How do elderly spouse care givers of people with Alzheimer disease experience the disclosure of dementia diagnosis and subsequent care?

Focus Group Study of Medical Stakeholders to Inform the Development of Resilient Together for Dementia: Protocol for a Postdiagnosis Live Video Dyadic Resiliency Intervention

BACKGROUND

Alzheimer disease and related dementias (ADRD) are increasingly common conditions that disrupt the lives of persons living with dementia and their spousal care partners. At the time of ADRD diagnoses, many couples experience challenges that produce emotional distress and relationship strain. At present, there are no interventions to address these challenges early after diagnoses to promote positive adjustment.

OBJECTIVE

The study protocol described here is part of the first phase of a larger program of research that aims to develop, adapt, and establish the feasibility of Resilient Together for Dementia (RT-ADRD), a novel dyadic skills-based intervention to be delivered over live video early after diagnosis, with the goal of preventing chronic emotional distress. This study will elicit and systematically summarize perspectives of ADRD medical stakeholders to inform the procedures (eg, recruitment and screening methods, eligibility, timing of intervention, and intervention delivery) of the first iteration of RT-ADRD prior to pilot-testing.

METHODS

We will recruit interdisciplinary medical stakeholders (eg, neurologists, social workers, neuropsychologists, care coordinators, and speech language pathologists) from academic medical center clinics in the departments treating persons living with dementia such as neurology, psychiatry, and geriatric medicine via flyers and word-of-mouth referrals from clinic directors and members of relevant organizations (eg, dementia care collaboratives and Alzheimer disease research centers). The participants will complete electronic screening and consent procedures. Consenting individuals will then participate in a 30- to 60-minute qualitative virtual focus group, held either via telephone or Zoom, using an interview guide designed to assess provider experiences with postdiagnosis clinical care and to gather feedback on the proposed RT-ADRD protocol. The participants will also have the opportunity to participate in an optional exit interview and web-based survey to gather additional feedback. Qualitative data will be analyzed using a hybrid inductive-deductive approach and the framework method for thematic synthesis. We will conduct approximately 6 focus groups with 4-6 individuals in each group (maximum N=30 individuals; until saturation is reached).

RESULTS

Data collection began in November 2022 and will continue through June 2023. We anticipate that the study will be completed by late 2023.

CONCLUSIONS

The results from this study will inform the procedures of the first live video RT-ADRD dyadic resiliency intervention focused on the prevention of chronic emotional and relational distress in couples shortly after ADRD diagnoses. Our study will allow us to gather comprehensive information from stakeholders on ways to best deliver our early prevention-focused intervention and gain detailed feedback on study procedures prior to further testing.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/45533.

Experiences of people with dementia and informal caregivers with post-diagnostic support: Data from the international COGNISANCE study

OBJECTIVES

The study aims to describe people with dementia and informal caregivers' respective experiences of support after diagnosis and compares these experiences. Additionally, we determine how people with dementia and informal caregivers who are satisfied with support differ from those dissatisfied.

METHODS

A cross-sectional survey study in Australia, Canada, the Netherlands, Poland, and United Kingdom was carried out to examine people with dementia and informal caregivers experience with support (satisfaction with information, access to care, health literacy, and confidence in ability to live well with dementia). The separate surveys contained closed questions. Analysis consisted of descriptive statistics and Chi-square tests.

RESULTS

Ninety people with dementia and 300 informal caregivers participated, and 69% of people with dementia and 67% of informal caregivers said support after diagnosis helped them deal more efficiently with their concerns. Up to one-third of people with dementia and informal caregivers were dissatisfied with information about management, prognosis, and strategies for living positively. Few people with dementia (22%) and informal caregivers (35%) received a care plan. People with dementia were more often satisfied with information, had more often confidence in their ability to live well with dementia, and were less often satisfied with access to care compared to informal caregivers. Informal caregivers who were satisfied with support were more satisfied with information and access to care compared to informal caregivers not satisfied with support.

CONCLUSIONS

Experience of dementia support can be improved and people with dementia and informal caregiver differ in their experiences of support.

Truth, hope and the disclosure of a dementia diagnosis: A scoping review of the ethical considerations from the perspective of the person, carer and clinician

This paper explores contemporary approaches to balancing truth with the provision of hope during the disclosure of a dementia diagnosis. We discuss the ethical significance of these practices as they relate to each member of the triad - the person, the carer and the clinician - at the point of diagnosis and beyond. The process of disclosing a diagnosis of dementia is complex. It encompasses breaking bad news while balancing hope, with truth about a progressive life-limiting condition. The process of receiving the diagnosis likewise challenges the person who may be unprepared for the diagnosis, while carers seek information and supports. The impact of receiving a diagnosis of dementia can be life-changing and harmful at the personal level - for both the person and carer. This risk of harm becomes a critical consideration for clinicians when deciding on the level of truth: what information should be relayed and to whom? That risk is also balanced against the ethical issue of patient autonomy, which includes the right to know (or not) and make informed decisions about therapeutic interventions. While the consensus is that the autonomy of the person living with dementia must be upheld, controversy exists regarding the extent to which this should occur. For instance, at diagnosis, it is common for clinicians to use euphemisms rather than the word dementia to maintain hope, even though people and carers prefer to know the diagnosis. This practice of therapeutic lying is a pervasive ethical issue in dementia care, made more acceptable by its roots in diagnosis disclosure.

