Relationship between speaking English as a second language and agitation in people with dementia living in care homes: Results from the MARQUE (Managing Agitation and Raising Quality of life) English national care home survey

OBJECTIVE

As not speaking English as a first language may lead to increased difficulties in communication with staff and other residents, we (1) tested our primary hypotheses that care home residents with dementia speaking English as a second language experience more agitation and overall neuropsychiatric symptoms, and (2) explored qualitatively how staff consider that residents' language, ethnicity, and culture might impact on how they manage agitation.

METHODS

We interviewed staff, residents with dementia, and their family carers from 86 care homes (2014-2015) about resident's neuropsychiatric symptoms, agitation, life quality, and dementia severity. We qualitatively interviewed 25 staff.

RESULTS

Seventy-one out of 1420 (5%) of care home residents with dementia interviewed spoke English as a second language. After controlling for dementia severity, age, and sex, and accounting for care home and staff proxy clustering, speaking English as a second language compared with as a first language was associated with significantly higher Cohen-Mansfield Agitation Inventory (adjusted difference in means 8.3, 95% confidence interval 4.1 to 12.5) and Neuropsychiatric inventory scores (4.1, 0.65 to 7.5). Staff narratives described how linguistic and culturally isolating being in a care home where no residents or staff share your culture or language could be for people with dementia, and how this sometimes caused or worsened agitation.

CONCLUSIONS

Considering a person with dementia's need to be understood when selecting a care home and developing technology resources to enable dementia-friendly translation services could be important strategies for reducing distress of people with dementia from minority ethnic groups who live in care homes.

Accessibility of health and social services to immigrant elders: the Islington Study

BACKGROUND

Numbers of immigrant elders are increasing and it is unclear whether they can access services.

AIMS

To examine service utilisation of older immigrants compared with their UK-born counterparts and relate it to health difficulties. Method Cross-sectional study in inner London measuring service use, mental health and disability.

RESULTS

A total of 1085 people aged > or = 65 years were interviewed. Independent predictors of contact with a general practitioner included being born in Cyprus. Cypriots were the only immigrant population to report significantly more somatic symptoms than those born in the UK (P=0.005). Africans and Caribbeans used day care and other social services most frequently.

CONCLUSIONS

Immigrants could access services. Africans and Caribbeans appear to have poorer physical health and thus have greater contact with services. Cypriots who experience depression may present with prominent somatic symptoms. This is likely to be due to a different idiom of distress.

Validation and normative data of health status measures in older people: the Islington study

BACKGROUND

Health related quality of life scales have been developed to measure a global picture of health and well-being from the patient's perspective. Separate validation of these measures in older people is important, as different areas of life are prioritized as important in older people and population norms for health status measures can differ with age.

OBJECTIVES

The aims of this paper were to examine the validity and acceptability of two health status measures the 12-item Health Status Questionnaire (HSQ-12) and 12-item Short Form Health Survey SF-12, and to present population norms in older people.

SETTING

A door-to-door survey in Islington, a borough of inner London.

SUBJECTS AND METHODS

The subjects were allocated to complete either the SF-12 (n = 541) or the HSQ-12 (n = 544) by alternating the questionnaires with each household visited. The first 135 people who completed the HSQ-12 were visited approximately 18 months later. Acceptability was measured examining the completion rate of the scales, and on a three-point scale. The short-CARE was used to elicit psychiatric symptoms and diagnoses. We collected data on health and social care, and subjective health problems.

RESULTS

Both scales distinguished between subjects with and without a variety of health states, including self-defined health problems, health problems diagnosed by valid scales, problems with vision and hearing, and receipt of health or social services. The HSQ-12, but not the SF-12, could distinguish between people with and without dementia, and had high completion rates for those living in the community but not in 24-hour care. Linear regression models demonstrated sensitivity to change in health status for the HSQ-12.

CONCLUSION

The SF-12 and HSQ-12 are acceptable and valid as health status instruments in large community-based studies of older people. The HSQ-12, but not the SF-12, is acceptable and valid for people with dementia.

Mental health of migrant elders--the Islington study

BACKGROUND

In the UK, 6% of those aged 65 years and over were born abroad, most of whom now live in inner-city areas. It has been suggested that ethnic elders are particularly vulnerable to mental illness.

AIMS

To compare the prevalence of dementia and depression in older migrants with those born in the UK.

METHOD

A cross-sectional community study of 1085 people aged 65 years or older in an inner-London borough.

