Minority ethnic groups in dementia care: a review of service needs, service provision and models of good practice

Immigration and access to dementia diagnostics and treatment: A nationwide study in Sweden

•Compared to Swedish-born people, foreign-born people were less likely to receive dementia diagnostic tests.•Being born in Africa or Europe was associated with lower chance of receiving cholinesterase inhibitors.•Asian-born people had higher chance of receiving cholinesterase inhibitors, but were less likely to receive memantine.•Disparities existed in dementia diagnostics and treatment between Swedish-born and foreign-born people, but were not consistent after adjusting for MMSE scores.

'It's a lonely journey': caregiving experiences and psychosocial distress among Chinese American dementia family caregivers

OBJECTIVES

Chinese American family caregivers of persons with Alzheimer's disease and related dementia (ADRD) are a vulnerable but understudied population. The goal of this qualitative study was to examine their caregiving experiences and psychosocial distress process and explore intervention strategies.

METHODS

In-depth individual interviews were conducted with 18 Chinese American dementia caregivers. All interviews were transcribed verbatim; thematic content analysis was conducted to construct a conceptual framework.

RESULTS

All participants reported high levels of caregiving stress associated with care-recipients' advanced symptoms and required assistance in activities in daily living. The relationship of caregiver and care-recipient was strained in their roles transition. The complex healthcare system, insurance policies, and a lack of linguistically appropriate services aggravated their psychosocial distress. Chinese cultural norms on 'family harmony' hindered their seeking of social support. Prolonged caregiving stress led to physical and mental impairment, including poor sleep, depression, and chronic conditions. Participants described their caregiving experience as 'a lonely journey' with a pervasive sense of hopelessness and withdrawal; their distress process was positively or negatively influenced by their coping strategies. All participants were eager for any kind of support; especially culturally appropriate programs that could improve their caregiving skills, self-care, and access to services.

CONCLUSION

Our data suggest that Chinese American dementia caregivers, especially those with limited English proficiency, experience elevated psychosocial distress, which was aggravated by the barriers to social support and health services due to their immigrant and minority status. Culturally appropriate targeted intervention is urgently needed for this underserved and vulnerable population.

Virtual Assessment as a Way to Reduce Help-seeking Barriers in Older Adults With Subjective Cognitive Decline

Subjective cognitive decline (SCD), a potential early marker for neurodegenerative disease such as Alzheimer's disease, is common among older adults. Although it is often regarded as a personal health concern, most individuals with SCD do not seek help from a health care professional. Help-seeking (HS) is a complex, individualized process with significant life-course implications, and older adults often face several barriers to HS across personal, socioeconomic, and cultural domains. The pandemic exacerbated these barriers by imposing additional limitations on in-person care. In response, virtual assessment became a popular method to conduct remote care. We provide a narrative review of the challenges and triumphs that came with the transition from in-person, pen-paper cognitive assessments to virtual cognitive assessments. In addition, we address the impact virtual assessment had in tackling barriers that previously limited individuals with SCD from formal HS. We argue that virtual cognitive assessment helps alleviate health access barriers to HS (e.g., cost, transportation, and physician availability) and allows individuals with different coping styles to undergo assessment within more convenient environments. We hope the findings presented in this review inform health care practice, public education, and future research targeted towards the use of virtual assessment to facilitate HS in older adults with SCD.

Education as a Moderator of Help Seeking Behavior in Subjective Cognitive Decline

OBJECTIVE

Disparities in Alzheimer disease (AD) and differences in help seeking (HS) across sociodemographic groups warrant public health concern. Research addressing such disparities must shift toward the earliest clinical manifestations of AD to optimize diagnosis, intervention and care planning. Subjective cognitive decline (SCD), a risk state for AD, provides an important context in which to examine sociodemographic-related disparities in HS.

PARTICIPANTS AND METHODS

One hundred sixty-seven cognitively healthy older adults (M age =73, M education =16) (26.4% Black, Asian, or "Other") completed SCD questionnaire, HS questions, and mood measures (depression and anxiety). Binary logistic adjusted regressions examined: (a) the association between SCD and HS; and (b) the extent to which education moderated the relationship between SCD and HS. SCD [b = 0.06, SE=0.13, P <0.001, odds ratio=1.06, 95% CI (1.03, 1.08)] and education [b=0.32, SE=0.09, P <0.001, odds ratio=1.37, 95% CI (1.15, 1.64)] were independently associated with HS, with significant interaction between education and SCD on HS [b=0.2, SE=0.01, P =0.01, odds ratio=1.02, 95% CI (1.00, 1.03)].

CONCLUSIONS

Findings elucidate the importance of tailoring SCD-related psychoeducational resources depending on educational background as a preliminary stepping-stone in encouraging HS among older adults who may be at particular risk for developing dementia.

Ethnicity and survival after a dementia diagnosis: a retrospective cohort study using electronic health record data

BACKGROUND

Individuals from minority ethnic groups in the UK are thought to be at higher risk of developing dementia while facing additional barriers to receiving timely care. However, few studies in the UK have examined if there are ethnic disparities in survival once individuals receive a dementia diagnosis.

METHODS

We conducted a retrospective cohort study using electronic health record data of individuals diagnosed with dementia from a large secondary mental healthcare provider in London. Patients from Black African, Black Caribbean, South Asian, White British, and White Irish ethnic backgrounds were followed up for a 10-year period between 01 January 2008 and 31 December 2017. Data were linked to death certificate data from the Office of National Statistics to determine survival from dementia diagnosis. Standardised mortality ratios were calculated to estimate excess deaths in each ethnicity group as compared to the gender- and age-standardised population of England and Wales. We used Cox regression models to compare survival after dementia diagnosis across each ethnicity group.

RESULTS

Mortality was elevated at least twofold across all ethnicity groups with dementia compared to the general population in England and Wales. Risk of death was lower in Black Caribbean, Black African, White Irish, and South Asian groups as compared to the White British population, even after adjusting for age, gender, neighbourhood-level deprivation, indicators of mental and physical comorbidities. Risk of death remained lower after additionally accounting for those who emigrated out of the cohort.

CONCLUSIONS

While mortality in dementia is elevated across all ethnic groups as compared to the general population, reasons for longer survival in minority ethnic groups in the UK as compared to the White British group are unclear and merit further exploration. Implications of longer survival, including carer burden and costs, should be considered in policy and planning to ensure adequate support for families and carers of individuals with dementia.

'It's just incredible the difference it has made': family carers' experiences of a specialist Lewy body dementia Admiral Nurse service

BACKGROUND

Lewy body dementia (LBD) is characterised by a complex array of symptoms. Being a family carer of someone with LBD can be challenging, and is associated with high levels of stress, depression and anxiety. Admiral Nursing services support family carers of people with dementia in the UK by providing tailored information, advice and therapeutic support. Recently, the Admiral Nurse model has been adapted to the needs of more specific populations, including the introduction of a new, specialist LBD Admiral Nurse.

OBJECTIVE

to explore family carers' experiences of the LBD Admiral Nurse service.

METHODS

fourteen family carers of people with LBD were interviewed about their experiences of the LBD Admiral Nurse service. Interview transcripts were analysed using thematic analysis.