Challenges in disclosing and receiving a diagnosis of dementia: a systematic review of practice from the perspectives of people with dementia, carers, and healthcare professionals

BACKGROUND

Disclosing a diagnosis of dementia is a key process involving people with dementia, carers, and healthcare professionals (HCPs) that can facilitate access to treatment and support. Receiving a diagnosis of dementia may represent a change in identity and loss of a planned-for future, resulting in an emotional impact for both people with dementia and carers. Delivering the diagnosis of dementia can be difficult and draining for HCPs.

METHODS

We conducted a systematic review that included studies which explored the experience of giving or receiving a diagnosis of dementia from the perspectives of people with dementia, carers, or HCPs. All study designs were eligible except for previous literature reviews. Findings were analyzed thematically and grouped into categories and then synthesized into a narrative review. The quality of all included studies was assessed.

RESULTS

Fifty-two studies were included in this review. Findings indicated that receiving a diagnosis is generally a negative process for people with dementia, carers, and HCPs and leaves carers in particular feeling uncertain over the prognosis and future of the person they care for. Disclosing a diagnosis of dementia is a difficult and complex process, for which formal training and guidance is lacking. Carers in particular would welcome more opportunity for realistic and hopeful discussions of the implications of receiving a diagnosis of dementia.

CONCLUSIONS

Changes in some aspects of disclosure, such as providing a truthful diagnosis to the person with dementia, have occurred over the last decade. A process approach involving pre-diagnostic counseling and follow-up appointments could enable discussions regarding prognosis and the future, create opportunities to clarify the diagnosis, and reduce emotional burden on HCPs. There is a need for more objective evidence that considers the perspectives of all individuals involved.

Ambivalent anticipation: How people with Alzheimer's disease value diagnosis in current and envisioned future practices

Emergent biomarkers for Alzheimer's disease (AD) are expected to provide earlier and more precise diagnoses. However, even if biomarkers live up to these expectations, it cannot be taken for granted that patients actually would value an earlier and more precise AD diagnosis. Based on an interview study, we aim to give more insight into the value of an AD diagnosis for patients, in existing as well as future practices, by describing how a diagnosis enables or may enable knowing, foreseeing, and acting in relation to one's illness. Our findings show that how people with AD value a diagnosis is not only characterised by great variety, as previous studies have shown, but also by profound ambivalence for the individual. With lack of treatment and poor prognostics as the status quo, this ambivalence and the way people deal with it are particularly linked to the far-from-straightforward capacity of an AD diagnosis to support anticipation of the future. We argue that in otherwise unchanged practices the envisioned future biomarker-based diagnostics are unlikely to reduce the ambivalence about receiving an AD diagnosis and, in particular, the challenges of anticipation that it entails. Rather, biomarker-based innovations may even reinforce some of the main issues involved.

Review of the Content and Quality of Mobile Applications About Alzheimer's Disease and Related Dementias

This study reviewed the content of mobile applications (apps) providing Alzheimer's disease or related dementias (ADRD) information and assessed quality of the apps. Characteristics, content, and technical aspects of 36 apps in the U.S. Google Play Store and App Store were coded, and quality of the apps was evaluated using the Mobile Application Rating Scale. Caregiving (62.1%) and disease management (55.6%) content was frequently provided. Few apps had an app community (8.3%) or a reminder function (8.3%). Overall, quality of the apps was acceptable; apps by health care-related developers had higher quality scores than those by non-health care-related developers. This analysis showed that ADRD-related apps provide a range of content and have potential to benefit caregivers, individuals with ADRD, health care providers, and the general public. Collaboration of ADRD experts and technology experts is needed to provide evidence-based information using effective technical functions that make apps to meet users' needs.

Needs of persons with dementia and their family caregivers in dementia cafés

BACKGROUND AND AIMS

Several studies have shown the effectiveness and diversity of dementia cafés, whereas there are few published articles in academic research focusing on what persons with dementia and their family caregivers need and whether the services provided satisfy their needs. This study aimed to identify the needs of persons with dementia and their family caregivers participating in dementia cafés in Japan.

METHODS

Interviews and participant observations were conducted in nine dementia cafés. Study participants were persons with dementia, their caregivers, and the staff in dementia cafés. Data were analysed using qualitative content analysis.

RESULTS AND DISCUSSION

A total of 24 participants were recruited. Needs for persons with dementia were subdivided into five categories: to express their feelings about their current condition; to be accommodated through consideration of their physical and cognitive status; for changes in their health conditions to be noticed; to enjoy entertainment; and to keep in touch with others inside and outside of the dementia café. Needs for family caregivers were subdivided into four subcategories: to express their feelings such as anxiety and guilt and complaints regarding caregiving; to consult about difficulties in daily life; to listen to other family caregivers' experiences; and to keep in touch with others inside and outside of the dementia café. The needs of persons with dementia and family caregivers differ partly.

