Health and Social Care Delivery Research, 10(10), 2022, p.180. Online only
Publisher:
National Institute for Health Research
Place of publication:
London
Background: Mild cognitive impairment in older adults is a risk factor for dementia. Mild cognitive impairment is a result of a diverse range of underlying causes and may progress to dementia, remain stable or improve over time. Objectives: We aimed to assess the evidence base around the assessment and management pathway of older adults with mild cognitive impairment in community/primary care...
(Edited publisher abstract)
Background: Mild cognitive impairment in older adults is a risk factor for dementia. Mild cognitive impairment is a result of a diverse range of underlying causes and may progress to dementia, remain stable or improve over time. Objectives: We aimed to assess the evidence base around the assessment and management pathway of older adults with mild cognitive impairment in community/primary care, hospital and residential settings. Data sources: In January 2021, we searched MEDLINE, EMBASE, PsycInfo, Scopus, Cumulative Index to Nursing and Allied Health Literature, The Cochrane Library (i.e. Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials), Science Citation Index and Social Science Citation Index. The search was limited to studies published in English between 2010 and 2020. Grey literature and citation searches were also performed. Methods: We performed two separate evidence reviews: (1) a descriptive review with narrative synthesis focusing on diagnosis, service provision and patient experience; and (2) a critical interpretive synthesis of evidence on the advantages and disadvantages of 'mild cognitive impairment' as a diagnostic label. Results: A total of 122 studies were included in the descriptive review, of which 29 were also included in the critical interpretive synthesis. Study participants were most commonly recruited from populations of community-living older adults or those who had sought medical help from their general practitioner for memory problems. Follow-up searching identified a further 11 studies for the critical interpretive synthesis. The descriptive review identified multiple barriers to efficient diagnosis, starting with patient reluctance to seek help. General practitioners have a variety of cognitive tests available, but substantial numbers of patients meeting criteria for dementia do not have a diagnosis recorded. Patients may be referred to a memory clinic, but these clinics are mainly intended to identify and support people with dementia, and people with mild cognitive impairment may be discharged back to their general practitioner until symptoms worsen. Availability of scanning and biomarker tests is patchy. Qualitative studies show that patients with mild cognitive impairment and their carers find the process of investigation and diagnosis difficult and frustrating to negotiate. The key finding from the critical interpretive synthesis was that the need for a 'timely' diagnosis outweighs the ongoing debate about the value, or otherwise, of early investigation and labelling of memory problems. Determining what is a timely diagnosis involves balancing the perspectives of the patient, the health system and the clinician. Conclusions: The two reviews reported here have applied different 'lenses' to the same body of evidence. Taken together, the reviews highlight the importance of a timely diagnosis for memory problems and identify barriers to obtaining such a diagnosis, from reluctance to seek help through to patchy availability of advanced diagnostic tests. Limitations: The review was primarily descriptive, reflecting the prespecified review questions. Study selection was complicated by lack of a consistent definition of mild cognitive impairment and its overlap with other memory disorders. It was not possible to employ double study selection, data extraction or quality assessment, although processes of checking and verification were used throughout the review. Future work: Priorities include evaluating remote methods of memory assessment and preparing for the likely future availability of disease-modifying treatments for early dementia. Research is needed on the investigation of memory problems in hospital and social care settings.
(Edited publisher abstract)
Subject terms:
community care, care pathways, dementia, systematic reviews, needs assessment, cognitive impairment, assessment, older people, memory, evidence, residential care, primary care, diagnostic tests, diagnosis;
Dementia: the International Journal of Social Research and Practice, 18(2), 2019, pp.514-529.
Publisher:
Sage
Overcoming barriers to earlier diagnosis of dementia in primary care is a core ambition of several government initiatives in the UK, with incentives put in place to promote earlier recognition by general practitioners and referral to specialists. This study was designed to explore general practitioners’ opinions concerning barriers to diagnosing dementia, following implementation of strategies...
(Edited publisher abstract)
Overcoming barriers to earlier diagnosis of dementia in primary care is a core ambition of several government initiatives in the UK, with incentives put in place to promote earlier recognition by general practitioners and referral to specialists. This study was designed to explore general practitioners’ opinions concerning barriers to diagnosing dementia, following implementation of strategies aimed at reducing them. The study involved in-depth, semi-structured interviews with 13 general practitioners from seven practices in North London or the West Midlands. Thematic analysis of interview transcripts was carried out using the Framework approach. The authors identified four major themes: organisational factors, clinician-related factors, patient-related factors and societal influences. The study findings revealed barriers previously unidentified in the literature which warrant further investigation, including the limits of diagnostic tools, lack of cultural applicability of these tools, and prioritisation of severe over mildly symptomatic patients by dementia services.