RESULTS

four themes were identified: theme 1 described how participants valued the LBD Admiral Nurse's specialist expertise, which contrasted with the lack of knowledge they encountered in other services. In theme 2, participants described how the practical, tailored support provided by the LBD Admiral Nurse enabled them to better manage a variety of caring-related challenges. Theme 3 captured the emotional benefits that participants gained from being able to talk to someone who understood their situation. In theme 4, participants explained how the reliability of the LBD Admiral Nurse's support helped them feel supported in their role.

CONCLUSIONS

the specialist knowledge and expertise of the LBD Admiral Nurse enabled family carers to better support the people they cared for, and to relieve some of the emotional stress associated with caring.

Dementia care needs for individuals and caregivers among Mexican Americans and non-Hispanic Whites

Mexican Americans (MA) are more likely to have cognitive impairment and dementia (CID), be diagnosed at an earlier age and live with CID longer, compared to non-Hispanic Whites (NHW). While studies have examined unmet needs of individuals with CID and their caregivers, few have focused on MA populations in the U.S. This paper examines the needs of community-residing individuals with CID and their caregivers in Nueces County, Texas, a county with one of the largest MA populations in the U.S., while exploring ethnic differences in needs identified. Using concept mapping, a mixed-method approach, qualitative input on perceived needs by informal caregivers and health professionals was collected. Participants then sorted and rated perceived needs. Using this information, multidimensional scaling and cluster analyses were conducted to map the relationship between perceived needs and determine their importance and priority. Five clusters were derived for caregivers and four for the health professionals. Themes across both caregivers and health professionals highlighted the need for specialized and team-based medical care, caregiver support and training, along with socio-economic and physical needs that help with day-to-day care of individuals with CID. Among caregivers, MA rated financial resources as more important and of higher priority compared to NHW. The health professionals' perspectives were aligned with those of all caregivers. By understanding the needs of caregivers and individuals with CID, we can help families deal with this disease and let caregivers thrive. This is especially important for minority populations like MAs.

“I Know Hyena. Do you Know Hyena?” Challenges in Interpreter-Mediated Dementia Assessment, Focusing on the Role of the Interpreter

Dementia assessment requires functional communication and interaction between healthcare professionals and the patient being assessed. These can be affected by the requirement for an interpreter to communicate with the patient. The purpose of this study was to elucidate the interactions between patient, healthcare professionals and interpreter, focusing on the role of the interpreter and the challenges that may arise in interpreter-mediated dementia assessment. The study had an ethnographic design in which the data consisted of audio and video recordings of 19 dementia assessments conducted in the presence of an interpreter. The data were analyzed using the constant comparative method. The results showed that the interpreter could affect the patient’s performance and results during the dementia assessment. The interpreter could alter the meaning and content of what was communicated, sometimes change information and instructions exchanged between the patient and healthcare professionals, could avoid interpreting everything being said, and occasionally made their own corrections to what was being communicated. This occurred mainly because of the interpreter’s lack of linguistic skills and the interpreter failing to adhere to the ethical guidelines governing their profession. These challenges could also occur when the interpreter was not familiar with the context of dementia assessment. Alterations made by the interpreter to what was being communicated could lead to incorrect evaluation of the patient’s cognitive abilities and health status. This, in turn, may lead to misjudgment of the patient’s remaining resources and symptoms and their required treatment and support.

Differences in survival and mortality in minority ethnic groups with dementia: A systematic review and meta-analysis

OBJECTIVES

Although there are disparities in both risk of developing dementia and accessibility of dementia services for certain minority ethnic groups in the United States and United Kingdom, disparities in survival after a dementia diagnosis are less well-studied. Our objective was to systematically review the literature to investigate racial/ethnic differences in survival and mortality in dementia.

METHODS

We searched Embase, Ovid MEDLINE, Global Health and PsycINFO from inception to November 2018 for studies comparing survival or mortality over time in at least two race/ethnicity groups. Studies from any country were included but analysed separately. We used narrative synthesis and random-effects meta-analysis to synthesise findings. The Newcastle-Ottawa Scale was used to assess quality and risk of bias in individual studies.

RESULTS

We identified 22 articles, most from the United States (n = 17), as well as the United Kingdom (n = 3) and the Netherlands (n = 1). In a meta-analysis of US studies, hazard of mortality was lower in Black/African American groups (Pooled Hazard Ratio = 0.86, 95% CI = 0.82-0.91, I²  = 17%, from four studies) and Hispanic/Latino groups (Pooled HR = 0.65, 95% CI = 0.50-0.84, I²  = 86%, from four studies) versus comparison groups. However, study quality was mixed, and in particular, quality of reporting of race/ethnicity was inconsistent.

CONCLUSION

Literature indicates that Black/African American and Hispanic/Latino groups may experience lower mortality in dementia versus comparison groups in the United States, but further research, using clearer and more and consistent reporting of race/ethnicity, is necessary to understand what drives these patterns and their implications for policy and practice.

Differences in Dementia Care Between Swedish-Born and Foreign-Born from Countries with Different Country Level Socioeconomic Position: A Nationwide Register-Based Study

Background:

With a growing elderly population worldwide, the prevalence of dementia is rapidly increasing. Studies from high income countries have shown that belonging to a minority ethnic group increases the risk of health disadvantages.

Objective:

The aim of the present registry-based study was to identify potential differences in diagnostics, treatment, and care of individuals with dementia focusing on foreign-born in Sweden and the impact of country level socioeconomic position (SEP).

Methods:

The study was based on a large dataset from the Swedish Dementia Registry (SveDem) and the Swedish Tax Agency’s population registry. Data on demographic variables, cognitive tests, clinical assessments, medication, diagnosis, and interventions initiated at diagnosis were collected. Country level SEP was determined by country of birth as classified by World Bank Country and Lending groups.

Results:

Of 57,982 patients with dementia registered in SveDem, 7,171 (12.4%) were foreign-born. The foreign-born were significantly younger at diagnosis (p < 0.001), had a lower MMSE score (p < 0.001), lower odds of receiving a specific dementia diagnosis (p < 0.001), lower use of acetylcholinesterase inhibitors (p < 0.001), and overall a higher use of neuroleptics compared with the Swedish-born group. The lower SEP, the greater differences to Swedish-born were seen in many of the examined variables.

Conclusion:

There were significant differences in dementia diagnostics, treatment, and care between foreign-born and Swedish-born, a lower SEP indicating greater differences. Further research should focus on various socioeconomic aspects and health care outcomes for a more profound analysis of equity in dementia care.

Barriers in access to dementia care in minority ethnic groups in Denmark: a qualitative study

OBJECTIVES

To explore barriers in access to dementia care in Turkish, Pakistani and Arabic speaking minority ethnic groups in Denmark.

METHOD

Semi-structured qualitative individual- and group interviews with minority ethnic family carers, primary care dementia coordinators, staff in elderly daycare, and multicultural link workers. Hermeneutic phenomenology was used as theoretical framework.

RESULTS

A total of 21 individual- and 6 group interviews were conducted, including a total of 35 participants. On the service user side, barriers in access to dementia care were related to lacking language proficiency and strong cultural norms, including familial responsibility for the care of older family members and stigma associated with mental illness and dementia. On the care provider side, the available formal services were rarely tailored to the specific needs of minority ethnic service users and were often considered inadequate or unacceptable.