CONCLUSIONS

Dementia cafés should create programmes and comfortable environments answering to the differences of their needs.

Impact of disclosure of a dementia diagnosis on uptake of support services: A pilot study exploring a post-traumatic stress approach

BACKGROUND

At time of diagnosis, people with dementia and their carers can access support services to help them to plan for their future care needs, but often they do not engage with these services. It is not clear why this occurs but a potential explanation explored in this paper is that disclosure of a dementia diagnosis is an overwhelming and highly stressful event that may lead to behavioural avoidance in the manner of post-traumatic stress. In this study we use a post-traumatic stress screening tool to determine whether being diagnosed with dementia shares some qualitative similarities with post-traumatic stress disorder and explore whether this is associated with a reduced likelihood to engage support services following diagnosis.

METHOD

We conducted a small pilot study through the local memory clinic with eight people with dementia and 11 carers returning surveys. Participants completed the Impact of Events Scale-Revised, a validated post-traumatic stress disorder screening tool, and also provided information regarding their experience of the diagnosis and subsequent use of support services.

RESULTS

One person with dementia and two carers had scores on the Impact of Events Scale-Revised indicating a probable diagnosis of post-traumatic stress disorder and two people with dementia and two carers scored within the range of clinical concern. The average Impact of Events Scale-Revised score of those who had taken-up a referral to home support was significantly lower than those who had not.

CONCLUSION

A dementia diagnosis can be associated with symptoms that are consistent with post-traumatic stress, which in turn may affect engagement with support services.

Transitioning into the caregiver role following a diagnosis of Alzheimer's disease or related dementia: A scoping review

OBJECTIVES

To identify experiences, needs, interventions and outcomes for caregivers of persons with Alzheimer's disease or related dementia as they transition into this new role following diagnosis.

DESIGN

Scoping review of published literature.

DATA SOURCES

A search for published articles was conducted in PsycINFO, Scopus, Ovid and Web of Science databases.

REVIEW METHODS

The Arksey and O'Malley methodological framework guided the review. Studies were screened independently for inclusion by two persons. A total of 955 studies, after duplicates removed, were found by the database search. From these, 127 full-text articles were retained through the screening of titles and abstracts by two reviewers. The two reviewers assessed 46 full-text articles for eligibility. The final 29 studies identified caregiver experiences, needs, and interventions during the period following a diagnosis of Alzheimer's disease or related dementia in the scoping review.

RESULTS

Twenty-nine studies were organized around three major categories: i) family caregiver experiences on receiving the diagnosis (n = 23), ii) needs during this time of transition (n = 18), and iii) interventions and outcomes to support their transition into the caregiver role (n = 5). While studies may have addressed more than one topic, 16 studies intersected categories of both caregiver experience and needs, and one study intersected categories of needs and interventions. There were several studies that focused more specifically on the caregiver's initial reactions to a diagnosis of Alzheimer's disease or related dementia (n = 9), the emotional responses to the diagnosis (n = 14), changes in personal relationships and responsibilities with a new role (n = 16). Caregiver needs following the diagnosis included knowledge and information (n = 14), emotional and psychological support (n = 11), and assistance with care planning (n = 7). Five papers examined interventions specifically tailored to caregiver needs at this juncture, which support the transition into the caregiver role.

CONCLUSIONS

The time of receiving a diagnosis of Alzheimer's disease or related dementia is a critical period in the process of transitioning into caregiver role. This period marks a new phase in the process of caring by family caregivers. Thus, it is important to fully understand the experiences and needs of caregivers and effective interventions in order to better support their transition into this new role.

Trapped like a butterfly in a spider's web: Experiences of female spousal caregivers in the care of husbands with severe mental illness

AIMS AND OBJECTIVES

To explore the experiences of female spousal caregivers in the care of husbands with severe mental illness.

BACKGROUND

Family involvement in the care of patients with chronic illness is essential to provide a backbone of support for them. However, little is known about how female spousal caregivers are confronted with challenges while taking care of their husbands with severe mental illness.

DESIGN

An exploratory qualitative study.

METHODS

Fourteen female spousal caregivers of people with severe mental illness (defined here as schizophrenia, schizoaffective disorders and bipolar affective disorders) were recruited using purposive sampling and were interviewed using a semistructured in-depth interview method. Data were analysed by conventional content analysis until data saturation was achieved.

RESULTS

Care of a husband with severe mental illness had a disruptive influence on the emotional relationships of the family and resulted in emotional detachment over time. Despite the caregivers' struggle to protect their families, the lack of supportive resources caused emotional exhaustion. Caregiving tasks interfering with their many other responsibilities, along with being a reference for family matters, led to loss of self. Consequently, they experienced psychological distress because of the transition to a caregiver role without any supportive resources.

CONCLUSION

Constant caring, without supportive resources, forced them to do various roles and manage other issues within the family. Being unprepared for a caregiving role led to the psychological distress of female spousal caregivers. Therefore, adequate information, education and supportive resources must be provided for spouses to facilitate their transition to caregiving roles.

