The recognition of dementia in "non-EMI" nursing home residents in South East England

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.

Association of diagnostic delay with impairment severity among institutional care facility residents diagnosed with dementia in Ontario, Canada

AIM

To compare the levels of cognitive function at the time of diagnosis among institutional care facility residents with dementia, who were diagnosed either before or after admission to a facility in Ontario, Canada.

METHODS

The study utilized a population-based secondary data analysis approach, using data from the Canadian Institute for Health Information's Continuing Care Reporting System from 2009 to 2011. Cognitive function within 30 days of diagnosis was measured by a seven-point cognitive performance scale (CPS) - 0 (intact) to 6 (very severe impairment).

RESULTS

Data were extracted from 39633 institutional care facility residents who had a diagnosis of dementia on record. The average CPS score was higher for residents whose diagnosis was made after admission to a facility than for residents whose diagnosis was made before admission (3.1 vs 2.9, P=0.009). The proportion of diagnosis at CPS ≥ 4 (moderately severe to very severe impairment) was also higher in the diagnosis after admission group (29.7% vs 24.6%, P=0.001). Multivariable analysis showed that diagnoses made after admission were more likely to be at a severe stage of cognitive decline (CPS ≥ 4) than diagnoses made before admission (adjusted odds ratio 1.49, P=0.001). A similar result was also noted when comparison was made between mild and moderate-to-severe stages of cognitive decline. After admission diagnoses were more likely to be at moderate-to-severe stages of cognitive decline (CPS ≥ 3) than before admission diagnoses (adjusted odds ratio 1.70, P=0.001).

CONCLUSION

Our findings suggest that dementia diagnoses after admission to institutional care facilities are more likely to be made at poorer stages of cognitive function decline.

Prevalence and correlates of potentially undetected dementia among residents of institutional care facilities in Ontario, Canada, 2009-2011

OBJECTIVES

This study aims to determine the prevalence of potentially undetected dementia among institutional care facility residents in Ontario, Canada, and to identify factors associated with undetection.

METHODS

We utilized a population-based secondary data analysis approach, pertaining to data from the Canadian Institute for Health Information's Continuing Care Reporting System, 2009-2011. Potentially undetected dementia was defined as having severely impaired cognitive function and requiring extensive assistance on activity of daily living (ADL) but no records of dementia diagnoses. Cognitive function was measured by the Cognitive Performance Scale (CPS), 0 (intact) to 6 (very severe impairment), and ADL by a hierarchy scale, 0 (independent) to 6 (total dependence).

RESULTS

Of the 242,957 residents who had no records of dementia diagnoses, 11.6% (n = 28,078) had a CPS score ≥4 (severe impairment or higher) and ADL score ≥3 (required extensive assistance or more). Data from 11,614 demented residents with corresponding CPS and ADL scores were used for comparison. Residents without dementia diagnosis were younger (77 vs. 84 years), more likely to have never married (20% vs. 6%), and have longer admission (4 vs. 2.8 years). The most significant factors for no diagnoses were never married (adjusted odds ratio = 2.1, 95% confidence interval [CI] = 1.91-2.29), admitted to hospital-based facilities (adjusted odds ratio = 1.58, 95% CI = 1.48-1.69), presence of schizophrenia (adjusted odds ratio = 1.43, 95% CI = 1.22-1.69), depression (adjusted odds ratio = 1.23, 95% CI = 1.16-1.29), and diabetes mellitus (adjusted odds ratio = 1.32, 95% CI = 1.26-1.40).

CONCLUSIONS

A large number of residents who had poor cognitive function and inadequate ADL ability did not have dementia diagnoses on record. Social and comorbid conditions were contributing factors to potentially undetected dementia.

Mortality in older care home residents in England and Wales

BACKGROUND

mortality in UK care homes is not well described.

OBJECTIVE

to describe 1-year mortality and predictors in older care home residents compared with community residents.

METHOD

cohort study using the THIN primary care database with 9,772 care home and 354,306 community residents aged 65-104 years in 293 English and Welsh general practices in 2009.