CONCLUSION

Care practices and perceived consequences of dementia in minority ethnic communities were heavily influenced by cultural factors leading to a number of persisting barriers to accessing dementia care services. There is a simultaneous need to raise awareness about dementia and the existence of dementia care services in minority ethnic groups, to reduce stigma, and to develop culturally appropriate dementia care options.

Exploration of the impact of the COVID-19 pandemic on people with dementia and carers from black and minority ethnic groups

INTRODUCTION

Despite community efforts to support and enable older and vulnerable people during the COVID-19 pandemic, many people with dementia and their family carers are still finding it difficult to adjust their daily living in light of the disruption that the pandemic has caused. There may be needs specific to black, Asian and minority ethnic (BAME) populations in these circumstances that remain thus far unexplored.

OBJECTIVE

The aim of the study was to explore the effects of the COVID-19 pandemic on people living with dementia and their family carers of BAME backgrounds, in relation to their experiences of community dementia care and the impact on their daily lives.

DESIGN

15 participants (persons with dementia and carers) were recruited for semistructured qualitative interviews. Respondents were of South Asian and Afro-Caribbean backgrounds. We used thematic analysis to analyse our data from a constructivist perspective, which emphasises the importance of multiple perspectives, contexts and values.

RESULTS

There were a number of ways that the COVID-19 pandemic has impacted BAME persons with dementia and carers with regard to their experiences of dementia community care and the impact on their everyday lives. In particular we identified eight key themes, with subthemes: fear and anxiety, food and eating (encompassing food shopping and eating patterns), isolation and identity, community and social relationships, adapting to COVID-19, social isolation and support structures, and medical interactions. Fear and anxiety formed an overarching theme that encompassed all others.

DISCUSSION

This paper covers unique and underexplored topics in a COVID-19-vulnerable group. There is limited work with these groups in the UK and this is especially true in COVID-19. The results showed that such impacts were far-reaching and affected not only day-to-day concerns, but also care decisions with long-ranging consequences, and existential interests around fear, faith, death and identity.

Telehealth in a Washington, DC African American Religious Community at the Onset of COVID-19: Showcasing a Virtual Health Ministry Project

The COVID-19 pandemic, with its disproportionate health and social-economic effects on the African American community, mandates bold new models to ensure that vulnerable communities receive maximum support and services. This article highlights a social work practice innovation model adapted from a traditional social work casework model. A group of multidisciplinary leaders strategized about ways to meet the needs of older African-American adults as many traditional government agencies were not sending staff into the community due to COVID-19. The result birthed a faith-based virtual health ministry.Using a faith-based virtual health ministry, church lay leaders and other professionals partnered with Master of Social Work (MSW) level social workers using a telehealth platform with technology tools to assist shut-in older adults in Washington, DC. The project uses a structured, coordinated care telehealth support model for a marginalized population. Telehealth within the rubric of healthcare models has not been demonstrated in African American communities, particularly older adults. Meeting the needs of shut-in older adults and marginalized groups within the COVID-19 pandemic may show innovation that can be translational for local governments and traditional safety net providers within a social work milieu.

How to adapt caring services to migration-driven diversity? A qualitative study exploring challenges and possible adjustments in the care of people living with dementia

BACKGROUND

Research on how services can be adapted to meet the needs of people with dementia with an immigrant or minority ethnic background is scarce. Several approaches have been discussed: offering services adapted to language and culture, adding bilingual staff to mainstream services, and providing cultural awareness and sensitivity training to health personnel in mainstream services. This study seeks to develop more knowledge of challenges and possible adjustments related to receive and provide public care for people living with dementia with an immigrant or minority ethnic background.

METHODS AND MATERIALS

Through a qualitative design, including 19 single interviews, 3 dyad interviews and 16 focus groups with older immigrants, relatives of immigrants with dementia, and health personnel, we explored experiences and perceptions related to receive and provide care for people with immigrant backgrounds living with dementia in Norway. The analysis were conducted inspired by Kvale and Brinkmann's three contexts of interpretations.

RESULTS

Challenges related to language and communication were emphasized as the most fundamental barrier to provide adjusted care; exemplified through cases of isolation and agitation among patients not able to communicate. Care services framed by the majority culture creates feelings of alienation and exclusion. Not having access to specific types of food and the possibility to listen to songs, music, literature or TV programs representing a familiar and homely context may prevent use of public dementia care. Findings also point to differences in moral views regarding life-prolonging treatment in advanced stages of dementia.

CONCLUSION

This study argues that to be able to address challenges related to migration-driven diversity one needs holistic care services that addresses individual as well as socio-cultural needs. A linguistically and culturally diverse workforce may represent an important resource, potentially reducing some of the problems related to communication. On a structural level, it seems necessary to allocate more time and resources, including the use of interpreters, when assessing and getting to know persons with dementia with another linguistic and cultural background. However, shared language does not guarantee understanding. Rather, one needs to become familiar with each person's way of being ill, on a cultural and individual level, including changes occurring living with progressive dementia. Getting to know a person and his/her family will also facilitate the possibility to ensure a more familiar and homely context. Thus, continuity in relation to language and culture is important, but continuity in relations may be equally important ensuring that people with dementia receive equitable care.

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.

"It is always me against the Norwegian system." barriers and facilitators in accessing and using dementia care by minority ethnic groups in Norway: a qualitative study

BACKGROUND

Dementia is one of the greatest health challenges in the contemporary world. Due to several barriers to accessing health care services, elderly immigrants constitute a group that poses special challenges in dementia diagnosis and treatment. The aim of this study was to explore the barriers and facilitators in accessing and using dementia care services by minority ethnic groups in Norway.

METHODS

The study utilised a qualitative design. The participants included family caregivers of individuals from minority ethnic groups living with dementia, representatives of immigrant communities, and representatives of health and care personnel working with people living with dementia. Individual semi-structured in-depth interviews were carried out in 2018 and 2019 in Oslo and Akershus. Interviews were analysed using thematic analyses.

RESULTS

Several barriers and facilitators in accessing and using dementia care services were identified, the most important of which were related to lack of knowledge of dementia, lack of awareness of dementia care services, lack of language skills, culturally based differences, the organisation of Norwegian dementia care services, and immigrants' socio-economic status. According to the study participants, having health care personnel in the family and further adaptation of dementia services to the needs of people with different cultural and linguistic backgrounds facilitate access to dementia services.

CONCLUSIONS

The study shows the need to develop inclusive policies that promote a patient-centred approach to ensure that individuals from minority ethnic groups receive appropriate dementia care.

Rotational care practices in minority ethnic families managing dementia: A qualitative study

BACKGROUND

Although minority ethnic families have a lower uptake of dementia care services, little research has explored how minority ethnic carers cope with and manage dementia care in their everyday lives. The aim of this study was to investigate organization of family dementia care in Turkish, Pakistani, and Arabic speaking minority ethnic families from the perspective of family carers, primary care dementia coordinators, and multicultural link workers in Denmark.

