-one matches were identified for 6,192 of 6,364 (97.3%) individuals with prior cognitive impairment and 687 of 712 (96.5%) hospitalized patients with prior cognitive impairment. In the fully balanced post-matched cohort, preexisting cognitive impairment was significantly associated with higher likelihood of SARS-CoV-2 infection (OR, CI: 1.51, 1.35-1.70); however, cognitive impairment did not confer higher risk of COVID-19 mortality (OR, CI: 0.96, 0.73-1.25). Discussion: To mitigate the effects of healthcare catastrophes such as the COVID-19 pandemic, strategies for targeted prevention and risk-stratified comorbidity management are warranted among the vulnerable sub-population living with cognitive impairment.

Racial and ethnic disparities in subjective cognitive decline: a closer look, United States, 2015-2018

BACKGROUND

Subjective cognitive decline (SCD), characterized by self-experience of deterioration in cognitive performance may be a precursor to Alzheimer's disease (AD). Given the association of AD with dependence and disability for a long duration, earlier the detection, the sooner people and their families can receive information regarding better management. It is critical to explore disparities amongst racial and ethnic populations with SCD in order to facilitate targeted interventions. The primary objective was to identify disparities in prevalence of SCD amongst Whites, Blacks and Hispanics by select sociodemographic characteristics and functional limitations in a U.S. population-based sample of non-institutionalized adults aged 45 and older. The secondary objective was to assess the association between SCD and select chronic conditions (angina, heart attack, stroke, diabetes, high blood pressure and high cholesterol) by race/ethnicity.

METHODS

Combined data (2015-2018) were obtained from the Behavioral Risk Factor Surveillance System (BRFSS) to conduct a population -based study. Analyses included 179,852 respondents aged 45 years or older who answered the SCD screening question as "yes" (n = 19,276) or "no" (n = 160,576). Descriptive statistics examined sociodemographic characteristics including functional limitations amongst racial/ethnic groups with SCD. Association of SCD with chronic conditions by race/ethnicity was also calculated.

RESULTS

Overall, 10.8% (CI: 10.6-11.1) of adults aged 45 years or older reported SCD.10.7% Whites, 12.3% Blacks and 9.9% Hispanics experienced SCD. Blacks and Hispanics with SCD were more likely to be in the younger age group (45-54 years), less educated, low income, without access to health care, living alone and with functional limitations. Only half had discussed cognitive decline with a health care professional. Prevalence of selected chronic conditions was significantly higher in all racial/ethnic groups with SCD.

CONCLUSIONS

Demographic trends predict a larger proportion of Hispanics and Blacks with SCD in the coming years. This information can lead to identification of opportunities for addressing negative SCD outcomes in minorities affected by inequitable conditions.

Stroke and Heart Attack Symptom Recognition in Older US Adults by Cognitive Impairment Status

INTRODUCTION

Cognitive impairment may make stroke and heart attack symptom recognition difficult, potentially resulting in treatment delays for those with these cardiovascular diseases (CVDs). Despite cognitive impairment affecting large numbers of older US adults who are also at increased risk of stroke and heart attack, little is known about stroke and heart attack symptom recognition in this population. As a result, this study sought to determine the impact of cognitive impairment on stroke and heart attack symptom recognition among older US adults.

METHODS

Using the 2014 and 2017 National Health Interview Surveys, we compared stroke and heart attack symptom recognition levels in US adults aged ≥65 years with cognitive impairment and those without cognitive impairment. Estimates of stroke and heart attack symptom recognition adjusted for CVD-related factors were assessed by cognitive impairment status. We also conducted analyses stratified by living arrangement and stroke and heart attack history for individuals with and without cognitive impairment.

RESULTS

US adults aged ≥65 years with cognitive impairment were observed to be 3.0-6.7% and 1.6-4.9%, respectively, less likely to recognize an individual stroke and heart attack symptom than similarly aged individuals without cognitive impairment. Recognition of all 5 stroke/heart attack symptoms was also lower among those with cognitive impairment, with this group being 9.7% less likely to recognize all stroke symptoms and 6.7% less likely to recognize all 5 heart attack symptoms compared to people without cognitive impairment. Following adjustment, individuals with cognitive impairment continued to have slightly lower recognition of certain individual stroke and heart attack symptoms as well as of all 5 symptoms of these conditions (stroke OR: 0.70 [95% CI: 0.58-0.85]; heart attack OR: 0.88 [95% CI: 0.75, 1.03]) than those without cognitive impairment. For individuals with cognitive impairment, living with others was linked with slightly better recognition of all individual stroke symptoms and heart attack history with better recognition of all individual heart attack symptoms.

CONCLUSIONS

Additional work is needed to address the challenge of improving recognition levels for specific stroke and heart attack symptoms in older US adults with cognitive impairment and especially for members of this group who live alone.