RESULTS

a total of 2,558 (26.2%) care home and 11,602 (3.3%) community residents died within 1 year. The age and sex standardised mortality ratio for nursing homes was 419 (95% CI: 396-442) and for residential homes was 284 (266-302). Age-related increases in mortality were less marked in care homes than community. Comorbidities and identification as inappropriate for chronic disease management targets predicted mortality in both settings, but associations were weaker in care homes. The number of drug classes prescribed and primary care contact were the strongest clinical predictors of mortality in care homes.

CONCLUSIONS

older care home residents experience high mortality. Age and diagnostic characteristics are weaker predictors of risk of death within care homes than the community. Measures of primary care utilisation may be useful proxies for frailty and improve difficult end of life care decisions in care homes.

The association of age with rate of cognitive decline in elderly individuals residing in supporting care facilities

OBJECTIVES

This study examines the effect of age on rate of cognitive decline in different stages of dementia, of nursing home and assisted-living residents.

METHODS

In this longitudinal study, the Mini Mental State Examination (MMSE) was used to measure rate of cognitive decline in subjects who were nondemented [Clinical Dementia Rating (CDR)=0; n=353], questionably demented (CDR=0.5; n=121), or frankly demented (CDR≥1; n=213) at baseline.

RESULTS

A generalized estimating equation was used to model the MMSE scores over time (mean follow-up 2.9±2.0 y). The generalized estimating equation model had the MMSE scores at successive follow-up time points as dependent variables and had linear and quadratic age, follow-up time from baseline, CDR at baseline, and all the interactions among them as independent variables, controlling for MMSE at baseline, sex, race, and education. The mean age of the entire sample was 85.2±7.4 years at baseline. There were no significant interactions of linear age effects with rate of cognitive decline. The analysis of interaction of quadratic age with rate of cognitive decline showed complex relationships: in the nondemented group, there was no substantial quadratic association of age with the rate of cognitive decline (P=0.13); in the questionable demented group, the oldest subjects declined relatively faster (P=0.02); and in the demented group, the youngest and oldest subjects tended to decline relatively less than subjects in the intermediate ages (P=0.07).

CONCLUSIONS

This study adds an additional aspect to the complexity of the association between age and rate of cognitive decline, showing that the direction and amplitude of this effect differs according to the stage along the course of cognitive decline.

Estimating the prevalence of dementia: cognitive screening in Glasgow nursing homes

OBJECTIVES

The purpose of this study is to establish existing levels of dementia in nursing homes.

DESIGN

The design was a randomised sample of every sixth nursing home resident in Glasgow City. Cognitive testing of 341 residents was carried out using the Standardised Mini Mental State Examination (SMMSE). For clients who had difficulty participating, the Functional Assessment Staging Tool (FAST) was used. Existing dementia diagnoses were compared with the prevalence indicated through cognitive testing.

MAIN OUTCOME MEASURES

Standardised Mini Mental State Examination and the FAST were used.

SETTING

This study was conducted in the nursing homes in the Glasgow City Council Local Authority, Scotland, UK (N = 49). Forty-eight homes participated in the study and one declined.

PARTICIPANTS

The participants were residents of the nursing homes in Glasgow City, including those in existing dementia units (sample = 422 of population 2532); 19 declined and 403 participated.

RESULTS

Two hundred thirty-four (58%) residents already had a diagnosis of dementia written in their care plans. One hundred twenty-eight residents (31.8%) without diagnosis of dementia in their care plans scored within the range of possible dementia (less than 24/30 on the SMMSE). A group of 55 (13.6%) residents had no diagnosis of dementia but had some type of cognitive impairment recorded in their notes and scored within the range of possible dementia on the SMMSE.

CONCLUSION

Existing levels of dementia diagnosis are 58%. This study finds an additional 31.8% of residents without a diagnosis of dementia who score within the range of possible dementia, giving a ceiling of 89.8%. It appears that underdiagnosis of dementia exists within this 31.8% group.

Under-recognition of dementia in long-term care homes in Hong Kong

OBJECTIVE

To examine the extent to which dementia in nursing homes is recognized by staff.

METHODS

About 189 residents with very mild to moderate dementia (Clinical Dementia Rating, CDR ≥ 0.5) and Mini-Mental State Examination (MMSE) = 10-24 were recruited from 12 nursing homes in Hong Kong. A senior staff in each home provided information on whether the participant was known to have dementia, and if so, the exact diagnosis. Logistic regression was conducted to predict identification by age, gender, whether for-profit or non-profit home, length of stay, MMSE, CDR, activities of daily living, and use of cholinesterase inhibitors and antipsychotic medications.