METHODS

Semi-structured qualitative individual and group interviews with minority ethnic family carers, primary care dementia coordinators, and multicultural link workers. Hermeneutic phenomenology was used as theoretical framework and results were analyzed using thematic analysis.

RESULTS

A total of 21 individual and four group interviews were conducted, including a total of 30 participants. A key finding was that the care responsibility was usually shared between several family members, who took turns to provide 24-hour care for the person with dementia. Rotational 24-hour care, either by having the person with dementia live with different family members or by having different family members take turns to move in with the person with dementia, emerged as a common alternative to formal care. Another important finding was that despite decreasing the burden of care of individual family carers, rotational care could be confusing and stressful to the person with dementia and could have a negative impact on the quality of life of all involved.

CONCLUSION

The way minority ethnic families organize dementia care have implications for understanding and communicating about support needs. Higher reliance on shared family care should not be taken to indicate that minority ethnic communities are not in need of support from formal services.

Cognitive disorders in migrants: retrospective analysis in a Center for Cognitive Disorders and Dementia in Milan

BACKGROUND

The number of migrants with dementia in Italy might increase considerably over the coming years due to the increasing flow of immigration and the aging of the population.

AIMS

We retrospectively registered rate and characteristics of demented migrant outpatients referred to one hospital in Milan from 2001 to 2017.

METHODS

Information about country of origin of migrants attending general neurology and memory clinics was obtained from their Italian tax code. Socio-demographic, cultural, and clinical characteristics were derived from their medical records.

RESULTS

Migrants with cognitive decline represented a minimal fraction (3.1%) of demented outpatients, but a grow rate of 400% was registered within the period of observation. A linguistic barrier resulted as the main obstacle for the application of available diagnostic tools for dementia.

DISCUSSION/CONCLUSION

Given the above-reported data, the implementation of strategies (such as transcultural diagnostic instruments) and policies dedicated to this growing health problem appears a priority for our health systems.

Understanding dementia in ethnically diverse groups: a qualitative study from Norway

As the number of older immigrants in Europe rises, dementia within minority ethnic populations warrants attention as a significant public health problem. Equitable health and care services constitute a prioritised health policy aim on both supranational and national levels in Europe and is formulated in the Norwegian health legislation. Through interviews and focus groups with older immigrants, relatives of immigrants with dementia and health personnel, we explored the perceptions of dementia among ethnically diverse groups in Norway. The findings show that many interpret symptoms such as memory loss and disorientation as a natural part of ageing. Others consider dementia symptoms to have a psycho-social origin, deriving from social isolation. Some describe symptoms as an expression of a potentially transient sign of madness, while others point to destiny and God's will, representing basic and unalterable causes. However, another pattern of perception includes viewing dementia as a potentially transient physical illness, including a belief in a medical cure. By investigating how people with dementia and their families understand and manage the condition, one may facilitate access to relevant and adapted information. Furthermore, by exploring how people relate to their illness, health personnel may challenge explanatory models that create unrealistic expectations of cure, as well as models that, due to stigma or normalisation of symptoms, prevent the use of public care.

Challenges in diagnosing dementia in patients with a migrant background - a cross-sectional study among German general practitioners

Background

Diagnosing dementia, a syndrome affecting 35.6 million people worldwide, can be challenging, especially in patients with a migrant background. Language barriers and language-based diagnostic tools, cultural differences in the perception of the syndrome as well as restricted access to healthcare can influence medical care. For the first time in Germany, this study investigates whether German general practitioners (GPs) feel prepared to meet the diagnostic needs of these patient groups and whether there are challenges and support needs.

Methods

A cross-sectional study among a random sample of 982 general practitioners in Germany was conducted from October 2017 to January 2018 (response rate: 34.5%). A self-developed, written, standardised questionnaire was used. Descriptive statistics as well as multiple logistic regression analyses were performed using data of 326 GPs.

Results

Ninety-six percent of GPs reported having experienced barriers at least once. Uncertainties in diagnosing dementia in patients with a migrant background were indicated by 70.9%. There was no significant association between uncertainties in diagnosing dementia and GPs’ sociodemographic characteristics. The most frequently reported barriers were language barriers that affected or prevented diagnostics (89.3%) and information deficits in patients with a migrant background (59.2%). Shameful interaction or lack of acceptance of the syndrome was also common (55.5%). A demand for more information about the topic was expressed by 70.6% of GPs.

Conclusions

Public health measures supporting GPs in their interaction with patients with a migrant background as well as information and services for dementia patients are needed. Efforts to facilitate access to interpreting services and to focus on people with a migrant background in healthcare are necessary.

Trial registration

German Clinical Trials Register: DRKS00012503, date of registration: 05/09/2017 (German Institute of Medical Documentation and Information. German Clinical Trials Register (DRKS) 2017). Clinical register of the study coordination office of the University hospital of Bonn: ID530, date of registration: 05/09/2017 (Universitätsklinikum Bonn. Studienzentrum. UKB-Studienregister 2017).

Validation of a European Cross-Cultural Neuropsychological Test Battery (CNTB) for evaluation of dementia

BACKGROUND

The aims of this study were to establish the diagnostic accuracy of the European Cross-Cultural Neuropsychological Test Battery (CNTB) for dementia in different ethnic populations in Western Europe, to examine its ability to differentiate cognitive impairment profiles for dementia subtypes, and to assess the impact of demographic variables on diagnostic properties.

METHODS

The study was a Western European cross-sectional multi-center study. A total of 66 patients with dementia and 118 cognitively intact participants were included across six memory clinics; 93 had ethnic minority background and 91 had ethnic majority background. Tests in the CNTB cover global cognitive function, memory, language, executive functions, and visuospatial functions.

RESULTS

Significant differences with moderate to large effect sizes were present between patients with dementia and control participants on all CNTB measures. Area under the curves (AUC) ranged from .62 to .99 with a mean AUC across all measures of .83. Comparison of ethnic minority and majority groups generally revealed higher sensitivity in the minority group but no significant difference in the mean AUC's across all measures (.84 vs78, P = .42). Comparison of impairment profiles for patients with Alzheimer's disease (AD) and non-AD dementia revealed that AD patients were significantly more impaired on the memory domain, whereas patients with non-AD dementia were more impaired on the executive functions domain.

CONCLUSIONS

The CNTB was found to have promising cross-cultural diagnostic properties for evaluation of dementia in the targeted minority and majority populations and could represent a valid cross-cultural alternative to other well-established neuropsychological test batteries when assessing patients from these populations.

Dementia and immigrant groups: a qualitative study of challenges related to identifying, assessing, and diagnosing dementia

Background

Along with the ageing of the general population, Europe’s migrant populations are also ageing, thus posing new challenges for dementia care services, particularly if the services are to be adjusted to persons with different linguistic and cultural backgrounds. From the perspective of health professionals, this study aims to explore challenges involved in identifying, assessing and diagnosing people with cognitive impairment/dementia who have different linguistic and cultural backgrounds.

Methods

Research on health professionals experiences regarding the management of dementia among immigrants is scarce and qualitative methods was used to address the objective of the study. Using qualitative in-depth interviews and focus-group discussions, we sought to gather participants’ experiences regarding the diagnostic process for immigrants with dementia. The material was analysed and interpreted based on Kvale and Brinkmann’s descriptions of three different contexts of interpretation: self-understanding, critical common-sense understanding, and theoretical understanding.