RELEVANCE TO CLINICAL PRACTICE

It is necessary to pay close attention to the spousal caregivers' own mental health problems while they care for their mentally ill husbands. Mental health professionals should adopt a new approach to the prioritisation and planning of policies that support both family caregivers and patients.

What is a 'timely' diagnosis? Exploring the preferences of Australian health service consumers regarding when a diagnosis of dementia should be disclosed

BACKGROUND

Recently the dementia field has shifted focus away from the early diagnosis debate in favour of 'timely' diagnosis. 'Timely' diagnosis disclosure takes into consideration the preferences and unique circumstances of the individual. Determining when diagnosis disclosure is 'timely' may be particularly complex if there are differing views between the individual, their family, and their health care providers regarding disclosure. This study explores the preferences of consumers regarding when a diagnosis of dementia should be communicated.

METHODS

A cross-sectional survey was conducted with English-speaking adults attending outpatient clinics at an Australian hospital. Participants were recruited by a research assistant in the clinic waiting room and invited to complete the survey on a web-connected iPad. The survey included questions examining socio-demographics and experience with dementia. Two scenarios were used to explore preferences for timing of diagnosis disclosure.

RESULTS

Of 446 participants, 92% preferred a diagnosis of dementia to be disclosed as soon as possible. Preferences were not associated with socio-demographics or previous dementia experience. Most participants also preferred disclosure to occur as soon as possible if their spouse or partner was diagnosed with dementia (88%). There was strong correlation between preferences for self and preferences for spouse (0.91).

CONCLUSIONS

These findings provide guidance to health care providers about preferences for disclosure of a dementia diagnosis, and may help to overcome potential barriers to timely diagnosis. As the prevalence of dementia increases, consumers' preference for diagnosis to occur as soon as possible has important implications for the health system.

Improving diagnostic communication in dementia

In many countries around the world, owing to the lack of specialists and equipment, delay up to a few years in help-seeking and getting diagnostic examinations for dementia is not uncommon (Sayegh and Knight, 2013), and this situation is considerably more serious in "atypical dementias" due to the challenge they present for differential diagnosis. For instance, a survey in the USA showed that misdiagnosis was common in patients with Lewy body dementia who, on average, saw at least three physicians over a year's time or more before getting the proper diagnosis (Lewy Body Dementia Association, 2010). Furthermore, in multiethnic communities, cultural and language barriers between practitioners and patients may lead to substantial delay as well (Sayegh and Knight, 2013).

The process of disclosing a diagnosis of dementia and mild cognitive impairment: A national survey of specialist physicians in Denmark

Background

Although general recommendations for diagnostic disclosure of dementia are available, little is known about how these recommendations are implemented. The aim of the current study was to investigate the process and content of dementia diagnostic disclosure meetings, and to compare key aspects of disclosing a diagnosis of dementia and mild cognitive impairment.

Method

A total of 54 specialist physicians in Danish dementia diagnostic departments completed an online survey on their practices regarding diagnostic disclosure of dementia and mild cognitive impairment. The influence of respondent characteristics was assessed, and differences on key aspects of disclosing a diagnosis of dementia and mild cognitive impairment were analyzed.

Results

The results suggest that among Danish specialist physicians, there is a general consensus regarding the organization of diagnostic disclosure meetings. However, differences in employed terminology and information provided when disclosing a dementia diagnosis were evident. Significant differences were present on key aspects of the diagnostic disclosure of dementia and mild cognitive impairment. For instance, 91% would use the term dementia during diagnostic disclosures compared to just 72% for mild cognitive impairment.

Conclusion

The range of practices reflected in the present study confirms the complexity of diagnostic disclosure and highlights the importance of preparation and follow-up strategies to tailor the disclosure process to the needs of individual patients with dementia and their caregivers. Due to earlier diagnosis of neurodegenerative disorders, more research is urgently needed on this aspect of the diagnostic process, especially to develop evidence-based models for the disclosure of mild cognitive impairment.

Caregivers' attitude toward disclosure of Alzheimer's disease diagnosis in Urban China

BACKGROUND

Disclosing the diagnosis of Alzheimer's disease (AD) to a patient is controversial. There is significant stigma associated with a diagnosis of AD or dementia in China, but the attitude of the society toward disclosure of such a diagnosis had not been formally evaluated prior to our study. Therefore, we aimed to evaluate the attitude toward disclosing an AD diagnosis to patients in China with cognitive impairment from their caregivers, and the factors that may affect their attitude.

METHODS

We designed a 17-item questionnaire and administered this questionnaire to caregivers, who accompanied patients with cognitive impairment or dementia in three major hospitals in Shanghai, China. The caregiver's attitude toward disclosing the diagnosis of AD as evaluated by the questionnaire was compared to that of disclosing the diagnosis of terminal cancer.

RESULTS

A majority (95.7%) of the 175 interviewed participants (mean 14.2 years of education received) wished to know their own diagnosis if they were diagnosed with AD, and 97.6% preferred the doctor to tell their family members if they were diagnosed with AD. If a family member of the participants suffered from AD, 82.9% preferred to have the diagnosis disclosed to the patient. "Cognitive impairment" was the most accepted term by caregivers to disclose AD diagnosis in Chinese.