RESULTS

It was observed that 42.3% of the sample had mild dementia and 14.8% had moderate dementia. Although identification rates increased with increasing severity of cognitive impairment, only 30.0% of those with mild dementia and 64.3% of those with moderate dementia were known to have dementia by the homes. Identification rates did not differ between for-profit homes and non-profit homes which had regular MMSE screening. Logistic regression analysis showed that only MMSE (OR = 0.85, 95% CI = 0.76-0.95, p = 0.005) and CDR = 2 (as compared with CDR = 0.5; OR = 4.78, 95% CI = 1.23-18.65, p = 0.024) were significantly associated with dementia recognition. No other factors were related to dementia recognition.

CONCLUSIONS

Despite a high prevalence of dementia in long-term care facilities, recognition of dementia as a medical condition in residents by staff was suboptimal, and MMSE screening in some homes did not seem to increase awareness significantly.

Underrecognition and undertreatment of dementia in Italian nursing homes

OBJECTIVE

To determine the prevalence of dementia diagnoses and the use of antidementia drugs in a cohort of Italian older nursing home (NH) residents.

DESIGN

Cross-sectional study.

SETTING

The NH residents participating in 2 studies: the U.L.I.S.S.E. study and the Umbria Region survey.

PARTICIPANTS

A total of 2215 nursing home residents.

MEASUREMENT

Each resident underwent a comprehensive geriatric assessment at baseline by means of the RAI MDS 2.0. Dementia diagnosis was based on ICD-9 codes.

RESULTS

The prevalence of dementia diagnosis according to ICD-9 codes was 50.7% (n = 1123), whereas 312 subjects had cognitive impairment with a cognitive performance scale score ≥3 without a diagnosis of dementia. Only 56 NH residents were treated (5% of the sample) and the main drugs used were cholinesterase inhibitor, whereas only 1 subject was treated with memantine. Limiting our analysis to patients with mild to moderate Alzheimer's disease, who are those reimbursed by the public health care system for receiving antidementia drugs, the percentage rose to 11.3%.

CONCLUSION

These findings demonstrate a high rate of underdiagnosis and undertreatment of dementia in Italian NH residents. Potential explanations include the lack of systematic assessment of cognitive functions, the limitations to antidementia drug reimbursement, the complexity of the reimbursement procedure itself, and the high prevalence of patients with severe dementia. Older NH residents still lack proper access to state-of-the-art diagnosis and treatment for a devastating condition such as dementia.

Screening cognitive impairment among institutionalized older Chinese men in Taiwan: a new minimum data set-based dementia screening tool is needed

Dementia screening is of great importance in various health settings for older people, long-term care facilities are no exception. The need for an effective dementia screening tool being culture sensitive is important. Minimum data set (MDS) is a population instrument for health care management in the world, which also covers dementia screening. The main purpose of this study was to evaluate the effectiveness of the MDS-based dementia screening tools among older Chinese men in the Veteran Home in Taiwan. Overall, 576 participants (mean age: 80.9±5.3 years, all males, 92.7% physically independent), 18.6% had cognitive impairment according to the mini-mental state examination (MMSE) (mean score: 26.7±3.9). However, the prevalence of cognitive impairment was 5.5% by MDS cognitive performance scale (CPS) and 18.9% by MDS cognition scale (MDS-COGS). The screening results of CPS and MDS-COGS were highly interrelated (γ=0.93, p<0.001), and MMSE scores were also significantly associated with CPS and MDS-COGS status (γ=-0.50, p<0.001 and γ=-0.52, p<0.001, respectively). Although the prevalence of cognitive impairment by MMSE and MDS-COGS are similar, the results are significantly inconsistent (p<0.001). In conclusion, both MDS-COGS and CPS were significantly correlated with MMSE scores, but significant inconsistence was noted between screening results of MMSE, CPS and MDS-COGS. Further study is needed to develop MDS-based dementia screening tools for older Chinese men in Taiwan.