Results

Health professionals described how families could attribute symptoms of dementia to processes of normal ageing, while others saw the symptoms as something shameful; both instances delayed or hindered help-seeking. Many clinicians had limited experience with older immigrants suffering from dementia, and general practitioners (GPs) in particular experienced difficulties assessing dementia due to language barriers and difficulties related to the involvement of the family or an interpreter. The findings illustrate challenges in assessment, such as unfamiliarity with test situations among those being assessed and lack of knowledge regarding appropriate diagnostic tools among health professionals. Lack of continuity and poor information exchange in the chain of care seem to reinforce many of these challenges.

Conclusions

Detection, treatment and care may be improved if primary care professionals strengthen their cross-cultural competences. Training in communication skills and in the use of cross-cultural assessment tools may help build competence and confidence when assessing and caring for people with different cultural and linguistic backgrounds. Closer collaboration among families, nurses in home-based services, dementia teams, and GPs may facilitate close monitoring of a patient over time. Such collaboration requires sufficient information exchange during transitions in the chain of care, continuity among health professionals, and a shared understanding of the goals for treatment and care.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3720-7) contains supplementary material, which is available to authorized users.

Barriers in general practitioners' dementia diagnostics among people with a migration background in Germany (BaDeMi) - study protocol for a cross-sectional survey

Background

Considering the targeted general practitioner-centred healthcare in Germany, general practitioners (GPs) are in the best possible position to increase awareness of all sorts of dementia, an age-related syndrome with rising relevance in the future. In Germany, a doubling of the number of cases from 1.55 million up to 3 million in 2050 is predicted. Diagnostics can be challenging, especially among patients with a migration background. Complicating factors include: Language-based diagnostic tools, cultural differences in handling the syndrome and its underlying diseases as well as a differing use of the healthcare system. Because of missing research in this field in Germany, the type, frequency and intensity of barriers as well as the way GPs cope with them is unknown. That is why it’s crucial to focus research on diagnostics in total and especially among this population group.

Methods

A cross-sectional study among a random sample of 1000 general practitioners in Germany is conducted in October 2017. A self-administered standardized questionnaire was developed, evaluated and send to the GP practices. A response rate of 30% is expected with one reminder letter. Descriptive statistics as well as, depending on the results, multivariable analyses will be executed. Based on these results and the stated needs, a cluster-randomized intervention study will be constructed to improve healthcare.

Discussion

This study is the first in Germany focusing on how dementia diagnostics in general practice is performed, what problems occur, especially because of a migration background of patients, and how GPs cope with them. Depending on the results, it should emphasize the necessity of dementia diagnostics to be adjusted to the needs of the rising amount of people with a migration background (22.5% in Germany, 2016) like concluded from international studies.

Trial registration

German Clinical Trials Register: DRKS00012503, date of registration: 05.09.2017. Clinical register of the study coordination office of the University hospital of Bonn: ID530, date of registration: 05.09.2017.

Awareness and understanding of dementia in South Asians: A synthesis of qualitative evidence

Background

Despite a growing elderly South Asian population, little is known about the experience of diagnosis and care for those living with dementia. There have been a number of individual qualitative studies exploring the experiences of South Asian people living with dementia and their carers across different contexts. There has also been a growing interest in synthesizing qualitative research to systematically integrate qualitative evidence from multiple studies to tell us more about a topic at a more abstract level than single studies alone. The aim of this qualitative synthesis was to clearly identify the gaps in the literature and produce new insights regarding the knowledge and understanding of the attitudes, perceptions, and beliefs of the South Asian community about dementia.

Methods

Following a systematic search of the literature, included qualitative studies were assessed by two independent reviewers for methodological quality. Data were extracted and pooled using the Joanna Briggs Institute Qualitative Assessment and Review Instrument (QARI). Findings were synthesized using the Joanna Briggs Institute approach to qualitative synthesis by meta-aggregation.

Results

Seventeen papers were critically appraised, with 13 meeting the inclusion criteria. Participants were mostly of South Asians of Indian background; followed by Pakistani with a few Sri Lankans. Missing South Asian countries from the current evidence base included those from Bangladesh, Bhutan, Maldives, and Nepal. Three meta-synthesis themes emerged from the analysis: (1) a poor awareness and understanding of dementia, (2) the experience of caregiving, and (3) the attitudes toward dementia care provision.

Conclusions

A consistent message from this qualitative synthesis was the limited knowledge and understanding of dementia amongst the South Asians. Whilst symptoms of dementia such as ‘memory loss’ were believed to be a part of a normal ageing process, some South Asian carers viewed dementia as demons or God’s punishments. Most studies reported that many South Asians were explicit in associating stigmas with dementia.

Determinants of having no general practitioner in Germany and the influence of a migration background: results of the German health interview and examination survey for adults (DEGS1)

BACKGROUND

It is aspired in the German healthcare system that general practitioners (GPs) act as initial contact for patients and guide through at all steps of medical treatment. This study aims at identifying factors associated with the odds of having no GP within the general population and especially among people with migration background.

METHODS

This cross-sectional analysis was based on the "German Health Interview and Examination Survey for Adults" (DEGS1) conducted by the Robert Koch Institute. Descriptive analyses as well as multiple logistic regression models were performed to analyse the impact of a migration background, age, gender, residential area, socioeconomic status (SES) and other factors on having no GP among 7755 participants.

RESULTS

9.5% of the total study population and 14.8% of people with a migration background had no GP, especially men, adults living in big cities and without chronic diseases. The odds of not having a GP were higher for people with a two-sided migration background (aOR: 1.90, 95% CI: 1.42-2.55). Among the population with a migration background, particularly young adults, men, people living in big cities and having a private health insurance showed higher odds to have no GP.

CONCLUSIONS

It is necessary to investigate the causes of the differing utilization of healthcare of people with a migration background and, if necessary, to take measures for an equal access to healthcare for all population groups. Further research needs to be done to evaluate how to get young people into contact with a GP.

[Prevalence of dementia of insured persons with and without German citizenship : A study based on statuatory health insurance data]

BACKGROUND

Elderly people with a non-German background are a fast growing population in Germany.

OBJECTIVES

Is administrative prevalence of dementia and uptake of nursing-home care similar in the German and non-German insured?

MATERIALS AND METHODS

Based on routine data, administrative prevalence rates for dementia were calculated for 2013 from a full census of data from one large sickness fund. Patients with dementia (PWD) were identified via ICD-10 codes (F00; F01; F03; F05; G30).

RESULTS

Administrative prevalence of dementia was 2.67% in the study population; 3.06% in Germans, and 0.96% in non-Germans (p value <0.001). Age and sex adjusted prevalence was comparable in the insured with and without German citizenship, except in women aged 80-84 (17.2 vs. 15.4) and for men in the age groups 80-84 (16.5 vs. 14.2), 85-89 years (23.4 vs. 21.5), and above 90 years of age (32.3 vs. 26.3). Standardized to the population of all investigated insured, 31.4% of all Germans with dementia had no longterm care entitlement vs. 35.5% of all patients without German citizenship. Of German patients, 55.1% were institutionalized vs. 39.5% of all patients without German citizenship.

