Undiagnosed dementia in primary care: a record linkage study

Background

The number of people living with dementia is greater than the number with a diagnosis of dementia recorded in primary care. This suggests that a significant number are living with dementia that is undiagnosed. Little is known about this group and there is little quantitative evidence regarding the consequences of diagnosis for people with dementia.

Objectives

The aims of this study were to (1) describe the population meeting the criteria for dementia but without diagnosis, (2) identify predictors of being diagnosed and (3) estimate the effect of diagnosis on mortality, move to residential care, social participation and well-being.

Design

A record linkage study of a subsample of participants (n = 598) from the Cognitive Function and Ageing Study II (CFAS II) (n = 7796), an existing cohort study of the population of England aged ≥ 65 years, with standardised validated assessment of dementia and consent to access medical records.

Data sources

Data on dementia diagnoses from each participant’s primary care record and covariate and outcome data from CFAS II.

Setting

A population-representative cohort of people aged ≥ 65 years from three regions of England between 2008 and 2011.

Participants

A total of 598 CFAS II participants, which included all those with dementia who consented to medical record linkage (n = 449) and a stratified sample without dementia (n = 149).

Main outcome measures

The main outcome was presence of a diagnosis of dementia in each participant’s primary care record at the time of their CFAS II assessment(s). Other outcomes were date of death, cognitive performance scores, move to residential care, hospital stays and social participation.

Results

Among people with dementia, the proportion with a diagnosis in primary care was 34% in 2008–11 and 44% in 2011–13. In both periods, a further 21% had a record of a concern or a referral but no diagnosis. The likelihood of having a recorded diagnosis increased with severity of impairment in memory and orientation, but not with other cognitive impairment. In multivariable analysis, those aged ≥ 90 years and those aged < 70 years were less likely to be diagnosed than other age groups; those living with a spouse (odds ratio 2.38, 95% confidence interval 1.04 to 5.41) were more likely to be diagnosed than people living alone. The median time to diagnosis from first meeting the criteria for dementia was 3 years. Diagnosis did not affect survival or the probability of a move to residential care.

Limitations

People with moderate to severe dementia at baseline could not consent to record linkage. The small numbers in some groups limited power to detect effects.

Conclusions

The lack of relationship between severity of non-memory impairment and diagnosis may reflect low awareness of other symptoms of dementia. There remains little objective evidence for benefits of diagnosis for people with dementia.

Future work

Potential benefits of diagnosis can be realised only if effective interventions are accessible to patients and carers. Future work should focus on improving support for people living with cognitive impairment.

Study registration

National Institute for Health Research Clinical Research Network Central Portfolio Management System (CPMS 30655).

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 20. See the NIHR Journals Library website for further project information.

Reciprocal relationships and the importance of feedback in patient and public involvement: A mixed methods study

Background

Reciprocal relationships between researchers and patient and public involvement (PPI) contributors can enable successful PPI in research. However, research and anecdotal evidence suggest that researchers do not commonly provide feedback to PPI contributors thus preventing them from knowing whether, how or where their contributions were useful to researchers and research overall.

Aims

The aim of this study was to explore the variation, types, importance of, and satisfaction with feedback given by researchers to PPI contributors in six PPI groups in England, and identify the barriers to the process of feedback.

Methods

An explanatory mixed methods sequential study design with a questionnaire survey followed by semi‐structured interviews with researchers and PPI contributors in six PPI groups. PPI contributors were involved in all stages of the research process.

Results

Researchers do not routinely give feedback to PPI contributors. Feedback was found to have different meanings: an acknowledgement, impact and study success and progress. PPI contributors who receive feedback are motivated for further involvement; it supports their learning and development and prompts researchers to reflect on PPI impact. The importance of the role of a PPI lead or coordinator to facilitate the process of providing feedback was also highlighted.

Conclusion

This study found no generic way to give feedback indicating that mutual feedback expectations should be discussed at the outset. PPI feedback needs to become integral to the research process with appropriate time and resources allocated. PPI feedback can be seen as a key indicator of mature, embedded PPI in research.