Health, wellbeing and nutritional status of older people living in UK care homes: an exploratory evaluation of changes in food and drink provision

Background

Food and drink are important determinants of physical and social health in care home residents. This study explored whether a pragmatic methodology including routinely collected data was feasible in UK care homes, to describe the health, wellbeing and nutritional status of care home residents and assess effects of changed provision of food and drink at three care homes on residents' falls (primary outcome), anaemia, weight, dehydration, cognitive status, depression, lipids and satisfaction with food and drink provision.

Methods

We measured health, wellbeing and nutritional status of 120 of 213 residents of six care homes in Norfolk, UK. An intervention comprising improved dining atmosphere, greater food choice, extended restaurant hours, and readily available snacks and drinks machines was implemented in three care homes. Three control homes maintained their previous system. Outcomes were assessed in the year before and the year after the changes.

Results

Use of routinely collected data was partially successful, but loss to follow up and levels of missing data were high, limiting power to identify trends in the data.

This was a frail older population (mean age 87, 71% female) with multiple varied health problems. During the first year 60% of residents had one or more falls, 40% a wound care visit, and 40% a urinary tract infection. 45% were on diuretics, 24% antidepressants, and 43% on psychotropic medication.

There was a slight increase in falls from year 1 to year 2 in the intervention homes, and a much bigger increase in control homes, leading to a statistically non-significant 24% relative reduction in residents' rate of falls in intervention homes compared with control homes (adjusted rate ratio 0.76, 95% CI 0.57 to 1.02, p = 0.06).

Conclusions

Care home residents are frail and experience multiple health risks. This intervention to improve food and drink provision was well received by residents, but effects on health indicators (despite the relative reduction in falls rate) were inconclusive, partly due to problems with routine data collection and loss to follow up. Further research with more homes is needed to understand which, if any, components of the intervention may be successful.

Trial registration

Trial registration: ISRCTN86057119.

An Assessment of the Diagnosis and Management of Dementia in Nursing Homes

OBJECTIVES

The purpose of this study was to evaluate the diagnosis and management of dementia in the nursing home setting through use of the Mini-Mental State Examination (MMSE) and monitoring of acetylcholinesterase-inhibitor (ACHEI) therapy.

DESIGN

Longitudinal cross-sectional study.

SETTING

Long-term care facilities in Indiana.

PATIENTS

Residents in long-term care facilities were included.

MAIN OUTCOME MEASURES

The number of residents with MMSE scores indicative of dementia, the presence of a dementia diagnosis, and receipt of ACHEI therapy.

RESULTS

Data were collected on 782 residents. An MMSE score was available within the past 12 months in 456 (58.3%) of residents. The median MMSE score was 17 and ranged from 0 to 30 points. Out of the total population, ACHEI therapy was prescribed in 165 (21.1%) residents. Seventy-five (29.2%) of the residents with mild-moderate dementia (MMSE = 10-26) were prescribed ACHEI therapy. The most frequently prescribed ACHEI was donepezil 10 mg/day prescribed in 98 (59.4%) of the residents receiving ACHEI therapy. Average length of ACHEI therapy was 9.0 months.

CONCLUSION

MMSE scores were not available in a large proportion of this nursing home population (41.7%). Of those residents with an available MMSE score, a significant number of them had scores indicative of dementia. Despite having scores indicative of dementia, 182 (70.8%) residents were not receiving AChEI therapy. An assessment to determine why residents were not receiving therapy is needed. Opportunities exist to improve the screening, diagnosis, and treatment of dementia in the nursing home setting.

An exploratory cluster randomized controlled trial of group exercise on mobility and depression in care home residents

Objective: To investigate the feasibility, acceptability and potential efficacy of group exercise for residents in care homes.

Design: Exploratory cluster randomized controlled trial.

Setting: Five randomly selected care homes in South Birmingham, UK.

Participants: Fifty-six care home residents (mean age 84.5, 71% female), 39 (70%) with cognitive impairments.

Intervention: Two homes (n = 28) were randomized to group exercise held twice weekly for five weeks. The remaining three homes (n = 28) formed the control group and received usual care, with no person specifically responsible for exercise training.

Outcome measures: Assessments were conducted at zero (pre-intervention), three (post-intervention) and six months (follow-up) using the Rivermead Mobility Index and Hospital Anxiety and Depression Scale or Stroke Aphasic Depression Questionnaire (depending on cognitive impairment). Adherence to group exercise and retention to the study were also documented.