(Edited publisher abstract)
Subject terms:
diagnosis, general practitioners, health care, primary care, attitudes, dementia, organisational culture, professional role, diagnostic tests;
Objectives: Using a sample of dementia caregivers, this study compared the diagnostic utility of the various short versions of the Zarit Burden Interview (ZBI) with the original scale to identify the most optimal one. The study then established externally validated cutoffs for the various ZBI versions using probable depression cases as a reference standard. Methods: Caregivers (N = 394; 236 males
(Edited publisher abstract)
Objectives: Using a sample of dementia caregivers, this study compared the diagnostic utility of the various short versions of the Zarit Burden Interview (ZBI) with the original scale to identify the most optimal one. The study then established externally validated cutoffs for the various ZBI versions using probable depression cases as a reference standard. Methods: Caregivers (N = 394; 236 males; Agemean = 56 years) were administered the ZBI and a self-report depression measure. Participants who exceeded the cutoff for the latter were identified as probable depression cases. For each of the ZBI versions, a receiver operating characteristic (ROC) curve was plotted against probable depression cases. The area under these ROC curves between the short versions and the original were then compared using a non-parametric approach. Results: Compared to the original ZBI, the AUROC were similar for the 6-item, 7-item, and two 12-item versions, but significantly worse for the other short variants. The sensitivity and specificity of the cutoffs for all ZBI versions ranged from 77.3% to 85.2% and 60.1% to 79.8%, respectively. Conclusions: The original ZBI had good utility in identifying probable depression in caregivers, while the 6-item variant can be a useful alternative when short versions are preferred.
(Edited publisher abstract)
Dementia: the International Journal of Social Research and Practice, 17(2), 2018, pp.138-163.
Publisher:
Sage
This study explores how manners of mediation, and the use of embodiment in interpreter-mediated conversation have an impact on tests of cognitive functioning in a dementia evaluation. By a detailed analysis of video recordings, we show how participants - an occupational therapist, an interpreter, and a patient - use embodied practices to make the tasks of a test of cognitive functioning...
(Edited publisher abstract)
This study explores how manners of mediation, and the use of embodiment in interpreter-mediated conversation have an impact on tests of cognitive functioning in a dementia evaluation. By a detailed analysis of video recordings, we show how participants - an occupational therapist, an interpreter, and a patient - use embodied practices to make the tasks of a test of cognitive functioning intelligible, and how participants collaboratively put the instructions of the tasks into practice. We demonstrate that both instructions and instructed actions - and the whole procedure of accomplishing the tasks - are shaped co-operatively by embodied practices of all three participants involved in the test situation. Consequently, the accomplishment of the tasks should be viewed as the outcome of a collaborative achievement of instructed actions, rather than an individual product. The result of the study calls attention to issues concerning interpretations of, and the reliability of interpreter-mediated tests and their bearings for diagnostic procedures in dementia evaluations.
(Edited publisher abstract)
Background: dementia is a common cause of altered decision-making capacity. Determining whether an individual has the ability to make a specific decision can be very challenging for both clinicians and researchers. The UK legislation requires that we both promote residual capacity where possible, and protect vulnerable adults who cannot make independent decisions. We evaluated published
(Edited publisher abstract)
Background: dementia is a common cause of altered decision-making capacity. Determining whether an individual has the ability to make a specific decision can be very challenging for both clinicians and researchers. The UK legislation requires that we both promote residual capacity where possible, and protect vulnerable adults who cannot make independent decisions. We evaluated published instruments designed to aid in the assessment of capacity, focussing on those meeting the UK legal requirements. We also consider further disease and culture-specific factors which may influence decision making. Methods: a search of electronic databases was made for articles published between 2000 and 2017 detailing structured tools for the assessment of mental capacity. These were evaluated against the UK legal requirements. Results: nine tools were identified which fulfilled the UK legal requirements. Their design and structure varied, as did the level of reliability and validity data available. Some instruments can be tailored for a specific decisional scenario, whilst others are designed for use by particular patient groups. Discussion: a wide range of mental capacity assessment instruments is available, but not all fulfil the UK legal requirements. Healthcare professionals and researchers should be mindful of personal, cultural and disease-specific factors when assessing capacity. No gold standard for capacity assessment exists, which hampers the evaluation of different approaches. A combination of the opinion of a healthcare professional or researcher trained in capacity evaluation, plus the use of a structured assessment tool is the most robust approach.