Aging in Place with Age-Related Cognitive Changes: The Impact of Caregiving Support and Finances

In the United States, aging in place is a common concept that refers to older adults’ desire to remain in their homes as they age. However, this ability to age in place is a complex process that is not only impacted by the home’s accessibility or individual functional abilities. This paper aims to examine different factors, such as home environment and home modification, caregivers, finances, and other supports present in the participants’ lives, that impact older adults with age-related cognitive changes (ARCC) (in)ability to age in place. Qualitative interviews with older adults with ARCC (n = 5) and their caregivers (n = 5) were conducted. The participants’ experiences while aging in place indicate that finances and caregiving support greatly impacted their lives at home and ability to age in place. Personal finances dictated where some of the participants could age and the support, they could afford from home health aides. Additionally, informal and formal caregivers were an important source of support that aided in the older adults’ ability to remain home. As researchers, we need to continue to address personal finances and the support that the individual has in their lives to most effectively promote aging in place and their life at home.

Detecting dementia among older, ethnically diverse residents of rural subsidized housing

Rural, ethnically diverse residents face at least twice the risk of Alzheimer's disease than urban residents. Chronic diseases such as diabetes and hypertension which increase dementia risk are more prevalent in rural areas with less access to specialty providers. A home-based approach for increasing dementia detection and treatment rates was tested among rural residents of government-assisted independent living facilities (N = 139; 78% non-White, and 70% with health literacy below 5th grade). Of 28 residents identified at risk during cognitive screening, 25 agreed to further in-depth assessment by adult gerontological nurse practitioners (AGNP). Fifteen of 25 (60%) completing consequent primary provider referrals were diagnosed with dementia and receiving new care (statistically significant; [χ2(1) = 76.67, p < .001, Phi = 0.743]). Home-based dementia management through a community engagement approach can help to meet the Healthy People 2030 goals of earlier detection and treatment and reduce the length of costly institutionalizations.

The Effects of the COVID-19 Pandemic on the Lived Experience of Diverse Older Adults Living Alone With Cognitive Impairment

BACKGROUND AND OBJECTIVES

Even before the COVID-19 pandemic, older adults with cognitive impairment living alone (an estimated 4.3 million individuals in the United States) were at high risk for negative health outcomes. There is an urgent need to learn how this population is managing during the pandemic.

RESEARCH DESIGN AND METHODS

This is a qualitative study of 24 adults aged 55 and older living alone with cognitive impairment from diverse racial/ethnic backgrounds. Participants' lived experiences during the pandemic were elicited via 59 ethnographic interviews conducted over the phone either in English, Spanish, or Cantonese. Using a qualitative content analysis approach, interview transcripts were analyzed to identify codes and themes.

RESULTS

Qualitative analysis of transcripts revealed 5 themes: (a) fear generated by the pandemic, (b) distress stemming from feeling extremely isolated, (c) belief in misinformation, (d) strategies for coping during the pandemic, and (e) the importance of access to essential services.

DISCUSSION AND IMPLICATIONS

This pandemic put a spotlight on the precarity and unmet needs of older adults living alone with cognitive impairment. Findings underscore the need to expand access to home care aides and mental health services for this population.

Ambivalent anticipation: How people with Alzheimer's disease value diagnosis in current and envisioned future practices

Emergent biomarkers for Alzheimer's disease (AD) are expected to provide earlier and more precise diagnoses. However, even if biomarkers live up to these expectations, it cannot be taken for granted that patients actually would value an earlier and more precise AD diagnosis. Based on an interview study, we aim to give more insight into the value of an AD diagnosis for patients, in existing as well as future practices, by describing how a diagnosis enables or may enable knowing, foreseeing, and acting in relation to one's illness. Our findings show that how people with AD value a diagnosis is not only characterised by great variety, as previous studies have shown, but also by profound ambivalence for the individual. With lack of treatment and poor prognostics as the status quo, this ambivalence and the way people deal with it are particularly linked to the far-from-straightforward capacity of an AD diagnosis to support anticipation of the future. We argue that in otherwise unchanged practices the envisioned future biomarker-based diagnostics are unlikely to reduce the ambivalence about receiving an AD diagnosis and, in particular, the challenges of anticipation that it entails. Rather, biomarker-based innovations may even reinforce some of the main issues involved.

Difficulty and help with activities of daily living among older adults living alone with cognitive impairment

INTRODUCTION

There is limited research on difficulties with activities of daily living (I/ADLs) among older adults living alone with cognitive impairment, including differences by race/ethnicity.

METHODS

For U.S. Health and Retirement Study (2000-2014) participants aged 55+ living alone with cognitive impairment (4,666 individuals; 9,091 observations), we evaluated I/ADL difficulty and help.