Results: No statistically significant improvements in mobility or depression were found in favour of group exercise. Retention to the study was high with 46 (82%) participants completing all assessments. Adherence to group exercise was somewhat lower with participants attending a mean of 3.61 out of 8.5 prescribed sessions (42.5%).

Conclusions: Group exercise can be delivered to care home residents with reduced mobility but it is not suitable for residents with severe cognitive impairment. An estimated sample size of 240 participants would be required to detect a clinically significant difference in the Rivermead Mobility Index with 90% power.

Identifying need in care homes for people with dementia: the relationship between two standard assessment tools

Considerable effort has been invested in improving assessment processes for older people, some of the most vulnerable of whom live in care homes. The paper compares two well-known assessment tools used in care homes, the CANE and the Minimum Data Set/Resident Assessment Instrument. There was poor agreement between the tools in terms of domains of need covered. Nineteen pairs of items could be compared, with agreement greater than 60% found on 11 items. Of the 15 items where kappa could be computed, seven significant values were found. High levels of agreement existed in relation to behaviour, psychological wellbeing, mood state, psychotic symptoms, incontinence, mobility and inadvertent self-harm (risk). The study suggests that tools commonly used for assessment are not interchangeable and that the selection of assessment tool should be determined by the setting in which it is used, the needs of the population being assessed, the skills and knowledge of those undertaking the assessment and the purpose of the assessment itself.

Care staff working with people with dementia

The complexity and diversity of the needs of older people in care homes presents challenges to those responsible for caring for residents, in particular nursing and care assistant staff providing the majority of direct care. This study examines the degree of knowledge and confidence of these staff in caring for people with dementia and seeks to identify factors which can contribute to greater confidence. It reveals that although staff knowledge of dementia is reasonable, confidence in dealing with related situations is lower. Results also suggest that training can positively influence staff confidence in dealing with behaviour associated with the condition, recognizing that it is one of many factors influencing performance as a paid carer. These findings are discussed in terms of the quality of care provided to residents with dementia, the forms such training might take and the importance of a work environment which facilitates on-the-job training.

Nurses' and nursing assistants' recognition of depression in elderly who depend on long-term care

INTRODUCTION AND METHOD

Recognition and treatment of depression is a quality indicator for nursing homes. Nurses and nursing assistants are in a particularly good position to recognize depression in long-term care. How well do nurses and nursing assistants recognize depression, compared with a DSM-IV diagnosis of depression? To answer this question a critical review of relevant literature in PubMed searches was performed.

RESULTS

It was found that nurses and nursing assistants recognize true depression in about 55% (sensitivity 42% to 78%) and "over-recognized" depression in about 40% of nondepressed patients (specificity 56% to 67%).

DISCUSSION

The prominent role of nurses and nursing assistants in daily mental health care is not reflected in the number of methodologically sound studies. Sensitivity of the Geriatric Depression Scale (GDS) is about 50% higher than nurses' recognition of depression. A specific recommendation for specially trained nursing assistants in depression management and standard use of screening scales in an update of the American Medical Directors Association's Clinical Practice Guideline on Depression might improve depression recognition, as well as nursing assistants' work satisfaction and staff turnover.

CONCLUSION

Recognition of depression by nurses and nursing assistants is low. Standard use of a screening scale like the GDS would improve recognition of depression in the elderly. More research is needed aimed at how nursing assistants can empower their role as mental health care provider in long-term care.

Proxy screening tools improve the recognition of dementia in old-age homes: results of a validation study

BACKGROUND

Despite the high true prevalence of dementia, demential disorders of residents of old age homes may often be not recognized. There is a need for a standardised tool which includes observations of nursing staff.

OBJECTIVE

To describe and validate the Dementia Screening Scale (DSS) for use by nursing staff in old-age homes.

METHODS

All residents of 20 randomly selected old age homes in the city of Mannheim, Germany (n = 1, 922) were rated by nurses using the seven-item proxy dementia rating scale. Based on a subset of residents (n = 598) the DSS was validated against independent diagnostic assessments made by trained psychologists including the Mini-Mental-State-Examination (MMSE), the Dementia Scale of the Brief Assessment Schedule (BAS DEM), and the Washington University Clinical Dementia Rating (CDR).