CONCLUSIONS

There was a higher prevalence of dementia in the very old insured without German citizenship compared to those with German citizenship, especially in men. Non-Germans showed lower uptake of nursing home care compared to Germans. Additionally, Germans had slightly higher nursing care entitlements. It should be investigated further how much of the difference is due to underdiagnosis, cultural differences, or lack of adequate diagnostic work-up.

Dementia and Migration: Family Care Patterns Merging With Public Care Services

This article focuses on cognitive impairment and dementia in the context of transnational migration. Based on data from focus group discussions and interviews, we conclude that to adjust to the needs of care within ethnic-minority communities, it is important to consider not only the availability of household and kin members but also the present understanding of obligation and reciprocity underlying the perception of care. Another important issue to realize is that caregivers, women in particular, might feel obliged to conform to a traditional caregiver role, but without the support from a wider extended family, and in the context of other pressing roles and duties. Consequently, health personnel should be wary of stereotyping and generalizing groups through "othering" ideologies and rather try to explore, understand, and adjust to the present and often fluctuating set of needs, as well as be aware of how and by whom these needs are articulated.

Caring for Ethnic Older People Living with Dementia - Experiences of Nursing Staff

The total number of persons living with dementia is estimated to double every 20 years and ageing migrant populations are growing in several countries. There are gaps in the health and social care of people from other countries, regardless of the efforts made when someone has a dementia diagnosis; similarly, receiving care in sheltered accommodation is less common. The aim of this study was to explore and describe the nursing staff's experiences of caring for non-Swedish speaking persons living with dementia in a Finnish speaking group home in relation to a Swedish speaking group home in Sweden. 27 qualitative semi-structured interviews were analysed using qualitative content analyses. The first main category, "communication", concentrated on language abilities and deficiencies, non-verbal language, highlighting the consequences of not understanding and the benefits of a common language. The second main category, "culturally oriented activities", focused on being served traditional food, celebrating holidays at the group home, the importance of traditions and the importance of familiar music as cultural elements. The Swedish speaking nursing staff could provide qualitative and equitable care, but the challenge was greater for them than for the bilingual nursing staff who spoke the same language as the residents.

Exploring family stigma among caregivers of persons with Alzheimer's disease: The experiences of Israeli-Arab caregivers

Providing care to persons with Alzheimer's disease poses challenges for spouses and adult children, including experiencing stigmatic beliefs towards themselves-i.e., family stigma. Drawing on the frameworks of ethnicity and stigma and ethnicity and dementia, the current study explored stigmatic experiences among Israeli Arab family caregivers of a person with Alzheimer's disease. Three focus groups with 20 caregivers (adult children and spouses) of persons with Alzheimer's disease were conducted. Data were analyzed using theory-led thematic analysis. Caregivers reported experiencing family stigma in two dimensions: public and affiliate stigma, in both the existence of an attribution process in which cognitive stereotypes elicit negative and positive emotions which in turn provoke behavioral attributions, was evident. Family stigma was found to be a discernible feature of everyday reality among Israeli Arab caregivers of persons with Alzheimer's disease and stress the importance of developing management strategies that are tailored to the socio-cultural characteristics of the caregivers.

Personhood in dementia care

Dementia has been understood primarily as a biomedical phenomenon with a trajectory of irrevocable decline related to neurodegenerative changes. However, growing evidence suggests that the performance and behaviour of persons with dementia are not exclusively determined by neuropathology but are also influenced by personal histories, social interactions and social contexts. This evidence shifts attention from the disease process to the need for a more in-depth understanding of the place of personhood in dementia care. Despite its intuitive appeal however, there is limited empirical research grounding this approach to care. This article articulates a framework for organizing research in this area that is based on a critical review and synthesis of research. It encompasses three interrelated and intersecting domains of inquiry: the subjective experience of the person with dementia, the immediate interactional environment and the broader socio-cultural context. Each domain encapsulates a unique but interrelated dimension of a person-centred approach to dementia care.

Dementia care in England and the social model of disability

This article reviews the development of a social model of disability and considers whether or not it provides a helpful framework for dementia care. The social model has not yet fully included cognitive impairment, although considerable work has been carried out with regard to learning disability. By applying this model to dementia care, those who surround people with dementia can review the impact that they as 'non-demented' people have on others; can reconsider the value of hearing and responding to personal experiences; can reframe the focus to consider abilities instead of losses; and can better understand the impact of public policy. The article also considers the present shortcomings of a disability model in terms of how it relates to dementia care and concludes with some thoughts for future consideration. The article draws heavily on the findings of a research project conducted by Dementia Voice and the University of the West of England, Bristol, UK to consider the needs of two sub-groups of people with dementia – younger people (i.e. those under the age of 65) and those from minority ethnic groups.

Black African and Caribbean British Communities' Perceptions of Memory Problems: "We Don't Do Dementia."

Objectives

We aimed to identify and explore the barriers to help-seeking for memory problems, specifically within UK Black African and Caribbean communities.

Method

We purposively recruited participants from community groups and subsequent snowball sampling, to achieve a maximum variation sample and employed thematic analysis. Our qualitative semi-structured interviews used a vignette portraying a person with symptoms of dementia, and we asked what they or their family should do. We stopped recruiting when no new themes were arising.

Results and significance

We recruited 50 people from a range of age groups, country of origin, time in the UK, religion and socio-economic background. Some of the barriers to presentation with dementia have been reported before, but others were specific to this group and newly identified. Many people recognised forgetfulness but neither that it could be indicative of dementia, nor the concept of dementia as applying to them. Dementia was viewed as a white person’s illness. Participants felt there was little point in consulting a doctor for forgetfulness. Many thought that seeing a GP was only for severe problems. Some said that their culture was secretive and highly valued privacy of personal affairs and therefore did not want to discuss what they regarded as a private and stigmatising problem with a GP. Participants did not appreciate their GP could refer to memory services who have more time and expertise. They were concerned about harm from medication and compulsory institutionalisation. Care should be from the family. Any intervention should emphasise the legitimacy of seeing a doctor early for memory concerns, that dementia is a physical illness which also occurs in the Black community, that help and time are available from memory services whose role is to prolong independence and support families in caring.

Immigrants with dementia in Swedish residential care: an exploratory study of the experiences of their family members and Nursing staff

BACKGROUND

Worldwide, there is a growing population of older people who develop dementia in a country other than that of their origin. When their dementia has reached an advanced stage, residential care is most often needed. People with dementia in Sweden are often cared for in group homes. For immigrants, this may mean a linguistically challenging care environment for both healthcare staff and the patients' family members. The aim of this study was to explore and describe the experiences of family members and professional caregivers regarding the care provided to immigrants with dementia in group homes in Sweden.

METHODS

An exploratory, descriptive study with a qualitative approach was chosen. In-depth semi-structured interviews were conducted with nine professional caregivers and five family members of people with dementia with Finnish, Estonian, Hungarian and Ingrian backgrounds; all were chosen purposefully. All people with dementia had lost their Swedish language skills as their second language. The data was analysed using qualitative content analysis.

