Mild cognitive impairment: not much harm; not much help

Mild cognitive impairment (MCI) represents a liminal state between full cognitive health and dementia. The diagnosis is applied unevenly and cannot be accurately prognosticated, even with the use of biomarkers, and there is no established intervention to reduce risk of progression to dementia. Owing to the limited benefit and potential for iatrogenic harm associated with an MCI diagnosis, a better understanding of its psychosocial consequences is needed. In the linked paper, Munawar and colleagues provide cautious optimism; their patients were generally unharmed by an MCI diagnosis. However, the majority of patients and families either did not recall or did not fully understand the implications for future dementia risk. Only 20% made lifestyle changes, and the number receiving hearing aids was very low. These data demonstrate the poor return on using the clinic as the setting for improving 'brain health'. Initiatives to prevent dementia are more effectively and equitably applied at population level.

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.

The role of the memory service in helping carers to prepare for end of life: A mixed methods study

OBJECTIVES

The objective of the study is to explore current practice and the role taken by UK memory services in helping carers of people with dementia prepare for the end of life.

METHODS

We used mixed methods including a survey (48 responses/51% response rate) and semistructured interviews (n = 12) with clinicians working in UK memory services accredited by the Memory Services National Accreditation Programme. We used descriptive statistics to report survey findings and thematically analysed interview and survey qualitative data.

RESULTS

Surveys: services routinely discussed with carers the progressive nature of dementia (89%), legal arrangements (health: 72%; finances: 74%), advance care planning (63%), and implications of loss of capacity (61%). Fewer services routinely discussed the terminal nature of dementia (41%) and meaning of death (11%) with carers. Most (89%) agreed that these conversations were in line with their role. Interview findings corresponded with survey findings. Themes included diagnosis considered too early to discuss end of life, discussions being inconsistent with a "living well" approach, people with dementia being resistant to conversations, and discussions of spirituality crossing professional boundaries. Services' capacity for follow-up with carers impacted on ability to broach these topics.

CONCLUSIONS

More in-depth and distressing topics such as end of life and advance care planning require longer follow-up to establish relationships to broach difficult topics. Variability in follow-up practices between services created inequity in the extent to which memory services could address these topics. More research is required to investigate the best method for broaching these topics with carers and the person with mild dementia within different health care contexts.

Patients' and carers' experiences of UK memory services

OBJECTIVE

The objective of this study is to test the validity of an accreditation programme for memory services in the UK by investigating whether different levels of accreditation status (excellent compared with accredited) are reflected in patients' and carers' reported satisfaction.

METHOD

A comparison of survey data from patient and carer feedback questionnaires collected from services as part of the accreditation process.

RESULTS

Five hundred and eighty-three patient questionnaires and 663 carer questionnaires were returned from 41 services. Patients and carers who attended memory services which were later 'accredited as excellent', were more likely than those who had visited 'accredited' services to have: been given written information about a variety of topics; been asked for feedback about using the memory service; and had found it easier to get to their appointments. Carers attending services accredited as excellent were more likely to have been offered an assessment of their needs.

CONCLUSION

Patients and carers had very good experiences of memory services overall whether they had standard or excellent accreditation. However, 'excellent' services were consistently better on a number of factors. This provides further support that the accreditation process is an important indicator of the quality of memory services.

A narrative review of evidence for the provision of memory services

BACKGROUND

One common finding in analyses of health systems with respect to dementia is that there is a "diagnosis gap" in dementia with less than a half of those with dementia ever attracting a diagnosis of dementia. The service response to this has been to develop memory clinics and other services to enable good quality diagnosis of the syndrome of dementia and its sub-types.

METHODS

This narrative review considers who memory assessment services are for and what they should aim to achieve. We will consider the evidence base and discuss "what good looks like."

RESULTS

The sparsity of the evidence base for the provision of memory services is striking. There is a lack of studies that have evaluated the absolute and relative impact of different models of diagnostic services or the impact of diagnosis and stage of illness at diagnosis.

CONCLUSIONS

There remains genuine uncertainly about: the positive and negative impacts of receiving the diagnosis of dementia; the effects of receiving the diagnosis of dementia at an earlier or later stage; and how best to provide memory assessment services in terms of clinical and cost-effectiveness. We need applied health research designed to fill these important evidence gaps, resolving uncertainty, and allowing the development and delivery of efficient and effective services and policy to enable people to live well with dementia. The methodology that will be needed will be a challenge since, due to ethical and practical considerations, it is likely to have to be observational rather than experimental.

Negotiating a labyrinth: experiences of assessment and diagnostic journey in cognitive impairment and dementia

OBJECTIVES

There has been a global push towards the earlier diagnosis of dementia, but there is little understanding of the transitions along the assessment and diagnostic pathway from the perspective of people affected by memory problems, cognitive impairment and early dementia. This study explores the experience of the assessment and diagnostic pathway for people with cognitive impairment and their family carers.

METHODS

Qualitative interviews with 27 people with cognitive impairment and 26 carers (20 dyads) using four memory services before and after diagnosis disclosure were conducted. Interview transcripts were subject to constant comparative analysis and interpretations subject to discussion at regular 'analysis clinics'.

RESULTS

Twelve sub-themes were identified along four points on the assessment journey. Feelings of confusion, uncertainty and anxiety over interminable waiting times dominated. Participants often felt without support to manage their uncertainties, emotions and did not know where to turn for support. Some were highly critical of the systemic process of assessment and diagnosis disclosure but were generally positive of the practice of individual professionals.

CONCLUSIONS

Service providers should review the process of assessment and diagnosis disclosure for people with cognitive impairment and their carers. They should develop a process that is person centred and accommodates the individualised preferences. The development of service systems to provide continuous relevant information and clarity to service users needs to involve all stakeholders, including people with cognitive impairment and their carers.

Memory clinics in context

The growing number of older people in all parts of the world raises the question of how best to respond to their health needs, including those associated with memory impairment. Specialist Memory Clinics have a role to play, complementing community services which reach out to older people with mental health problems and encompassing younger people who become forgetful. Dementia is the most common syndrome seen, but there are other important treatable conditions which present with subjective or objective dysmnesia. Memory Clinics provide a high quality, devoted focus for early intervention, treatment, support and research.