CONCLUSION

This study suggests most of the well-educated individuals in a Chinese urban area favored disclosing the diagnosis when they or their family members were diagnosed with AD.

The oldest carers: A narrative review and synthesis of the experiences of carers aged over 75 years

As populations age, numbers of older carers are increasing. These carers play a vital role in supporting others, often partners or spouses with dementia. This narrative review synthesised peer-reviewed evidence published over the last two decades concerning the experiences of carers aged over 75 years, specifically exploring whether their experiences differ from those of younger carers. Four electronic databases were searched and 4102 publications were identified. Eighteen studies involving over one thousand carer participants were included (11 quantitative, 6 qualitative, and 1 mixed-methods study). Most studies came from Europe or North America and almost all were cross-sectional, but few directly compared younger and older carers, making it difficult to determine whether carers' experiences vary with age. Quantitative studies generally emphasised the challenges of caring and frequently highlighted, for example, relationships between carer characteristics and negative outcomes such as burden. Qualitative studies were often more positive, emphasising carers' active responses and the rewards of caring. The normality of caring was highlighted, with some suggesting that caring may be less challenging for older than for younger carers. As with younger carers, being an older carer can be both rewarding and difficult. Our understanding of the experiences of these older carers would be enhanced with more research specifically comparing older and younger carers or comparing older carers and those not in a caring role. Carers are diverse and future research should explore the experiences of carers from different demographic groups. More longitudinal research perhaps focusing on caring dyads and mutual caring is needed.

Effects of Self-Management Groups for People with Dementia and Their Spouses--Randomized Controlled Trial

OBJECTIVES

To investigate the effect of self-management group rehabilitation for persons with dementia (PwD) and their spouses on their health-related quality of life (HRQoL), the cognition of the PwD, and the costs of health and social services.

DESIGN

A randomized controlled trial.

SETTING

Primary care and memory clinics in the Helsinki metropolitan area, Finland.

PARTICIPANTS

PwD (N = 136) and their spouses (N = 136).

INTERVENTION

Couples were randomized to usual care or eight-session self-management groups for PwD and concurrently for their spouses. Sessions aim to enhance self-efficacy and problem-solving skills and to provide peer support.

MEASUREMENTS

The primary outcome measures were the HRQoL of PwD (measured using a generic, comprehensive (15-dimensional), self-administered instrument (15D)) and spouses (measured using the RAND-36) and the spousal Sense of Competence Questionnaire (SCQ). Secondary outcome measures were PwD cognition (Verbal Fluency (VF), Clock Drawing Test (CDT)) and costs of health and social services during 24 months.

RESULTS

At 3 months, the spouse physical component of the RAND-36 improved (mean change 1.0, 95% confidence interval (CI) = -0.5 to 2.4) for those undergoing the intervention and worsened for controls (mean change -2.0, 95% CI = -3.5 to -0.4) (P = .006 adjusted for age, sex, baseline value of the physical component of the RAND-36). There were no differences between the groups on the mental component of the RAND-36, the SCQ, or the 15D. At 9 months, PwD change in VF was -0.38 (95% CI = -1.03 to 0.27) in intervention group and -1.60 (95% CI = -2.26 to -0.94) for controls (P = .011 adjusted for age, sex, baseline MMSE score). CDT changes were similar to VF changes. Differences in incremental costs between the groups was -436 € per person per year (95% CI = -4,986 to 4,115) for PwD (P = .35 adjusted for age, CDR) and -896 € per person per year (95% CI = -3,657 to 1,864) for spouses (P = .51 adjusted for PwD age, CDR).

CONCLUSIONS

The intervention had beneficial effects on the HRQoL of spouses and the cognitive function of PwD without increasing total costs.

TRIAL REGISTRATION

anzctr.org.au Identifier: ACTRN12611001173987.

Symptoms of depression and anxiety after the disclosure of the diagnosis of Alzheimer disease

BACKGROUND AND PURPOSE

Many people fear that the disclosure of the diagnosis of Alzheimer disease (AD) to patients will prompt depressive symptoms or catastrophic reactions. We aimed to prospectively evaluate the modification of anxiety and depressive symptoms 3 months after the disclosure of the diagnosis of AD.

METHODS

A total of 100 consecutive newly diagnosed patients with AD (mild or moderate stage) and their caregivers were included. The evolution of symptoms of depression and anxiety was assessed with the Zung Self-Rating Depression Scale (Zung SDS) and the depression item of the Neuropsychiatric Inventory (NPI-d) and the anxiety item of the Neuropsychiatric Inventory (NPI-a). After 3 months, the caregivers were asked their opinions on the global effect of the disclosure using a Likert-type scale.

RESULTS

At 3 months, there was no significant change in the mean NPI-d (P = .87) and Zung SDS (P = .18) and a significant reduction in the NPI-a (P = .05). The NPI-d worsened in 22% of patients, improved in 22%, and remained unchanged in 56%. The NPI-a worsened in 12% of patients, improved in 33%, and remained unchanged in 54%. The caregivers rated the global effect of the disclosure as negative in 8%, neutral in 71%, and positive in 21% of patients. None of the patients or their proxies reported suicide attempts or catastrophic reactions.