RESULTS

Among 4.3 million adults aged 55+ living alone with cognitive impairment, an estimated 46% reported an I/ADL difficulty; 72% reported not receiving help with an I/ADL. Women reported more difficulty than men. Compared to white women, black women were 22% more likely to report a difficulty without help, and Latina women were 36% more likely to report a difficulty with help. Among men, racial/ethnic differences in outcomes were not significant. Patterns of difficulty without help by race/ethnicity were similar among Medicaid beneficiaries.

DISCUSSION

Findings call for targeted efforts to support older adults living alone with cognitive impairment.

Expectations and Concerns of Older Adults With Cognitive Impairment About Their Relationship With Medical Providers: A Call for Therapeutic Alliances

We sought to understand the expectations and concerns of older adults with cognitive impairment with regard to their relationship with medical providers. In particular, we observed whether study participants were involved in therapeutic alliances. Medical providers and patients create therapeutic alliances when they agree on the goals of the treatment and share a personal bond. Whereas such alliances have been studied in cancer research, little is known about therapeutic alliances in dementia research. Data were gathered in a qualitative study of 27 older adults with cognitive impairment and analyzed with narrative analysis. We introduce four case studies that illustrate the effects of having or missing a therapeutic alliance. Whereas the participant in the first case benefited from a therapeutic alliance, the other cases are marked by different experiences of abandonment. Findings suggest that interventions should concentrate on ways to enhance the relationship between medical providers and patients with cognitive impairment.

Personalized Cognitive Stimulation through Personhood: A Case Report on Dementia Diagnosis Acceptance and Therapeutic Engagement

Objectives: Dementia related cognitive impairment, as forgetting recent memories, brings several emotional challenges to patients and their families. This paper reports a case of a non-collaborative high-education level patient. who recurrently refused a set of conventional cognitive stimulation exercises, as he also was in refusal of his cognitive impairment. The aim of this report is to show the benefits of a personalized cognitive stimulation (PCS) program.Methods: A24-sessions PCS program was conceived within a person-centered care approach and in active co-creation between the therapist and the patient.Results: The results evidence the patient's increasing therapeutic engagement in the proposed activities, along with mild cognitive improvement. This procedure also promoted a diagnosis acceptance and the patient's mood stabilization. Two illustrative materials used in this tailored intervention are available as supplemental material.Conclusions: Cognitive stimulating programs benefit from tailoring and personalization. Personalization indeed helped the patient feeling engaged and increased his participation in the activities. Furthermore, his mood stabilized, and the patient accepted his cognitive impairments. Thus, PCS is a way of reaching person-centered care.Clinical implications: PCS may be used to improve patient's engagement in the stimulating activities. Also, PCS promoted the dementia diagnosis acceptance..

Ethical Issues Raised by the Introduction of Artificial Companions to Older Adults with Cognitive Impairment: A Call for Interdisciplinary Collaborations

Due to the high costs of providing long-term care to older adults with cognitive impairment, artificial companions are increasingly considered as a cost-efficient way to provide support. Artificial companions can comfort, entertain, and inform, and even induce a sense of being in a close relationship. Sensors and algorithms are increasingly leading to applications that exude a life-like feel. We focus on a case study of an artificial companion for people with cognitive impairment. This companion is an avatar on an electronic tablet that is displayed as a dog or a cat. Whereas artificial intelligence guides most artificial companions, this application also relies on technicians "behind" the on-screen avatar, who via surveillance, interact with users. This case is notable because it particularly illustrates the tension between the endless opportunities offered by technology and the ethical issues stemming from limited regulations. Reviewing the case through the lens of biomedical ethics, concerns of deception, monitoring and tracking, as well as informed consent and social isolation are raised by the introduction of this technology to users with cognitive impairment. We provide a detailed description of the case, review the main ethical issues and present two theoretical frameworks, the "human-driven technology" platform and the emancipatory gerontology framework, to inform the design of future applications.

Walking the Tightrope between Study Participant Autonomy and Researcher Integrity: The Case Study of a Research Participant with Alzheimer's Disease Pursuing Euthanasia in Switzerland

This article addresses ethical issues in the conduct of ethnographic research with vulnerable study participants, such as individuals with cognitive impairment. Seven ethical issues emerged from this case study, in which a participant diagnosed with Alzheimer's disease wished to pursue euthanasia in Switzerland: (a) How to protect the participant's autonomy while ensuring his decision had not resulted from untreated depression or modifiable social factors; (b) How to interpret self-harm; (c) How to protect the research team members' "mandated reporter" status; (d) How to counteract the attractive qualities of pro-euthanasia videos depicting an easy end to personal suffering; (e) How to find a better alternative to the common practice of reporting self-harm cases to Adult Protective Services and then removing these cases from studies; (f) How to leverage a participant's trust to address these issues; and (g) Whether researchers should do anything further to help address unmet needs in similar situations.