Correction to: Abstracts from the NIHR INVOLVE Conference 2017

[This corrects the article DOI: 10.1186/s40900-017-0075-x.].

Regional working in the East of England: using the UK National Standards for Public Involvement

PLAIN ENGLISH SUMMARY

Involving patients and members of the public to help shape and carry out research is recommended in health research in the United Kingdom (UK). There are a number of regional networks of Patient and Public Involvement (PPI) groups, which support the collaboration between researchers, patients and public members. We are a group of researchers, patients and public members who came together via a PPI regional network in the East of England to collaborate on a research study about the extent of feedback from researchers to PPI contributors.The aim of this paper is to use the recently developed UK National Standards for Public Involvement to structure our thinking about what worked well and what did not, within our recently completed study. We believe this paper is one of the first to use the National Standards to structure a retrospective reflection on PPI within a study.Our findings showed that there are benefits of regional working, including easier access to public members and bringing together researchers, public members and those who run PPI groups for research collaboration. The main challenges included involvement of people before studies are funded and working across organisations with different payment processes.The National Standards for Public Involvement has provided a useful framework to consider how best to involve patients and members of the public in research and could be a helpful structure to reflect on successes and challenges in individual projects and also regional, national or international comparisons of PPI in research.

ABSTRACT

Background Regional networks of Patient and Public Involvement (PPI) organisations, including academic institutions, health and social care services, charities, patient and public groups and individuals, can play an important part in carrying out health research. In the UK, recommendations by the National Institute of Health Research (NIHR) encourage the use of regional, collaborative networks with shared resources and training. Methods The newly developed UK National Standards for Public Involvement were used as a framework for a retrospective reflection of PPI within a recently completed research study which focused on feedback from researchers to PPI contributors. PPI contributors, those running PPI groups (PPI leads) and researchers involved in the study have contributed to this reflection by completing evaluation forms throughout the research alongside notes of meetings and co-authors' final reflections. Results Results revealed a number of successes where the regional network was particularly useful in bringing together PPI contributors, those who lead PPI groups and researchers. The regional network helped researchers to get in touch with patients and members of the public. Challenges included involving people before funding and bureaucratic and financial barriers when working across different organisations in the region. The importance of working together in flexible, informal ways was key and on-going support for the PPI contributors was vital for continued involvement, including emotional support not just monetary. The first four National Standards of inclusive opportunities, working together, support and learning and communications were particularly useful as means of structuring our reflections. Conclusions To our knowledge, this is one of the first research studies to use the UK National Standards for Public Involvement as a framework to identify what worked well and the challenges of PPI processes. It is suggested that as more reflective papers are published and the National Standards are more widely used in the UK, many lessons can be learnt and shared on how to improve our Patient and Public Involvement within research studies. Evaluations or reflections such as these can further enhance our understanding of PPI with implications for regional, national and international comparisons.

Supporting shared decision-making for older people with multiple health and social care needs: a protocol for a realist synthesis to inform integrated care models

INTRODUCTION

Including the patient or user perspective is a central organising principle of integrated care. Moreover, there is increasing recognition of the importance of strengthening relationships among patients, carers and practitioners, particularly for individuals receiving substantial health and care support, such as those with long-term or multiple conditions. The overall aims of this synthesis are to provide a context-relevant understanding of how models to facilitate shared decision-making (SDM) might work for older people with multiple health and care needs, and how they might be applied to integrated care models.

METHODS AND ANALYSIS

The synthesis draws on the principles of realist inquiry, to explain how, in what contexts and for whom, interventions that aim to strengthen SDM among older patients, carers and practitioners are effective. We will use an iterative, stakeholder-driven, three-phase approach. Phase 1: development of programme theory/theories that will be tested through a first scoping of the literature and consultation with key stakeholder groups; phase 2: systematic searches of the evidence to test and develop the theories identified in phase 1; phase 3: validation of programme theory/theories with a purposive sample of participants from phase 1. The synthesis will draw on prevailing theories such as candidacy, self-efficacy, personalisation and coproduction.