(Edited publisher abstract)
Journal of Applied Research in Intellectual Disabilities, 31(5), 2018, pp.725-742.
Publisher:
Wiley
Background: The increasing number of individuals with an intellectual disability who are at risk of developing dementia highlights the need to use measures with strong psychometric properties as part of the screening, assessment and diagnostic process. Method: Searches were made of clinical and good practice guidelines and English language journal articles sourced from Proquest, Web of Science...
(Edited publisher abstract)
Background: The increasing number of individuals with an intellectual disability who are at risk of developing dementia highlights the need to use measures with strong psychometric properties as part of the screening, assessment and diagnostic process. Method: Searches were made of clinical and good practice guidelines and English language journal articles sourced from Proquest, Web of Science and Scopus databases (up to July 2017) for tools which were designed or adapted for the purpose of helping to diagnose dementia in people with intellectual disability. Results: Based on a detailed review of 81 articles and guidelines, the present authors identified 22 relevant tools (12 cognitive, 10 behaviour). These were reviewed in terms of their psychometric properties. Conclusions: A number of tools were found to be available for use with people with intellectual disability; however, few were specifically standardized for this purpose which also had comprehensive information about reliability and validity.
(Edited publisher abstract)
Background: many people living with dementia remain underdiagnosed and unrecognised. Screening strategies are important for early detection. Objective: to examine whether the Lawton’s Instrumental Activities of Daily Living (IADL) scale, compared with other cognitive screening tools—the Mini-Mental State Examination (MMSE), and the Ascertain Dementia 8-item Informant Questionnaire (AD8)—can...
(Edited publisher abstract)
Background: many people living with dementia remain underdiagnosed and unrecognised. Screening strategies are important for early detection. Objective: to examine whether the Lawton’s Instrumental Activities of Daily Living (IADL) scale, compared with other cognitive screening tools—the Mini-Mental State Examination (MMSE), and the Ascertain Dementia 8-item Informant Questionnaire (AD8)—can identify older (≥ 65 years) adults with dementia. Design: population-based cross-sectional observational study. Setting: all 19 counties in Taiwan. Participants: community-dwelling older adults (n = 10,340; mean age 74.87 ± 6.03). Methods: all participants underwent a structured in-person interview. Dementia was identified using National Institute on Aging-Alzheimer’s Association core clinical criteria for all-cause dementia. Receiver operator characteristic curves were used to determine the discriminant abilities of the IADL scale, MMSE and AD8 to differentiate participants with and without dementia. Results: 917 (8.9%) participants with dementia were identified, and 9,423 (91.1%) participants without. The discriminant abilities of the MMSE, AD8 and IADL scale (cutoff score: 6/7; area under curve = 0.925; sensitivity = 89%; specificity = 81%; positive likelihood ratio = 4.75; accuracy = 0.82) were comparable. Combining IADL with AD8 scores significantly improved overall accuracy: specificity = 93%; positive likelihood ratio = 11.74; accuracy = 0.92. Conclusions: the findings support using IADL scale to screen older community-dwelling residents for dementia: it has discriminant power comparable to that of the AD8 and MMSE. Combining the IADL and the AD8 improves specificity.
(Edited publisher abstract)
International Journal of Geriatric Psychiatry, 32(3), 2017, pp.274-287.
Publisher:
Wiley
Objective: The array of demanding tasks carried out by caregivers of people with dementia have significant negative impacts on their physical, mental and social well-being. Needs assessment allows individuals to indicate the extent to which their needs across different areas have or have not been met, allowing for estimations of the prevalence of needs and the extent to which help is required...
(Publisher abstract)
Objective: The array of demanding tasks carried out by caregivers of people with dementia have significant negative impacts on their physical, mental and social well-being. Needs assessment allows individuals to indicate the extent to which their needs across different areas have or have not been met, allowing for estimations of the prevalence of needs and the extent to which help is required. This approach is extremely valuable in a clinical context, as it enables identification of the areas with which caregivers report a particular desire for help and allows targeting of support and resources to those who identify high levels of unmet needs. This systematic review aimed to critically examine the psychometric properties of measures that assess unmet needs of caregivers of people with dementia.