CONCLUSIONS

The disclosure of AD is safe in most cases and may improve anxiety. Symptoms of depression and anxiety worsen only in a minority of patients. The fear of depression or catastrophic reaction should not prevent clinicians to disclose the diagnosis of AD.

Disclosing a dementia diagnosis: what do patients and family consider important?

BACKGROUND

The literature available on the format of the feedback session following assessment of memory impairment is minimal. This study explored how this information should be presented from the perspective of patients and their families.

METHODS

Thirty-two semi-structured interviews were conducted with memory clinic patients and their carer at the clinic visit that followed the feedback session, to ask: what they recalled, what they found helpful, and what they thought was the best way to disclose a diagnosis of dementia. A second interview was conducted with 14 patient/carer dyads at their next appointment.

RESULTS

Recall of information from the feedback session was variable. Most respondents (76% of patients; 66% of carers) thought that a direct approach was best when informing the patient of a dementia diagnosis, and that both written information and compassion demonstrated by the doctor were helpful. Opinions on whether all the information should be given at once or in stages were divided.

CONCLUSIONS

The current format of the feedback session needs revision to improve recall. Patients and their families want a direct approach to be used by a supportive and professional doctor with an opportunity to ask questions. They want the support of a family member or friend when they are told of their diagnosis and they would like a written summary to refer to afterwards.

The experience of self and threats to sense of self among relatives caring for people with Alzheimer's disease

This study explored how the relatives of people with Alzheimer's disease expressed Self 2 and Self 3 according to Harré's social constructionist theory of selfhood. Having a relative with Alzheimer's disease affects one's life. In this study, we concentrated on how close relatives of people with Alzheimer's disease experienced their sense of self. This study was descriptive and qualitative. Interviews were conducted with 20 relatives of 10 people with Alzheimer's disease from 2009 to 2011. The data were analysed according to Harré's social constructionist theory of selfhood including Selves 2 and 3. Participants reported that Alzheimer's disease challenged their personal attributes, relations and positioning. Understanding how Alzheimer's disease affects the sense of self among close relatives is important, as this knowledge is pivotal for supporting these relatives who are often informal caregivers in ways that enable a fulfilling and meaningful life.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

What it means to be an adult child of a person with dementia

The prevalence of dementia as a disease has increased worldwide with advancing age and growing population numbers, affecting whole families. However, most previous research does not separate the spouses or cohabitants from the adult children, but instead regards all next of kin involved in the everyday care of the person suffering from dementia as caregivers. This has made it difficult to find previous research regarding what it means to be an adult child of a person with dementia, and as such, the aim of this study is to explore that topic. The method used was narrative interviews analysed using phenomenological hermeneutics. Our comprehensive understanding showed that to be an adult child of a person with dementia means being burdened with the responsibility to act on behalf of the diseased parent despite a deep sense of grief and loss, which leads to frustration and despondence. The adult children's existence and reality are threatened not only by the loss of the parent but also by the possibility that one day they too may inherit the disease. This could be compared to a psychic crisis, which is defined as a situation that leads to radical changes in the afflicted person's relationship to life and reality, or, simply, “an upset in a steady state”. The findings suggest that adult children of people with dementia are in need of support for a substantial period of time in order to adapt to the fact that they have lost a parent who is still alive. They also need information about the disease and the process of diagnosis and treatment to feel more a part of the process, as well as understand the behavior and needs of their parent.

A wish to know but not always tell -- couples living with dementia talk about disclosure preferences

Most research on disclosure issues in dementia has focused on what it is like to receive a dementia diagnosis. Little is known about the disclosure preferences that people with dementia and their cohabiting spouses have. In this study, we explore disclosure preferences and focus on what couples living with dementia want to know and tell about the disease. The study is based on 40 qualitative interviews (20 with people with dementia and 20 with their spouses). The analysis revealed five preference patterns regarding what the couples wanted to know and how they felt about sharing information concerning the disease with others. The patterns have been called: (1) want to know and tell (no reservations about it); (2) want to know and tell (some reservations about it); (3) want to know but do not want to tell; (4) want to know but cannot decide if we want to tell and (5) cannot agree on either knowing or telling. They show that couples' preferences about what they want to know are related to what they are willing to tell. The findings also show that it is usually the preferences of the person that has a dementia diagnosis that guide the stand that couples take as far as disclosure issues are concerned. Thus, the findings show the type of interdependence that exists when one person in a couple has received the diagnosis, and the life of the two people as a couple is challenged as a result of this.

Experiences of long term ongoing structured support in early stage of dementia - a case study

BACKGROUND

The prevalence of dementia diseases is increasing worldwide with advancing age and growing populations. In Sweden alone, which currently has a population of approximately 9 million people, there are about 25 000 persons diagnosed each year with a dementia. Consequently, after such a diagnosis, there is a need for support. The recipients of that support include next of kin who seek a variety of information, including potential lifestyle changes and ways of dealing with personality changes in their loved one who has a dementia.