ETHICS AND DISSEMINATION

Ethics approval for the stakeholder interviews was obtained from the University of Hertfordshire ECDA (Ethics Committee with Delegated Authority), reference number HSK/SF/UH/02387. The propositions arising from this review will be used to develop recommendations about how to tailor SDM interventions to older people with complex health and social care needs in an integrated care setting.

Late deterioration after decompression illness affecting the spinal cord

A former amateur diver presented with a progressive paraparesis. Thirteen years previously he had developed acute spinal cord dysfunction immediately after dry hyperbaric exposure. He had completely recovered motor function in the intervening period. No alternative reason for the later decline emerged from detailed investigation.

Spinal cord compression due to metastatic spread from a primary carcinoid tumour of the thymus

We reported a patient with spinal cord compression due to the metastatic spread of a primary carcinoid tumour of the thymus to bone. Prompt surgical decompression with local radiotherapy led to good functional recovery and survival at 2 years without further recurrence.

Dietary modification of Parkinson's disease

To investigate the efficacy of a low-protein diet suitable for long-term use, and to observe the effect in a double-blind manner of re-introducing large neutral amino acids or an inactive placebo amino acid, eight patients with 'on-off' phenomenon were given a low-protein diet suitable for long-term use, and then the diet was supplemented with large neutral amino acids (LNAA) or placebo in a double-blind crossover trial. Five patients had improved Parkinsonian disability on a low-protein diet compared to normal diet. On supplementing the diet with LNAA or placebo, three subjects' Parkinson's disease was significantly better on placebo and there was a trend towards improvement on placebo noticed subjectively by seven patients; however, there was no overall significant difference in disability measured by mobility diaries. Thus, we have been unable to show that the improvement on a low-protein diet is due to a reduction in LNAA, rather than a placebo effect, possibly due to the paucity of subjects; however, the patients' identification of the LNAA supplement suggests that it is a genuine effect.

Severe ocular side effects of perhexilene maleate: case report

We report a case of perhexilene maleate (PEXID) toxicity in which the presenting feature was loss of vision secondary to chronic papilloedema. Vortex keratopathy similar to that seen in amiodarone keratopathy was present, and corneal and conjunctival biopsy findings are presented. To our knowledge this is the first case report of a keratopathy occurring in perhexilene toxicity. After withdrawal of the drug the papilloedema and keratopathy subsided, but some visual deficit remains. The properties of perhexilene maleate and other amphiphilic drugs are described, and the possible aetiology of vortex keratopathy is discussed.

Controlled trial of plasma exchange in acute inflammatory polyradiculoneuropathy

A randomised controlled trial of exchange versus no exchange was conducted to find out whether plasma exchange would be useful in acute inflammatory polyradiculoneuropathy. It was calculated that 15 patients would be required in each group to demonstrate a worthwhile improvement in functional ability 1 month after completion of treatment. Treatment comprised five exchanges in 10 days (55 ml plasma/kg body weight/exchange). Both groups received normal supportive care and were followed up periodically for a year. Overall the treated group showed a slight but not significant benefit (p greater than 0.05); at two weeks' follow-up of patients admitted to the trial within 14 days of onset of neuropathic symptoms, p = 0.07. These results do not provide grounds for recommending plasma exchange for the treatment of severe AIP.

Neurosyphilis in the Leicester area

Twenty patients with neurosyphilis are reviewed. They were gathered over a 15-year period during which the overall incidence was 0.18 per 100,000, though fewer cases appeared in the latter half of the study. The commonest presentation was with mental symptoms and classical forms of neurosyphilis were rarely seen. No patient presented with epilepsy. There is a case for the more selective use of serological testing.

Autoantibody to nerve tissue in a patient with a peripheral neuropathy and an IgG paraprotein

The antibody activity of a benign IgG lambda paraprotein to nerve tissue in a case of peripheral neuropathy has been investigated using immunohistochemical methods on tyrpsin-treated, formalin-fixed, paraffin-embedded tissue. IgG lambda was found in th sural nerve biopsy of the patient. Specific binding of the purified IgG lambda paraprotein and its isolated F(ab')2 fragment to homologous nerve and brain tissue was demonstrated. Similar activity was not demonstrable on fresh frozen cryostat sections. The results suggest that tests for autoantibodies to nerve tissue in neuropathological disorders should not be confined to fresh frozen tissue substrates.