Methods: Medline, Embase, PsycINFO and Cochrane electronic databases were searched between January 1990 and August 2015 for English-language publications describing the development or validation of measures assessing the unmet needs of adult caregivers of people with dementia. The psychometric properties of included measures were assessed against standard criteria for psychometric quality.
Results: Four measures met the inclusion criteria. Only half of the indices of psychometric quality were tested across measures. Three measures had adequate internal consistency reliability, of which one also showed adequate test–retest reliability. Two measures reported adequate construct validity, while criterion validity was not assessed for any measure.
Conclusions: There is a clear need to develop a psychometrically rigorous instrument to identify the unmet needs of caregivers of people with dementia.
(Publisher abstract)
Subject terms:
dementia, needs assessment, unmet need, literature reviews, diagnostic tests, carers, instruments;
GPs' are often ambivalent about memory clinics with conflicting views about the value of a diagnosis. This article reports on a survey in North-west Wales to examine their thinking.
(Edited publisher abstract)
GPs' are often ambivalent about memory clinics with conflicting views about the value of a diagnosis. This article reports on a survey in North-west Wales to examine their thinking.
(Edited publisher abstract)
Subject terms:
general practitioners, memory, dementia, diagnosis, diagnostic tests, surveys, assessment;
International Journal of Geriatric Psychiatry, 31(8), 2016, pp.837-857.
Publisher:
Wiley
Background: Depression in older adults is often under recognised despite it being the most common mental health illness in this age group. An increasing older adult population highlights the need for improved diagnostic rates. Brief versions (15 items or less) of the Geriatric Depression Scale (GDS), which are suitable for busy clinical practice, could improve detection rates.
Objective: This study aimed to establish the diagnostic accuracy of brief versions of the GDS.
Methods: Twelve electronic databases of published and unpublished literature were searched. Study selection was in accordance with predefined inclusion and exclusion criteria. A recognised gold-standard diagnostic instrument was used as a comparator against data pertaining to the use of a brief version of the GDS in an older adult population. The QUADAS-II was utilised for quality assessment. Narrative analysis and, where possible, meta-analysis were performed.
Results: Thirty-two studies were identified that provided diagnostic data regarding seven brief versions of the GDS (1, 4, 5, 7 8, 10 and 15-item versions). Pooled sensitivity was 0.89 (95% confidence interval (CI) 0.80–0.94), and specificity was 0.77 (95% CI 0.65–0.86) for the GDS-15 at the recommended cut-off score of 5. Meta-analysis of other brief versions was not possible because of an insufficient number of studies with standardised items.
Conclusions: Results suggest the possibility of selective reporting of cut-off scores, and therefore, findings should be approached cautiously. Studies should report all cut-off scores, and all brief GDS versions should be compiled of standardised items.
(Edited publisher abstract)
Background: Depression in older adults is often under recognised despite it being the most common mental health illness in this age group. An increasing older adult population highlights the need for improved diagnostic rates. Brief versions (15 items or less) of the Geriatric Depression Scale (GDS), which are suitable for busy clinical practice, could improve detection rates.
Objective: This study aimed to establish the diagnostic accuracy of brief versions of the GDS.
Methods: Twelve electronic databases of published and unpublished literature were searched. Study selection was in accordance with predefined inclusion and exclusion criteria. A recognised gold-standard diagnostic instrument was used as a comparator against data pertaining to the use of a brief version of the GDS in an older adult population. The QUADAS-II was utilised for quality assessment. Narrative analysis and, where possible, meta-analysis were performed.
Results: Thirty-two studies were identified that provided diagnostic data regarding seven brief versions of the GDS (1, 4, 5, 7 8, 10 and 15-item versions). Pooled sensitivity was 0.89 (95% confidence interval (CI) 0.80–0.94), and specificity was 0.77 (95% CI 0.65–0.86) for the GDS-15 at the recommended cut-off score of 5. Meta-analysis of other brief versions was not possible because of an insufficient number of studies with standardised items.
Conclusions: Results suggest the possibility of selective reporting of cut-off scores, and therefore, findings should be approached cautiously. Studies should report all cut-off scores, and all brief GDS versions should be compiled of standardised items.
(Edited publisher abstract)