AIMS AND OBJECTIVES

The aim was to explore four couples experiences in long-term ongoing structured support groups.

DESIGN

A single-case study using semi-structured interviews supported by 'diary notes' maintained by each participating couple were used.

METHOD

Semi-structured interviews were analysed using content analysis.

RESULT

Three categories represent the findings across the four cases: Knowledge about the disease, Sense of comfort and support, and, Kinship through shared experiences. One category, Longing for kinship was created exclusively for one of the couples. Viewing the emerging categories from a healthy ageing perspective, both comfort and support and kinship through shared experiences can be considered as components of larger themes of support and social interaction.

CONCLUSIONS

Findings suggest that structured support groups are a good way to encourage discussions, allow persons with dementia to express themselves and support healthy ageing among partners.

Expectations, experiences, and tensions in the memory clinic: the process of diagnosis disclosure of dementia within a triad

BACKGROUND

Health communication studies emphasize the importance of addressing the needs and expectations of patients and families with the disclosure of grave medical conditions. However, little attention has focused on their expectations and experiences of the clinical encounters in diagnosis disclosure of dementia.

METHODS

In-depth post-encounter interviews with ten patients and 17 companions from two memory clinics in Israel were analyzed using grounded theory. The analysis focused on identifying their expectations, their experiences, and their perceptions of the process and outcomes.

RESULTS

Major differences exist between patients' and companions' expectations. Patients' expectations were an expression of the lack of knowledge/understanding of the visit's purpose and of insight into the memory deterioration. Companions had more clear-cut expectations: some desired confirmation of the legitimacy and pertinence of their concerns about their relatives' memory problem, whereas others hoped to allay their concerns. Patients' dissatisfaction stemmed mostly from their perceptions of the process, communication, and outcome. Companions' dissatisfaction stemmed from lack of information or of tailored follow-up processes for implementing recommendations provided by the clinic.

CONCLUSIONS

Our findings expose two main issues challenging fulfillment of the different and frequently opposing expectations of patients and companions. The first is a consequence of the multi-participant nature of the encounter and the second relates to the character and severity of the disease itself. The discordance between the expectations of the two participants generates conflicts that interfere with meeting their diverse needs within the encounters - with consequent disappointment. The implications of these issues merit consideration in the planning of dementia management.

Psychosocial factors that shape patient and carer experiences of dementia diagnosis and treatment: a systematic review of qualitative studies

BACKGROUND

Early diagnosis and intervention for people with dementia is increasingly considered a priority, but practitioners are concerned with the effects of earlier diagnosis and interventions on patients and caregivers. This systematic review evaluates the qualitative evidence about how people accommodate and adapt to the diagnosis of dementia and its immediate consequences, to guide practice.

METHODS AND FINDINGS

We systematically reviewed qualitative studies exploring experiences of community-dwelling individuals with dementia, and their carers, around diagnosis and the transition to becoming a person with dementia. We searched PubMed, PsychINFO, Embase, CINAHL, and the British Nursing Index (all searched in May 2010 with no date restrictions; PubMed search updated in February 2012), checked reference lists, and undertook citation searches in PubMed and Google Scholar (ongoing to September 2011). We used thematic synthesis to identify key themes, commonalities, barriers to earlier diagnosis, and support identified as helpful. We identified 126 papers reporting 102 studies including a total of 3,095 participants. Three overarching themes emerged from our analysis: (1) pathways through diagnosis, including its impact on identity, roles, and relationships; (2) resolving conflicts to accommodate a diagnosis, including the acceptability of support, focusing on the present or the future, and the use or avoidance of knowledge; and (3) strategies and support to minimise the impact of dementia. Consistent barriers to diagnosis include stigma, normalisation of symptoms, and lack of knowledge. Studies report a lack of specialist support particularly post-diagnosis.

CONCLUSIONS

There is an extensive body of qualitative literature on the experiences of community-dwelling individuals with dementia on receiving and adapting to a diagnosis of dementia. We present a thematic analysis that could be useful to professionals working with people with dementia. We suggest that research emphasis should shift towards the development and evaluation of interventions, particularly those providing support after diagnosis.

Experiences of the patients and their caregivers regarding the disclosure of the diagnosis of Alzheimer's disease: a Belgian retrospective survey

Although the disclosure of the diagnosis of Alzheimer's disease (AD) is recommended by several guidelines, many clinicians do not announce the diagnosis to their patient. One of the main arguments against disclosure is the fear of a depressive reaction. Our aim was to report the experience and agreement of patients and their caregivers regarding the disclosure of the diagnosis of AD. All the patients with a diagnosis of AD attending our memory clinic were screened during 1 year. The patients and their caregivers were interviewed with a structured questionnaire. We included 108 patients (mean age = 77; Mini-Mental State Examination = 21) and matched caregivers (mean age 65). Twenty-nine percent of patients said they had suffered when the diagnosis was disclosed and 5% wished they had not been informed. Four percent felt more sad or depressed and 14% more anxious since the disclosure. The caregivers reported that 32% of patients had suffered from the disclosure, but only 15% were still suffering. In 85% of cases, the caregivers thought that the disclosure was useful. If they could go back in time and decide whether to disclose or not the diagnosis, only 4% of caregivers would retrospectively disagree to disclose the diagnosis to the patient. The disclosure of AD can induce anxiety and sadness. However, these negative feelings seem to persist only in a minority of patients. The vast majority of patients and caregivers agrees with the disclosure.