The place of peripheral neurectomy in the management of trigeminal neuralgia

One hundred and forty-six patients with trigeminal neuralgia were studied. Of 49 patients ultimately maintained pain-free by non-medical means, 26 underwent peripheral neurectomy. Twenty of these achieved excellent pain control in the longer term and 5 of the remaining 6 became more responsive to carbamazepine after operation. Seven patients required repeat neurectomies. Peripheral neurectomy is a useful and simple method of pain control in trigeminal neuralgia.

A comparison of flight of colours with visually evoked responses in patients with multiple sclerosis

The flight of colours test was performed in a series of patients with multiple sclerosis. Visually evoked responses were then measured in the same patients. The two tests were found to be comparable in their ability to detect disturbance in the visual system.

The use of choline chloride in ataxic disorders

Fourteen patients with a variety of ataxic disorders were given choline chloride, double blind for six weeks, in an attempt to improve gait and manual dexterity. One patient withdrew before receiving the active drug, twelve patients showed no functional improvement, but one achieved greater mobility; his response, which was dose dependent, ceased when choline was stopped and was reproducible.

Diencephalic epilepsy in a patient with agenesis of the corpus callosum confirmed by computerised axial tomography

A case of diencephalic epilepsy is described in whom stereotyped attacks of spontaneous hypothermia and diaphoresis occurred over a 20 year period. No abnormality of the hypothalamo-pituitary-adrenal axis was found, and there was no evidence of an intracranial mass lesion. Pneumoencephalography and computerised axial tomography (EMI scan) demonstrated agenesis of the corpus callosum.

Neurosurgery in the older patient

The outcome of brain and spinal surgery has been assessed in 141 patients who were over the age of 65 at the time of operation. Patients tolerated investigation and surgery remarkably well and good results were obtained for benign lesions. Survival times and the contribution of surgery to reducing disability in malignant disease were disappointing.

Treatment of paroxysmal disorders in multiple sclerosis with carbamazepine (Tegretol)

During an eight year period, 32 patients with definite or suspected multiple sclerosis (MS) were seen with paroxysmal neurological disturbances, which included tonic seizures, paroxysmal dysarthria, paraesthesiae and pain in the limbs, as well as trigeminal neuralgia. In 21 of these patients the paroxysmal disorders were treated with carbamazepine, and in six the effect was compared with placebo. In the majority carbamazepine was effective in controlling the paroxysmal symptoms. Side-effects were troublesome in a few patients, but they could usually tolerate small doses, which still gave relief. Although the patho-physiological basis for these paroxysmal disorders remains unexplained, their response to carbamazepine suggests a common mechanism.

Primary neurogenic orthostatic hypotension

Eight further cases of neurogenic orthostatic hypotension are described together with a necropsy study on one case. Three cases showed evidence of autonomic dysfunction in isolation, while in five cases this was accompanied by evidence of more diffuse central nervous system degeneration. (Parkinsonism, cerebellar ataxia, dementia, pyramidal signs, bulbar weakness, and muscular wasting were all seen in varying proportions.)The various clinical presentations, investigations, pathology, treatment, and prognosis are discussed. In the experience of the authors, when assessed, an abnormal Valsalva response is invariable, confirming the breakdown of the circulatory reflex. A normal vasopressor response is likewise invariable, eliminating an abnormality of blood vessels themselves, and confirming the lesion as neurogenic. The demonstration of loss of sweating to indirect body heating, which also is usual suggests that the defect is central or on the efferent side of the reflex and a normal pilo-erector response to acetylcholine confirms this as preganglionic. Emphasis is laid on the non-specificity of many accepted physiological tests in this disorder and on the delay in diagnosis consequent upon the variable presentation.