RESULTS

Three main categories and seven subcategories were identified. The first main category: A new living situation comprised the subcategories: adjusting to new living arrangements and expectations regarding activities and traditional food at the group home, the second main category: Challenges in communication with the subcategories: limited communication between the immigrant with dementia and the Swedish-speaking nursing staff and the consequences of linguistic misunderstandings and nuanced communication in a common language and the third main category: The role of the family member at the group home with the subcategories: a link to the healthy life story of the family member with dementia and an expert and interpreter for the nursing staff.

CONCLUSIONS

The family member played a crucial role in the lives of immigrants with dementia living in a group home by facilitating communication between the nursing staff and the PWD and also by making it possible for PWD to access the cultural activities they wanted and which professional caregivers were either not able to recognise as needed or could not deliver.

Euthanasia and physician-assisted suicide in dementia: A qualitative study of the views of former dementia carers

BACKGROUND

Despite media and academic interest on assisted dying in dementia, little is known of the views of those directly affected.

AIM

This study explored the views of former carers on assisted dying in dementia.

DESIGN

This was a qualitative study using thematic analysis.

SETTING/PARTICIPANTS

A total of 16 former carers of people with dementia were recruited through national dementia charities and participated in semi-structured interviews.

RESULTS

While many supported the individual's right to die, the complexity of assisted dying in dementia was emphasized. Existential, physical, psychological and psychosocial aspects of suffering were identified as potential reasons to desire an assisted death. Most believed it would help to talk with a trained health professional if contemplating an assisted death.

CONCLUSION

Health workers should be mindful of the holistic experience of dementia at the end of life. The psychological and existential aspects of suffering should be addressed, as well as relief of physical pain. Further research is required.

Dementia in a Black and minority ethnic population: characteristics of presentation to an inner London memory service

Aims and method To examine data on referrals to an inner-city London memory service to explore any differences in referral rates, cognitive assessments and stages of dementia at presentation between ethnic groups. Results African-Caribbean patients were well represented in the memory service. They were diagnosed with dementia on average 4.5 years younger than their White British counterparts and were more likely to be diagnosed with a vascular or mixed type dementia. However, scores on initial cognitive testing were significantly lower in the African-Caribbean group, possibly representing more advanced disease at presentation. Clinical implications Initiatives to access Black and minority ethnic populations earlier in the course of their illness should be considered. Professionals need to consider the potential for cultural bias in memory testing and diagnosing dementia in these populations, and the importance of cultural competency in assessments.

Help-seeking for dementia: a systematic review of the literature

BACKGROUND

Help-seeking (HS) for dementia presents a great challenge, especially because a timely and appropriate HS process might be associated with better outcomes for the person with dementia, their caregivers, and society. A clear understanding of the HS concept and its measurement in the area of dementia might improve the effectiveness of the process.

AIMS

The aims of our systematic review were: (1) to systematically obtain and evaluate the relevant literature on HS and dementia; and (2) to summarize current research findings and draw conclusions for future research and clinical care in this area.

METHOD

A systematic review of the literature on HS and dementia was conducted up till June 2013.

RESULTS

From the 478 retrieved articles, 48 were included in the review. Conceptually, the studies examined professional and nonprofessional sources of help; showed preference for seeking help from close relatives followed by primary health caregivers; and identified inadequate knowledge and stigmatic beliefs as the main barriers to HS. The majority of the studies did not rely on a theoretical framework.

CONCLUSIONS

Although the body of literature in the area of HS and dementia is growing, several conceptual and methodological limitations still have to be resolved to advance knowledge in the area.

The use and misuse of short cognitive tests in the diagnosis of dementia

Short cognitive tests are widely used in medicine to assess patients with memory problems but their role in the assessment of patients with cognitive problems is often misunderstood. They are a part of the examination of the patient and not tests for dementia or 'case-finding tools'. This misunderstanding leads to widespread misconceptions concerning short cognitive tests and could lead to major over diagnosis or under diagnosis of dementia. Their use in clinical practice particularly in response to national directives aimed at increasing diagnosis rates in dementia needs a clear understanding of their role and limitations. A new classification of short cognitive tests is proposed with guidance on their use in clinical medicine.

Dementia and migration: Pakistani immigrants in the Norwegian welfare state

This article is about dementia disease in the context of transnational migration. Focusing on the example of Pakistani immigrants in Norway, the article explores response processes surrounding signs and symptoms of dementia. Particular attention is lent to understanding how Norwegian-Pakistani families ‘negotiate dementia’ in the space between their own imported, culturally defined system of cure and care, and the Norwegian health-care culture, which is characterised by an inclination towards public care and biomedical intervention. Based on field observations and in-depth interviews with Norwegian-Pakistani families and hospital professionals working with dementia, we show that the centrality of the traditional family in Norwegian-Pakistanis' identity claims has significant implications for how Norwegian-Pakistanis relate to the Norwegian health-care culture, and for how signs and symptoms of cognitive decline are read and responded to in a migratory context.

Evolution of a community-based participatory approach in a rural and remote dementia care research program

BACKGROUND

Community-based participatory research (CBPR) approaches are valuable strategies for addressing complex health and social problems and powerful tools to support effective transformation of social and health policy to better meet the needs of diverse stakeholders.

OBJECTIVES

Since 1997, our team has utilized CBPR approaches to improve health service delivery for persons with dementia and their caregivers in rural and remote settings. We describe the evolution of our approach, including benefits, challenges, and lessons learned over the last 15 years.

METHODS

A multistage approach initiated an ongoing CBPR research program in rural dementia care and shaped its direction based on stakeholders' recommendation to prioritize both community and facility-based care. Strategies to develop and foster collaborative partnerships have included travel to rural and remote regions, province-wide community meetings, stakeholder workshops, creation of a Decision-Maker Advisory Council to provide ongoing direction to the overall program, development of diverse project-specific advisory groups, and a highly successful and much anticipated annual knowledge exchange and team-building event.

LESSONS LEARNED

Partnering with stakeholders in the full research process has enhanced the research quality, relevance, application, and sustainability. These benefits have supported the team's evolution from a relatively traditional focus to an integrated approach guiding all aspects of our research.

CONCLUSIONS

Developing and sustaining the full range of stakeholder and decision-maker partnerships is resource-and time-intensive, but our experience shows that community-based participatory strategies are highly suited to health services research that is designed to support sustainable service delivery improvements.

A qualitative study into the use of formal services for dementia by carers from culturally and linguistically diverse (CALD) communities

Background

People with dementia and their family carers need to be able to access formal services in the community to help maintain their wellbeing and independence. While knowing about and navigating one’s way through service systems is difficult for most people, it is particularly difficult for people from culturally and linguistically diverse (CALD) communities. This study addresses a lack of literature on the use of formal services for dementia by people from CALD backgrounds by examining the experiences and perceptions of dementia caregiving within four CALD communities – Italian, Chinese, Spanish and Arabic-speaking – in south western Sydney, Australia.

Methods

The study used a qualitative design and the methods included focus groups with family carers and one-to-one interviews with bilingual/bicultural community workers, bilingual general practitioners and geriatricians. A total of 121 family carers participated in 15 focus groups and interviews were held with 60 health professionals. All fieldwork was audiotaped, transcribed and subjected to thematic analysis.