RESULTS

Using the CDR as a gold standard, the DSS correctly classified at a cut-off of 2/3, 85.8% of the mildly, moderately, or severely demented residents. The accuracy of the DSS was only a little worse than that of the MMSE and the BAS DEM.

CONCLUSION

The DSS is well-suited for the recognition of dementia in old age homes. It achieved a better validity than global diagnosis-related staff assessments and compared to performance-based instruments. It is easier to apply, more economic, and associated with a fewer rate of non-response.

Behavioural disturbance triggers recognition of dementia by family informants

OBJECTIVE

To determine the frequency of unrecognised dementia in a group of community dwelling elderly, and to identify factors associated with dementia recognition by informants. SAMPLE SELECTION: People over 65 years with an AGECAT case or subcase organic diagnosis or an MMSE < or = 23 were identified from a database of community dwelling elderly. A psychiatrist to confirm the diagnosis of dementia according to ICD-10 criteria interviewed these individuals.

STUDY PARTICIPANTS

Sixty-two community dwelling elderly meeting ICD-10 criteria for dementia whom had reliable informants.

METHODS

Prior to the start of the interview the informant was questioned about whether they felt the patient had memory difficulties and if so whether they had a medical evaluation for their memory problems. A psychiatrist then interviewed the patient and informant to establish whether that patient met ICD-10 criteria for dementia. Basic sociodemographic details were collected and the following assessments were carried out: the Blessed Dementia Rating Scale, the Clinical Dementia Rating Scale, the Behave-AD and the Baumgarten Behavioural Disturbance Scale.

ANALYSIS

Univariate and step-wise forward logistic regression analysis were used to examine the factors associated with recognition of memory difficulties.

RESULTS

Twenty-nine percent of family informants of people with dementia failed to recognise a problem with their relatives'memory. Where memory difficulties were recognised only 39% of this group received a medical evaluation. Using univariate analysis recognition of memory difficulties by family informants was associated higher levels of behaviour disturbance ( p = or < 0.0011), greater functional impairment ( p = 0.0039), with increasing cognitive impairment ( p = 0.013). Using a logistic regression model, to test the independence of these variables, increasing behavioural disturbance (p = 0.0001) was associated with recognition of dementia by family informants.

CONCLUSIONS

Recognition of memory problems by family members is associated with increasing behavioural disturbance. Even with recognition of dementia, families often fail to seek medical attention. Education of the lay public on the early signs and symptoms of dementia must be a key first step in improving recognition of dementia in the community dwelling elderly.

Dementia assessment and management

Dementia is a common yet potentially underdiagnosed illness in the long-term care setting. Targeted screening for dementia should be routine practice, as a diagnosis of dementia will have benefits to the care of the patient. Assessment of dementia should proceed in a step-wise approach and should be tailored to the needs of the individual patient. Management of dementia involves care for the cognitive changes, behavioral changes, functional changes, and emotional issues. It also involves the management of other illnesses in light of the dementia, consideration of the needs and well-being of the caregiver, and particular attention to advanced care planning. Management techniques and goals should evolve as the patient's illness progresses. This comprehensive approach to management of dementia may reduce morbidity and mortality associated with this illness. This model of care provides patients and families with needed information and resources, a clear view of prognosis, and necessary attention to quality of life issues.

The assessment of older people's needs in care homes

In many countries there is a concern to improve assessment procedures for older people to avoid misplacement in nursing homes and ensure that rehabilitation takes place where possible. The study examined assessment documentation in 126 care homes in North West England. On a set of core domains for assessing need, the level of coverage varied considerably. The use of standardised scales was infrequent apart from those that measured risk of developing pressure sores. Some important key domains were infrequently mentioned on the assessment forms including mental health, pain, oral health and foot care. The most frequently covered items were the activities of daily living. There were clear differences in the assessment approaches employed in different types of home. The lack of inclusion of certain key health areas on some assessment forms suggests that the well-being and quality of life of some residents may be poorly addressed, and that further work is required for the standard of assessment in care homes to match that in community-based care.