The transition to dementia--individual and family experiences of receiving a diagnosis: a review

BACKGROUND

Consensus recommends early recognition of memory problems through multi-disciplinary assessment in memory clinics; however, little is known about the experiences of people accessing such services. The aim of this review was to synthesis empirical evidence on patient and carer experiences in the transition to dementia.

METHODS

This review updates an earlier review (Bamford et al., 2004) on the topic of disclosure of the diagnosis of dementia. Key electronic databases were searched including OVID Medline, CINAHL, Web of Science, EMBASE, and Sociological Abstracts; this was supplemented by hand searching of reference lists and contact with experts in the field. Only papers published after 2003 were included.

RESULTS

Of the 35 papers included in the review, only one study observed the process of disclosure and only two papers explored the effects on the person with dementia's health. The vast majority of people with dementia wished to know their diagnosis. The key challenges for the person with dementia were coming to terms with losses on multiple levels. Although there may be short-term distress, the majority of people with dementia do not appear to experience long-term negative effects on their psychological health. For family carers, becoming the main decision-maker and adjusting to increased responsibility were common concerns.

CONCLUSIONS

There is still little empirical research observing the process of diagnostic disclosure in dementia. Studies exploring the views of patients and their families suggest this should be an ongoing process with the provision of support and information tailored to individual needs. The term "Alzheimer's disease" appears to have more negative connotations than the word "dementia".

Difficult diagnoses: Family caregivers' experiences during and following the diagnostic process for dementia

Diagnosing Alzheimer's disease and related dementias (ADRD) and adequately connecting families with information and supportive services continue to be challenging processes. Definitive diagnoses can take months and there is often little in place to systematically link families with community organizations. In this brief descriptive study, the researchers examined family caregivers' (N = 106) experiences with these processes. While specialists and sophisticated tests were often used, 58% of caregivers reported that a definitive diagnosis still took 3 months or longer, with 12% waiting more than 1 year. Caregivers also indicated that they were not provided with adequate information about the disease or about community resources both at the time of diagnosis and 1-year following the diagnosis. These findings suggest that there is ample opportunity to improve services offered to families affected by ADRD and that additional training, coordination, and cooperation may enhance our ability to help during and following the diagnosis.

[Informing of the diagnosis in dementia]

Dementia is a syndrome characterized by a progressive deterioration of cognitive functions, accompanied by psychiatric symptoms and behavioral disturbances that produce a progressive and irreversible disability. The way it should communicate the diagnosis of dementia is a key discussion point on which there is no unanimous agreement so far. The communicating of the diagnosis of dementia is a complex issue that affects not only, the patient but also to caregivers and health professionals who care and must conform to the ethical principles governing medical practice (autonomy, nonmaleficence, beneficence, and justice). Therefore, from the Dementia Working Group of the Catalan Geriatric Society (Grupo de Trabajo de Demencia de la Sociedad Catalana de Geriatría) arises the need to review the issue and propose a course of action for the disclosure of diagnosis.

Challenges associated with transition to caregiver role following diagnostic disclosure of Alzheimer disease: a descriptive study

BACKGROUND

The prevalence of Alzheimer's disease is rising. The large number of new cases identified each year means that many new families will set upon a long trajectory of caring for a relative with dementia. Diagnostic disclosure of Alzheimer's disease marks the official transition to the caregiver role, yet this early period of the caregiver career have rarely been studied.

OBJECTIVES

Based on Meleis's theoretical framework for role transition, the objectives of this study were to document the characteristics of the caregiving context during the transition to the caregiver role following diagnostic disclosure of Alzheimer's disease and to compare these characteristics by caregiver gender and kinship tie to the relative.

DESIGN SETTINGS AND PARTICIPANTS

A descriptive design was used. Data were collected using standardized measures selected in accordance with the role transition theoretical framework. The sample recruited in Quebec (Canada) cognition clinics comprised 122 caregivers of an elderly relative diagnosed with Alzheimer's disease in the past nine months.

RESULTS

Findings reveal the context of care to be marked by several challenges for caregivers. The majority of caregivers receives little informal support, has poor knowledge of available formal services, and has difficulty planning ahead for the relative's future care needs. Caregivers themselves report a lack of preparedness to provide care. Compared with men caregivers, women seem to have more problems controlling disturbing thoughts about their new caregiver role and to experience more family conflicts and psychological distress. Compared with offspring caregivers, spouse caregivers are less able to respond to the relative's disruptive behaviors, make less use of problem-solving strategies, and report fewer family conflicts.

CONCLUSIONS

The challenges faced by caregivers during the transition to the caregiver role are sensitive to nursing interventions. Pro-active interventions from the outset of the caregiving career, such as early assessment of caregiver needs for support and of caregiver preparedness to provide care as well as early psycho-educational interventions, are essential to foster positive caregiver responses to the challenges of their new role.