RESULTS

Compared with those born in the UK, the prevalence of dementia was raised in African-Caribbeans (17.3%, relative risk=1.72, Cl=1.06-2.81) and lower for the Irish-born (3.6%, relative risk=0.36, Cl=0.17-0.87). All those of African-Caribbean country of birth were significantly younger (P=0.000) but no more likely to be taking antihypertensive drugs. They were no more likely to report having cardiovascular problems but had increased rates of diabetes (P<0.0000). The overall prevalence of depression was 18.3% (95% Cl=16.1-20.7). The highest prevalence rate was found among those born in Greece and Turkey (27.2%, Cl=17.9-39.6). Migration per se does not appear to be a risk for depression and dementia in this population.

CONCLUSIONS

The excess of dementia may be of vascular aetiology. There is the potential for primary or secondary prevention.

Persecutory symptoms and perceptual disturbance in a community sample of older people: the Islington study

BACKGROUND

While there are extensive studies of paranoid symptoms and perceptual disturbance (PPD) in younger adults, relatively little is known about older adults with similar symptoms.

METHOD

This study took place in Islington, an inner London borough. Enumeration Districts were randomised to provide a sampling frame. Residents aged 65 or over were interviewed at home. The Short-CARE was used to elicit psychiatric symptoms and diagnosis. Sociodemographic particulars were elicited using the Client Sociodemographic and Service Receipt Inventory. Questions were asked regarding sight and hearing. We used subsections of the geriatric mental scale to identify people who had PPD symptoms. Medications taken were recorded. We asked 'Do you have any health problems?' as a screening question for subjective health problems.

RESULTS

We interviewed 720 people. Twenty-eight (3.9%) participants scored positively on the PPD sub-scales of the GMS. A forward logistic regression analysis for independent predictors of PPD found the significant independent predictors were dementia (p = 0.0000; odds ratio 6.8), drinking alcohol in last 6 months (p < 0.03; odds ratio 0.3), drinking alcohol to help sleep (p < 0.005; odds ratio 9.6), subjective memory loss (p < 0.007; odds ratio 3.3) and uncorrected visual impairment (p < 0.02; odds ratio 2.8).

CONCLUSION

There is a relatively high prevalence of PPD in older people living in the community. This is not associated with higher use of services despite the increased needs. Further studies should consider interventions to meet this unmet need.

Drug treatment of older people with affective disorders in the community: lessons from an attempted clinical trial

BACKGROUND

Depression and phobic anxiety disorders are the most common psychiatric disorders in people aged 65 and over. SSRI antidepressants are effective in treating both conditions in younger people, and in treating depression in hospital samples of older subjects. No studies have investigated the efficacy of SSRIs in older people with these conditions living in the community.

OBJECTIVES

To evaluate the efficacy and feasibility of treating older people suffering from depression and/or phobic anxiety in the community with fluoxetine alone.

DESIGN

Subjects identified as depressed and/or anxious at screening were offered open-label fluoxetine and were reassessed for affective illness at 3 and 6 months.

MEASURES

Outcome was assessed using the depression subscale of the Short Comprehensive Assessment and Referral Evaluation (Short-CARE) Scale and the Anxiety Disorder Scale.

RESULTS

Of 67 subjects with depression and/or phobic anxiety, 55 (81%) were eligible to take fluoxetine. Fifty-four (98%) of these agreed to follow-up but only six (11%) agreed to take medication. No subject was still taking medication by the end of the study. Among those subjects on whom follow-up data were available, 70% of subjects depressed at screening and 97% of those with phobic anxiety retained their diagnoses at 3 months; at 6 months, the figures were 65% and 92% respectively.

CONCLUSIONS

Drug treatment alone is not acceptable to older patients in the community with depression and phobic anxiety disorders. Discussion of symptoms with an appropriate professional is insufficient therapy on its own. Further work is needed to evaluate the effectiveness of a key worker such as a mental health nurse in coordinating treatment of patients with these disorders.

Do health and use of services differ in residents of sheltered accommodation? A pilot study

OBJECTIVE

To compare the rates of mental health problems, disability and use of health and social services of older people living in sheltered accommodation with those of the rest of the community in the same age group.

DESIGN

Door-to-door survey in randomly selected enumeration districts. The districts contained three sheltered accommodation complexes. Residents from these addresses were compared with the others.

SETTING

London Borough of Islington.

SUBJECTS

700 men and women aged 65 or over.

MAIN OUTCOME MEASURES

Short-CARE depression, dementia and activity scales; the Guy's/Age Concern anxiety scale; individual items detailing problems with mobility, vision and hearing; use of a number of health and social services.

RESULTS

The only difference in mental health variables on univariate analysis was a greater severity of cognitive impairment and dementia symptoms in sheltered accommodation. When demographic differences were taken into account, the association with cognitive impairment became statistically insignificant. There were significant associations between residence in sheltered accommodation and several of the disability variables. Increased use of health and social services by sheltered residents remained significant after disability and living alone were taken into account.