Predictors of caregiver unawareness and nontreatment of dementia among residents of assisted living facilities: the Maryland Assisted Living Study

OBJECTIVE

Assisted living (AL) is a rapidly expanding residential option for the senior population. With increased utilization, it becomes important to understand the detection and treatment of dementia in this setting, but little is known. The objective of this study was to identify and evaluate factors associated with caregiver unawareness of dementia and failure to treat dementia in AL.

METHODS

The setting was a cross-sectional study of a random sample of AL facilities in central Maryland (The Maryland Assisted Living Study). Geriatric psychiatrists evaluated 198 participants and assigned dementia diagnoses to 134 residents (67.7%). The extent to which dementia was recognized and treated in these facilities was estimated on the basis of caregiver interview and chart review data. Using logistic regression models, demographic, cognitive, and functional measures were evaluated as predictors of caregiver unawareness and nontreatment of dementia.

RESULTS

Severity of cognitive and functional impairment, number of neuropsychiatric symptoms, and male gender were all independent predictors of caregiver unawareness of dementia. Family and caregiver unawareness of dementia and female gender were predictors of failure to treat dementia. Detection and treatment were not associated with race, age, or overall medical health.

CONCLUSIONS

Caregivers were more likely to be unaware of dementia in residents who did not have severe cognitive impairment or obvious behavioral and functional problems. Caregiver and family unawareness were in turn associated with nontreatment. Observed gender differences in detection and treatment will require replication and further study. These observations suggest that systematic educational interventions for caregivers and families may improve detection and hence treatment in the AL setting.

Knowing the diagnosis and counselling the relatives of a person with dementia: the perspective of home nurses and home care workers in Belgium

Home nurses and home care workers share the care for a person with dementia with family caregivers, and are confronted with their needs for medical and service-related information, for advice on how to cope with the behaviour changes, and for emotional support. The first objective of the present study was to describe some of the conditions for effective counselling, such as the perception that knowing the diagnosis has positive consequences for the formal caregivers. A second objective was to describe the formal caregivers' counselling practice, and ascertain its relationship with the psychological variables of attitudes, self-efficacy and subjective norm. A postal questionnaire was sent to 287 home nurses and 1259 home care workers in a defined region of Belgium; the questionnaire was returned by 169 home nurses (58.9% response) and 665 home care workers (52.8% response). The Theory of Planned Behaviour was the organising framework which underpinned the development of the instruments. Only the 168 home nurses and 601 home care workers reporting experience with caregiving to people with dementia were included in the analysis. Formal caregivers indicated that knowing the diagnosis was important, but it could facilitate or hinder caregiving. They were able to describe behavioural characteristics which are indicative of dementia, but only in a limited way, and their strategies to uncover the diagnosis were also limited. Formal caregivers reported that they supported family members emotionally, advised about communication with the person with dementia and informed family caregivers about services. However, providing family caregivers with information about dementia lagged behind these forms of support. In general, nurses scored higher than home care workers. Multiple linear regression analysis was used to investigate the relationships between self-reported practice and the concepts of the model. In both professions, attitudes and self-efficacy were found to be strong independent predictors, and the implications for practice are discussed.

De facto imprisonment and covert medication use in general nursing homes for older people in South East England

BACKGROUND AND AIMS

There is growing interest in ethical issues in nursing home care, including capacity to consent to residence and covert medication use. This study assessed capacity to consent to residence amongst a group of randomly selected residents of non-specialist UK nursing homes and examined the prevalence of de facto imprisonment and covert medication.

METHODS

A cross-sectional prevalence study amongst residents in randomly selected non-specialist nursing homes in South East England. 445 residents (97 men and 348 women) were randomly selected from 157 nursing homes.

RESULTS

14% (64) of the residents interviewed lacked the capacity to consent to residence. 6.1% (27) of residents were prevented from leaving but less than half of these lacked the mental capacity to consent to residence and may be therefore, de facto, unlawfully imprisoned. 4.7% (21) of residents on medication had received it covertly in the nursing home.

CONCLUSIONS

A significant number of residents in the nursing homes studied did not appear to have the mental capacity to consent to being there, possibly in contravention of the Human Rights Act 1998. There appears to be a small but worrying prevalence of de facto imprisonment, and covert medication use in residents without severe cognitive impairment.