Results

People from CALD communities are often unfamiliar with the concept of formal services and there may be strong cultural norms about maintaining care within the family, rather than relying on external services. CALD communities often have limited knowledge of services. There is a preference for services that will allow families to keep their relative at home, for safety as well as cultural reasons, and they are particularly reluctant to use residential care. While there is a preference for ethno-specific or multicultural services, mainstream services also need to ensure they are more flexible in providing culturally appropriate care. Positive outcomes occur when ethno-specific services work in partnership with mainstream programs. Dementia service providers need to develop a trusting relationship with their local CALD communities and promote their services in a way that is understandable and culturally acceptable to members of these communities.

Conclusions

While members of CALD communities may have difficulties accessing formal services, they will use them if they are culturally and linguistically appropriate and can meet their needs. There are a number of ways to improve service provision to CALD communities and the responsibility for this needs to be shared by a range of stakeholders.

Comparison of performance on three neuropsychological tests in healthy Turkish immigrants and Danish elderly

BACKGROUND

Appropriate neuropsychological tests for cross-cultural assessment of dementia in elderly ethnic and linguistic minorities are generally lacking in Europe. The aim of this study was to investigate the cross-cultural applicability of the Recall of Pictures Test (RPT), Clock Reading Test (CRT), and supermarket fluency (SF) in samples of Turkish immigrants and Danish elderly.

METHODS

Samples of Turkish immigrants and Danish elderly were recruited from the Greater Copenhagen area. All participants were screened for factors known to affect cognitive test performance. Those who were included in the study underwent an approximately two-hour assessment, where the RPT, CRT, and SF were applied as a part of a comprehensive battery of neuropsychological tests.

RESULTS

A total of 109 elderly participants were included in the study: 73 Turkish and 36 Danish. Significant differences were found between the Turkish and Danish samples in CRT and SF performances, but not in any of the RPT measures. Age and acculturation level were the only demographic variables with significant impact on test performances. Performance data for the three tests are presented as percentiles.

CONCLUSIONS

Although small differences were observed between the Turkish and Danish samples on the CRT and SF, we consider the three tests to be important neuropsychological tests for assessment of dementia in elderly patients from ethnic minority migrant populations.

Pathways to dementia diagnosis among South Asian Canadians

Urban centers are increasingly ethnically diverse. However, some visible minorities are less likely than their majority counterparts to seek and receive services and treatment for dementia. This study explored experiences of South Asian Canadians, Canada's largest visible minority group, prior to dementia diagnosis. Six persons with dementia and eight of their family carers described their early perceptions of dementia-related changes, actions taken, including help seeking and diagnosis, and affective responses. Early signs were attributed to aging or personality. Even after cognitive enhancers were prescribed, some respondents continued to believe that the dementia symptoms were 'normal'. Family carers' affective responses may be related to their attributions. Before seeking medical attention, family carers modified physical or social environments because of symptoms. Help seeking was delayed up to four years, even with significant dementia symptoms. Recognition of a health problem was influenced by safety concerns, emergence of new symptoms following trauma, and treatment for other health problems. For some, relatives living outside the home or outside Canada were instrumental in recognizing a problem and convincing family carers and persons with dementia to seek medical attention. The pathway to diagnosis might be easier with outreach to help South Asian immigrants differentiate between normal aging and dementia. Symptom recognition by physicians treating other acute conditions was a portal to dementia services for others. Screening and referral in acute care could result in earlier diagnosis and treatment.

Geographic distribution of dementia mortality: elevated mortality rates for black and white Americans by place of birth

We hypothesized that patterns of elevated stroke mortality among those born in the United States Stroke Belt (SB) states also prevailed for mortality related to all-cause dementia or Alzheimer Disease. Cause-specific mortality (contributing cause of death, including underlying cause cases) rates in 2000 for United States-born African Americans and whites aged 65 to 89 years were calculated by linking national mortality records with population data based on race, sex, age, and birth state or state of residence in 2000. Birth in a SB state (NC, SC, GA, TN, AR, MS, or AL) was cross-classified against SB residence at the 2000 Census. Compared with those who were not born in the SB, odds of all-cause dementia mortality were significantly elevated by 29% for African Americans and 19% for whites born in the SB. These patterns prevailed among individuals who no longer lived in the SB at death. Patterns were similar for Alzheimer Disease-related mortality. Some non-SB states were also associated with significant elevations in dementia-related mortality. Dementia mortality rates follow geographic patterns similar to stroke mortality, with elevated rates among those born in the SB. This suggests important roles for geographically patterned childhood exposures in establishing cognitive reserve.

Quality of dementia diagnostic evaluation for ethnic minority patients: a nationwide study

BACKGROUND/AIMS

Diagnostic evaluation of dementia for ethnic minority patients may be challenging. This study aimed to evaluate the quality of diagnostic evaluation of dementia for patients from ethnic minorities in Denmark.

METHODS

The Danish national hospital registers were used to identify patients from the main ethnic minority groups in Denmark, who were diagnosed with dementia in the period 2005-2007. Three raters independently reviewed the patients' medical records. Data were compared to data from a previous similar study in the general Danish population.

RESULTS

Fifty-seven medical records were reviewed. An acceptable diagnostic workup was documented in only 23% of the patients. Dementia diagnosis was confirmed in 35%. Significant differences in the quality of the diagnostic evaluation were found between patients from ethnic minorities and the general population.

CONCLUSION

There are significant ethnic disparities in the quality of diagnostic evaluations and outcome of dementia in the secondary healthcare sector.

The role of the bilingual/bicultural worker in dementia education, support and care

Members of minority populations often have difficulty knowing about and accessing dementia services. One of the strategies used to promote access is the employment of bilingual/bicultural workers (sometimes referred to as multicultural, link or outreach workers). This study involved interviews with 24 bilingual/bicultural workers in south western Sydney, Australia to gain a better understanding of their role within the dementia field. Seven themes emerged: importance of working with family; process of building trust when moving between two cultures; importance of understanding the culture; self-care and culture; flexibility of their role; linking community members; and linking communities to mainstream services. Bilingual/bicultural workers play a significant and complex role in supporting individuals and families within their community who are affected by dementia. The significance of their role needs to be more clearly acknowledged in the development of policy, further research and service provision within the dementia field.

Research and dementia, caring and ethnicity: a review of the literature

Despite the need for services which are culturally appropriate there is a dearth of robust research on the impact of ethnic background on dementia and caregiving. A literature search has revealed a relative lack of published research from the UK, with more US studies available. This paper provides a review of the literature on these topics and includes a critique of ethnicity categorisation and commonly held assumptions. It explores the complexities of the concept of ethnicity and examines its significance in relation to understandings of health and illness in general, and dementia in particular. Ethnic background appears to account for differences in experiences of dementia and caregiving, but other compounding variables, including socio-economic factors and education, also need to be taken into account when considering the experiences of specific ethnic communities. The paper concludes that ethnicity is significant in regard to how people experience dementia and caregiving, but also highlights a continuing need for research which explores the impact of ethnic background in a sensitive and sophisticated manner.