CONCLUSIONS

The residents of sheltered accommodation were more disabled than the general elderly population but, in contrast to those in residential care, did not have a great excess of mental health problems. Indeed, the possibility was raised that sheltered accommodation may protect against depression in people who live alone.

The symptomatology of depression in the elderly

Older people may have a different pattern of depressive symptoms to that found earlier in life, in particular having more somatic symptoms and less overt low mood symptoms. Few attempts have been made to relate such differences to more general aspects of cognitive or emotional processing, such as the presence of dysfunctional attitudes or of alexithymia. Symptom differences within depression in old age have also received relatively little study, as has the ability of individual symptoms to distinguish between depressed and non-depressed elderly populations. These issues have been examined in two studies. In the first, a random sample of 700 subjects aged 65 years and over were identified through door-knocking in randomized enumeration districts in Islington, a socially deprived region of inner city London, and evaluated using a shortened version of the Comprehensive Assessment and Referral Evaluation (Short-CARE), which incorporates a depression subscale (DPDS). All 18 DPDS items distinguished significantly between depressed and non-depressed subjects (P < 0.0001). Depressed men were significantly more pessimistic than depressed women (63 versus 40%; P < 0.05); non-significant trends suggested that depressed women are more worried (39 versus 22%) and more restless (50 versus 31%), and depressed men more likely to be 'not very happy' or 'not happy at all' (53 versus 36%). There were no significant differences between older (age > 74 years) and younger subjects. Several other Short-CARE items, predominantly addressing subjective memory and disability, also distinguished significantly between the depressed and non-depressed groups. Logistic regression analysis identified eight items of the DPDS contributing significantly to the predictive ability of the total scale. In the second study, the Toronto Alexithymia Scale (TAS) and the Dysfunctional Attitudes Scale (DAS; 3) were administered to primary-care attenders aged > 64 years, and those with significant depressive symptoms were matched by age and sex to a depression-free control group. Depressed subjects had higher scores on both the TAS (Mann-Whitney U-test z = -4.71, P < 0.0001) and on the DAS (z = -2.49, P < 0.02).

An intervention study with husband and wife carers of older people with a psychiatric illness

BACKGROUND

Individual packages of care were devised for spouses of older people with psychiatric illness.

METHOD

Randomised controlled trial with blind follow up. Intervention group members were offered multidisciplinary packages while controls received no extra help. Both groups were reassessed 12-14 weeks later. The initial control group then received intervention; both were reassessed at 24-28 weeks.

RESULTS

Although no significant differences emerged in group mean scores for affective illness or social difficulties, carers who were mentally ill at outset improved significantly.

CONCLUSION

Interventions targeted at caregiving spouses with affective disorder are acceptable and efficacious.

LIMITATION

It was impossible to compare treatment with no treatment.

Cost of community care for older people

BACKGROUND

There has been no published study that considers actual costs in a representative sample of people aged > or = 65 years. The present study describes the financial costs of formal community services for elderly people with dementia, depression, anxiety disorder or physical disability.

METHOD

Psychiatric morbidity, physical disability and services received were assessed by standardised questionnaire in randomly selected Islington enumeration districts. Subjects were interviewed at home (n = 700).

RESULTS

Dementia was the most expensive disorder per sufferer in terms of formal services. Those with depression were also high users of health services. Despite presenting to health services, 90% were not treated with appropriate drugs. In contrast, social services were received by people who were activity-limited or with dementia. The highest service cost for the population as a whole was for the physically disabled. In multivariate analysis the significant predictors of high service costs were living alone, being physically ill, depression, dementia and increasing age.

CONCLUSIONS

Failure to detect and treat depression and the anxiety disorders in older people, despite their presentation to medical services, may have major economic consequences as well as contributing to individual suffering.

Depression and other psychiatric morbidity in carers of elderly people living at home

OBJECTIVE

To describe the mental health of a community sample of carers of elderly people with dementia, depression, or physical disability and to compare that with the mental health of other adults living in the household and of those living alone.

DESIGN

Assessment of psychiatric morbidity and physical disability with standardised questionnaire in randomly selected enumeration districts; subjects were interviewed at home.

SETTING

London Borough of Islington.

SUBJECTS

700 people aged > or = 65 and other coresidents.

MAIN OUTCOME MEASURE

Depression measured with standardised interview.

RESULTS

The prevalence of depression was not significantly higher in carers overall (15%) than in coresidents (11%). Being a woman carer was a significant predictor of psychiatric illness. Depression was more common in the carers of people with a psychiatric disorder than in coresidents (24% v 11%, P < 0.05) and in those living alone (19%). Depression was most common (47%) in women carers of people with dementia.

CONCLUSION

The increase in psychiatric morbidity reported in carers of people with psychiatric disorders may reflect the lack of a confiding relationship.